Frier Levitt on LinkedIn: Plan Sponsor Sues Former PBM Over Manufacturer Rebates: A Cautionary Tale (2024)

Payback Time! Community Pharmacists Cheer Class Action Lawsuit Against PBMs to Recoup DIR FeesOur chance to claw back the clawbacks, says National Community Pharmacists AssociationNCPASeptember 27, 2023ALEXANDRIA, Va. (Sept. 27, 2023) –The National Community Pharmacists Association loudly applaudeda class action lawsuit filed against vertically consolidated CVS Health, Caremark, and Aetnathat aims to recoup for independent pharmacies millions of dollars in what the lawyers say are wrongful back-end penalties for Medicare Part D prescriptions, otherwise known as pharmacy direct and indirect remuneration fees.“It’s payback time,”said NCPA CEO B. Douglas Hoey.“Finally, community pharmacies have a chance to recover DIR fees that were unfairly taken. PBMs have been gaming the system for a long time, and it’s time to turn the tables.”The lawsuit, announced today by the law firms Berger Montague PC and Cohen & Gresser LLP, claims that Caremark – the largest pharmacy benefit manager in the country and a subsidiary of Fortune 6 corporation CVS Health – has been assessing pharmacy DIR fees in violation of federal antitrust laws and state laws governing contracts. The lawsuit also challenges Caremark’s agreements to arbitrate claims as being unfair and unenforceable.“It’s very common for individual pharmacies to pay hundreds of thousands of dollars a year in fees that they can’t possibly anticipate, and in many cases long after the point of sale,”he said.“Moreover, those fees do nothing more than line the pockets of PBMs like Caremark. It’s a mafia-style shakedown. We’re thrilled that community pharmacists have a chance to recoup some of their money.”NCPA will be doing more than cheerleading for the lawsuit,said Hoey.“We have worked with these law firms and several others for over a year to educate them on the anticompetitive behaviors of PBMs, including CVS Caremark. Now, we’ll focus on educating our members about the suit and other ways they can recoup the fees that were taken from them wrongfully. In fact, lawyers from Berger Montague, Cohen & Gresser and another firm leading the cause will brief NCPA members at the organization’sannual convention in Orlando, October 14-17.” “We’ve been fighting the PBMs on behalf of our members on Capitol Hill, in the agencies, and in the courts for decades. We’ve made a lot of progress on all those fronts. But this is a fight directly benefiting our members and a way to potentially get back some of the billions of dollars in fees wrongfully taken by the PBMs.”Anyone interested in attending NCPA’s Annual Convention should contact Andie Pivarunas at andrea.pivarunas@ncpa.org.To see the full article, use link below!https://lnkd.in/e2qgGeg4

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Frier Levitt attorneys successfully prevented the termination of an Ohio pharmacy from a major PBM's provider network. The PBM had sought to terminate the pharmacy due to instances in which the PBM’s members were alleged to have denied requesting medications which were otherwise properly dispensed and billed. With the assistance of Frier Levitt, the pharmacy effectively disputed these denials, addressed other PBM concerns, and demonstrated its compliance with network participation terms, ultimately securing its position as a network provider.Read more here: https://bit.ly/3FaJyqLIf you are concerned about the potential termination of your pharmacy, or have recently been terminated by a PBM, Frier Levitt can help. Contact us today to speak with an attorney. #FrierLevitt #PBMs #NetworkTermination #LegalVictory

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An Iowa pharmacy recently received a refund of $137,000 from a pharmacy benefit manager (PBM) following a complaint about the PBM's practice of retroactively recouping funds. The recouped amount pertained to "effective rate reconciliation" for the 2022 period. However, Iowa has recently implemented laws prohibiting PBMs from retroactively reducing reimbursem*nt. Other states taking such action include North Dakota and Tennessee.Read article by Frier Levitt attorneys Dae Y. Lee, Pharm.D, JD, CPBS and Lucas Morgan to learn more: https://bit.ly/44jCodWPharmacies are encouraged to challenge improper PBM practices within the framework of such laws, however, navigating these laws can be complex. With our extensive knowledge of PBMs, Frier Levitt attorneys are ready to assist you. Contact us to speak with an attorney about how payors and pharmacies can leverage the various laws and protections afforded to pharmacies.#FrierLevitt #Iowa #PBMconduct #PBMs #PharmacyLaw #backpay #complaint

