Big three PBMs cut loose more specialty pharmacies as scrutiny grows

Pharmacy benefit managers have broadened their crackdown on specialty pharmacies, with at least 8 cut off from reimbursement in recent days. The PBMs are targeting pharmacies with close ties to particular drugmakers, saying the relationships favor brands over generics, jacking up health spending and running afoul of their own reimbursement rules.

The pharmacies say they help patients get access to drugs they need, often with the help of copay assistance programs funded by pharma companies. The PBMs say the pharmacies they're targeting are "captive" operations with "a really high proportion of sales" from a particular drugmaker.

Express Scripts ($ESRX), CVS Health ($CVS) and OptumRx have now jettisoned a variety of specialty pharmacies. Express Scripts gave the heave-ho to half a dozen of them in the past week, Reuters reports, including Linden Care, a pharmacy tied to Horizon Pharmaceuticals ($HZNP). Linden had focused on Horizon's combo painkiller, Duexis, which had been excluded from some top PBM formularies because it pairs two off-patent drugs and costs $500 for a 30-day supply, Reuters reports. And OptumRx, the UnitedHealth ($UNH) PBM, jettisoned Irmat Pharmacy, which derived 60% of its scripts from Galderma and Almirall drugs.

All three major PBMs have cut ties with Philidor, the specialty pharmacy that landed Valeant Pharmaceuticals ($VRX) in hot water last month. Philidor had been processing scripts for a slate of Valeant's dermatology meds, including the newly launched Jublia, until questions about its operations--and its relationship with Valeant--sent the drugmaker's shares tumbling.

"The Valeant-Philidor relationship woke payers up to potential problems in their pharmacy networks," Adam Fein, president of Pembroke Consulting, told the news service. "We are now seeing much greater scrutiny of the independent pharmacies that may not be complying with payer requirements."

The pharmacies say the heavyweight PBMs are picking on smaller independents to protect their own mail-order operations. Linden Care and Irmat each said as much in lawsuits they filed against Express Scripts and OptumRx, respectively.

Horizon CEO Timothy Walbert

"Our philosophy of ensuring that patients get the medicine their doctors prescribe is threatening Express Scripts' profiteering and exposing what we believe is a lack of care for patients and respect for physicians," Horizon CEO Timothy Walbert said last week in a statement.

The specialty pharmacy crackdown is, in a way, a continuation of a long battle between PBMs and drugmakers that use copay coupons to boost sales. CVS Health and Express Scripts rolled out their first exclusionary formularies to target copay discounts on a range of older and me-too meds. The PBMs said drugmakers were using the discounts--which limit patients' out-of-pocket spending on scripts, and can cut copays to nil in some cases--to circumvent their own tiered formulary rules designed to steer patients to lower-cost generics.

- see the Reuters news
- and a statement from Irmat Pharmacy's attorney

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