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Protect Your Patients from PBM Abuse
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Protect Your Patients from PBM Abuse

The latest draconian move by ESI and CVS/Caremark to eliminate compound prescription coverage is just the latest in a series. Blue Cross/Blue Shield of Tennessee, Prime Therapeutics, US Healthcare, and others have all taken steps to severely limit coverage or created barriers for pharmacists to submit claims for needed medications.

But, if you are a participating pharmacy provider in any third-party plan, you have to know what you can and cannot do before telling your patients about the ramifications of a plan’s changes. “What many pharmacists don’t realize is that their network contract or the provider manual itself strictly prohibits telling a patient about changes to coverage, speaking out publicly about a third-party insurer or PBM, posting alerts or messages on social media or list-serves,” says IACP Vice-President of Government Affairs and General Counsel Cynthia Blankenship.  “It seems like a restriction of an individual’s freedom-of-speech but it’s not.  By signing a contract and agreeing to abide by that contract’s terms, a pharmacist may have unknowingly given up the right to criticize or say anything to anyone about that third-party.”

IACP has already noticed many postings on listserves and blogs by compounding pharmacists speaking out against a specific third-party program. All members should be aware that such action in direct defiance of a contract could result in termination from the network for not only compounded prescriptions but also all prescriptions and pharmacy services. Before taking any action – even something as simple as telling your patient that their plan is changing --  read  your contract and the provider manual to see whether or not you are permitted to do so.

What can you do to protect yourself but, at the same time, get the message out about PBM and third-party attempts to deny coverage?  

IACP is working with a coalition of compounding pharmacy industry leaders, patient advocacy groups, consumer groups, and others to reach out directly to consumers and inform them of their rights and how to raise their voices to employers, union leaders, payors, state and federal legislators, and state insurance commissioners. Watch for a major announcement next week with specific action items you can take to protect your patients and your business.

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