Our pharmacy has seen a 42% drop in what is being covered over the last 6 months. Big drop. Big % of scripts beginning to require Prior Auths. More rollouts from Express Scripts on plans that will be dropping over 1,000 NDCs. This is not an adjustment, this is beginning to be a slaughter. Next up is Optum RX in September. UHC sent letter to their patients a month ago. Wish it was an adjustment and they just simply started capping reimbursements. I certainly would like to continue this run. I will ride it out.
When a PBM is now seeing an RX come over with multiple NDCs they are automatically flagging it for prior auth or denial.
3, 2, 1... someone's going to say I'm all doom and gloom and I am just jealous I was not on the train. Dude, I have been on the train. I'm just giving first hand info of what is happening out there. I'm sure people can keep doing this and make some money.
PCAB will help some with customers wanting a credentialed pharmacy. But a local pharmacy that was PCAB accredited just lost their major contracts. PCAB doesn't protect you when it comes to how the PBMs evaluate whether you are compliant with how you do business (collecting copays, paying employees, billing etc..) PCAB only helps with credibility that the pharmacy is not a fly by night operation as many of these that popped up are overnight doing a major money grab in the market.
Really sucks in some regards because this stuff does work. But the dang manufacturers keep coming up with new bulk chemicals and loading them at high AWP which means they can be billed out for ungodly amounts. It is going to be a cat and mouse game with pharamcies trying to push through new formulas, new NDCs not on ESI's non-covered list. Eventually the game will catchup with them.
The more patients will not receive their compound, less likely docs are going to be to continue to prescribe it. And if your pharmacy is handing out that non-covered formula for a discounted cash price, lookout because that violates the 'usual and customary' clause of the pharmacy's contract.
When a PBM is now seeing an RX come over with multiple NDCs they are automatically flagging it for prior auth or denial.
3, 2, 1... someone's going to say I'm all doom and gloom and I am just jealous I was not on the train. Dude, I have been on the train. I'm just giving first hand info of what is happening out there. I'm sure people can keep doing this and make some money.
PCAB will help some with customers wanting a credentialed pharmacy. But a local pharmacy that was PCAB accredited just lost their major contracts. PCAB doesn't protect you when it comes to how the PBMs evaluate whether you are compliant with how you do business (collecting copays, paying employees, billing etc..) PCAB only helps with credibility that the pharmacy is not a fly by night operation as many of these that popped up are overnight doing a major money grab in the market.
Really sucks in some regards because this stuff does work. But the dang manufacturers keep coming up with new bulk chemicals and loading them at high AWP which means they can be billed out for ungodly amounts. It is going to be a cat and mouse game with pharamcies trying to push through new formulas, new NDCs not on ESI's non-covered list. Eventually the game will catchup with them.
The more patients will not receive their compound, less likely docs are going to be to continue to prescribe it. And if your pharmacy is handing out that non-covered formula for a discounted cash price, lookout because that violates the 'usual and customary' clause of the pharmacy's contract.