While the drugs provided by specialty pharmacies are costly, given the novel therapies needed to treat very small patient populations, specialty pharmacies operate on razor thin margins of 1-6%.
DIR fees assessed by PBMs against specialty pharmacies can range between 3 and 5% or more. Thus, specialty pharmacies are often reimbursed PBMs for less than their costs to obtain the life-saving medications they dispense. And that’s before a specialty pharmacy even begins providing the high-touch services that support patient access, persistency and compliance, and coordinating care with referring prescribers and reporting outcomes.
As it stands, PBMs are applying DIR fees retroactively to pharmacies based on their performance against “quality” metrics, most of which apply only to retail pharmacies, not specialty pharmacies. PBMs should acknowledge the inapplicability of these metrics to specialty pharmacies and create performance metrics that are applicable, instead of assigning to the specialty pharmacy the average score of other pharmacies in each category and then calculating DIR fees accordingly.