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JUNE 22, 1999, TUESDAY

SECTION: IN THE NEWS

LENGTH: 5186 words

HEADLINE: PREPARED TESTIMONY OF
STUART L. BASCOMB
VICE PRESIDENT OF EXPRESS SCRIPTS, INC.
BEFORE THE HOUSE JUDICIARY COMMITTEE
SUBJECT - OPPOSING H.R. 1304
("QUALITY HEALTH-CARE COALITION ACT OF 1999")

BODY:

 
Stuart L. Bascomb
Express Scripts Testimony of Stuart L. Bascomb
I. Introduction.
My name is Stuart L. Bascomb. I am the Executive Vice President of Express Scripts, Inc. I have been a senior executive at Express Scripts since 1986 and am the company lead in sales. I play an active role in pharmacy network development as well.
I have been extensively involved in the pharmaceutical industry for over 28 years, 18 years in retail and the last 10 years with Express Scripts, a pharmacy benefit management company CPBM"). I am the past Chairman of the Board of the Pharmaceutical Care Management Association. I also have been involved with the Chain Drug Industry's Accounting Principles Committee and the Chain Drug Industry's Administration and Operations Committee. Due to the depth of my experience both in the provider and PBM sides, I feel that I am qualified to address the impact that H.R. 1304 will have on the cost and availability of prescription drug benefits.
Express Scripts is the nation's largest independent PBM. We currently provide managed prescription drug services to more than 47 million individuals in the United States and Canada. We provide better and more affordable drug therapy to countless individuals every day.
PBMs are an important innovation in the health care market. PBMs contract with plan sponsors to administer their members' prescription drug programs through a network of pharmacies. Due to the administrative efficiencies that PBMs bring, network pharmacies are able to offer discount pricing. Because these pharmacies are linked on-line through sophisticated PBM computer systems, they are able to monitor quality issues and resolve them quickly.
PBMs are important to consumers because they help to lower the price of prescription drugs by negotiating discounts on prescription drugs with pharmaceutical manufacturers and increasing the efficiency of pharmacy business operations. PBMs also have helped to increase patient access to drug benefits -including important breakthrough drugs -- by making them more affordable to health care plans and their members. This includes lowering the out-of-pocket costs patients are required to pay for prescription drugs. And, PBMs have played an important role in assuring patients that the pharmacies they deal with meet high quality standards by requiring network pharmacies to be credentialled and audited.
However, H.R. 1304 threatens to undercut the ability of PBMs to provide lower cost prescription drug benefits to consumers.I want to add that, on behalf of myself and Express Scripts, we have a great deal of respect for the tremendous role and value of community pharmacies in the health care system. In fact, a recent report by Schering Laboratories found that, on average, patients' approval rating of independent pharmacies is at 70%. 1/ This said, many pharmacists are independent business owners with their own set of pressures. Given the opportunity to negotiate collectively to increase their fees, such pharmacists will almost certainly do so instead of forming productive and efficient joint ventures that benefit themselves as well as their customers.
As a company that has been instrumental in lowering pharmaceutical costs for employers and consumers, we are concerned that H.R. 1304 would undercut our ability to fight rising health care costs and expand access to prescription drugs for patients across the country. We urge members of this Committee to reject this proposal because, if enacted, it will halt efforts by PBM companies like ours to develop innovative strategies, many of which are in cooperation with community pharmacies, to decrease total health care spending and improve health outcomes. II. Background on Pharmaceutical Benefit Managers (PBMs).
PBMs manage the pharmacy benefits of patients who are covered by health plan sponsors, whether through an employer, union, insurance company or health maintenance organization ("HMO"). Pharmaceutical costs have increased dramatically over the last two decades and currently are one of the fastest growing components of medical care. PBMs manage both the quality of care and the costs of prescription drugs. Our cost containment efforts include programs focused on reducing the costs of administering the drug benefit and, where clinically appropriate, encouraging, with physician approval, a more cost effective treatment. PBMs contract with plan sponsors (those who pay for prescription drug benefits for their employees or members) to perform a myriad of tasks, including:
- Contracting with community retail pharmacists to form a network of participating providers;
- Administering sophisticated point of sale claims processing, concurrent drug utilization review and payment systems;
- Providing retrospective drug utilization review;
- Developing and managing drug formulaties;
- Negotiating discounts and rebates with pharmaceutical manufacturers;
- Extensive reporting to plan sponsors to assist in managing patient care and program costs;
- Maintaining quality control; and
- Providing mail service pharmacy.
