Product Selection and Drug Pricing in Long-term Care Pharmacy

by Mike Sosnowik, President, PharmSaver

Some of us are old enough to remember the good old days in the 1970s and ‘80s, when a fight with multiple pharmacy benefit managers (PBMs) was not a daily occurrence. Third-party billing was a small percentage of overall prescriptions filled. Many states went so far as to require price boards prominently posted, and generics were always profitable. But like the airport payphone and the pharmacy soda fountain, these are things of the past.

PBM Audits, MAC, and Clawbacks

The world today is PBM driven. MACs (maximum allowable costs), audits, and clawbacks are today’s reality. However, usual and customary pricing still plays a role. To the PBM commercial plans it functions as a tool to prevent pharmacies from undercutting high-tiered copays. Long-term care (LTC) pharmacies, by virtue of varied patient payers, regularly use usual and customary, and it often becomes an important part of pricing and negotiation with nursing home owners and operators to de…