Over the past year, CVS Caremark began taking a series of actions against pharmacies who were dispensing "aberrant quantities" of medications within a particular therapeutic category. Despite never defining "aberrant quantities," CVS Caremark continued to place pharmacies whose dispensing practices were flagged for this reason under adjudication and payment suspension and/or subjected them to a Mail Order Addendum for being a "non-standard retail pharmacy." According to CVS Caremark, pharmacies that...

As the calendar year comes to an end, Pharmacy Benefit Managers (PBMs) often review pharmacies that participate in their networks. Such reviews may include an evaluation of past audit performances or any past adverse action taken against the pharmacy, or such reviews might include requesting the pharmacy to undergo "re-credentialing." Pharmacies that are asked to undergo re-credentialing are often asked a series of questions associated with general ownership structure, location...

Aetna has sent out notices of termination to Medicare Part D Network pharmacies based on a recent guidance from the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG). In the guidance, CMS and the OIG do not recommend termination as the response to any indicia of these billing practices. With respect to compounding and specialty pharmacies, CMS specifically advises that "pharmacies that specialize...

Recently, Pharmacy Benefit Managers (PBMs) have been subjecting pharmacies and their credentialing applications to additional scrutiny. In one instance, a major PBM sought to terminate a pharmacy for its failure to report disciplinary action against the Pharmacist-In-Charge's license that occurred over 17 years prior. In another instance, another PBM attempted to terminate a pharmacy for allegedly not updating its ownership information. Frier Levitt was able to assist both pharmacies in...

In January of 2018, Prime Therapeutics announced that it would no longer accept any new Dispensing Physician practices into its pharmacy networks. "Grandfathered" Dispensing Physician practices that were already in Prime’s networks would remain unaffected. However, earlier this year, Prime altered its position and in addition to preventing new Dispensing Physician practices from entering into its networks, Prime began terminating a number of existing Dispensing Physician practices without any stated...