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Breaking Down the 2026 Consolidated Appropriations Act and Its Impact on Specialty Pharmacy | NASP Specialty Pharmacy Podcast · Pharmacy Podcast Network

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  Speaker 1: You are listening to the global network of podcasters dedicated
• 0:09
  Speaker 1: to the pharmacy profession. Welcome to the Pharmacy Podcast Network.
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  Speaker 2: You're listening to the NASP Specialty Pharmacy Podcast, a collaboration
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  Speaker 2: between the National Association of Specialty Pharmacy and the Pharmacy
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  Speaker 2: Podcast Network. Each episode dives deep into trends, challenges, innovations,
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  Speaker 2: and patient centric practices shaping the future of this dynamic
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  Speaker 2: and rapidly evolving industry. Whether you're a pharmacist or healthcare provider,
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  Speaker 2: patient advocate, or industry leader, you'll hear expert insights, real
• 0:54
  Speaker 2: world evidence, and thought provoking discussion that highlights all that
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  Speaker 2: makes specialty pharmacy.
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  Speaker 3: In support of NASP's mission to empower specialty pharmacy stakeholders
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  Speaker 3: to advance the standard of patient care, NASP supports a
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  Speaker 3: free market healthcare system in which all specialty pharmacies compete
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  Speaker 3: on the same fare and level playing field because that
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  Speaker 3: is in the best interest of the patients we collectively serve.
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  Speaker 3: NASP is committed to working with all stakeholders and policymakers
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  Speaker 3: to ensure that all patients have access to the life
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  Speaker 3: saving medications they need and the high touch patient care
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  Speaker 3: and support services they deserve from the pharmacy of their choosing.
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  Speaker 4: Well, my name Michila Arquette, and I am the President
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  Speaker 4: and CEO of the National Association of Specialty Pharmacy. I
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  Speaker 4: am delighted to welcome two very special guests, Jonathan L.
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  Speaker 4: Schwischer and Bradley A. Wasser, to this episode of the
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  Speaker 4: NASP podcast. Jonathan Swischer is chair of the Dwayne Morris
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  Speaker 4: Pharmacy Litigation Group and a member of the firm's Governing
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  Speaker 4: Partners Board. For more than twenty five years, mister Swisher
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  Speaker 4: has represented thousands of independent pharmacies and healthcare providers in regular, laty,
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  Speaker 4: civil and criminal proceedings. His practice is dedicated to representing
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  Speaker 4: all provider types throughout the US, including specialty pharmacies, mail
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  Speaker 4: order pharmacies, retail pharmacies, compounding pharmacies, home infusion pharmacies, telehealth pharmacies,
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  Speaker 4: hospital pharmacies, home care pharmacies, long term care pharmacies, oncology pharmacies,
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  Speaker 4: among others. He has handled thousands of matters on behalf
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  Speaker 4: of such providers involving all aspects of their business operations,
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  Speaker 4: including but not limited to issues with payers and pharmacy
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  Speaker 4: benefit managers, PBM audit appeals, challenges to network terminations, refusals
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  Speaker 4: to provide network access, and in the submission of credentialing applications.
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  Speaker 4: Bradley A. Wesser focuses his practice on litigation, regulatory compliance,
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  Speaker 4: and government advocacy, with a nationally recognized concentration in pharmacy
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  Speaker 4: law and disputes involving pharmacy benefit managers. He provides strategic legal, regulatory,
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  Speaker 4: and business council to pharmacies, healthcare providers, and national healthcare associations,
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  Speaker 4: as well as clients and other regulated industries. As a
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  Speaker 4: member of Dwayne Morris's Pharmacy Litigation Group, mister Wasser has
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  Speaker 4: developed deep experience representing pharmacies of all types, retail, mail order, infusion,
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  Speaker 4: institutional and specialty in high stakes matters involving PBMs and
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  Speaker 4: insurance companies. IS work spans disputes over network participation rates,
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  Speaker 4: provider terminations, audits, reimbursement rates, and contractual negotiations. The information,
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  Speaker 4: thoughts and opinions expressed today belongs solely to the speakers
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  Speaker 4: and do not necessarily reflect those of NASP. Jonathan and
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  Speaker 4: brad thanks so much for joining me.
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  Speaker 5: Today, Jill, this is Jonathan.
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  Speaker 6: Thank you very much for that introduction, and we very
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  Speaker 6: much appreciate the opportunity to participate in today's podcast.
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  Speaker 4: The twenty twenty six Consolidated Appropriations Act is being described
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  Speaker 4: as one of the most significant federal peace reform packages
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  Speaker 4: to date. What events do you think motivated the passage
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  Speaker 4: of the Act, Jonathan.
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  Speaker 6: Child, It's a good question, and I think to understand
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  Speaker 6: what led to PBM reform in the Consolidate Appropriations Act
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  Speaker 6: of twenty twenty six, it would be helpful for your
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  Speaker 6: listeners for me to provide a summary of the events
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  Speaker 6: that led to the passage of the act. Rarely in
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  Speaker 6: the practice of law is there a timeline leading to
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  Speaker 6: the passage of a law that involves so many years
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  Speaker 6: and so many factors. While for much as society, the
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  Speaker 6: Act might be the first time they're learning about PBMs
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  Speaker 6: and the plights of independent specialty pharmacies, which for purposes
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  Speaker 6: of today, means pharmacies not affiliated with PBMs, there's an
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  Speaker 6: approximate seventy year history of events and developments that had
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  Speaker 6: to occur to summon the requisite congressional support to introduce
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  Speaker 6: pass the PBM reform Act, and being sensitive to the
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  Speaker 6: hour that we have for this podcast, let me try
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  Speaker 6: to summarize as succinctly as possible now seventy years or
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  Speaker 6: so of grassroots efforts by independent specialty pharmacies, rules implemented
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  Speaker 6: by CMS, laws passed among various states, and government agency
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  Speaker 6: investigations and.
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  Speaker 5: Combination drove the passage of the Act.
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  Speaker 6: The first approximate thirty years of the seventy years in
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  Speaker 6: which PBMs have existed pretty easily summarized, as you and
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  Speaker 6: most of your listeners are likely aware. PBMs developed in
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  Speaker 6: the nineteen sixties. Their original role was relatively mundane and
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  Speaker 6: non controversial. They were simply paid a faith to assist
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  Speaker 6: insurance companies and processing claims by pharmacies.
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  Speaker 5: For their drug plans.
