Pharmacy benefits managers have been auditing pharmacies for years, and have been seeking recoupment for perceived discrepancies. This concept is nothing new. However, Catamaran has recently engaged in practices expanding upon the traditional audit procedures and has embarked on a recent trend of terminating pharmacies for a whole host of reasons. Whether as a result of considerations as part of its recent merger with OptumRx or as a result of other business considerations, Catamaran has emerged as one of the most aggressive PBMs in terms of terminating pharmacies for a variety of issues.
Often times, the stated basis for Catamaran’s termination can be something seemingly minor, such as a single discrepant claim totaling less than $1,000 in discrepancies. In fact, we have seen instances where Catamaran has terminated pharmacies when no discrepancies were found. Catamaran utilizes its Pharmacy Membership Evaluation Committee, or PMEC, to review pharmacies for potential termination, allowing pharmacies to make additional arguments as to why termination should not be proper. However, as mentioned above, Catamaran’s PMEC routinely recommends termination even in exceedingly minor circumstances.
As a result, it is important that pharmacies receiving Catamaran audits proactively arm themselves with every defense possible. Often times, the best approach to avoiding termination is to successfully navigate even minor audits with Catamaran. Frier Levitt has a great amount of experience successfully appealing audits and network terminations. If your pharmacy has received an audit notice from Catamaran, or has been referred to Catamaran’s PMEC, contact Frier Levitt today.
