Earlier this year, CMS issued its Medicare Part D Final Rule addressing DIR fees, among other things. It is important to remember that the rule does not eliminate DIR fees but moves them to the point of sale. The rule becomes effective January 1, 2024, meaning that the pharmacies will face a DIR cliff when they will be required to pay double DIR fees: one large chunk retroactively at the end of 2023 and starting to pay DIR fees at the point of sale beginning January 1, 2024.
The rule applies only to Medicare claims and it is unclear whether private plans will follow the lead and contractually prohibit retroactive fees.
Ambiguity surrounds the final rule and there are many unanswered questions. But it seems that PBMs will be paying pharmacies the lowest possible reimbursement at the point of sale, providing pharmacies with the opportunity to earn back additional reimbursements based on future performance. Such a roadmap is open to interpretation and potential PBM abuse.
The reform also requires CMS to develop pharmacy performance measures but it is unclear which metrics CMS will use. Lastly, the rule also appears to mandate that PBMs (or Part D plans) adequately describe DIR fees on their remittance advices.
I – personally – have many concerns with the proposed rule as the rule fails to give solid directions as how it will be implemented. All that we know is that the DIR fees under Medicare plans will be moved to the point-of-sale starting January 1, 2024.