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Our latest article discusses Michigan’s Pharmacy Benefit Manager Licensure and Regulation Act.Delve into this new legislation and its implications here:

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🔍 Don't overlook the risks of unresolved PBM audit discrepancies! Recently, with the help of Frier Levitt attorneys Harini Bupathi and Andrea Christine Hageman, Esq., an independent pharmacy resolved over $200,000 of audit findings from a major PBM. Learn how to navigate PBM audits and protect your pharmacy's interests.Read our latest article: https://lnkd.in/dN6uBRB4 If your pharmacy is currently responding to an audit or has yet to formally respond to audit findings issued by a PBM, contact us for assistance today.#FrierLevitt #PBMAudits #IndependentPharmacies #LegalVictory

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Our latest article discusses Michigan’s Pharmacy Benefit Manager Licensure and Regulation Act.Delve into this new legislation and its implications here:

Our latest article discusses Michigan’s Pharmacy Benefit Manager Licensure and Regulation Act.Delve into this new legislation and its implications here:

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Tenth Circuit Holds Oklahoma’s Patient’s Right to Pharmacy Choice Act Is Preempted by Federal LawInPharm. Care Mgmt. Ass’n v. Mulready, No. 22-6074, __F.4th__, 2023 WL 5218138 (10th Cir. Aug. 15, 2023), Plaintiff-Appellant Pharmaceutical Care Management Association (PCMA), a trade association representing pharmacy benefit managers (PBMs), brought an action on behalf of its members against Oklahoma’s Insurance Commissioner and the Oklahoma Insurance Department (“Oklahoma”) to challenge Oklahoma’s Patient’s Right to Pharmacy Choice Act and related regulations on the basis that the Act was preempted by ERISA and Medicare Part D. PCMA appealed the district court’s ruling that ERISA did not preempt four provisions of the Act and the court’s ruling that Medicare Part D did not preempt one provision. The Tenth Circuit Court of Appeals reversed the district court and held that: (1) ERISA preempted the Act’s restrictions regarding pharmacies in the PBM network; (2) ERISA preempted the Act’s probation prohibition applying to pharmacists on probation; and (3) Medicare Part D’s preemption clause mandates field preemption; and (4) Medicare Part D preempted the Act’s network restriction requiring PBMs to accept any willing provider.Link to court decision and summary in the comments.#ERISA #ERISApreemption #PBMs #pharmacybenefitmanagers #ERISAhealthplans

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Supreme Court Resolves Circuit Split Re: Knowledge Requirement under the False Claims ActAs reported by JD Supra, on June 1, 2023, the Supreme Court unanimously ruled that defendants charged with violations of the False Claims Act (FCA) in United States ex rel. Schutte v. SuperValu, Inc. violate the statute when they submit claims for reimbursem*nt that are fraudulent, even if they can subsequently demonstrate that their claim for reimbursem*nt was based on an “objectively reasonable” interpretation of the regulations governing the claim’s reimbursem*nt. The FCA imposes liability on a defendant that “knowingly” submits a claim for reimbursem*nt from a federal program (like Medicare) that is false.This ruling operates to shut off defenses that had previously been available to FCA defendants. For example, the Seventh Circuit held that a retail pharmacy defendant could not be held to have “knowingly” presented a fraudulent claim for reimbursem*nt when its claim was based on an “objectively reasonable” interpretation of the Medicare and Medicaid drug pricing regulations. The Supreme Court overruled the Seventh Circuit and instead held that the “objectively reasonable” finding was irrelevant to the FCA’s knowledge requirement. Instead, the Court held that the requirement refers to “knowledge and subjective beliefs—not to what an objectively reasonable person may have known or believed.”In other words, the Court held that the knowledge at issue in FCA cases is subjective—what the defendant actually thought or believed when they submitted the claims—not what a reasonable person would think in the same situation. While this opinion may remove a potential defense for defendants and may cause more cases to be resolved at the jury, rather than summary judgment, stage, it may provide a different defense option for defendants. The subjective knowledge standard imposed by the court could provide for a defense that permits a defendant to assert that their claim for reimbursem*nt, while objectively untrue, was not knowingly false because the defendant had a subjectively-held, albeit mistaken, belief that the claim was true.

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Our latest article discusses Michigan’s Pharmacy Benefit Manager Licensure and Regulation Act.Delve into this new legislation and its implications here:

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