PHARMACY ALERT: Increasing Terminations Over Prior Authorization Process

In a recent trend, the Blue Cross and Blue Shield Federal Employee Program (“FEP”), whose pharmacy benefits are administered by CVS Caremark, has been seeking an increasing amount of terminations of network pharmacy providers. Specifically, the FEP’s Network Review Committee has been reviewing pharmacies’ claims history and other aspects of their performance to determine compliance with CVS Caremark’s Provider Agreement, and in the event that alleged non-compliance is identified, the Network Review Committee has been seeking termination with little notice and opportunity to address.

One of the most commonly cited basis of termination has been in association with pharmacies’ prior authorization process over a particular group of drug products. The prior authorization process is complex, time consuming, and often requires coordination between multiple parties to be completed. That said, given the complicated process and onerous requirements, pharmacies and prescribers alike, must ensure that accurate information and representations are made in the course of submitting prior authorizations.  Pharmacies that receive these notices of termination are highly encouraged to review and analyze their prior authorization processes prior to providing any responsive communications.

How Frier Levitt Can Help

Contact us today if you have received a notice of termination from FEP or CVS Caremark, or if you have any questions regarding the prior authorization process.  Frier Levitt helps review and analyze pharmacy practices and their prior authorization processes to ensure regulatory compliance and compliance with pharmacy benefit managers’ (“PBMs”) terms and conditions. In addition, Frier Levitt offers flat fee services aimed at pharmacies to help prepare policies and procedures regarding the prior authorization process, and “legal audit” services, which include a robust revise of a pharmacy’s practices.