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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...

Frier Levitt Saves Texas-Based Pharmacy over $1.6 Million in PBM Audit

Frier Levitt successfully saved over $1.6 Million for an independent pharmacy located in Texas against a desktop-audit conducted by a major Pharmacy Benefit Manager (PBM). The PBM claimed several different discrepancies, including inventory shortfalls, missing prescriptions, and failure to collect copays. The total amount of chargeback based on the alleged discrepancies was approximately $1.9 Million. Attorney Dae Y. Lee, Pharm.D., Esq., CPBS, conducted an extensive review of the alleged discrepancies...

Manufacturer ALERT: False Claims Act Violation for Selling Unapproved Medical Devices

On September 13, 2019, Manhattan U.S. Attorney for the Southern District of New York announced that the Government has simultaneously filed and settled a civil fraud lawsuit under the False Claims Act against Avalign Technologies, Inc. (Avalign) and its subsidiary, Instrumed International, Inc. (Instrumed), for manufacturing and selling medical devices that were not cleared by the U.S. Food and Drug Administration (FDA.) As part of the settlement, Avalign and Instrumed...