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PBM Update - Prime Therapeutics

Jul 15, 2019

Prime Therapeutics Update: 10% Drug List and Enhanced Oversight

By: Andrew Fisher

Part of ORCHIDsocial

There has been a lot of buzz in the independent pharmacy industry lately about Prime Therapeutics’ aggressive enforcement of something about which many of us have heard over the last couple of years. I am referring to their elusive 10% drug list. I first heard about this list in 2016, but I had never actually seen the entire list until recently. The list reads like a who’s who of profitable generic medications (with a couple of branded drugs and quite a few compounded drug ingredients thrown in for good measure). I’m not sure how even poor Diclofenac 1% gel (generic Voltaren) made the cut, as it is not that expensive or profitable for pharmacies, but, apparently, Prime doesn’t like it.

Prime’s argument is that the medications on this list should not exceed more than 10% of the drug mix at a traditional retail, community pharmacy. I have a couple of questions about that. How is a pharmacy supposed to control what medications patients are prescribed to that extent? And how does it help patients if pharmacies have to start turning down filling their prescription or charge them a self-pay price so that the pharmacy doesn’t run afoul of this rule? How are pharmacies even supposed to know? Perhaps the most challenging part of this whole situation is that Prime has not made this list public, so a pharmacy won’t even know they are exceeding the arbitrary 10% threshold until it is too late.

This 10% list is certainly another challenge that pharmacies must overcome, and the alternatives are not pretty. You can easily lose your Prime Therapeutics contract if the drugs on the list exceed more than 10% of your total prescription fills for Prime patients. Even if Prime doesn’t terminate your pharmacy, they will likely place you into what is called an Enhanced Oversight Agreement, which grants them even more power to hurt your business. For example, if your pharmacy is under an Enhanced Oversight Agreement, Prime can conduct more on-site audits than might be allowable under your state law – and they can charge you up to $2,500 for the privilege of having them stand around in your store, harassing your staff and wasting your time.

Fortunately, there are things that pharmacies can do to reduce the risk of exceeding the limit that Prime has imposed. ORCHID has a copy of the entire list of medications, and we have worked with several pharmacies recently to analyze their risk and help them implement a strategy to lower the percentage of medications that they are dispensing that appear on this list. We’d love to work with you to determine what percentage of your pharmacy’s prescriptions for Prime patients are for drugs appearing on the 10% list. If you are over, or too close for comfort, we can develop and implement a strategy to lower that percentage and keep you away from the aggressive enforcement Prime is conducting right now. Please contact us to get more information.