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  Speaker 6: It was a series of really mundane administrative tasks. In
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  Speaker 6: the nineteen seventies and eighties, however, certain PBMs sought out
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  Speaker 6: additional sources of revenue, and they began to offer insurance
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  Speaker 6: companies additional services, such as developing networks for pharmacies, developing
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  Speaker 6: formularies that pharmacies had to follow, and setting reimbursement rates
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  Speaker 6: for prescriptions filled by the independent pharmacies of their network.
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  Speaker 6: The revenue for these types of services were primarily compensated
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  Speaker 6: based on benchmarks as to how much the PBMs could
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  Speaker 6: demonstrate they were saving their insurance plan clients. This really
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  Speaker 6: was the origin of kebms not viewing independent pharmacies as
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  Speaker 6: business partners, but often as adversaries regarding the amount of
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  Speaker 6: revenue that PBMs otherwise generate. And during the nineteen seventies,
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  Speaker 6: nineteen eighties, and continuing into the nineteen nineties, the terms
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  Speaker 6: and conditions that PBMs established to allow pharmacies to participate
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  Speaker 6: in these networks became stricter and stricter. The reimbursement rates
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  Speaker 6: dramatically lessened, and it became much more difficult for independent
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  Speaker 6: pharmacies to service their customers.
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  Speaker 5: And over these three.
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  Speaker 6: Decades, thousands of pharmacies nationally began to complain about how
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  Speaker 6: certain PBMs it evolved and how they were making it
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  Speaker 6: very difficult for.
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  Speaker 5: Them to stay in business now.
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  Speaker 6: PBMs, on the other hand, during this time period would.
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  Speaker 5: Respond quite differently.
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  Speaker 6: They would say that their increased scrutiny of pharmacies seeking
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  Speaker 6: to participate in their networks helped to eliminate pharmacies that
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  Speaker 6: were not best qualified or most appropriate to service their
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  Speaker 6: insurance company clients. They also would routinely teut that these
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  Speaker 6: approaches were reducing reimbursement rates, thus saving significant sums for
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  Speaker 6: insurance companies and allowing them to reduce the costs of
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  Speaker 6: their insurance.
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  Speaker 5: And while legislators on.
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  Speaker 6: Both the state and federal level would often be the
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  Speaker 6: audience for these dueling positions during this timeframe.
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  Speaker 5: There were no laws on either a.
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  Speaker 6: State or federal level that empowered them to do anything
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  Speaker 6: about these complaints. The standard response from state and federal
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  Speaker 6: legislators would be, with regard to pharmacies, we feel your pain,
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  Speaker 6: but absent any laws on the books, there's really nothing
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  Speaker 6: we can do to assist. So the advice that these
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  Speaker 6: legislators would often the pharmacies or the lawyers representing them,
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  Speaker 6: was to either seek relief in courts based upon common law,
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  Speaker 6: or engage a lobbyist to try to convince legislators to
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  Speaker 6: introduce a bill which might a couple of years later
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  Speaker 6: receive sufficient support.
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  Speaker 5: Usually, these complaints are.
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  Speaker 6: Coming from pharmacies at a point in time in which
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  Speaker 6: they think that their.
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  Speaker 5: Business is imminently at risk.
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  Speaker 6: They don't have the ability either financially or otherwise to
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  Speaker 6: participate in litigation or lobbying efforts.
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  Speaker 5: So for quite some time, these.
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  Speaker 6: Pharmacy complaints just couldn't lead to PBM reform. Now, the
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  Speaker 6: early two thousands is really when the landscape changed with
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  Speaker 6: regard to PBM reform in the way in which legislators
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  Speaker 6: on the state and federal level would consider the complaints
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  Speaker 6: from independent pharmacies. At that point, as you and your
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  Speaker 6: ANASP members are likely aware, PBMs began to seek additional revenue,
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  Speaker 6: and the primary source that they turned to to develop
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  Speaker 6: that revenue was by developing and opening affiliated pharmacies. So
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  Speaker 6: all the major PBMs opened either brick and mortar pharmacies
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  Speaker 6: or mail order pharmacies, and at that point the PBMs
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  Speaker 6: who were responsible for deciding which independent pharmacies would participate
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  Speaker 6: in their networks and with what conditions, were now in
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  Speaker 6: direct competition with the pharmacies owned and operated by certain
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  Speaker 6: of the PBMs. This led to quite a few additional
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  Speaker 6: complaints by independent pharmacies that they were being excluded by
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  Speaker 6: certain PBMs from networks.
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  Speaker 5: They were being terminated without cause or with cause based.
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  Speaker 6: Upon immateial grounds, and far too often the reinforsement that
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  Speaker 6: they were being forced to accept was below their wholesale costs.
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  Speaker 6: So as these complaints grew louder and louder, CMS became
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  Speaker 6: concerned about how these tactics were impacting the Medicare population.
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  Speaker 6: This led to what we consider to be the first
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  Speaker 6: truly meaningful reform on a federal level, and that was
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  Speaker 6: in two thousand and three with the passage of the
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  Speaker 6: Medicare Prescription Drug Improvement and Modernization Act. That was the
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  Speaker 6: law that required that Medicare party sponsors permit any pharmacy
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  Speaker 6: willing to accept the plans terms of additions to participate
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  Speaker 6: in the Part D network.
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  Speaker 5: That was pretty significant progress on a federal front, but the.
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  Speaker 6: Concern as of two thousand and three was the law
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  Speaker 6: did not require that PBMs or insurance companies otherwise act
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  Speaker 6: reasonably with regard to independent pharmacies. It was years later
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  Speaker 6: that CMS began to issue guidance that terms and conditions
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  Speaker 6: of Medicare party networks had to be reasonable and irrelevant,
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  Speaker 6: and fortunately these principles were later codified into law. The
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  Speaker 6: main problem that existed thereafter up until the passage of
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  Speaker 6: the PBM Reformact is the fact that CMS did not
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  Speaker 6: have enforcement authority to the extent that an independent pharmacy
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  Speaker 6: believed that a PBM was not complying with the reasonable
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  Speaker 6: and relevant obligations that CMS said PBMs were required to
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  Speaker 6: abide bym went out of its way to make clear
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  Speaker 6: that Congress did not bestow upon it the ability to
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  Speaker 6: get in the middle of a dispute between pharmacies and
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  Speaker 6: PBMs as to whether a PBM was acting reasonably regarding
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  Speaker 6: network participation conditions, reimbursement rates, etc.
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  Speaker 5: Now, Brad'll discuss surely.
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  Speaker 6: How that is largely being remedied by the PBM reformat.
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  Speaker 6: But let me just make a couple of other points
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  Speaker 6: and then I'll hand it back off to you.
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  Speaker 5: One thing that I.
