PBMs are increasingly terminating pharmacies for minor infractions of the provider manuals or network enrollment forms. These terminations are contrary to the PBM's obligations under law and the parties' agreements, and may have collateral consequences if the underlying allegations involve wrongdoing. In this case, we profile the steps that led to a successful network reinstatement for an Illinois pharmacy.

Our client, an Illinois pharmacy, was targeted by a major PBM with cease-and-desist notices that alleged violations of the Provider Manual. Although the pharmacy responded to the PBM in an attempt to address the allegations, the PBM terminated the pharmacy anyway. At that point, the pharmacy retained our firm, and we immediately sprung into action to reverse the impending termination on short notice.

Successful PBM Appeals Often Require Legal Advocacy

Throughout the appeal process, HLA's experienced healthcare defense attorneys meticulously presented documentation and legal analysis that systematically addressed the PBM's alleged violations and demonstrated that either no violation occurred, or that any violation was an isolated error that did not support termination. Specifically, we combine our arguments on the facts with extensive legal research and analysis demonstrating why the PBM is not entitled to terminate the agreement at issue under relevant federal, state, and common law.

HLA's Legal Methods are Tailored to Each Case

Our method for approaching these cases is to present the client's narrative and facts in a convincing and compelling fashion, relying on our subject matter expertise, to explain why vague statements in a manual do not prohibit or apply to the facts at issue. In addition, it is important to address the PBM's concern that the conduct at issue not recur. Accordingly, because our firm employs the former Chief Compliance Officer of United Health Group, we are in a position to recommend tailored compliance strategies that the PBMs will accept in mitigation.

As part of our work in this case, our healthcare compliance specialists implemented new standard operating procedures, updated policies, and retrained staff, convincing the PBM to reinstate the pharmacy based on improved compliance protocols. This often tips the balance towards reinstatement.

Network Termination Can be Avoided

We work on many network appeals, so we can be efficient in budgeting to achieve desirable results. In this case, the pharmacy was about to be sold to a new owner, and the network termination obviously destroyed a lot of that value. By winning network reinstatement on appeal, we were able to dramatically increase the owner's return on investment. Nonetheless, if you are at risk of termination, the earlier you involve qualified counsel, the better. We are always available to help.

Frequently Asked Questions

Semaglutide Compliance Program: A Must Have

The semaglutide industry is relatively new, and significant regulatory enforcement typically lags by at least two years. Accordingly, all participants involved in the semaglutide supply chain should implement well-designed compliance programs now to reduce the risk and severity of future regulatory action.

Read More >>

Federal Prosecutors Focus on Ozempic Violations

Intense semaglutide demand has now drawn the attention of regulators beyond the Food & Drug Administration (FDA) and state boards. Last month, a woman was charged by federal prosecutors with violations of criminal law related to misbranded and adulterated weight loss drugs. This prosecution marks the first of many to come.

Read More >>

Express Scripts FWA Investigative Alert: Crackdown on CoverMyMeds Provider Accounts

Express Scripts is targeting prior authorization Fraud, Waste & Abuse involving the use of CoverMyMeds provider accounts by pharmacies. Pharmacies and physicians beware.

Read More >>

Corporate Advice: Asset Deals – Advantages & Disadvantages

In the final Part Three of a three-part series on corporate transactions, we describe important considerations around structuring the sale of a business as an "asset" sale.

Read More >>