The pharmacy benefit manager industry is coming under increased scrutiny by insurance companies and large chain pharmacies, according to news reports. Audits and reconciliation of reimbursement by a large insurer and at least one chain have revealed some PBMs are coming up short on reimbursement.
CVS is embroiled in a dispute with PBM Prime Therapeutics over below-cost MAC pricing and the debate has gone public in federal court. CVS sets its loss at $50 million.
On the heals of CVS’s suit, one of the nation’s larges insurance companies, Anthem is suing Express Scripts for $15 billion over drug pricing. The insurer says the PBM did not pass along its savings from negotiated drug prices. Anthem alleges the $15 billion represents drug price over-payments it made, along with the remainder of its 10-year contract with Express Scripts.
Although its contract with Prime Therapeutics calls for it to set reimbursement based on market conditions, a vice president at Prime confirmed with a Senior VP at CVS that Prime’s changes to MAC prices were not related to changes in market for prescription drugs but were designed to give Prime a competitive advantage in bidding to plan sponsors.