Within the past several weeks, pharmacies across the country have begun to receive notices of “non-compliance” from various PBMs, including Prime Therapeutics (Prime). For example, pharmacies were recently notified of Prime’s 10% billing threshold for certain targeted drug products, such as compounds, non-FDA approved drugs, and single ingredient products used in compounds. The same correspondences list over 250 drug names subject to this billing threshold, greatly expanding these notices from mainly non-FDA approved products to products routinely prescribed and dispensed by pharmacies across the country.
In its correspondence, Prime suggests that the pharmacy previously agreed to such billing thresholds. However, many pharmacies may not have been held to any previous requirement or other form of notice that a pharmacy must meet such billing thresholds for these targeted drug products.
Pharmacies receiving these notices must act diligently to preserve their rights. Pursuant to these letters, a failure to bring the pharmacy into compliance with this 10% billing threshold is likely to result in network termination.
It is critical that pharmacies first review their Provider Agreement and all associated credentialing materials that it has with a PBM when a PBM alleges “non-compliance.” If a pharmacy has not previously agreed to a specific term or condition of its Provider Agreement (i.e., a 10% billing threshold for the aforementioned drugs/products), then a PBM cannot allege “non-compliance”. To understand your rights in responding to an allegation of non-compliance, Contact Frier Levitt today to speak with an attorney.
