Lawsuits Allege Independent Specialty Pharmacies Frozen Out by PBMs

Specialty pharmacies are taking action against practices implemented by pharmacy benefit managers (PBMs) that have caused the pharmacies’ revenues to plummet.

Prime Aid Pharmacy, which provides treatments to patients with conditions such as HIV, rheumatoid arthritis, and hepatitis C virus is among the pharmacies impacted financially, according to The New York Times. Prime Aid has a staff that speaks 10 languages, and provides delivery services that have proven especially useful during winter months when bad weather can delay deliveries.

Unfortunately, Prime Aid has been facing financial hardships ever since Express Scripts barred their customers from purchasing drugs from the pharmacy, according to the article. Instead, Express Scripts customers are being directed towards Accredo, the PBM’s own specialty pharmacy, Prime Aid told The Times.

This action caused Prime Aid to lose nearly half of its patients in a short span of time, and caused them to file a lawsuit against Express Scripts, The Times noted. There have been 6 other lawsuits filed against PBMs alleging similar actions within the last year.

Specialty pharmacies sell the most expensive drugs on the market, and are a crucial part of the healthcare industry. With more independent specialty pharmacies closing their doors as a result of PBM actions, patient health is at stake.

Many PBMs have their own pharmacies and specialty pharmacies, including industry giants CVS and Express Scripts. However, the main focus of these PBMs should be to provide prescription drug benefits for insurers and large employers, according to the article.

In the lawsuit, Prime Aid and other specialty pharmacies are alleging the Express Scripts is using its market influence to sway customers towards Accredo. Patients whose drug benefit is managed by Express Scripts typically cannot receive coverage if the pharmacy is out-of-network, meaning that patients would have to spend thousands of dollars out of pocket, which is not likely to occur.

Express Scripts has denied these claims, stating that less than 1% of pharmacies are removed from their network in a given year, according to the article. The company does, however, disclose that they have increased their oversight of pharmacies due to a lawsuit that alleged Philidor Rx Services, a mail-order pharmacy, was involved in an illegal kickback scheme with Valeant Pharmaceuticals.

Prior to being removed from the network, Prime Aid said they had a good relationship with the PBM, and was processing millions of dollars’ worth of claims for hepatitis C virus cures, such as Sovaldi (sofosbuvir) and Viekira Pak (ombitasvir, paritaprevir, and ritonavir tablets; dasabuvir tablets).

The pharmacy alleges that Express Scripts terminated their relationship when the pharmacy did not cancel 7 drug claims after patients did not pick up their drugs. The PBM also cited Prime Aid paying a penalty to New Jersey to avoid disciplinary actions after a pharmacist improperly filled a prescription as a reason for termination, according to the article.

An employee of Prime Aid told The Times that after the pharmacy was no longer in-network, former customers and their physicians received phone calls to notify them of the change. A majority of patients who were taking specialty drugs were transferred to Accredo, and other patients were transferred to other pharmacies. Express Scripts, denying the statement, said that only 16% of Prime Aid’s customers now fill their prescriptions at Accredo, according to the article.

Additionally, other pharmacies have said that the PBM is enforcing a provision that will not allow them to mail a substantial amount of specialty drugs to patients, which the pharmacies feel they cannot negotiate. This provision will likely prevent numerous patients from receiving the medications they need unless they transfer to Accredo, which is a mail-order only pharmacy.

PBM advocates have said that it is up to the companies to decide which pharmacies are in-network, and these networks can be customized by employers and insurers.

Facing similar consequences, Cystic Fibrosis Pharmacy was declared out-of-network just as costly cystic fibrosis drugs were launched, according to the article.

While a PBM’s main focus should be lowering costs for their customers without affecting access to medication, independent specialty pharmacies who have been removed from their networks argue that these companies are not doing so, and are seeking to put a stop to these actions.