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PBM Complaint Results in $137,000 Backpay to IPA Member

An Iowa pharmacy received $137,000 in backpay after submitting PBM complaints to the Iowa Insurance Division (IID) for negative reconciliation as part of the PBM's 2022 effective rate reconciliation. IPA encourages Iowa pharmacies to submit complaints of PBM violations to IID!

An Iowa pharmacy received $137,000 in backpay after submitting PBM complaints to the Iowa Insurance Division (IID) for negative reconciliation as part of the PBM's 2022 effective rate reconciliation.

As a result of the complaint, the PBM fully refunded the pharmacy for the reconciled amounts and indicated commercial claims subject to the recently passed Iowa PBM legislation will not be subject to effective rate reconciliation moving forward. The PBM indicated all pharmacies in Iowa subject to this reconciliation would be reimbursed.

Following unanimous approval of HF 2384 during the 2022 Iowa Legislative Session, PBMs operating in Iowa are prohibited from charging remuneration fees or retroactively reducing reimbursement through reconciliation or any other means on commercial plans. Specifically, Iowa Administrative Code Ch. 191—59.3(510B) provides, a PBM “shall not retroactively reduce or increase reimbursement, through adjustment or reconciliation or any other means, of a clean claim paid to pharmacies.”

IPA encourages Iowa pharmacies to submit complaints of PBM violations of Iowa Code 510B or Iowa Administrative Code Chapter 59 to IID using this form. Patients also have the ability to submit complaints of PBM abuses to IID. IPA created this resource to educate patients on PBM's impact on their health.

Information on what and how to submit complaints to IID can be found on IPA's PBM Enforcement page.


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