Frier Levitt Successfully Overturns PBM Network Enrollment Denial for New York Pharmacy

Frier Levitt recently helped a New York based pharmacy overturn a network enrollment denial by a major Pharmacy Benefit Manager (“PBM”).  The PBM rejected the pharmacy’s enrollment application due to allegations of “common association or affiliation” with another pharmacy that had previously been terminated from the PBM’s network – a common excuse on which PBM’s rely to unceremoniously deny independent pharmacies enrollment in their preferred networks, regardless of how attenuated an alleged affiliation may be.

After gathering all relevant information from the pharmacy, Frier Levitt attorneys Dae Lee and Adam Farkas prepared a robust appeal response detailing the pertinent facts which refuted the supposed affiliation.  Once the PBM reviewed the pharmacy’s appeal response, our attorneys engaged in meet-and-confer discussions with the PBM’s representative and further contested the unwarranted enrollment denial.  Shortly thereafter, the PBM reversed the enrollment denial and allowed the pharmacy to participate in its network.

The credentialing process and accompanying application are onerous for independent pharmacies and require pharmacies to disclose business and ownership information, pharmacy licenses, dispensing practices, and disciplinary actions taken against the pharmacy and/or its owners. As demonstrated by this case, PBMs regularly scrutinize pharmacy applications, searching for any reason to deny enrollment, regardless of whether the rejection is remotely justifiable, with the intention to promote the PBM’s owned or affiliated pharmacies. While states have attempted to address such predatory conduct through Any Willing Provider laws and other statutes, these laws are often vague and provide enough wiggle room for PBMs to unjustifiably reject independent pharmacies’ enrollment applications. As such, in the event of PBM enrollment rejections,  pharmacies should utilize the appeal process applicable to each PBM to contest the attempted rejection to the fullest extent.

How Frier Levitt Can Help

Frier Levitt’s life sciences attorneys are highly knowledgeable and experienced in the terms of various PBM Manuals and Provider Agreements, as well as applicable state and federal laws which regulate the practice of pharmacy. Frier Levitt attorneys employ that knowledge to protect the rights of pharmacies facing unjust PBM conduct and assist them in challenging egregious PBM actions. Contact us  if your pharmacy has been subject to an adverse action by a PBM, including unwarranted audit findings, recoupment, and/or network termination/rejection.