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  Speaker 6: Assume most of your listeners are aware of, and it's
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  Speaker 6: important to keep in mind, is that CMS and the
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  Speaker 6: federal government can only regulate Medicare and ARISA plants. States,
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  Speaker 6: on the other hand, can only regulate commercial plants. What's
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  Speaker 6: interesting about the last approximate thirty years is that states
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  Speaker 6: have really been ahead of the curve passing laws for
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  Speaker 6: the benefit of independent pharmacies. And it was actually states
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  Speaker 6: who in the early to mid nineteen nineties were the
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  Speaker 6: first to pass any willing provider laws to protect independent pharmacies,
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  Speaker 6: and over the next approximate twenty years, once again it
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  Speaker 6: was the states that took the lead in expanding the
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  Speaker 6: rights to independent pharmacies to go beyond any willing provider.
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  Speaker 6: So the grassroots efforts by independent pharmacies to reach out
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  Speaker 6: to state legislators has really been the initial source of
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  Speaker 6: certain protections for independent pharmacies. The challenges to those laws
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  Speaker 6: tend to go through the court system.
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  Speaker 5: When the courts would then affirm the.
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  Speaker 6: Legality of the laws that states were passing, it was
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  Speaker 6: often the federal government who would then becoming more aware
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  Speaker 6: as to what was going on with independent pharmacies, pass
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  Speaker 6: or attempt to pass laws for the benefit of pharmacies
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  Speaker 6: that would impact again the types of plans that the
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  Speaker 6: federal government has the right to regulate, that is ARISA
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  Speaker 6: and medicare.
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  Speaker 5: The last five years, and.
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  Speaker 6: I'll conclude with this, we really have seen more efforts
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  Speaker 6: at reform. I would say more developments that led to
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  Speaker 6: the passage of the Act than we've seen in the
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  Speaker 6: last approximate seventy years. It's pretty well known that since
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  Speaker 6: mid twenty twenty two, the FTC has been conducting a
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  Speaker 6: study an investigation into PBMs. They've issued two interim reports
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  Speaker 6: which contain very detailed findings as to the manner in
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  Speaker 6: which PBMs, according to the FTCA, certain PBMs, according to
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  Speaker 6: the FTC, have acted unfairly towards independent pharmacies such as
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  Speaker 6: patient steering reimbursement rate. In the second of the two
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  Speaker 6: interim reports, I think is of particular interest to an
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  Speaker 6: ESPNUTS members because the focus was on specialty pharmacies and
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  Speaker 6: specialty medications, and for the course of approximately seventy pages,
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  Speaker 6: the FTC and a fairly detailed manner detailed the way
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  Speaker 6: in which certain PBMs were complicating business for specialty pharmacies.
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  Speaker 6: They noted that far too often certain PBMs would categorize
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  Speaker 6: medications to be specially medications when in reality they were retail.
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  Speaker 6: They identified circumstances in which certain PBMs would require that
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  Speaker 6: individuals only obtain specialty medications from pharmacies in their specially networks.
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  Speaker 6: Independent pharmacies far too often have extreme difficulty getting into
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  Speaker 6: the specialty networks that certain PBMs establish, and up until
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  Speaker 6: the message of the Act, PBMs would have a relatively
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  Speaker 6: easy time convincing insurance plan clients to require that individuals
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  Speaker 6: who require specialty medications only get them from the specialty
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  Speaker 6: pharmacies that are owned or affiliated by the PBMs. So
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  Speaker 6: those two interim reports, coupled with a groundswell of protection
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  Speaker 6: that has developed on a state level, coupled with some
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  Speaker 6: court opinions which have recognized the legality of legislators trying
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  Speaker 6: to benefit independent pharmacies, really is what led to what
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  Speaker 6: we're here to discuss today, the PBM reformat. So with
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  Speaker 6: that introduction, let me pause and we'll continue the discussion
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  Speaker 6: about the act.
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  Speaker 4: Sure, can I just ask a question for clarification purposes?
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  Speaker 4: So when we're talking about independent pharmacies, we are talking
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  Speaker 4: about out really non affiliated pharmacies with the PBM. Right,
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  Speaker 4: it's not just the independent retail pharmacies. It's right, like
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  Speaker 4: a specialty pharmacies aren't that, But it's it's everybody.
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  Speaker 7: Right.
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  Speaker 6: Any pharmacy that is not affiliated with the PBM falls
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  Speaker 6: within my definition of an independent pharmacy. Yeah, the pharmacies
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  Speaker 6: that are not affiliated with the major PBMs, the ones
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  Speaker 6: that are not large retail chains that are known to
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  Speaker 6: be owned by the PBMs, These these are truly independent pharmacies.
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  Speaker 6: Whether they are specialty retail or other types.
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  Speaker 4: Wonderful, Thank you. So, which provisions do you think will
• 18:40
  Speaker 4: have the biggest operational impact on PBMs and pharmacies over
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  Speaker 4: the next couple of years.
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  Speaker 7: Yeah, and show us as Brad, I'm happy to take
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  Speaker 7: that question, and thanks for that. So, you know, look,
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  Speaker 7: there are a number of provisions that impact PBMs and
• 18:55
  Speaker 7: pharmacies that that pharmacies, particularly us as pharmacy attorneys, you know,
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  Speaker 7: are paying particular attention to. And you know, look, we're
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  Speaker 7: going to closely monitor over the next couple of years
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  Speaker 7: how they're going to impact or how they will be impacting,
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  Speaker 7: you know, the operations of the PBMs, the treatment by
• 19:13
  Speaker 7: PBMs of non affiliated pharmacies, you know, et cetera. But
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  Speaker 7: but there's a couple of provisions particularly related to you know,
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  Speaker 7: those operational changes that stand out from our perspective, you know,
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  Speaker 7: and I think the largest is those touching on you know,
• 19:31
  Speaker 7: pharmacy network access and the any willing provider law, which
• 19:35
  Speaker 7: Jonathan had just talked about.
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  Speaker 8: But let me touch on that a little bit last.
