Blog

»  Posts By    

PHARMACY ALERT: History and Status of Generic Effective Rate

We first reported in late 2018 that Pharmacy Benefit Managers (PBMs) and Pharmacy Services Administrative Organizations (PSAOs) have implemented a new type of post-sale recoupment called Generic Effective Rate (GER) upon their member pharmacies. In particular, CVS Caremark ("Caremark") have been in the forefront, either directly or through its contracted PSAOs, to collect payments made to the pharmacies allegedly in excess of the contracted GER. Caremark started imposing GER liabilities...

Frier Levitt Helps Utah-based Pharmacy Reduce Audit Recoupment by 90%

Frier Levitt recently helped a Utah-based independent pharmacy who was facing an audit conducted by a local Health Insurance Plan. The Plan alleged various discrepancies including missing signature logs, misfilled prescriptions, and incorrect billing. These discrepancies racked up significant audit fines and the Pharmacy reached out to Frier Levitt's attorneys to help assist the Pharmacy in appealing the audit results. Under the Firm's guidance, the Pharmacy gathered the requisite documentation...

Plan Sponsor ALERT: Ohio Continues Its Fight Against Abusive PBM Practices

The State of Ohio has become one of the many states that have fallen victim to PBMs' abusive revenue tactics, as detailed in an audit report finding that the state's PBMs — OptumRx and Caremark — charged the state a spread of 31% on generic drugs. As a result, the state was charged $224 million, at the expense of the taxpayers, more than what these PBMs paid pharmacy providers in...

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...