In a growing trend, CVS Caremark (Caremark) has joined the ranks of PBMs to begin offering a mail order network in both commercial and Medicare Part D networks. Caremark has recently contacted a number of pharmacies participating in Caremark retail networks requiring they accept a Mail Order Pharmacy Addendum. This notice to pharmacies Caremark has identified to be operating under a "non-standard retail pharmacy model" based on the volume of...

A year ago, Prime Therapeutics (Prime) announced that it would no longer accept new Physician Dispensing entities into their pharmacy networks starting on or around January 29, 2018. At the time, Prime had not terminated any Dispensing Physician entities that were already participating providers in its pharmacy networks and had made overtures that their participation would remain unaffected. Many Physician Dispensing entities nevertheless braced for aggressive audits and investigations, out...

PBMs often conduct invoice reconciliation audits to ensure pharmacies maintain sufficient quantities of medications to support the quantities billed. Recently, a New York-based pharmacy was facing a large recoupment following a PBM invoice reconciliation audit when the PBM alleged the pharmacy did not have proper inventory. Despite the submission of the underlying invoice documentation and even pedigree, the PBM refused to consider the pharmacy's purchases on the basis of a...

Recently, Frier Levitt assisted a Florida-based pharmacy in a PBM audit that alleged the pharmacy had mailed into certain states without a valid non-resident licensure to do so. Frier Levitt was able to prove that the pharmacy did in fact maintain active nonresident licensures in several states or was not required to maintain licensure at the time of dispensing. In other instances, the pharmacy did not dispense medications to patients...

Frier Levitt recently assisted an independent pharmacy with a PBM audit in which the PBM claimed the pharmacy had inventory shortfalls for over twenty drugs. Frier Levitt reviewed the pharmacy's invoice documentation, and submitted an appeal on behalf of the pharmacy. While awaiting results of the appeal, the pharmacy received a notice of termination from the PBM based on the inventory shortfalls identified in the audit. Frier Levitt worked with the PBM...