Frier Levitt Successfully Reverses Plan-Initiated PBM Network Termination for New Jersey Pharmacies Under Common Ownership
Frier Levitt was recently successful in reversing a plan-initiated PBM network termination for NJ pharmacies that are under common ownership. Back in 2019, the PBM conducted an audit over the pharmacies on behalf of its plan client and alleged discrepancies involving highly reimbursable drugs and medical necessity of those drugs. After reviewing the relevant records, Frier Levitt compiled and submitted a robust appeal response. The pharmacies did not hear back from the PBM until recently receiving a notice of termination. However, the notice did not contain any details regarding the underlying basis of the termination, nor did it reference the previous audit. Frier Levitt immediately reached out to the PBM challenging the unwarranted termination, and as a result, it was ultimately rescinded.
Pharmacies that undergo any audit or investigation with a PBM are cautioned to take proactive efforts to resolve any discrepancy findings in their entirety, no matter how seemingly insignificant, as unresolved findings may lead to termination. Also, PBMs can terminate pharmacies that are commonly owned and/or affiliated with other pharmacies that (i) have been previously terminated from the PBM’s pharmacy networks, (ii) have had suspected fraud, waste, and abuse, or (iii) have had serious/significant audit findings. PBMs notoriously scrutinize pharmacies through audits, investigations, and even credentialing/recredentialing processes. Thus, it is important that pharmacies take all PBM actions seriously and be prepared to defend against their allegations.
How Frier Levitt Can Help
Frier Levitt’s Life Sciences attorneys are well versed in the terms of various PBM Manuals and Provider Agreements, as well as applicable state and federal laws which regulate the practice of pharmacy. Frier Levitt leverages that knowledge to effectively protect the rights of pharmacies that are unfairly targeted by PBMs and assist them in implementing corrective measures to ensure compliance with relevant laws, regulations, and PBM contract terms and conditions. Contact us if your pharmacy has been subject to an adverse action by a PBM, including unwarranted audit findings, recoupment, and/or network termination.