ESI Fees Violate Federal Policy; NCPA Pushes CMS for Clarity, Accountability

ALEXANDRIA, Va. (May 31, 2024) – Following a May 29 call, during which staff with the Centers for Medicare & Medicaid Services confirmed that “bonus pool fees” being employed by Cigna’s Express Scripts are in violation of federal Medicare Part D rules, the National Community Pharmacists Association is seeking clarity from the agency on: 1) when pharmacies will be paid back by ESI; 2) how they will be paid back; and 3) if ESI must stop collecting bonus pool fees moving forward.

NCPA first notified CMS of ESI’s bonus pool fees in early January. As it became increasingly clear that these price concessions were being improperly assessed – and that they were amounting to millions of dollars enriching ESI at the expense of independent pharmacies – NCPA publicly blasted these fees and other contractual issues in April and specifically pushed the agency for action in May. 

With the latest push for clarity, Ronna Hauser, PharmD, NCPA’s senior vice president of policy and pharmacy affairs, wrote in a May 30 letter to CMS that NCPA and its members eagerly await prompt relief. ESI has shown with its actions on the bonus pool fee, including its current system that allegedly makes it difficult to stop collecting bonus pool fees, that ESI did not take steps to comply with federal policy, Hauser wrote.

Almost half of independent pharmacy owners/managers participating in a February 2024 NCPA survey said that ESI was the pharmacy benefit manager causing the most financial stress in Medicare Part D. Ninety-three percent of survey respondents said they will be less willing to participate in Medicare Part D pharmacy networks next year if their 2024 experience in Medicare Part D continues; 32 percent said they are considering closing their business within this calendar year. Payers and plans must work with the PBMs they own or are affiliated with – like Express Scripts – to be sure pharmacies are reimbursed for prescription services at a reasonable and fair rate, NCPA says, and policymakers like CMS must hold these entities accountable if and when their actions are not in compliance with laws, rules, regulations, or other requirements.