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PHARMACY ALERT: PBMs and Notices of “Non-Compliance”

Within the past several weeks, pharmacies across the country have begun to receive notices of "non-compliance" from various PBMs, including Prime Therapeutics (Prime). For example, pharmacies were recently notified of Prime's 10% billing threshold for certain targeted drug products, such as compounds, non-FDA approved drugs, and single ingredient products used in compounds. The same correspondences list over 250 drug names subject to this billing threshold, greatly expanding these notices from...

Frier Levitt Re-Opens PBM Audit Overturning All Findings

Frier Levitt recently helped an Oklahoma-based pharmacy overturn all findings from a PBM audit after re-opening the audit which had been closed for over a year. During the time of the audit, the PBM maintained that it did not receive the pharmacy’s timely submission of appeal documentation and refused to accept any further documentation after the PBM finalized the audit results, which subjected a number of claims to recoupment. The...

Frier Levitt Saves Two Pharmacies a Combined Total of $8MM

Frier Levitt recently assisted an Arizona-based pharmacy where the PBM began withholding well over $2.4 million before any audit results were issued. Upon release of the initial audit results, the PBM alleged (1) prescriber denial; (2) inventory shortfall; (3) unlicensed mailing; and (4) failure to collect copayment. As such, the PBM attempted to recoup a total amount of over $4 million. After submitting an appeal addressing each allegation as well...

Frier Levitt Helps Lower $2.7 million Audit to $25k for Independent Pharmacy

Recently, a Florida pharmacy underwent an invoice reconciliation audit by a PBM. During this audit, the PBM requested a list of the pharmacy's wholesalers and copies of the pharmacy's purchase history to be sent directly from the manufacturers. While the pharmacy engaged in diligent efforts to address this audit request, the pharmacy inadvertently excluded certain wholesalers and purchase information, consequently subjecting the pharmacy to a $2.7 million recoupment for inventory...

Frier Levitt Helps Florida-based Independent Pharmacy Reduce PBM Audit Recoupment by 90%

A Florida-based pharmacy was facing a $120k audit with a PBM for several different discrepancies, including inventory shortfalls, alleged prescriber and patient denials, and claims submission errors. Frier Levitt worked with the pharmacy to identify the PBM's underlying basis for the audit results. Following the pharmacy's submission of additional documentation and the PBM's review of such information, the audit recoupment amount was reduced to $12k. Frier Levitt also assisted the...