In addition, PBMs may work with plan sponsors to design drug benefits to achieve objectives for a quality and cost effective benefit. This includes determining how much of the cost of prescriptions employees will be asked to pay, which drugs will be covered, whether mail service pharmacies will be used and whether patients will be offered economic incentives to use equivalent lower cost alternatives.
PBMs have been instrumental in lowering pharmaceutical cost trends for employers and consumers. 2/ PBMs have been the driving force in automating the claims processing, adjudication and payment process, resulting in more efficient pharmacy and benefit administration. Over 90% of all third party prescription claims are now adjudicated on- line, saving both time and money and significantly improving cash flow to the pharmacies. By bringing third party plans to pharmacy networks, PBMs also have achieved reductions in both pharmacy dispensing fees and actual drug ingredient costs because of the volume of patients. The average pharmacy dispensing fee has fallen 33% over the past ten years. Efforts by PBMs to negotiate drug discounts from manufacturers in return for placing the manufacturer's drug on a health plan's formulary also have reduced the cost of drug benefits.

All of these reductions ultimately have been passed on to the consumer in the form of stable health insurance premiums and lower out-of-pocket pharmaceutical costs, and for the plans, lower administrative expenses. These same benefits are realized not only by "private" health plans, but by the federal government in its prescription drug coverage programs, such as the CHAMPUS, Veterans, Medicaid and the Federal Employee Health Benefits Plan ("FEHBP") programs.
In achieving these cost-savings and efficiencies, PBMs also have helped improve health care quality in several ways. First, they have enabled broad consumer access to drug coverage, including the use of breakthrough pharmaceuticals. By bringing down the cost of pharmacy benefits, PBMs have enabled more insurance plans and employers to provide drug coverage. The number of those who have access to drug insurance has risen significantly over the past few years. In 1986, 30% of all prescriptions dispensed at retail were third party payers. By 1998, over 68% were third party payers.
Consequently, drug therapy has become more affordable for people covered by our services. Once high-priced out-of-reach drugs are now accessible for everyday treatment. Many working people covered by our services would not be able to afford the out-of-pocket cost of a 30- day supply of drugs. According to a report to be published by Express Scripts this month, last year's annual per patient cost -- on an average wholesale price basis before copayments, discounts and active management -- was $329.48, up from $282.48 in 1997. New drugs introduced since 1992 accounted for 35.6% ($117.55) of the 1998 pharmacy benefit costs. A single prescription for a post-1992 new drug cost an average of $72 in 1998.3/ The 1998 average copayment was 20% of the cost of the drug. This low out-of-pocket share makes drugs much more accessible to Americans. Even if retrospectively reimbursed, many working people and their families could not afford a 30-day supply of some common drugs. For example, the average retail prescription price of a common cholesterol lowering drug, is $100 month, or $1200 annually.
The more affordable drug benefit coverage, the more employers are able to maintain and expand pharmacy benefits. Indeed, PBMs now are being considered as a cost-effective way to provide Medicare patients with drug care benefits.4/ The selection of drugs available to consumers has increased as well. The result has kept greater number of people well, thereby reducing overall health costs and improving the quality of life for countless Americans.
Second, PBM-driven efficiencies have improved the quality of drug therapy. The PBM-driven automation of pharmacies now allows the pharmacist to be immediately notified if a newly prescribed medication conflicts with an existing prescription dispensed at another pharmacy. The shared pharmacy network that is managed by a PBM provides a fast and efficient way to identify drugs that may be more appropriate to individual patients. It also provides a means of identifying therapeutically equivalent or generic drug options for consideration by the patient's physician.
Third, PBMs have helped improve the quality and accessibility of pharmacies. Network pharmacies must be "credentialled." Every pharmacy participating in a PBM or health plan network must meet specific standards, including licensure, insurance and quality assurance requirements. Moreover, by creating a network, PBMs offer health plan payers a number of geographically accessible pharmacies. A patient can go into any network pharmacy and expect the same out-of-pocket charge for the drug. In fact, most of the members that we serve access networks that constitute 95% of the available pharmacies. In a sense, the network levels the playing field for independent pharmacies, chains and discounters. The patient pays the same copayment no matter which pharmacy he or she uses. These consumer advantages rebound to the pharmacists' benefit by bringing them more third party payer customers. In short, contracted networks are a win-win for all involved.
