Last week we sent two reports highlighting the increasing pressure on PBMs in response to onerous business practices. The first described action being taken in Washington to investigate and legislate ‘fixes’ to many of the questionable practices….. top of the list being DIR fees and clawbacks. The second detailed how a small independent SP was successful in obtaining an arbitrator’s ruling restoring millions of dollars in DIR fees that were clawed back by CVS.
Only hours later, another specialty pharmacy, AHF Pharmacy (part of the AIDS Healthcare Foundation) announced that it was also filing suit against Express Scripts.
The crux of the law suit is now seemingly a song as old as time….. AHF claims that Express Scripts manipulates the Medicare “Star Ratings” system resulting in inaccurate performance scores for many of its pharmacies. These arbitrary low scores allow the PBM to claw back Medicare benefits ($$s) from pharmacies. As we have seen, the claw backs can occur months or years later. AHF says that the cash then goes into the PBM’s pocket. The manipulation especially impacts specialty pharmacies due to the ‘rigging’ of the rating system.
Specialty pharmacies nationally should be alert to how these actions play out (PBM owned SPs may watch for other reasons). It may be too early to say that these examples are sufficient to point to a trend….. but if it walks like a duck….. ya know how that continues. Even if federal relief is in the offing, there is small likelihood that restitution of previously clawed back $$s will be included.
Express Scripts Sued by AHF Over ‘Claw Backs’
July 14, 2022 — LOS ANGELES–(BUSINESS WIRE)–AIDS Healthcare Foundation (AHF), the largest global AIDS organization, which cares for over 100,000 individuals living with HIV or AIDS in the United States, filed a lawsuit in the U.S. District Court for the Eastern District of Missouri, Eastern Division, against Express Scripts, one of the three dominant U.S. pharmacy benefits managers (PBMs), and a subsidiary of Cigna, the $47-billion global health-insurance behemoth. The case, AIDS Healthcare Foundation v. Express Scripts, Inc. (Case No. 4:22-cv-00743), was filed yesterday.
AHF is the owner of the “AHF Pharmacy” chain of pharmacies, ………… (press release continues)