Aetna has sent out notices of termination to Medicare Part D Network pharmacies based on a recent guidance from the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG). In the guidance, CMS and the OIG do not recommend termination as the response to any indicia of these billing practices. With respect to compounding and specialty pharmacies, CMS specifically advises that “pharmacies that specialize in compounded drugs may have billing patterns that differ from traditional pharmacies and may not be indicative of fraud.” Nevertheless, Aetna has been conducting reviews of pharmacies’ claims activities in its Medicare Part D Network in efforts to remove “outliers” from its networks. In identifying such “outliers” for alleged Fraud, Waste, and Abuse (FWA), Aetna has been terminating pharmacies with little notice. Aetna has specifically targeted pharmacies dispensing Lidocaine creams and other topical treatments.
Frier Levitt is currently assisting pharmacies to fight Aetna’s decision to terminate them from its network. Frier Levitt has successfully litigated against PBMs and Plan Sponsors for unwarranted terminations.
If your pharmacy has received a notice of termination from Aetna, contact Frier Levitt today to speak to an attorney.