Pharmacy network protections and anti-steering

Specialty Drugs may be provided by Prime, an affiliate of Prime, or other Specialty Pharmacy that has a written arrangement with Prime or Claim Administrator.

Recorded reference: Page 46

Published rationale. The pharmacy network belongs to Prime. Exhibit 7 Section 6(a) on page 44 makes Prime responsible for providing and maintaining the network and for reimbursing pharmacies under its own Network Contracts, and Section 6(f) provides for pharmacy claims audits, which are recoveries after adjudication. Specialty Pharmacy is defined on page 49 as a pharmacy designated by the Claim Administrator or PBM to dispense by mail from central locations, and page 46 says Specialty Drugs may be provided by Prime or an affiliate of Prime, with mail order likewise routed through a Prime designated pharmacy. There is no any willing pharmacy clause, no claim finality protection, and no prohibition on steering into affiliated channels. The one member protection, on page 44, is that pharmacies may not switch to a higher cost product without a request. The general statement on page 26 that provider choice belongs to the Covered Person does not override the channel design, so bad.

Prime requires its Network Participants to not switch Covered Prescription Drug Products to a higher cost product unless requested to by the Member and/or the Member’s Physician.

Recorded reference: Page 44

Published rationale. On Page 44, Section 6.a provides a helpful member protection by requiring network participants not to switch a covered prescription product to a higher cost product unless requested by the member or physician. However, the agreement lacks broader network protections found in the model contract published by Mark Cuban and collaborators, such as a complete prohibition on steering patients toward PBM-owned pharmacies, protections against post adjudication clawbacks, and an open willing provider participation guarantee.

Prime requires its Network Participants to not switch Covered Prescription Drug Products to a higher cost product unless requested to by the Member and/or the Member’s Physician.

Recorded reference: Page 44

Published rationale. Page 44 contains a narrow member protection against a network participant switching to a higher cost product without a request. The same page assigns network construction and pharmacy reimbursement to Prime under separate contracts, and page 27 allows retained mail and specialty discounts. Pages 43 through 49 do not guarantee any willing pharmacy admission, bar plan or PBM steering toward related pharmacies, prevent retrospective pharmacy clawbacks, or prohibit volume-conditioned reimbursement. Page 8 describes offsets and overpayment recovery for providers generally, although that language is not a clear pharmacy-specific retroactive fee term. The single anti-switching constraint merits partial credit, but it does not provide the model's pharmacy choice, finality and anti-steering package.

Prime requires its Network Participants to not switch Covered Prescription Drug Products to a higher cost product unless requested to by the Member and/or the Member’s Physician.

Recorded reference: Page 44

Published rationale. Page 44 says Prime requires network pharmacies not to switch a covered product to a higher cost product unless the member or the member's physician requests it. Page 26 says the choice of a provider is the covered person's and that Claim Administrator will not interfere with that relationship. Those are limited protections. They are not a ban on steering claims into Prime affiliated mail or specialty pharmacies. Pages 28 and 46 contemplate that mail and specialty may be operated by an affiliate of Prime, and nothing forbids channel steering. There is no any willing pharmacy right. Network participation is by contract with Prime or Claim Administrator. Reimbursement is not stated to be independent of volume. Pharmacy claims are not declared final at adjudication. Section 4.2 on Page 8 authorizes recovery of overpayments by offset against future payments, including cross plan offsets. Page 44 adds pharmacy claims audits for contract integrity. The model contract requires final adjudication, no volume condition, no steering into owned pharmacies, and any willing pharmacy participation at the plan's terms. A product switch limit and a non-interference sentence are present and weaker, with the steering and finality protections absent. That is partial rather than missing.

Specialty Drugs may be provided by Prime, an affiliate of Prime, or other Specialty Pharmacy that has a written arrangement with Prime or Claim Administrator

Recorded reference: Page 46

Published rationale. The model term requires finality of adjudicated claims, no volume conditioned reimbursement, no steering into the vendor's own pharmacies, and any willing pharmacy participation. None of these protections appear, and the structure runs the other way. Page 46 permits specialty drugs to flow through Prime or a Prime affiliate, page 27 lets Prime keep margin on mail and specialty channels, and page 28 confirms those channels may be affiliate operated, which is the economics of steering rather than a ban on it. The pharmacy network is built and maintained by Prime under its contract with the Claim Administrator on page 44, with no any willing pharmacy clause, and section 6(f) authorizes pharmacy claims audits while pages 8 and 9 authorize post payment recovery processes against providers. The draft leaves the network and channel routing entirely in the vendor's hands.