As part of standard audits, Pharmacy Benefit Managers (PBMs) routinely request pharmacies to provide documents pertaining to claim submissions, including but not limited to all claims of a specific drug product and any reversed claims. However, in recent audits, CVS Caremark has been flagging more pharmacies for allegedly dispensing claims in excess of CVS Caremark’s 25% “aberrant quantity” threshold. Certainly, this is an alarming trend as dispensing aberrant quantities of covered items is a breach of the volume provision found in Caremark’s Provider Manual.
CVS Caremark’s “aberrant quantities” list identified drug products that the pharmacies must monitor for their dispensing. Despite never defining “aberrant quantities,” CVS Caremark continued to flag pharmacies’ dispensing practices. According to CVS Caremark, pharmacies that dispense a relatively higher number of claims in a therapeutic category or for one drug product are not servicing the needs or habits of “local Prescribers or Plan Sponsor formularies.”
The pharmacy’s failure to cure the dispensing quantities may allow PBM’s to impose monetary sanctions and other penalties, including, but not limited to, network termination and suspension. If a pharmacy is terminated based on failure to cure aberrant quantities, the pharmacy must wait one year before applying to re-enroll in the network. The application must also include a Corrective Action Plan addressing the pharmacy’s policies to remediate the situation.
However, pharmacies faced with these allegations do have certain rights and defenses. Pharmacies can dispute Caremark’s numbers in carefully crafted appeal responses. It is also essential to highlight any claims the pharmacy reversed that Caremark might have included in assessing the alleged quantity. Ultimately, pharmacies may also be able challenge the aberrant quantities list altogether on the basis that these medications are otherwise included on the formulary selected and established by Caremark.
To stay ahead of the curve, pharmacies should (i) be aware of the products on the aberrant quantity list that is updated from time to time, and (ii) if they are dispensing products on the list, run regular internal audits to determine if any drug products found on the aberrant quantity list are over the 25% threshold found in Caremark’s Provider Manual.
How Frier Levitt Can Help
Pharmacies that receive a notice of dispensing drugs above the volume provision should contact us today to aid in curing the breach and preventing future termination.
