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PBMs Taking Hard Stance Over Use of Patient Assistance Programs

Recent enforcement actions over allegations regarding assisting pharmaceutical manufacturers to pay improper kickbacks to Medicare beneficiaries are not the only issues currently impacting Patient Assistance Programs (PAPs). PBMs are also taking an increasingly hard stance over the use of PAPs by specialty and retail pharmacies across the country. Some PBM Provider Manuals include explicit terms and conditions regarding the use of financial hardship policies, but many are silent with regard...

Pharmacy ALERT: PBM Re-credentialing Requests and Performance Reviews

As the calendar year comes to an end, Pharmacy Benefit Managers (PBMs) often review pharmacies that participate in their networks. Such reviews may include an evaluation of past audit performances or any past adverse action taken against the pharmacy, or such reviews might include requesting the pharmacy to undergo "re-credentialing." Pharmacies that are asked to undergo re-credentialing are often asked a series of questions associated with general ownership structure, location...

Plan Sponsor ALERT: Reverse Auction Procedure Does Not Protect States from PBM Abuse

In September 2018, New Jersey Governor Phil Murphy announced that the State of New Jersey awarded the Pharmacy Benefit Manager (PBM) contract to OptumRx and agreed to pay OptumRx $6.7 billion over three years to manage and administer pharmacy benefits for the State. Although "reverse auction" is a step in the right direction, such procedure is meaningless unless Plan Sponsors implement contractual tools that protect themselves from PBMs' revenue tactics...

Pharmacy ALERT: Prime Therapeutics Raises Its Standards on Off-Label Claims

Recently, Prime Therapeutics (Prime) announced that its member pharmacies should only dispense prescriptions with dosage strengths and routes of administration that are consistent with manufacturer prescribing information. Prime also now further requires that the pharmacies should anticipate providing scientific evidence demonstrating the efficacy and safety of the prescriptions. Such onerous document requests by Pharmacy Benefit Managers (PBMs) have been prevalent with respect to Medicare Part D claims. In fact, it...

$4 Million Settlement Latest in Growing Trend of Patient Assistance Program Scrutiny

On November 20, 2019, The Assistance Fund (TAF) agreed to pay a $4 million settlement and enter a three-year integrity agreement, to resolve allegations of False Claims Act violations related to paying impermissible kickbacks to Medicare beneficiaries. This represents the third settlement involving a patient assistance fund in the past month, indicating a trend in enforcement action. TAF operated assistance programs to assist patients, including Medicare beneficiaries, with co-payment, co-insurance,...