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Prime Therapeutics, LLC Takes Steps to Exclude New Dispensing Physicians from Its Pharmacy Network

Prime Therapeutics has announced that it will no longer accept Dispensing Physician entities into its pharmacy network starting January 29, 2018.  The PBM will begin blocking PSAOs from adding physician dispensers.  We also anticipate that Prime Therapeutics will likely increase auditing scrutiny on existing Dispensing Physician entities through aggressive audits and investigations.

Legal tools exist to challenge Prime’s decision.  This affront to the healthcare system follows the misguided path CVS Caremark traveled down in early 2016. Following CVS Caremark’s similar decision to exclude Dispensing Physicians, the physician dispensing industry responded with a massive protest.  Industry response focused both on the benefits that Dispensing Physicians bring to the healthcare system through close coordination of patient care and treatment as well as arguments that CVS Caremark’s changes violate state and federal law. The Community Oncology Alliance commissioned an extensive White Paper, authored by Frier Levitt. Following these protests, CVS Caremark reversed its decision to deny network admission of new Dispensing Physician entities and also reversed its decision to terminate existing Dispensing Entities.  While Prime is not as large as Caremark, in terms of patient lives, challenging the PBM’s recent action is critical.

If your physician dispensing entity has been excluded by a PSAO, or by Prime Therapeutics directly, or has faced additional auditing scrutiny from Prime Therapeutics, contact Frier Levitt today to learn our healthcare attorneys can help.