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  Speaker 7: Let me circle back to that because I think that's
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  Speaker 7: probably the biggest topic of discussion for US and it
• 19:45
  Speaker 7: has such impact or potential to impact our clients and
• 19:49
  Speaker 7: you know, as well as PBMs and other stakeholders and
• 19:53
  Speaker 7: how they're going to be operating on a going forward
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  Speaker 7: basis with respect to how they're treating PBMs, how they
• 19:59
  Speaker 7: might be designing pharmacy networks, how it impacts reimbursement rates
• 20:04
  Speaker 7: for pharmacies, etc. So one particular area of interest also
• 20:11
  Speaker 7: and again I also go back to the annauling provider
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  Speaker 7: piece is delinking PBM compensation from drug prices. And we're
• 20:20
  Speaker 7: also starting to see this type of legislation come down
• 20:24
  Speaker 7: in states, particularly Colorado and California have recently passed laws
• 20:29
  Speaker 7: that require de linking. And what that means effectively is
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  Speaker 7: that what at least the Consolidation Appropriations Act has said
• 20:37
  Speaker 7: is that it prohibits PBMs in medicare party from earning
• 20:42
  Speaker 7: compensation that's directly tied to the list price of drugs,
• 20:49
  Speaker 7: rebate amounts that the PBMs may be receiving for putting
• 20:52
  Speaker 7: drugs on their formularies, or other sort of volume based
• 20:56
  Speaker 7: fees or remuneration that they're when I say they the
• 21:01
  Speaker 7: PBMs are receiving and and effectively, I think you know
• 21:05
  Speaker 7: how we're going to see this d linking requirement impacting
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  Speaker 7: PBMs is that you know, I think they're going to
• 21:11
  Speaker 7: move towards more you know, quote unquote bona fide flat
• 21:15
  Speaker 7: fee arrangements with their plan sponsors, with drug manufacturers. And
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  Speaker 7: I think the goal behind this type of legislation and
• 21:22
  Speaker 7: the provision specifically within the Act was to eliminate incentives
• 21:27
  Speaker 7: to favor high cost drugs with larger reimbursements. And the
• 21:32
  Speaker 7: way from our perspective that that benefits specialty pharmacies, uh,
• 21:37
  Speaker 7: is by eliminating PBM incentives.
• 21:41
  Speaker 8: To favor higher cost drugs.
• 21:44
  Speaker 7: You know, from our perspective, we're hopeful that it's going
• 21:48
  Speaker 7: to reduce spread pricing meaning uh, you know, the amount
• 21:53
  Speaker 7: that the PBMs charts that the health plans versus the
• 21:56
  Speaker 7: amount that they reimburse pharmacies, you know, and that will
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  Speaker 7: they will increase reimbursement to pharmacies that are going forward basis.
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  Speaker 7: But it also we think will work to eliminate incentives
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  Speaker 7: for patients steering that you know, the PBMs currently have
• 22:13
  Speaker 7: where as Jonathan mentioned, oftentimes they are steering patients to
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  Speaker 7: their own affiliated pharmacies, their own affiliated specialty pharmacies, you know,
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  Speaker 7: because by delinking that specific compensation to drug prices, moving
• 22:29
  Speaker 7: you know, PBMs away from, like we said, incentives to
• 22:34
  Speaker 7: favor higher cost drugs. Hopefully you know that that levels
• 22:39
  Speaker 7: the playing field and it allows additional access by the
• 22:44
  Speaker 7: non affiliated specialty pharmacies to service patients where PBMs are
• 22:50
  Speaker 7: not saying, well, you know, if we send that you know,
• 22:54
  Speaker 7: twenty thousand dollars prescription to our own pharmacy, we're going
• 22:58
  Speaker 7: to be able to obtain significantly higher amount than we
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  Speaker 7: otherwise would. You know, The goal here with this provision
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  Speaker 7: is really a level the playing field across the board,
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  Speaker 7: you know, and we're hopeful we're going to really see
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  Speaker 7: that that operational impact on pharmacies, especially specialty pharmacies that
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  Speaker 7: are obviously unaffiliated with the PBMs. I think another provision
• 23:21
  Speaker 7: that is going to have a big impact on you know,
• 23:24
  Speaker 7: the PBM industry as well as pharmacies, or the enhanced
• 23:28
  Speaker 7: transparency and reporting requirements that are mandated by the Act,
• 23:33
  Speaker 7: and that the Act imposes what I would say are
• 23:38
  Speaker 7: extensive reporting obligations on PBMs because there are in certain
• 23:43
  Speaker 7: instances going to be required to provide semi annual reporting
• 23:49
  Speaker 7: or at least annual disclosures to the federal government. And
• 23:53
  Speaker 7: you know, particularly the CMS that deal with rebate amounts
• 23:57
  Speaker 7: that they're receiving from drug manufacturers or planned sponsors, uh,
• 24:02
  Speaker 7: the spread pricing charges that they're engaged in pharmacy reimbursement methodologies,
• 24:10
  Speaker 7: you know, clawbacks and fees that they're you know, taking
• 24:13
  Speaker 7: from or charging to pharmacies, you know, affiliated pharmacy arrangements
• 24:20
  Speaker 7: like we've talked about, and really compensation you know, received
• 24:24
  Speaker 7: from manufacturers as well. And I think you know, CMS
• 24:29
  Speaker 7: having access to these substantial reportings and this data, they're
• 24:35
  Speaker 7: going to be able on a going forward basis to
• 24:38
  Speaker 7: use the data for future rulemaking to the extent that
• 24:42
  Speaker 7: I think that this data is revealing, uh, you know,
• 24:45
  Speaker 7: an uneven playing field that CMS buy or excuse me,
• 24:49
  Speaker 7: that Congress by enacting this law is really hoping to
• 24:54
  Speaker 7: to to make much more even. And and I think
• 24:58
  Speaker 7: the third provision, as I had indicated, that really is
• 25:03
  Speaker 7: going to be most important to independent or let me
• 25:07
  Speaker 7: let me say non affiliated pharmacies really are the network
• 25:11
  Speaker 7: access and any willing provider provisions and the implications therein
• 25:17
  Speaker 7: by the act, which ultimately will strengthen pharmacy access protections
• 25:23
  Speaker 7: by increasing scrutiny by the government on PBMs of patients
• 25:28
  Speaker 7: steering affiliated pharmacy favoritism, which you know, as I just
• 25:34
  Speaker 7: talked about, we're constantly seeing a lot and that's one
• 25:37
  Speaker 7: of the areas that non affiliated especially pharmacies, are really
• 25:43
  Speaker 7: being impacted by. You know, also, I think this is
• 25:47
  Speaker 7: going to address reimbursement disparities that Jonathan had talked about.
• 25:52
  Speaker 7: And really we're hopeful that you know, these sort of
• 25:54
  Speaker 7: forms and the any Willing Provider side will act to
• 25:59
  Speaker 7: curve restrictive network practices and allow pharmacies who have an
• 26:04
  Speaker 7: interest in participating in PBM networks to be.
• 26:06
  Speaker 8: Able to do so.
• 26:07
  Speaker 7: And really, you know, the Act what it does is
• 26:10
  Speaker 7: it increases the regulatory focus on the pharmacy network equity.
