Pharmacy Law Lowdown: Copay Collection Compliance

In this month’s edition of Pharmacy Law Lowdown, legal experts Lucas Morgan, Esq, and Dae Lee, PharmD, Esq, CPBS, from Buchanan Ingersoll & Rooney, dive deep into a critical issue surfacing in the wake of major FTC settlements: the intensifying focus on copay collection during pharmacy benefit manager (PBM) audits.

Despite the industry watching the fallout from settlements involving Caremark and Express Scripts, pharmacies are facing a more immediate threat in the form of aggressive “patient pay amount” scrutiny.

This episode highlights the dangerous misconception that legal compliance is enough. Morgan and Lee emphasize that PBM contracts often impose stricter requirements than state or federal laws, and failure to meet these specific contractual standards can be catastrophic. They break down the complexities of varying copay amounts, the proper use of manufacturer coupons, and the “most challenging” area of all: financial hardship waivers.

A major takeaway for pharmacy owners is the absolute necessity of meticulous documentation. Whether it is an independent assessment of a patient's inability to pay or a simple receipt for a cash transaction, our experts warn that records retention is key.

Without proof, PBMs may not only recoup the copay amount but the entire reimbursement for the claim, often leading to contract termination and reports to state boards of pharmacy. Furthermore, the episode warns that habitual waiving of copays without proper documentation can even trigger kickback violations under Medicare or Medicaid.

To protect your practice from these high-stakes consequences, tune in to the full-length episode for practical tips on tightening your policies and navigating the complex PBM-pharmacy relationship.

Be sure to tune into Drug Topics for important updates in pharmacy law and how to handle them from hosts Dae Lee, PharmD, Esq, CPBS, and Lucas Morgan, Esq, shareholders at Buchanan Ingersoll & Rooney, a national law firm that provides legal, business, regulatory, and government relations advice to a wide range of clients. All episodes of Pharmacy Law Lowdown will be available in video format via DrugTopics. Check out our most recent episode here: Pharmacy Law Lowdown: GLP-1 Compounding.