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Survey: Generic reimbursement lag an impediment to community pharmacy




ALEXANDRIA, Va. – Patient access to generic prescription drugs and community pharmacies are both increasingly at risk due to inadequate reimbursement rates that fail to cover the cost of filling prescriptions, according to a new survey of 700 community pharmacists conducted by the National Community Pharmacists Association.


“For decades community pharmacists have promoted the appropriate use of generic drugs to lower costs. However, more recently the price for some of these medications has skyrocketed 1,000% or more virtually overnight while reimbursement rates paid to community pharmacists have inexcusably lagged behind for weeks or months,” stated NCPA CEO Douglas Hoey.


“This survey finds that this problem has only grown more severe over the past two years and requires urgent attention from federal and state policymakers,” Hoey added. “Community pharmacies cannot be expected to continually fill many prescriptions at a significant loss. Ultimately patients are impacted as well. Some patients are already skipping medication due to higher prices and copays or are forced into the Medicare coverage gap or ‘donut hole’ sooner. Others will likely find it more difficult to find certain generic drugs at all because their pharmacy can no longer afford to stock and dispense them.”


The new survey asked pharmacists to describe their experiences in this area since an earlier 2013 survey first documented the problem. Among the findings:


  • Virtually every pharmacist experienced a “large upswing” in the acquisition cost of a generic drug over the past six months, with approximately 80% stating that this occurred in at least 26 instances during this period;

  • 93% said the situation has grown worse since the 2013 survey; and

  • The vast majority of pharmacists (87%) said it took one month or longer for reimbursement rates (often MACs or “maximum allowable costs”) to be updated by the insurance plan’s pharmacy benefit manager to reflect market costs. Nearly all pharmacists (92%) said the problem of slow MAC updates has deteriorated since 2013 and that appeals to update reimbursement benchmarks are typically denied or ignored by the PBM.

Respondents were also asked to mention specific drugs and instances of below-cost reimbursement. The most commonly cited medications include Benazepril (high blood pressure); Clomipramine (antidepressant); Digoxin (control heart rate); Divalproex (to treat seizures and psychiatric conditions); Doxycycline (antibiotic); Budesonide (asthma); Haloperidol (psychotic disorders); Hydroxychroloquine (rheumatism arthritis, malaria); Levothyroxine (hypothyroidism); Methylphenidate (Attention Deficit Hyperactivity Disorder);Morphine (pain); Nystatin/Triamcinolone (fungal skin infections); Pravastatin (high cholesterol; heart disease); Tamsulosin (benign prostatic hyperplasia-BPH); and Tizanidine (muscle relaxant).


To mitigate this problem Reps. Doug Collins, R-Ga., and Dave Loebsack, D-Iowa, have introduced H.R. 244, The MAC Transparency Act. It would apply to Medicare Part D, the military’s TRICARE program and the Federal Employees Health Benefits Program and would require MAC benchmarks to be updated every seven days to better reflect market costs and allow pharmacists to know the source by which such benchmarks are set. The Centers for Medicare & Medicaid Services, in response to NCPA’s concerns, issued a final rule in May 2014 to require price updates in Medicare Part D every seven days starting in 2016. 


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