• 26:15
  Speaker 7: And really what the provisions of the Act are doing
• 26:21
  Speaker 7: is not necessarily federalizing you know, stronger protections under the
• 26:26
  Speaker 7: any Willing Provider law, but they are providing the opportunities
• 26:30
  Speaker 7: for cms to work through additional regulatory rulemaking processes and
• 26:37
  Speaker 7: really define what should be considered reasonable and relevant when
• 26:43
  Speaker 7: we're talking about contracts that are offered to pharmacies. Under
• 26:48
  Speaker 7: the any Willing Provider provisions.
• 26:50
  Speaker 8: Et cetera.
• 26:51
  Speaker 7: So let me stop there and see what other questions
• 26:54
  Speaker 7: you may have shield and you know, we can certainly
• 26:55
  Speaker 7: continue the discussion on any Willing provider law, what CMS
• 26:59
  Speaker 7: is going to do on a going forward basis, and
• 27:02
  Speaker 7: how that's going to impact independent pharmacies as well as
• 27:05
  Speaker 7: the PBM industry.
• 27:07
  Speaker 4: Do you agree, Brad like a lot of these provisions
• 27:09
  Speaker 4: are helpful, right, but only if they're enforced, like the
• 27:13
  Speaker 4: reporting requirements.
• 27:15
  Speaker 7: Well, you're absolutely right about that, Chill, and that's a
• 27:19
  Speaker 7: huge issue that you know. I think Jonathan will will
• 27:23
  Speaker 7: say the exact same thing that we see on a
• 27:25
  Speaker 7: daily basis. You know, regardless of how good the reform is,
• 27:29
  Speaker 7: regardless of how many you know, strong laws there are
• 27:32
  Speaker 7: on the books, to the extent that there is no
• 27:36
  Speaker 7: entity or to enforce those laws or enforcement mechanisms are
• 27:41
  Speaker 7: not acted upon, You're right, I mean that has an
• 27:45
  Speaker 7: impact to diminish the bite, if you will, of those laws.
• 27:51
  Speaker 8: That have been passed. So we absolutely need you.
• 27:54
  Speaker 7: Know, those reform or excuse me, we also absolutely need
• 27:57
  Speaker 7: those enforcement mechanisms. One nice thing about the law is
• 28:03
  Speaker 7: the increased federal enforcement authority. When I say the law,
• 28:07
  Speaker 7: the increased federal enforcement authority that has been mandated under
• 28:12
  Speaker 7: the Act. So the Act authorizes stronger oversight of you know,
• 28:18
  Speaker 7: all the provisions that are you know, discussed here in
• 28:21
  Speaker 7: mandated therein as well as ongoing or existing you know,
• 28:28
  Speaker 7: regulatory issues, existing laws, et cetera, by you know, CMS,
• 28:34
  Speaker 7: the Department of Labor when it touches on ARISSA related
• 28:37
  Speaker 7: issues HHS, you know, which might have a larger authority
• 28:42
  Speaker 7: and preview obviously of CMS, as well as FDA, et cetera.
• 28:47
  Speaker 7: And then also the Treasury Department. You know, the law,
• 28:51
  Speaker 7: the Act, uh, you know, indicates that civil monetary penalties
• 28:57
  Speaker 7: would be applied for inaccurate reports or non compliance by PBMs.
• 29:02
  Speaker 7: You know, some of those penalties can reach up to
• 29:05
  Speaker 7: ten thousand dollars a day for certain violations of the Act. So,
• 29:11
  Speaker 7: you know, just to bring that home, I think and
• 29:13
  Speaker 7: form Bratt and Bratt.
• 29:14
  Speaker 6: Can I can I just jump in and just and
• 29:15
  Speaker 6: what more government agency to the the mix. You know,
• 29:21
  Speaker 6: I mentioned shield the FTC and the fact that since
• 29:25
  Speaker 6: twenty twenty two they've been involved in a six piece
• 29:28
  Speaker 6: study of PBMs. The the FTC has jurisdiction over any
• 29:35
  Speaker 6: company in any industry that is involved in unfair trade practices.
• 29:41
  Speaker 5: And what is.
• 29:44
  Speaker 6: I would say a pretty reasonable conclusion based upon the
• 29:50
  Speaker 6: approximate one hundred and forty pages of findings that the
• 29:54
  Speaker 6: FTC has already issued with regard to certain PBMs, is
• 29:58
  Speaker 6: that they have concluded that PBMs have engaged in unfair
• 30:04
  Speaker 6: trade practices, that certain acts, at least as the date
• 30:08
  Speaker 6: those reports were issued, constitute unfair trade practices. We are
• 30:15
  Speaker 6: anticipating that the FTC will be issuing a final report,
• 30:21
  Speaker 6: hopefully by the end of this year. We don't believe
• 30:24
  Speaker 6: that the change in the administration since the study commenced
• 30:28
  Speaker 6: is going to impact either the pace in which they
• 30:33
  Speaker 6: will conclude the investigation or the findings that have already
• 30:35
  Speaker 6: been reached, and we expect that the final report will
• 30:38
  Speaker 6: be pretty much a recap of what they previously found
• 30:43
  Speaker 6: in the interim report. So the FTC will also have
• 30:47
  Speaker 6: enforcement authority to go after anyone in the industry that
• 30:52
  Speaker 6: they believe is involved in unfair trade practices. So, in
• 30:58
  Speaker 6: addition to HHS the Treasury Department, we expect that the
• 31:05
  Speaker 6: FTC is going to be particularly active with enforcement actions
• 31:09
  Speaker 6: and what is particularly notable for us as pharmacy attorneys
• 31:14
  Speaker 6: is in between the first and second report, the FTC,
• 31:19
  Speaker 6: without any forewarning or notice, issued a report that it
• 31:26
  Speaker 6: had determined that as an agency, it was not being
• 31:31
  Speaker 6: aggressive enough in enforcing what it deems to be unfair
• 31:38
  Speaker 6: trade practices and braining them in. So, if you look
• 31:45
  Speaker 6: at the dates of the interim report, the date in
• 31:48
  Speaker 6: which that notice was issued by the FTC, and then
• 31:51
  Speaker 6: the second report, I think it's fair to assume that
• 31:55
  Speaker 6: that report was largely influenced by what the FTC was
• 32:00
  Speaker 6: concluding with regard to certain players in the PBM industry.
• 32:05
  Speaker 5: That the notice that the FTC has.
• 32:08
  Speaker 6: A responsibility to be more aggressive formally bringing complaints against
• 32:15
  Speaker 6: companies that they believe are involved in unfair trade practices
• 32:18
  Speaker 6: from here on out should be much more of an expectation.
