DIR fees are a mechanism regulated by CMS which allows Part D plans to charge a per prescription fee to pharmacies. Plans are increasingly expanding the use of these fees as alternative means of extracting price concessions outside the time of adjudication. These fees can take many forms, such as a fee tied to specific performance metrics (e.g. generic dispensing rates); fees to be part of a preferred cost share pharmacy network; or to reconcile point-of-sale reimbursement with contracted rates. Some DIR fees are not negotiable. Additionally, DIR fees are deducted post adjudication from each paid claim; they do not show on the adjudicated response. When Part D plans do this, the price of the prescription can appear higher than the actuarial benefit, leaving patients with higher copays and cost sharing.