Pharmacy Benefit Managers Restricting Physician Drug Dispensing?

September 2, 2016

Many patients who receive prescription drugs get them from dispensing physician practices. Since 2006, these dispensaries have participated as in-network providers for various Medicare Part D pharmacy networks; however, now physician dispensaries are in danger of being reclassified as out-of-network.

Many patients who receive prescription drugs get them from dispensing physician practices. Since 2006, these dispensaries have participated as in-network providers for various Medicare Part D pharmacy networks; however, now physician dispensaries are in danger of being reclassified as out-of-network, according to a white paper from the Community Oncology Alliance (COA).

According to the paper, recent actions by pharmacy benefit managers (PBMs) indicate a move to increase corporate profits by declaring all physician dispensing to be out-of-network.  Currently, the only PBM that has stated an intention to restrict patient access to physician dispensing is CVS Caremark, which will put its new policy in place effective January 1, 2017. 

Studies have shown that when patients receive medication directly from a treating physician they are more likely to adhere to the medication regimen, receive the medication in a more timely manner, and have improved health outcomes.

“This has been particularly true in oncology, where intense cancer treatments can span many years, requiring regular physician visits for chemotherapy and checkups,” the white paper says. “Keeping patients close to their oncologists lessens the burden of this devastating disease.”

According to the COA white paper, despite these benefits, PBMs have begun “systematically and surgically limiting access” to dispensing physician practices, by shifting the availability of these drugs to mail order pharmacies owned or associated with PBMs.

“During my 26 years as an oncologist, I have witnessed a vast improvement in the quality of life as cancer care has moved from the hospitals to physician offices, and now, to oral drugs patients can take at home,” said Bruce Gould, MD, COA president and a practicing oncologist at Northwest Georgia Oncology Centers in Marietta, Georgia, in a press release. “Now new actions by PBMs, such as CVS Caremark, would set cancer care back immensely. Today, oral drugs are often the best option for cancer patients. If the planned PBM restrictions are implemented, then patients needing oral therapies will find their access to drugs limited and their care fragmented. Meanwhile in many cases, they will also have to deal with delays in obtaining their drugs and costlier care.”

In addition, all of the major PBMs have increased their presence in the specialty drug market, where dispensing physicians frequently treat Medicare beneficiaries with cancer. Recently, the PBMs have launched or acquired their own specialty pharmacies, the white paper says, in “an attempt to gain market share in the growing specialty drug space.”

According to the paper, “Federal law protects dispensing physicians and physician-owned pharmacies against termination from Medicare networks. The Centers for Medicare and Medicaid Services clearly requires that Part D sponsors comply with the Medicare “Any Willing Provider” requirements. A PBM’s refusal to contract with any provider that is willing to comply with their terms and conditions is a violation of these Federal statutes.”