III. Pharmacists Have Boycotted and Fixed Prices in Past Efforts to Raise Fees and Reduce Consumer Choices.
While consumers have benefited from the cost savings produced by PBMs and other managed care organizations, some pharmacists have resisted attempts by such organizations to reduce pharmacy costs and implement other steps to make drugs and pharmacy services more efficient and affordable. In certain instances, pharmacists have boycotted PBM plans and attempted to fix prices in an effort to raise their fees. This has resulted in reduced consumer choice and higher prices for employers, government programs and consumers. Examples of such efforts include the following:
- In December 1998, the Asociacion de Farmacias Region de Arecibo CAFRA"), an association of approximately 125 pharmacies operating in northern Puerto Rico, and one of AFRA's officers, agreed to settle FTC charges that they had fixed prices and engaged in an illegal boycott in an effort to obtain higher reimbursement rates for pharmacy goods and services under Puerto Rico's government managed care plan for indigents.5/ AFRA's boycott enabled the pharmacists to increase reimbursement rates by 22%.
- In May 1998, five institutional pharmacies in Oregon agreed to settle FTC charges that they unlawfully fixed prices, leading to higher reimbursement levels for servicing Medicaid patients in Oregon long-term care institutions. 6/ These five pharmacies, negotiating jointly through the Institutional Pharmacy Network ("IPN"'), together provide pharmacy service for approximately 80% of the patients who receive institutional pharmacy services in Oregon. By engaging in collective negotiations over price and terms and agreeing to fix the fees they charged, the pharmacies were successful in raising reimbursement levels. As a result, three managed care plans with which IPN negotiated paid IPN members a higher rate than they paid to other institutional pharmacies.
- In 1994, the FTC obtained a consent decree against the Baltimore Metropolitan Pharmaceutical Association, Inc. ("BMPA") and the Maryland Pharmacists Association ("MPhA") for file gaily conspiring to boycott the prescription drug plan for Baltimore city government employees./7 In order to coerce higher reimbursement rates for prescriptions in response to cost-containment measures initiated by the Baltimore city government, BMPA, MPhA and some of its members exhorted pharmacists that operated within Baltimore to stop participating in the plan and coordinate their joint activities. These actions increased the cost of obtaining drugs through prescription drug plans and reduced price competition between the firms providing these prescriptions, ultimately harming Baltimore consumers.
- In 1992-93, the Southeast Colorado Pharmacal Association ("SCPhA"), which consists of approximately 19 of the 22 pharmacies located in seven counties in southeastern Colorado, conspired to boycott a prescription drug program offered to state retirees. In an effort to force the program to increase its reimbursement rate for prescriptions, SCPhA members refused to fill prescriptions under the plan and placed notices in local newspapers announcing their refusal./8 This conspiracy increased the prices consumers paid to pharmacies for prescriptions filled under third-party benefit plans.
- In the late 1980's, various retail druggists in New York participated in a conspiracy to boycott the New York State Employees Prescription Program, successfully forcing an increase in reimbursement rates for pharmacies filling prescriptions for public employees. This conspiracy cost the state of New York approximately $7 million over an 18 month period and defeated a cost-containment initiative which would have reduced the reimbursement amounts paid to pharmacies when they filled prescriptions for some 500,000 state employees and retirees./9
Most pharmacies work within existing laws to advance the quality care of their patients. However, in all the above instances, pharmacists acted against the interests of consumers in an effort to increase their profits. 10/ Fortunately, the antitrust laws provided a means to halt this conduct. However, H.R. 1304 would eliminate this safety mechanism, resulting in higher prices for federal government plans, private plans and all of the plan participants, employees, retirees and dependents these plans serve.
IV. The MeCarran-Ferguson Act Does Not Exempt Insurers from Antitrust Oversight/Regulation in their Dealings with Pharmacists.
Some proponents of H.R. 1304 have suggested that the legislation is necessary to provide a counter-weight to the McCarran-Ferguson Act. This is untrue. The McCarran-Ferguson Act does not provide an antitrust exemption to health plans in their dealings with pharmacists. Agreements among insurers or PBMs regarding contracts with individual pharmacists remain subject to antitrust scrutiny, as do mergers among PBMs or health plans.