• 32:22
  Speaker 6: So while cms hhs are certainly going to be paying
• 32:29
  Speaker 6: attention to the way in which PBMs are or are
• 32:33
  Speaker 6: not complying with the Act, we expect that the FTC
• 32:37
  Speaker 6: is also going to be a major player, and if
• 32:38
  Speaker 6: the conduct that issue is serious enough. The DOJ formed
• 32:44
  Speaker 6: a couple of years ago a Healthcare Task Force, the
• 32:47
  Speaker 6: purpose of which is to investigate, among others, PBMs that
• 32:55
  Speaker 6: they believe may be involved in certain anti competitive behavior.
• 33:00
  Speaker 6: And we expect that as the Act moves forward and
• 33:04
  Speaker 6: its provisions are much more clearly defined, that couple with
• 33:09
  Speaker 6: a final report by the FTC will also likewise cause
• 33:13
  Speaker 6: the Dooja to move forward with certain enforcement activity. So
• 33:17
  Speaker 6: there's multiple sources that now have the legal authority to
• 33:22
  Speaker 6: enforce any violations of either the Act itself or what
• 33:29
  Speaker 6: I would say are existing laws that prohibit unfair trade
• 33:34
  Speaker 6: practices or certain anti competitive behavior.
• 33:40
  Speaker 9: All right, so what is the current status of the Act,
• 33:43
  Speaker 9: So chill as you may be aware and your listeners
• 33:46
  Speaker 9: may be aware, the Act passed in February of this year.
• 33:51
  Speaker 7: You know, not all provisions, though, went into effect immediately,
• 33:59
  Speaker 7: and you know, I can talk about that briefly because
• 34:01
  Speaker 7: there are still some issues I would say are quote
• 34:05
  Speaker 7: unquote influx. And what I mean by that is, you know,
• 34:09
  Speaker 7: over the next couple of years, there are requirements in
• 34:14
  Speaker 7: which the government, particularly CMS, has to begin rulemaking and
• 34:21
  Speaker 7: guidance development. And that's with regards specifically to reasonable and
• 34:27
  Speaker 7: relevant standards Number one, And as Jonathan had mentioned, you know,
• 34:32
  Speaker 7: part of the regulatory scheme under the Federal Ning Willing
• 34:36
  Speaker 7: Provider Law by Medicare party is that contractual terms and
• 34:41
  Speaker 7: conditions need to be quote unquote reasonable and irrelevant. You know,
• 34:46
  Speaker 7: they have to have reasonable and relevant standards for pharmacies
• 34:50
  Speaker 7: to participate in those PBM and part D sponsored networks.
• 34:55
  Speaker 7: So over the next year or so, UH, we're going
• 35:00
  Speaker 7: to see that CMS is going to publish a notice
• 35:04
  Speaker 7: of proposed rulemaking UH to define those reasonable and relevant terms.
• 35:09
  Speaker 7: I think we're going to see a lot of input
• 35:11
  Speaker 7: from pharmacy stakeholders as well as other uh, you know,
• 35:14
  Speaker 7: PBM industry stakeholders indicating what terms uh contractually you know
• 35:21
  Speaker 7: that that government relationships between PBMs and pharmacies. UH, you
• 35:27
  Speaker 7: know what those standards should be. You know what those
• 35:30
  Speaker 7: pharmacy participation requirements should look like, what network access protections
• 35:36
  Speaker 7: should be included in those standards, and you know potentially
• 35:40
  Speaker 7: applicable what reporting obligations by the PBMs and transparency and
• 35:45
  Speaker 7: disclosure may be required to be provided to pb to
• 35:49
  Speaker 7: excuse me, to be provided by PBMs to pharmacies.
• 35:53
  Speaker 8: Ondergoing uh forward basis and then back?
• 35:58
  Speaker 5: Can I just can I just jump in on one
• 35:59
  Speaker 5: thing there.
• 36:00
  Speaker 8: Yeah, please job.
• 36:02
  Speaker 5: On this particular point.
• 36:05
  Speaker 6: One thing I want to make sure that your listeners
• 36:09
  Speaker 6: are aware of is the fact that they now have
• 36:14
  Speaker 6: the opportunity, assuming that they own and operate a pharmacy,
• 36:19
  Speaker 6: to work with CMS to help to define what constitutes
• 36:26
  Speaker 6: reasonable and relevant terms of network participation. While we have
• 36:32
  Speaker 6: always found CMS to be a pretty welcoming government agency
• 36:37
  Speaker 6: in terms of fielding concerns by independent pharmacies, at this
• 36:43
  Speaker 6: point in time they're making clear that their doors are
• 36:47
  Speaker 6: as open as ever to field not just complaints but
• 36:52
  Speaker 6: assistants and helping them define what should ultimately be determined
• 36:57
  Speaker 6: to be a fair, reasonable and appropriate set of terms
• 37:03
  Speaker 6: and conditions for network participation.
• 37:05
  Speaker 5: So most of the.
• 37:06
  Speaker 6: Major pharmacy associations are already communicating with CMS.
• 37:14
  Speaker 5: We know that.
• 37:17
  Speaker 6: A number of independent pharmacies have already reached out to
• 37:22
  Speaker 6: CMS and are working with CMS to provide feedback on
• 37:27
  Speaker 6: what they believe would constitute very reasonable terms for the ACT.
• 37:35
  Speaker 6: One thing that is important is that there is a
• 37:39
  Speaker 6: deadline for associations or pharmacies to convey that information to CMS.
• 37:47
  Speaker 6: The deadline for any comments or other feedback to be
• 37:53
  Speaker 6: provided is in April of twenty twenty seven. So to
• 37:57
  Speaker 6: the extent that any of your listening would like the
• 38:01
  Speaker 6: opportunity to connect with CMS and share their thoughts on
• 38:07
  Speaker 6: what could constitute reasonable and relevant terms of network participation
• 38:12
  Speaker 6: for a pharmacy of their type. Getting that emotion now
• 38:17
  Speaker 6: really could be quite important. The biggest issue that I
• 38:23
  Speaker 6: think pharmacies want to share with CMS is what is
• 38:30
  Speaker 6: reasonable with regard to reimbursement. That is another area where
• 38:35
  Speaker 6: I think states are ahead of the curve, which have
• 38:39
  Speaker 6: been often much more specific than the federal government has
• 38:44
  Speaker 6: up until now.
• 38:45
  Speaker 5: So far, too.
