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The Ins and Outs of PBMs Webinar Recording

https://www.youtube.com/watch?v=RgWy4EZpWIY&feature=youtu.be In a world where PBMs also operate their own in-house specialty pharmacies, the incentive to reduce competition has never been stronger. PBMs have used a variety of reasons to justify network termination, many of which are easily avoidable. But to do so requires knowledge by pharmacies, as well as swift and careful action when addressing audits, investigations and credentialing applications. In this recorded webinar, Jesse C. Dresser, Esq. attorney...

Pharmacy ALERT: Amending Rate Schedules in the Middle of a Contract Term

It has been widely reported that Express Scripts has recently issued rate amendments to its Pharmacy Provider Contracts. These purported rate amendments in many instances come on the heels of multiyear contracts that were executed just a few months ago, sometimes after strenuous back and forth negotiating between the pharmacy and the PBM. Moreover, these rates are set to become effective in the very near term, smack dab in the middle of...

DOJ Position on Off-Label Promotion: What’s Changed and What’s the Same

It is well known that the U.S. Food and Drug Administration (FDA) has long taken the position that a medical device or drug manufacturer who promotes any unapproved uses of FDA-approved devices/drugs is in violation of the Federal Food, Drug, and Cosmetic Act (FDCA). The FDA has asserted that off-label promotion leads to misbranding of the product and circumvention of the regulatory approval process that is taken to ensure product...

Billing the Patient’s Plan or Billing the Local Affiliate: Difficulties for Home Infusion Providers Servicing Patients of National Corporations

A recent trend has emerged for home infusion providers seeking to service local patients who may be employed by, or receive healthcare coverage through, a large organization headquartered out of state.  When servicing the local patients, home infusion providers are often instructed to submit major medical claims through the local affiliate of the health insurer, despite the fact that the patient might have a plan issued through another affiliate of...

Pharmacies Must Use Caution When Dealing with Third Party Auditing Companies

Over the past few years, PBMs have increasingly hired third party companies – such as SCIO, Xerox, Conduent or others – to conduct pharmacy audits. Many times, these companies are compensated based on the amount of money they recoup on behalf of the PBM (thus, they are incentivized to find as many discrepancies as possible). They are given very little training and certainly are not made aware of applicable audit...