The McCarran-Ferguson Act deals with the business of insurance, i.e., the underwriting and spreading of risk. It does not provide a blanket antitrust exemption that covers all activities of insurers. Indeed, dealings between insurers and pharmacists generally are outside of the McCarran-Ferguson antitrust exemption.


Two instances of judicial review of agreements between insurers and pharmacies and/or pharmacists regarding drug reimbursements provide excellent examples of how insurers are not protected from antitrust scrutiny by the McCarran-Ferguson Act in their dealings with pharmacists. The first example is found in Group Life & Health Insurance Co. v. Royal Drug Co. 11/, a Supreme Court case addressing allegations by owners of independent pharmacies that Blue Shield of Texas had violated the Sherman Act by entering into prescription reimbursement agreements with certain pharmacies. Specifically, the independent pharmacists alleged that Blue Shield's Pharmacy Agreement, under which a participating pharmacy agreed to furnish prescription drugs to Blue Shield's policy holders for $2 a prescription and Blue Shield agreed to reimburse the pharmacy for the pharmacy's cost of acquiring the amount of drug prescribed, was an agreement to fix prices. Policy holders patronizing pharmacies that did not participate in the Pharmacy Agreement were reimbursed at 75%. According to the independent pharmacists, this caused Blue Shield's policyholders not to deal with certain of the non-participating pharmacists, thereby constituting an unlawful group boycott as well.
In its defense, Blue Shield claimed that its conduct came within the McCarran-Ferguson Act and therefore was exempted from antitrust scrutiny. The Supreme Court disagreed, noting that the exemption applied to the business of insurance, not to the business of insurers. The Court observed that, "The primary elements of an insurance contract are the spreading and underwriting of a policyholder's risk." 12/ The disputed Pharmacy Agreements did not involve the underwriting or spreading of risk, but were merely arrangements for the purchase of goods and services by Blue Shield. "There is not the slightest suggestion in the legislative history that Congress in any way contemplated that arrangements such as the Pharmacy Agreements in this case, which involve the mass purchase of goods and services from entities outside the insurance industry, are the business of insurance."13/
Portland Retail Druggists Ass'n v. Kaiser Foundation Health Plan, l4/ provides another example of insurer conduct toward pharmacists that was subject to the antitrust laws. Several retail pharmacies and non- profit trade associations to which some of the pharmacies belonged brought separate antitrust actions against HMOs alleging, among other things, that the contractual arrangements by which the organizations acquired drugs from manufacturers, wholesalers and distributors violated the antitrust laws. The HMOs claimed an antitrust exemption under the McCarran-Ferguson Act. The appellate court disagreed, holding that these arrangements did not constitute the business of insurance and, consequently, did not fall within the McCarran-Ferguson exemption.
The retail pharmacists also alleged that Kaiser had attempted to monopolize the business of drug sales by coercing drug companies, wholesalers and distributors to grant Kaiser prices lower than those otherwise available to retail pharmacies, in violation of Section 2 of the Sherman Act. They further alleged that Kaiser had resold drugs they had obtained at prices less than those that could have been charged by the retail pharmacists, thus inflicting injury on the retail pharmacists. The appellate court allowed these allegations to stand, thus again subjecting HMO conduct toward pharmacists to antitrust scrutiny.
V. Pharmacists Can Form Networks and Collaborate Under the Antitrust Laws.
Pharmacists have more than enough flexibility under the antitrust laws to adapt to a rapidly changing marketplace by forming alliances, joint ventures, networks and other collaborative activity without the protection of H.R. 1304. In fact, Express Scripts contracts with no fewer than eight such pharmacist joint ventures, which include over 7,000 pharmacies. In addition, Express Scripts is active in the National Health Information Network ("NHIN'), a coalition comprised of most major pharmacy chains and independent software vendors, on Y2K compliance for pharmacies.
In 1996, the Department of Justice and the Federal Trade Commission ("FTC") issued the most recent version of their statements of enforcement policy and analytical principles relating to health care and antitrust.15/ These principles are designed to guide all health care providers, including pharmacists, regarding ways they can engage in collaborative activity consistent with the antitrust laws. As outlined by these Health Care Statements, pharmacists can engage in a wide-range of activity without antitrust risk. These include:
- Information Sharing: The Health Care Statements provide a "safety zone" that allows pharmacists to exchange price and cost information under certain conditions. 16/ Moreover, the antitrust enforcers will not challenge information exchanges even if they do not come within these safety zones if the procompetitive justifications for the exchanges outweigh any anticompetitive effects.
