Pharmacies face serious PBM risks when issues that arise in audits are not properly addressed from recoupments and network terminations, to governmental investigations. Preparation and preventative measures are key to ensuring a positive audit... Read More
Frier Levitt successfully reversed a network enrollment denial by a major Pharmacy Benefit Manager (“PBM”) against a New Jersey-based community pharmacy. Since the pharmacy is located in a city identified as being in a “HEAT Zone,” the PBM... Read More
Three years ago, many PBMs enacted exceptions and waivers to their respective Provider Agreements and Manuals that would have otherwise limited the ability of participating pharmacies to provide services by way of mail to members during the COVID-19... Read More
In an ongoing trend, pharmacy benefit managers ("PBMs") have reinforced their terms and conditions on network pharmacies’ involvement on the prior authorization process. As we discussed last year (read here), health plans utilize the prior... Read More
Frier Levitt helped a New York pharmacy successfully appeal initial audit results in their entirety that were issued by a large PBM. Despite the pharmacy’s submission of purchase information directly from its wholesalers, the PBM alleged... Read More
Frier Levitt successfully helped a Louisiana-based pharmacy resolve a finding for overpayment from a large insurance plan, who demanded a significant sum of money be returned to the plan on the basis that prior authorizations obtained by the... Read More
A major PBM has recently begun issuing notices to pharmacies stating that they have been identified as having “atypical” dispensing activities during period claim reviews. Although these notices are not related to a formal audit, the PBM still... Read More
An Ohio-based pharmacy client was recently placed on payment suspension due to alleged inventory shortfalls during a Pharmacy Benefit Manager (“PBM”) audit before initial audit results were even issued, leaving the pharmacy with limited to no... Read More
In the course of pharmacy audits, PBMs are increasingly requesting from pharmacies copies of Drug Supply Chain Security Act (“DSCSA”) track and trace documents, commonly known as “T3” documentation. The T3, which consists of the Transaction... Read More
Rising drug prices have forced consumers to seek out and utilize the most affordable sources to obtain their prescription medications. Whether it’s through commercial insurance, prescription discount cards, or manufacturer assistance programs,... Read More