• 38:46
  Speaker 6: Often the agreements that are provided to pharmacies by certain PBMs,
• 38:54
  Speaker 6: the reimbursement rates are non negotiable, and often those reimbursement
• 38:59
  Speaker 6: rates are going to be below the wholesale costs that
• 39:03
  Speaker 6: independent pharmacies incur and purchasing medication. So where the starting
• 39:08
  Speaker 6: point is reimbursement below wholesale costs, and all the administrative
• 39:13
  Speaker 6: services that have to be provided by particularly specialty pharmacies
• 39:18
  Speaker 6: in delivering those medications making sure that their customers are
• 39:23
  Speaker 6: being properly cared for are not reimbursed. I mean, it
• 39:27
  Speaker 6: really really becomes difficult for pharmacies to remain in operation
• 39:33
  Speaker 6: if their wholesale costs are not covered, and hopefully they're
• 39:39
  Speaker 6: getting something a little bit above that which allows them
• 39:42
  Speaker 6: to offset the administrative costs. So what would constitute reasonable
• 39:47
  Speaker 6: reimbursement is now on the table, What would constitute a
• 39:52
  Speaker 6: reasonable dispensing fee is now on the table. The extent
• 39:57
  Speaker 6: to which certain services are tended to the provision of
• 40:02
  Speaker 6: medication is on the table. So for independent pharmacies who
• 40:07
  Speaker 6: have been looking for an opportunity to improve their financial circumstances,
• 40:15
  Speaker 6: the next year really is the best opportunity up until
• 40:19
  Speaker 6: now they will ever ever.
• 40:20
  Speaker 5: Had to do that.
• 40:24
  Speaker 7: Yeah, and I agree completely with Jonathan, And you know
• 40:28
  Speaker 7: what you're just saying, John, And I think you know,
• 40:30
  Speaker 7: I just wanted to add the point that you know,
• 40:32
  Speaker 7: CMS is directive to define what terms are quote reasonable
• 40:38
  Speaker 7: and relevant to participation in a party network is extremely
• 40:41
  Speaker 7: important to your point, John, I think his PBMs historically
• 40:46
  Speaker 7: have argued that pharmacies, you know, technically out of the
• 40:48
  Speaker 7: angle and provider law could you know, always join their networks.
• 40:52
  Speaker 7: But you know, they impose contractual conditions that make it
• 40:57
  Speaker 7: you know, most typically economic or otherwise you know, sometimes
• 41:02
  Speaker 7: operationally impossible for the pharmacy to you know, either participate
• 41:06
  Speaker 7: accurately in the network to be profitable in the network,
• 41:10
  Speaker 7: or even to join a network where reimersial rates are
• 41:14
  Speaker 7: so low you know that they're not going to be
• 41:16
  Speaker 7: able to continue operations to the extent that you know,
• 41:19
  Speaker 7: the reimburse below wholesale costs and to sort of just
• 41:23
  Speaker 7: to pick up on the last point about April first,
• 41:26
  Speaker 7: twenty twenty seven that John mentioned being the deadline.
• 41:29
  Speaker 8: Once all those comments are.
• 41:31
  Speaker 7: In, you know, around that time in the spring of
• 41:34
  Speaker 7: next year, HHS or CMS rather is then going to
• 41:39
  Speaker 7: be required to issue a request for information to analyze
• 41:44
  Speaker 7: trends in PBM participation contract terms, you know, et cetera.
• 41:50
  Speaker 7: You know, and then that's going to be another opportunity
• 41:53
  Speaker 7: for stakeholders to be able to specifically.
• 41:55
  Speaker 8: Comment to CMS.
• 41:57
  Speaker 7: So obviously, I think when that time comes, Sheila, certainly
• 42:02
  Speaker 7: your members and other pharmacy stakeholders are definitely going to
• 42:07
  Speaker 7: want to get in and you know, provide comments, and
• 42:10
  Speaker 7: I'm sure we're going to be seeing a huge influx
• 42:13
  Speaker 7: of those.
• 42:14
  Speaker 8: And then two years from.
• 42:17
  Speaker 7: Now, a year after that, in about April twenty twenty eight,
• 42:21
  Speaker 7: CMS is then required at least under the Act to
• 42:24
  Speaker 7: establish their final standards for what are going to be
• 42:28
  Speaker 7: reasonable and relevant contract terms, which will then ultimately go
• 42:32
  Speaker 7: into effect January first of twenty twenty ninth.
• 42:38
  Speaker 4: So do you foresee any challenges to the Act in
• 42:41
  Speaker 4: what do those look like?
• 42:44
  Speaker 8: I think we certainly do.
• 42:47
  Speaker 7: And one of the things that we typically see are
• 42:51
  Speaker 7: challenges to any I guess, subversion of his status quo.
• 42:55
  Speaker 7: You know, whether they're from pharmacy benefit managers, pharmacy benefit
• 43:00
  Speaker 7: manager associations p c m A, you know, other stakeholders,
• 43:06
  Speaker 7: et cetera. We think anything that you know might impact
• 43:12
  Speaker 7: their bottom line is very likely to be challenged by
• 43:16
  Speaker 7: by the courts. I can't tell you sitting here right
• 43:18
  Speaker 7: now that you know that's going to be particularly successful.
• 43:22
  Speaker 8: You may be aware. And then, Jonathan, if you want
• 43:24
  Speaker 8: to apply on this, I think you have some.
• 43:26
  Speaker 7: Very good insight into this that very recently there were
• 43:30
  Speaker 7: a number of stakeholders that challenged the IRA, you know,
• 43:35
  Speaker 7: the Inflation Reduction Act negotiation requirements. You know that CMS
• 43:39
  Speaker 7: is engaged in, and very recently the Supreme Court shot
• 43:43
  Speaker 7: down rich for assert meaning you know, petitions that those
• 43:48
  Speaker 7: entities have filed to get the Supreme Court to hear
• 43:52
  Speaker 7: their case as to why that law is problematic, why
• 43:56
  Speaker 7: they don't think the law is constitutional, et cetera. So
• 43:59
  Speaker 7: I certainly, I do think we're going to be seeing
• 44:01
  Speaker 7: constitutional challenges, you know, pushing on cmses authority, you know,
• 44:07
  Speaker 7: arguments that they don't have the authority to you know,
• 44:10
  Speaker 7: implement certain of you know, the rulemaking that that they're
• 44:14
  Speaker 7: being directed to, that they don't have the authority to
• 44:17
  Speaker 7: define reasonable and relevant terms because those should be subject
• 44:20
  Speaker 7: to private negotiation. But I do think, you know, that
• 44:23
  Speaker 7: that constitutional line in the challenge to the rulemaking authorities
• 44:27
  Speaker 7: where we're going to see challenges coming to this act.
• 44:33
  Speaker 5: So just I guess that a couple of extra points.
