Questions For Non-PBM, PBM Experts

This blog entry is directed towards PBM experts who are not PBM’s or employed by a PBM. We are searching for the truth about the deep black vortex of the PBM world……………

Here are a few questions we recently posed to a PBM and would like to hear any comments the reader may have:

  1. You have just offered a new contract with seemingly better reimbursement rates tied to AWP. There is no indication what your MAC pricing is. What percentage of total Rx claims in the last 12 months were based on MAC pricing? ANSWER: 86%.
  2. Will you provide MAC pricing and guarantee those for 12 months? ANSWER: Crickets
  3. You have represented that your contract is a “pass through” contract. In other words we reimburse you the same amount you pay the pharmacy thereby eliminating spread pricing. Since you now are offering us a different AWP reimbursement schedule, does that mean you have re-negotiated all 60,000+ pharmacy agreements to reflect the new reimbursement rates? ANSWER: Crickets
  4. Who is your aggregator and who owns it? ANSWER: Our aggregator is (Redacted) and we own it, a subsidiary of our PBM.
  5. You have represented that we get 100% of all rebates. Is that still true? ANSWER: Yes
  6. Ok, when the aggregator you own receives rebates from the various manufacturers do they pass 100% of those rebates on to you? ANSWER: Crickets
  7. As you know we have removed specialty drugs from the formulary. which were formerly only available through your own specialty pharmacy. Now you say you need to increase your management fees by 211% because you have taken a “significant financial hit.” How is that possible if your contract is a pass-through contract? ANSWER: Crickets
  8. You say that with the change in our formulary by removing specialty drugs you are increasing AWP reimbursement which will offset some of this increase. You have also represented this formulary change will result in the doubling of our rebates next year. I’m not sure I understand that. Could you explain please? ANSWER: Intelligible followed by crickets.

RiskManager@RiskManagers.us

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