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Medical Supply Wholesaler Wins Insurance Coverage Dispute for Abbott Litigation

Last month, the Wisconsin Supreme Court ruled that West Bend Mutual Insurance Co. was required to defend a medical supply wholesaler in a lawsuit alleging it sold "gray market" versions of Abbott Laboratories' diabetes test strips. The Court found that even though Abbott alleged that the wholesaler had acted in an intentional manner, the insurance policy could not escape its "duty to defend" where other claims alleged were covered by...

Pharmacies Face Expanded “Effective Rate” Withholdings from PSAOs

Late last year, Epic Pharmacy Network, Inc. (Epic) sent demands to network pharmacies notifying its members that it will withhold future payments because of a Generic Effective Rate (GER) adjustment. The adjustments surprised many pharmacies that were unaware of any withholding resulting in multiple state and federal court lawsuits. Now, in 2019, pharmacies must be as diligent as ever to ensure that Pharmacy Services Administration Organizations (PSAOs) and Pharmacy Benefit...

PHARMACY ALERT: PSAOs Amending Pharmacy Participation Agreements

Recently, pharmacies have been finding that Pharmacy Services Administrative Organizations (PSAOs) are amending their pharmacy agreements. Pharmacies should closely review these revisions to determine how their rights may change under the new contract amendments. Reviewing there visions is made even more important due to numerous PSAOs seeking to withhold moneys for GER and DIR reconciliations at the close of 2018. Often, PSAO pharmacy amendments become binding if a pharmacy does...

PHARMACY ALERT: Pharmacy Obtains TRO Against PSAO Preventing GER Withholding

Epic Pharmacy Network, Inc. (Epic) was ordered today to turnover any funds that it has already withheld and refrain from withholding further payment to a pharmacy in its network as a result of a Generic Effective Rate (GER) adjustment once a security bond is in place by the moving pharmacy.  Pharmacy Services Administrative Organizations (PSAOs) recently sent out "Notice of GER Deductions" to pharmacies in its network advising that the...

Why Out-of-Network Providers Need a Limited Power of Attorney from Patients After Recent Appellate Court Decision

Many OON providers utilize assignment of benefit forms so that a provider can be paid by an insurance company directly or the provider can dispute nonpayment or under payment instead of this action being taken by the patient. However, last week in American Orthopedic & Sports Medicine, v. Independence Blue Cross Blue Shield; Horizon Blue Cross Blue Shield of New Jersey, the 3rd Circuit Court of Appeals determined that anti-assignment...