Pharmacies participating in patient assistance and copay programs administered through ConnectiveRx are facing a new reality. In recent months, program participants have reported a notable uptick in program terminations and increased scrutiny from ConnectiveRx, often triggered by patterns of activity that the program deems “suspicious.”
Frier Levitt has been contacted by a growing number of pharmacies and other program participants reporting sudden terminations and unexpected document requests from ConnectiveRx. The trend is accelerating, and pharmacies that fail to act quickly risk loss of program access.
Common Triggers for ConnectiveRx Scrutiny
Although ConnectiveRx has not publicly explained the increase in enforcement activity, pharmacies should expect increased oversight of claims and closer scrutiny of program participation going forward. Even pharmacies with legitimate business practices may find themselves flagged if their claims activity falls outside expected program parameters. Because participation in these programs often represents an important source of patient access and pharmacy revenue, even a temporary suspension or termination can have immediate operational and financial consequences.
The types of activity drawing scrutiny, and in some cases resulting in program termination, include:
- unusual claim volume,
- geographic concentration of claims in a single area or ZIP code cluster,
- prescriber- or pharmacy-level irregularities such as unusually high prescriber claim counts or claims consistently submitted at or near program caps; and
- inconsistent insurance claim information.
ConnectiveRx has also been tracking frequent claim reversals, particularly where submissions have resulted in high reimbursement or appear designed to circumvent program limits, as well as coordination-of-benefits concerns. Notably, many of these flags can be triggered even where a perfectly legitimate explanation exists.
In addition to the activity-based triggers above, we are seeing ConnectiveRx issue document requests seeking information to verify program compliance. These requests should not be treated as routine administrative inquiries. They often represent the program’s effort to evaluate whether a participant should remain eligible for continued participation. Failure to respond promptly and completely has resulted, and may continue to result, in immediate termination from the program. The downstream consequences can be significant. Patients may lose access to copay assistance, and pharmacies may face immediate revenue disruption.
What to Do If You Receive a Document Request or Program Termination
If you have already been terminated or have received a document request, time is of the essence. The response window is typically narrow, and how you respond initially can determine whether your participation in the program is preserved or lost. Waiting too long to respond, providing incomplete information, or failing to understand what ConnectiveRx is requesting may significantly reduce the likelihood of successfully resolving the matter.
How Frier Levitt Can Help
Frier Levitt has represented pharmacies in ConnectiveRx program disputes and related regulatory matters. We regularly advise pharmacies responding to document requests, program terminations, and other compliance issues affecting manufacturer-sponsored patient assistance and copay programs. If your pharmacy has been terminated, received a document request, or is facing increased scrutiny, contact our team.
Senior Counsel
