Over time the Thriving Pharmacist has reported many different problems with Pharmacy Benefit Managers and the stranglehold they often have over the profession and practice of pharmacy. In many ways, pharmacy is to blame for allowing this power over itself become entrenched. At least part of this is pharmacy owners and chain executives not paying enough attention to the details of contracts.
But the PBMs themselves are also duplicitous. Consider a fax my pharmacy received the other day. This fax was a Pharmacy Network Agreement for a new plan. A fax like this is often overlooked in part because it is a densely worded legal document. Looking closely at the document, however, revealed a few interesting facts:
The pharmacy name was not included on this fax. Instead the pharmacy was identified by its National Provider Identifier. So instead of the agreement reading
This pharmacy agreement (“Agreement”)…between [PMB Name and address] and [Pharmacy Name]
it instead listed the pharmacy’s 10 digit NPI. This was obviously a computer generated document that was blast-faxed. While unusual, this was not the only interesting aspect of the contract. At the end of the 3 page contract, just above the space provided in the signature section, was the following:
Initials _______ indicate that you do not wish to participate in the XXX network
And below the signature space provided:
You will be automatically enrolled into the XXX network on 12/2/2017
If you do not wish to participate in the network, you must fax this signed agreement back…
In other words: you are will be contracted if you do nothing. You must opt out of the contract buy initialing and signing the contract.
So how does one become contracted without signing a contract that doesn’t even include your company’s name? This is a good question, but the answer probably lies in another contract the pharmacy is already participating in that allows the PBM to force an opt-out for new contracts. This type of duplicitous contract is yet another example of how the PBMs have managed to ensnare the profession of pharmacy.
If you are familiar with pharmacy over the past decade, you are probably just nodding your head. Nothing here is new or surprising. But I bring this up for a good reason. Pharmacy is entering a new era in many states, with new networks being formed that pay pharmacy for actually managing the patient and not just drug distribution. Pharmacies are being paid to improve outcomes on the medical side of the equation.
At present, there is not one set model for pharmacy payment. But as these networks mature, there will undoubtedly be companies trying to embed themselves in the middle once again. Pharmacy needs to be smarter.
fool me once, shame on — shame on you. Fool me — you can’t get fooled again.
— George W. Bush
Pharmacy must maintain control of its own destiny this time around, and this means paying attention to the details.