With the help of Frier Levitt attorneys, an independent Florida pharmacy was allowed to continue its participation in a patient assistance program, despite the program’s attempts to terminate based on “suspicious claims” alleged to have been submitted by the pharmacy. Specifically, the patient assistance program alleged that a recent audit identified several instances in which the pharmacy dispensed refills of prescriptions earlier than authorized, rendering them ineligible for reimbursement by the patient assistance program, despite the program’s previous approval of the claims. However, thanks to Frier Levitt, the pharmacy was able to establish that the claims at issue were in compliance with the patient assistance program’s own terms and conditions, as well as highlighting the rights afforded to the pharmacy under their contract, in order to resolve the termination.
While PBMs are one of the largest threats to independent pharmacies, it is important to note that they are not the only types of entities which perform pharmacy audits, nor are they the only conditions which pharmacies must abide by. Although these contractual obligations and terms are often seen as unnecessary impediments to pharmacies’ operations and procedures, they often hold the key to successfully challenging disciplinary actions and obtaining a favorable outcome. In response to the patient assistance program’s position that the submission of the relevant claims violated its terms, Frier Levitt attorneys reviewed the terms in their entirety to confirm whether there were any conditions which limited claim eligibility based on the amount of time between refills. Upon confirmation that no such terms existed, Frier Levitt emphasized that the claims at issue did in fact comply with the applicable terms, and that therefore termination of the pharmacy based on any instances of violation of these terms would be improper.
In addition, Frier Levitt attorneys worked with the pharmacy to emphasize that no unnecessary refills of the medication were provided to the patient and that the pharmacy dispensed in accordance with the directives and authorization from the underlying prescribers. Together, the pharmacy and Frier Levitt attorneys also identified an additional provision which entitled the pharmacy to rely on the patient assistance program’s previous approval of the relevant claims to further establish the impropriety of termination on this basis. Accordingly, this success highlights how important it is for pharmacies to be aware of all remedies and rights available to them under their contracts in order to leverage them in their favor.
How Frier Levitt Can Help
If you have recently received adverse audit findings and are concerned about the potential termination from a PBM network or healthcare program, Frier Levitt can help. Contact us to speak to an attorney.
