Oscar Health (“Oscar”) has recently suspended claims adjudication for a number of pharmacies in Miami-Dade County and the surrounding South Florida area. The suspended pharmacies share two characteristics. Each dispenses pre-exposure prophylaxis (“PrEP”) for HIV prevention. Each is also a contract pharmacy for one or more 340B covered entities. Many of these pharmacies have no apparent connection to any alleged wrongdoing. Even so, they can no longer adjudicate claims for Oscar members. Oscar is also suspending claims for prescriptions written by certain prescribers. These actions are disrupting patient care and access to critical medications. Affected pharmacies must act promptly to assert their rights under Florida law.
Oscar Health’s October 2026 Lawsuit Against an Alleged 340B PrEP Scheme
Against the backdrop of these suspensions, on October 23, 2026, Oscar and several of its affiliated health plans filed a federal lawsuit (the “Complaint”) against a nonprofit clinic that is a 340B covered entity, several prescribers, insurance brokers, and four pharmacies. Oscar alleges that brokers enrolled individuals in Oscar’s Affordable Care Act (ACA) plans and paid their premiums on the condition that the members join the clinic’s “PrEP program” and accept prescriptions for Descovy, a brand-name PrEP medication. According to the Complaint, those prescriptions were routed to the four defendant pharmacies, which billed Oscar more than $49 million for drugs the clinic had acquired at 340B prices. These claims remain allegations, and no court has made any findings on the merits.
Pharmacy Suspensions May Extend Beyond the Alleged Scheme
Oscar has not publicly explained the basis for the current wave of pharmacy suspensions. It is unclear whether they are tied to the conduct alleged in the Complaint. However, the profile of the affected pharmacies suggests Oscar may be applying overly broad criteria. While the suspended pharmacies dispense the same class of drug and participate in the same federal program as the defendants named in the Complaint, suspending pharmacies based solely on those characteristics, without evidence of individual wrongdoing, would be overinclusive and could disrupt care for vulnerable patients.
Importantly, neither dispensing PrEP nor serving as a 340B contract pharmacy is suspect on its own. The Complaint itself acknowledges that covered entities may use registered contract pharmacies and that the 340B program can generate a legitimate financial benefit that supports care for vulnerable patients. PrEP is a recommended preventive service, and under federal law, Oscar members pay no cost-share for it. Treating every pharmacy that dispenses PrEP under a 340B contract as suspect sweeps in compliant providers. It penalizes them for providing the safety-net care the 340B program is designed to support.
How Oscar Health’s Pharmacy Suspensions Disrupt PrEP Access and Patient Care
Oscar reported more than 1.1 million Florida members as of December 31, 2025. When a pharmacy loses the ability to adjudicate Oscar claims, its Oscar patients lose more than their pharmacy of choice. Many PrEP patients rely on pharmacies that coordinate refills, monitoring reminders, and communication with prescribers. Some affected patients have had to find not only a new pharmacy but also a new prescriber to restart their PrEP. Every gap in access to PrEP is a gap in protection against HIV.
The harm also extends beyond patients receiving PrEP. Affected pharmacies serve patients living with HIV, hepatitis C, sexually transmitted infections, and other conditions. Many of their Oscar patients have no connection to any 340B covered entity. Moreover, Oscar has reportedly contacted thousands of patients, directing them to move their prescriptions to pharmacies affiliated with Oscar’s pharmacy benefit manager (“PBM”). For patients managing HIV or relying on PrEP, a forced change of pharmacy or prescriber is not a minor inconvenience. It risks missed doses and interrupted care.
Oscar Health Also Rejecting Claims for Prescriptions Written by Certain Prescribers
The suspensions are not limited to pharmacies. Oscar is also rejecting claims for prescriptions written by certain prescribers. As a result, even pharmacies that remain in Oscar’s network may be unable to adjudicate claims for those prescribers’ prescriptions. Patients of those prescribers may be unable to fill their prescriptions using their Oscar coverage at affected pharmacies.
Oscar has not publicly identified which prescribers are affected or the criteria it used to select them. Pharmacies should review recent claim rejections for prescriber-level edits and request the basis for those rejections in writing.
Florida PBM Law: Potential Protections for Suspended Network Pharmacies
Florida’s PBM law contains several provisions relevant to network pharmacies. A PBM may not unilaterally change the terms of a pharmacy’s participation contract. This rule applies to contracts signed, amended, adjusted, or renewed on or after July 1, 2023. If a pharmacy is terminated from a network, the PBM must still pay what it owes on adjudicated claims for services provided before the termination. The exceptions include circumstances involving fraud by the pharmacy or where otherwise required by law. A PBM also may not terminate, penalize, or disadvantage a pharmacy for exercising its rights under Florida’s PBM law. The Florida Office of Insurance Regulation must impose a $5,000 fine for each violation of these protections.
What Suspended Pharmacies Should Do Now
Pharmacies that have received an adjudication suspension from Oscar should consider the following steps:
- Review the suspension notice, the applicable network agreement, and the Oscar and PBM provider manuals. Identify any stated basis for the suspension and every notice, appeal, and dispute deadline.
- Request, in writing, the specific grounds for the suspension and the claims or data on which Oscar relied, including the basis for any prescriber-level claim rejections.
- Assemble documentation showing that the pharmacy is not connected to the scheme alleged in the Complaint. This may include 340B contract pharmacy agreements, prescriber diversity, patient choice of pharmacy, and the absence of any premium assistance or patient steering arrangements.
- Document the impact on patients, including interrupted therapy and patients forced to change pharmacies or prescribers.
- Avoid informal admissions or entering into new agreements with Oscar or its PBM before consulting counsel.
How Frier Levitt Can Help
Frier Levitt represents pharmacies nationwide in PBM and payor audits, payment and adjudication suspensions, and network terminations. Our attorneys also regularly advise 340B covered entities and contract pharmacies on program compliance and contract pharmacy disputes. If your pharmacy has been suspended by Oscar, or if you are a patient who has lost access to PrEP at your pharmacy of choice, contact Frier Levitt to speak with an attorney today.
Senior Associate
