March 22, 2022

NHIA submitted comments on a CMS proposed rule: Medicare and Medicaid Programs; CY 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs, which would alter the way pharmacy price concessions, including direct and indirect remuneration (DIR fees), are calculated by pharmacy benefit managers (PBMs). 

According to CMS, the changes outlined in the proposed rule are intended to achieve the goals of meaningful price transparency, consistent application of all pharmacy payment concessions by all Part D sponsors, and to prevent cost-shifting to beneficiaries and taxpayers. In addition, the agency wanted to address an unsustainable increase in DIR fees and the small percentage of price concessions being passed through to beneficiaries at the point of sale. 

While NHIA supports CMS’s efforts to address the abusive practices of PBMs surrounding DIR, the association expressed concerns that unless all pharmacy price concessions are accounted for at the point of sale at the claim level, PBMs could restructure pharmacy fees to circumvent the intent of the proposed rule. NHIA also opposes allowing for an “alternative negotiated price” for drugs in the coverage gap and requests that CMS apply the proposed revised definition of negotiated price consistently throughout the Part D benefit, which would benefit Medicare beneficiaries. 

Read the comments.