PBMs acts generating legal actions

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.