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PBM Imposed “DIR” Fees on Pharmacies Survey

A “DIR” fee is really a catch-all term used to describe a number of different types of post adjudication “fees” imposed on pharmacies in Medicare Part D.  For example, a “DIR” fee may be charged to a pharmacy for Part D network participation and may be based a per claim charge or a reconciliation between the adjudicated rate indicated to the pharmacy and the contracted/effective rate with the pharmacy.

 
1. How much information or specificity is given as to how much and when DIR fees will be collected or assessed ?
2.

When you receive a notice informing you that you owe a certain dollar amount to the PBM attributable to DIR fees—Do you ever receive an itemized accounting that tells you how much money was actually deducted on each claim?
3. After DIR fees are extracted from the pharmacy, how often is the net pharmacy reimbursement below the pharmacy’s drug acquisition cost?
4. One trademark of these pharmacy DIR fees is that they are assessed after claim adjudication.  In your experience, what is the timeframe that most PBMs collect DIR fees from your payments?
 
5. Pharmacy DIR fees began in the Medicare Part D marketplace.  There are reports that similar types of pharmacy fees are starting to be assessed even in the commercial markets.  How would you assess their prevalence?
6.

How significantly are DIR fees and other post adjudication reimbursement reductions affecting your pharmacy’s ability to provide patient care and remain in business?
PBM Imposed Copay “Clawbacks” Affecting Patients

This PBM phenomenon is becoming more prominent and increasing costs to patients.  Typically, the PBM will instruct the pharmacy to collect from the patient an elevated co-pay amount that is higher than the contracted reimbursement with the pharmacy.  Subsequently, the PBM will “clawback” the excess amount from the pharmacy and pocket it.  This often happens in high deductible prescription drug plans when the entire prescription is being paid for by the patient.  Patients believe they are paying just the cost of the drug in their front end deductible, but do not realize that often a large part of what they pay is going straight to the PBM.   

 
9. How often have you seen this taking place in your pharmacy in the past month?
10. Does this practice seem to be endemic to all PBMs or are there some that are more prevalent?
12. In your practice, is this taking place in Part D?
13. Some PBM contracts reportedly restrict the ability of pharmacists to proactively tell the patient that their prescription drug could cost less if the pharmacy was permitted to process it outside  of their insurance plan (i.e., as a “cash” transaction). In other words, the patient has to directly ask the pharmacist if a “cash” transaction is cheaper before the pharmacist can volunteer such information. In the past month, how often have “gag clause” restrictions prevented you from informing the patient about “other” options or alternatives?
15. Demographic Information:
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