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NCPA survey challenges MAC, audits


Abusive auditing and unfair reimbursement practices harm community pharmacists’ ability to provide critically needed patient counseling and care to seniors, according to a new survey released Sept. 18 by the National Community Pharmacists Association.

NCPA polled more than 350 community pharmacists about their recent experience with audits conducted by pharmacy benefit managers and other Medicare Part D plan intermediaries. The survey also asked about generic drug reimbursement caps known as maximum allowable costs, or MACs. 

Among the findings:

  • 96% stated that a typical PBM contract has minimal or no transparency on how generic pricing is determined or what the reimbursement rate will be;

  • Almost 50% of respondents said that more than 10% of the time, PBMs set MAC reimbursement for generics below the pharmacy’s cost of simply acquiring the drug, much less dispensing and overhead costs, and 92% said payments are not increased promptly to reflect a drug’s rising market costs;

  • 3-in-4 pharmacists said audit requirements across Medicare Part D plans are not consistent, increasing their compliance burden; and

  • Nearly 87% stated that PBM reimbursement and auditing practices are “significantly” or “very significantly” affecting their ability to provide patient care and remain in business.

When asked which drugs had MAC limits set below the pharmacy’s cost of acquiring the product, more than 600 drugs were identified, including budesonide (for asthma); atorvastatin (cholesterol); clarithromycin (antibiotic); fentanyl patches (pain); hydrocodone (pain/inflammation); and methylprednisolone (steroid for allergic reactions, skin conditions and breathing disorders).

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