Further Evidence That PBMs are Failing on Government Programs

At CMS’ oversight and enforcement conference last week Jonathan Blanar, the agency’s Deputy Director of Compliance Enforcement, presented the following slide. In this slide, you will see actions CMS has imposed against Medicare health plans in the last two years, and for what reasons. It’s further evidence that pharmacy benefit managers (PBMs) are failing Medicare beneficiaries and the plans enrolling them.

PBMs have a big hand in the first category, coverage determinations, though they’re not entirely culpable.  What’s maddening about that tally is the fact that appeals and grievances rules in Medicare haven’t changed much in the 17 years since they were first issued, and PBMs and plans are still screwing it up.  To CMS, appeals are the most important consumer protection at the point of service, so they dish those findings out regularly.

It’s the second category, formulary administration, that’s most disturbing.  The numbers speak for themselves.  But Blanar added this color, the most frequent findings, which included the following and are a damning indictment of PBMs as the Keystone Kops of government programs:

• Unapproved quantity limits
• Unapproved utilization management practices
• Failure to properly administer the CMS transition policy
• Improperly effectuating a prior authorization or exception request
• Failure to provide a transition supply of a non-formulary medication