- Joint Purchasing Arrangements: The antitrust enforcers recognize the procompetitive efficiencies of joint purchasing arrangements. 17/ Consequently, independent pharmacists can collaborate in purchasing arrangements that allow them to obtain significant discounts from pharmaceutical manufacturers. - Network Arrangements: The Health Care Statements also recognize that pharmacist networks serve a procompetitive purpose by enabling independent pharmacy owners to develop efficiencies in furnishing pharmaceutical items and services to PBMs and third party payers.18/
Two recent FTC advisory opinions illustrate the latitude pharmacists currently have in forming collaborative arrangements. One example is the establishment of the Orange Pharmacy Equitable Network ("OPEN"'), which received a favorable FTC Advisory Opinion on May 19, 1999. OPEN's intention is to create a network linking drug prescribing, dispensing and patient education/disease management services in a structure in which prescribing doctors, the dispensing pharmacies and the disease management pharmacists would share common economic incentives to work together to manage drug therapy in the interest of reducing overall medical costs.19/
OPEN's product would be provided under a single contract to be negotiated and executed by OPEN on behalf of its members. Pharmacies would be paid for drug dispensing and compliance monitoring services and pharmacists would be paid for disease management services. A withhold from the payment for drug product dispensing would be placed in a risk pool, along with the savings realized in budgeted expenses for drugs and in expected medical costs, and the funds within the pool would be shared between OPEN and the physician group according to an agreed formula. OPEN's share would be distributed to pharmacies and pharmacists based on the number of value units accrued for billed services and the number of prescriptions filled. All OPEN members would be eligible to participate in the network and there would be no restriction on the ability of pharmacies to participate in other networks.
The FTC staff concluded that this proposal did not raise significant antitrust risks and would not be challenged if implemented as described. The advisory opinion noted that the structure of OPEN appears to foster integration among pharmacies, pharmacists and prescribing physicians in a cooperative effort to assure the most appropriate and cost-effective drug treatment. It observed: "This type of arrangement appears to offer a potential for achieving significant efficiencies, both in terms of more cost-effective management of pharmaceutical and medical benefits and in terms of improving the quality of pharmaceutical therapy provided to patients." 20/
The OPEN network resembles another innovative collaborative arrangement among pharmacists set up by the New Jersey Pharmacists Association ("NJPA") in 1997, which also was approved by the FTC staff 21/ NJPA intended to establish two pharmacist service networks to offer health education and monitoring services to diabetes and asthma patients. In providing these educational services, participating pharmacists would, among other things, meet with patients and assess their condition, review their medication history and set objectives for disease management, including modification of patient habits. These services would not involve dispensing medication and may be provided in the patient's home. As outlined to the FTC, NJPA intended to market these services to insurance companies, HMOs, managed care organizations, pharmacy benefit managers and other third party payers. NJPA would negotiate the fees for such services with third party payers, allowing payers to agree to capitated fees or, alternatively, negotiate a shared risk reward compensation plan in which the pharmacies share in cost savings achieved in treating high risk patients. If costs were lower for an identified group of patients than they were during a defined baseline period, the pharmacies would receive a part of the money saved as compensation.
The FTC approved the proposed networks and noted the procompetitive benefits of the arrangements.

The ventures proposed by NJPA did not involve agreement on drug prices, just the price of patient education services, and consequently created no greater opportunity for collusion on the sale of prescription drugs than did the perfectly lawful existence of the NJPA itself. In addition, the FTC noted the significant competition to NJPA's proposed networks arising from doctors, registered nurses and dietitians, physician assistants and competing networks.
Both of these proposed networks were reviewed and approved under the existing antitrust laws, without the exemption outlined in H.R. 1304. They illustrate how pharmacists currently have a wide variety of options in structuring their dealings with each other and with health plans. They also demonstrate that the antitrust laws do not prohibit pharmacist collaboration that has the potential to benefit consumers; rather they are aimed at cartel behavior, such as that which would be exempted under H.R. 1304. Express Scripts' existing arrangements with collaborative groups of pharmacists reflect the fact that the existing legal structure permits activities which benefit pharmacists and their patients. Indeed, Express Scripts competes with other PBMs for the business of these networks. Any attempt by a single PBM or plan to unreasonably decrease the rate paid to pharmacists below a competitive level results in pharmacies declining to participate, thereby denying the PBM the necessary access to pharmacies it needs to be competitive with other PBMs. Pharmacists, even in today's competitive market, retain reasonable profit margins - approximately 20- 28%; H.R. 1304 would provide an opportunity for pharmacists to increase these margins even further, without providing any assurances that patients would be better served.
