Drug Topics - February 11, 2008 - (Page 34) 34 DRUG TOPICS FEBRUARY 11, 2008 www.drugtopics.com Cover Story companies at least, “there is an incentive for drug companies to reduce the NCPA has predicted that AMP,” Kreling explained. Of course for pharmathe AMP rule would drive cists, the lower the estab10,000 pharmacies out lished AMP for a drug, the lower the reimbursement they would receive of business for dispensing it. As the January 1, 2007, deadline approached, pharmacists grew increasingly anxious as CMS gave few indications as to when it would issue the rule. Pharmacists, however, received the first of many reprieves. CMS finally issued the preliminary rule at the end of December 2006. Despite the reprieve, pharmacy organizations were vocal in their criticism of the proposed rule. Under the rule, the expected savings ballooned from $6.3 billion to $8 billion over a five-year period. One NACDS official called it a “recipe for disaster” while NCPA termed it a “Scrooge-like proposal.” In addition to the overall concern with using AMP as a measure for pharmacy reimbursement, NCPA and NACDS focused on a few key provisions that they felt made the AMP rule particularly onerous. While the DRA mandated that CMS set reimbursement at 250% of AMP it left open questions of what data would be includ, ed in AMP and how it would define the retail class of trade. The proposed rule, released in late December, reDT CAPSULE The state of dispensing fees ccording to a nationwide dispensing fee study commissioned by the Coalition for Community Pharmacy Action, it now costs pharmacies on average $10.50 to dispense a medication. However, as the costs of running a pharmacy have risen, dispensing fees offered by many state Medicaid programs lag well behind, averaging just $4.50. A number of states have adopted “hold harmless” provisions that promise to increase dispensing fees if AMP reduces the pharmacy reimbursement. Other states have moved to increase the dispensing fee directly. Changes are subject to CMS’ approval and the agency has only ruled on Louisiana so far. Below are a few of the states that have taken steps to increase dispensing fees: South Carolina: Raised fee from $4.05 to $9.94 for all Medicaid prescriptions. Texas: Increased fee from $5.14 to $7.50 with provisions to go as high as $12.50 based on AMP. Wisconsin: Eliminated a provision that reduced the dispensing fee by $.50. It is now $4.88. Louisiana: CMS rejected a proposed increase from $5.14 to $10 for brands, $15 for generics, but has not ruled on a new proposal to raise it to $10.10 for all drugs. A ceived more than 1,600 comments as well as letters of concern from more than 250 senators and representatives. Particularly troublesome was CMS’ definition of the retail class of trade. In the initial definition, CMS lumped independent, chain, and mail-order pharmacies together, but also included PBMs and any other outlet “that purchases, or arranges for the purchase of, drugs from a manufacturer, wholesaler, distributor, or other licensed entity and subsequently sells or provides the drugs to the general public.” The inclusion of mail-order pharmacies and nursing homes seemed especially unfair to many pharmacy officials. In the comments submitted to CMS about the rule, NACDS and NCPA both criticized the inclusion of mail-order pharmacies because they received discounts that were not available to other retail pharmacists. Another criticism of the CMS rule was its inclusion of various discounts that are not readily available to most retail pharmacies. In addition to traditional sales to retail pharmacies, CMS also proposed to include: •Sales to wholesalers and manufacturers who act as wholesalers. •Sales to hospitals and intermediate care facilities where the drug is used in the outpatient pharmacy. •Discounts, rebates, or other price concessions to PBMs associated with retail pharmacy. •Sales directly to patients or outpatient clinics. •Rebates, discounts, or other price concessions. •Sales and associated rebates, discounts, and other price concessions under Part D, Medicare Advantage, State Children’s Health Insurance Program, state pharmaceutical aid programs, and Medicaid programs associated with retail pharmacy. There were other concerns about the rule. CMS, for example, expanded the range of drugs to be included under the rule to go well beyond AB-rated drugs to include non-equivalent drugs. In addition, CMS relaxed the language that required the drugs to be “available in the states” to “available in the United States,” meaning that the drugs would no longer be required to be available in all 50 states. Others contended that CMS grossly underestimated the rule’s impact on community pharmacies and might cause many of them to leave the program. In rural areas where access to pharmacies is already limited, such withdrawal from the program could violate the Medicaid program’s guarantee of access to community pharmacies. The opposition takes shape Pharmacists were not alone in their opposition to the rule. The Pharmaceutical Care Management Association (PCMA), a trade group representing PBMs, objected to the inclusion of PBM rebates, arguing that “including this information would not only have been http://www.drugtopics.com
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.