New Website Reveals DIR Fee Problems


NASP takes aim at DIR fees.

A new web site from the National Association of Specialty Pharmacy (NASP) spotlights the negative consequences of direct and indirect remuneration (DIR) fees.

“These fees are inflating prescription drug costs for the sickest, most vulnerable seniors-the very patients the Medicare Part D program was designed to protect-and threatening the specialty pharmacies that serve the unique needs of patients living with complex, life-altering, and often life-threatening diseases,” NASP said in a statement about the site,

The site serves as a hub of educational materials and resources for patients, health-care providers, legislators, government administrators, industry analysts, media, and taxpayers, according to NASP. also features an online petition and contact information for constituents to call or write their elected officials and urge them to stop DIR fees.

“Big pharmacy benefit management firms have worked hard to make DIR fees so complicated and opaque that very few people understand how they impact sick seniors enrolled in Medicare,” said Sheila Arquette, BSPharm, Executive Director of NASP

The fees also endanger the integrity of the Medicare Part D program, Arquette said. “While debates continue over runaway prescription drug prices from Capitol Hill to local town halls, sick and vulnerable seniors are increasingly shouldering the brunt of DIR fees, which erode access to the vital clinical and patient support services required of such breakthrough specialty medications. exposes how these dangerous and misaligned fees threaten both seniors’ pocketbooks and our entire healthcare system.”

recent paper published in JAMA Internal Medicine finds that, due to the structure of the Medicare Part D benefit design, rebates and remunerations-including DIR fees-actually increase patients’ out-of-pocket costs.

Read More: Are Rebates Responsible for Higher Drug Costs?

“Big PBMs risk putting profits over patients, and squeezing out the specialty pharmacies working as an extension of physicians treating sick seniors as they manage complex, life-altering, or life-threatening diseases,” said Rebecca Shanahan, JD, NASP President and CEO of Avella Specialty Pharmacy. “It’s time for Washington to take action by requiring PBMs to stop DIR fees and enhance transparency by opening up their ‘black box’ of information.”

In addition, PBMs should work with specialty pharmacies to establish standards and incentives that apply to the unique services provided or patients treated by specialty pharmacies, according to Shanahan.

The Pharmaceutical Care Management Association (PCMA), told Drug Topics that "This special interest agenda would increase costs for Medicare seniors. Direct and Indirect Remuneration (DIR) is a form of performance-based payment used by PBMs to promote value and quality and helps keep premiums down for Medicare beneficiaries."

They added that "Price concessions that PBMs negotiate with drug manufacturers and drugstores and report to the Centers for Medicare & Medicaid Services as DIR are generating significant savings for the federal government and are projected to save enrollees in standalone Part D plans $48.7 billion on their premiums over the next 10 years."

Updated 8/16 to include statements from PCMA

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