V. H.R. 1304 Would Only Raise Prices and Reduce Access, Not Benefit Consumers.
H.R. 1304 is unnecessary and unwise. Existing laws allow pharmacies and pharmacists to work together in ways that are procompetitive and efficient. Passage of this bill would result in increased pharmaceutical costs and reduced quality of drug therapy, severely injuring American consumers. We strongly urge that Congress reject this bill and continue to allow PBMs to develop efficient and innovative ways to decrease health care costs.
FOOTNOTES:
1/ Schering Laboratories, Schering Report XXI, America's Pharmacist (June 1999).
2/ See Experiences of Health Maintenance Organizations with Pharmacy Benefit Management Companies, HHS OIG Report, April 1997 (stating that HMOs report that the biggest benefit of using PBMs is their ability to help control prescription costs).
3/ Express Scripts Drug Trend Report, June 1999.
4/ Legislation has been proposed advocating PBM involvement in Medicare drug benefits as a way to provide prescription drug coverage to fee-for-service Medicare enrollees.
5/ In re Asociacion de Farmacias Region de Arecibo, (Network Inc., No. C-3855 (March 2, 1999) (WL, FATR FTC)).
6/ In re Institutional Pharmacy, (Network Inc., No. C-3822 (August 11, 1998) (WL, FATR FTC)).
7/ In re Baltimore Metropolitan Pharmaceutical Ass'n, Inc. (WL, FATR- FTC), 117 F.T.C. 95 (1994).
8/ In re Southeast Colorado Pharmacal Ass'n, 116 F.T.C. 51 (1993).
9/ In re Chain Pharmacy Ass'n of New York State, Inc., 114 F.T.C. 327 (1991).
10/ The FTC also obtained a consent decree against RxCare of Tennessee in 1996 for implementing a most-favored nation ("MFN") clause that required members of RxCare that accepted a reimbursement rate lower than the RxCare rate to demand the lower reimbursement rate for all its RxCare business. In re RxCare of Tennessee, Inc. 121 F.T.C. 762 (1996). Because RxCare's business constituted such a large percentage of the pharmacies' third-party business, the clause made it very expensive for pharmacies to discount their reimbursement rates to other payers. Consequently, they rarely did so. In effect, this MFN clause created a price floor for pharmaceutical reimbursements in Tennessee.
11/ 440 U.S. 205 (1979).
12/ Id. at 211.
13/ Id. at 224 (citations omitted).
14/ 662 F. 2d 641 (9th Cir. 1981).
15/ Statements of Antitrust Enforcement Policy in Health Care, 4 Trade Reg. Rep. (CCH) 13,153 (August 28, 1996) ("Health Care Statements").
16/ Absent extraordinary circumstances, the antitrust authorities will not challenge such an information exchange if the exchange is managed by a third party; the information provided is based on data more than three months old; and there are at least five providers of information of which no one provider's data accounts for more than 25% on a weighted basis and the data is aggregated such that it would not allow participants to identify prices. Id. at 20,811, Health Care Statement 6(A).
17/ Absent extraordinary circumstances, the antitrust agencies will not challenge any joint purchasing arrangement in which "the purchases account for less than 35% of the total sales of the purchased product or service in the relevant market" and in which the cost of the jointly purchased item "accounts for less than 20% of the total revenues from all products or services sold by each competing participant in the joint purchasing arrangement." Id. at 20,812, Health Care Statement 7(A).
18/ According to the Health Care Statements, "multiprovider networks will be evaluated under the rule of reason, and will not be viewed as per se illegal, if the providers' integration through the network is likely to produce significant efficiencies that benefit consumers, and any price agreements (or other agreements that would otherwise be illegal) by the network providers are reasonably necessary to realize these efficiencies." Id. at 20, 826, Health Care Statement 9(A).
19/ Orange Pharmacy Equitable Network, FTC Advisory Opinion, (May 19, 1999). (http://www.ftc.govfoc/adops/operadop.htm).
20/ Id. at 5.
21/ New Jersey Pharmacists Ass'n, FTC Advisory Opinion (Aug. 12, 1997). http://www.ftc.gov/os/1997/9708/newjerad.htm).
END


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