• 44:35
  Speaker 6: So yeah, what Brad's referring to is as of today,
• 44:38
  Speaker 6: a very recent decision by the US Supreme Court on
• 44:42
  Speaker 6: May eighteenth, twenty twenty six, not to allow cert which
• 44:46
  Speaker 6: means it refused to hear an appeal from certain drug
• 44:50
  Speaker 6: manufacturers who are challenging the legality of the Inflation Reduction Act.
• 44:54
  Speaker 5: And I would say that the US.
• 44:56
  Speaker 6: Supreme Court's refusal to consider that kind of in line
• 45:01
  Speaker 6: with the circumstances in which over the past few years,
• 45:05
  Speaker 6: it has refused to hear other petitions for served. Other
• 45:10
  Speaker 6: appeals that touch upon what would constitute fair and reasonable
• 45:16
  Speaker 6: terms for network participation failed to touch upon the issues
• 45:23
  Speaker 6: between PBMs and pharmacies with regard to what constitutes appropriate reimbursement.
• 45:29
  Speaker 6: Most of your listeners might be familiar with the Rutledge matter,
• 45:34
  Speaker 6: where Arkansas passed the law as to a minimum amount
• 45:38
  Speaker 6: of reimbursement that pharmacies in that state were to receive
• 45:43
  Speaker 6: when they filled medications.
• 45:46
  Speaker 5: The lobbying group that Brad referred to, PCMA challenged.
• 45:50
  Speaker 6: The legality of that law, claim that that law was
• 45:58
  Speaker 6: implicating Arisa, and because as was implicating Arissa, a state
• 46:02
  Speaker 6: did not at the ability to pass that law. In
• 46:05
  Speaker 6: that case, the US Supreme Court accepted, it agreed to
• 46:09
  Speaker 6: hear the appeal, and it determined that Arkansas's efforts to
• 46:14
  Speaker 6: address a minimum amount of reimforsement did not implicate Arissa.
• 46:19
  Speaker 5: And therefore it was lawful.
• 46:22
  Speaker 6: I think, and again, we can never predict what the
• 46:27
  Speaker 6: US Supreme Court may or may not do. I agree
• 46:30
  Speaker 6: with Brad that we're likely to see challenges to the Act.
• 46:36
  Speaker 6: I am fairly optimistic based upon the current state of
• 46:39
  Speaker 6: the case law that those challenges.
• 46:43
  Speaker 5: Are not going to be successful.
• 46:47
  Speaker 6: Now, there are going to be some other laws that
• 46:51
  Speaker 6: are being passed on a state.
• 46:53
  Speaker 5: Level that I think are going to be in the
• 46:56
  Speaker 5: courts over the next couple of years.
• 46:58
  Speaker 6: So, for example, states that are really going out of
• 47:02
  Speaker 6: their way to protect independent pharmacies have recently passed laws
• 47:06
  Speaker 6: prohibiting certain PBMs from owning or operating a pharmacy in
• 47:13
  Speaker 6: their state. That was first done in Arkansas, immediately challenged
• 47:18
  Speaker 6: by PCMA, and the courts issued an injunction preventing the
• 47:25
  Speaker 6: state from implementing that law, which would have essentially caused
• 47:29
  Speaker 6: the closure of any brick and mortar pharmacies located in
• 47:34
  Speaker 6: the state that are affiliated with PBMs, would have prohibited
• 47:38
  Speaker 6: PBMs from meeting mailing medications into the state. I think
• 47:42
  Speaker 6: that the states that have passed similar laws that are.
• 47:46
  Speaker 5: Being challenged by PBMs in their.
• 47:48
  Speaker 6: Lobbying groups, I think those cases are going to move
• 47:52
  Speaker 6: through the court system. I think they give rise to
• 47:55
  Speaker 6: some interesting constitutional questions. But however those cases play out
• 48:01
  Speaker 6: is not going to impact the provisions of the Act.
• 48:05
  Speaker 6: Those provisions, first of all, are on the state level,
• 48:07
  Speaker 6: and the provisions contain their in really don't overlap with
• 48:11
  Speaker 6: the types of cases we anticipate seeing.
• 48:15
  Speaker 5: Like the case in Arkansas over the next couple of years.
• 48:21
  Speaker 4: So this is only the beginning, right, much more to come, much.
• 48:25
  Speaker 5: More to come. But for.
• 48:30
  Speaker 6: Most pharmacies which have for many years really pled with
• 48:39
  Speaker 6: the federal government to provide them.
• 48:42
  Speaker 5: Some protection with regard to their bills.
• 48:46
  Speaker 6: For Medicare beneficiaries individuals who are participating in ARISA insurance plans,
• 48:56
  Speaker 6: we are on the brink of what will be the
• 49:00
  Speaker 6: most significant reform they or PBMs have experienced since the
• 49:07
  Speaker 6: inception of PBMs, And for pharmacies that for decades were
• 49:13
  Speaker 6: expressing concern about their ability to get into networks, day
• 49:16
  Speaker 6: in networks be reimburse fairly that this really marks the
• 49:23
  Speaker 6: best opportunity that we and they have ever seen that
• 49:30
  Speaker 6: can finally delivered to them the kind of reform they've
• 49:33
  Speaker 6: desperately been seeking. So we're hopeful that by twenty twenty nine,
• 49:38
  Speaker 6: the schedule that's in place will remain in place, and
• 49:43
  Speaker 6: by twenty twenty nine the Act will be law. It
• 49:47
  Speaker 6: will be enforceable, the way in which reasonable and relevant
• 49:51
  Speaker 6: will be defined in a way that is bare and
• 49:54
  Speaker 6: appropriate for both pdms and pharmacies, and pharmacies will be
• 49:59
  Speaker 6: able to to service their customers without the constant worry
• 50:05
  Speaker 6: as to whether or not doing so as they believe
• 50:08
  Speaker 6: is necessary from a financial standpoint, is unfeasible.
• 50:15
  Speaker 4: Well, thank you so much Jonathan and Brad for chatting
• 50:17
  Speaker 4: with me and for breaking down right the twenty twenty
• 50:20
  Speaker 4: six Consolidated Appropriations Act. There's a lot in here to digest.
• 50:26
  Speaker 5: Well, thank you very much, Shila, Yeah, thank you.
• 50:29
  Speaker 8: Shall us is our pleasure today.
• 50:31
  Speaker 4: As a reminder, NEESP corporate members are invited to be
• 50:34
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• 50:37
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• 50:41
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• 50:44
  Speaker 4: n et dot org or visit our website at www
• 50:49
  Speaker 4: dot na SP n e T dot org. Until next time,
• 50:54
  Speaker 4: have a great day,