While it hasn’t gone through yet, some say the deal to merge CVS Caremark and Aetna will be bad for health care. “It’s going to face many hurdles,” said Adam Fein, president of Pembroke Consulting. Some House Democrats are calling for a hearing to examine the merger, which still faces the Federal Trade Commission. Some antitrust experts have stated that the deal could result in higher drug prices and less consumer choice. Aetna could simply drive their prescription business to CVS pharmacies, and charge more to patients who fill their drugs elsewhere.
The $69 billion merger could have major implications for patients. The deal would combine medical benefits and pharmacy benefits, and hopefully allow better treatment of those patients – a result yet to be seen after the 2015 merger of United Health Care and OptumRx, which resulted in a deal with the Walgreens 8,000 plus pharmacies to fill 90-day supply prescriptions at home delivery copay amounts, while independent and other community pharmacies saw copay clawbacks!
Larry Merlo, the CEO of CVS Health said, “While the traditional health care system could be overseeing people’s care, it isn’t,” and described the potential merger as, “an opportunity to meet a huge unmet need.” But some are asking if they wanted to change the health care landscape, why haven’t they done so already? Others say that the rumored interest of Amazon to enter the pharmaceutical supply industry is behind the potential merger.
According to the New York Times, “Some worry that the nation’s health care system will come to resemble a series of kingdoms, where consumers are locked into separate ecosystems of pharmacies, doctors and health care clinics depending on their insurance provider.” B. Douglas Hoey, CEO of the National Community Pharmacists Association said, “You may be bounced from kingdom to kingdom.” PAAS wonders if you could even be locked out of a (contract) kingdom? Aetna has over 22 million members that they can direct to CVS!
CVS Health and Aetna say that fewer people will fall through the cracks, getting high-quality and low-cost medical care at their corner drug store. Is CVS planning on ramping up their over 1,000 Minute Clinics for walkin medical care?
If the deal goes through, Aetna’s CEO is said to receive about $500 million in exit pay and stock options, so it’s a good deal for at least one person. Time will tell whether or not the deal is good for patients, and how it will affect independent pharmacies.
Walmart, Sam’s Club Fined $825,000 for Auto Refills
On May 29, 2018 Walmart Stores, Inc. and Sam’s West, Inc. (Sam’s Club) reached an agreement to settle allegations that their pharmacies in Minnesota submitted claims to Medicaid that violated requirements surrounding auto-refills.
In the settlement Walmart and Sam’s agreed to pay $825,000 to resolve federal and Minnesota False Claims Acts violations.
ESI Enforcing Mail Order and Formulary Limits
PAAS recently became aware of Express Scripts (ESI) enforcing their mail order and formulary compliance limitations. Several pharmacies have received Cease & Desist notices from ESI and even one contract termination notice.
ESI is using patient address information to make assumptions as to which claims are being mailed outside of the pharmacy’s service area because ESI does not allow mail order under a standard retail contract. The notices are not indicating what ESI is using for service area. Notices have been issued for assumed mail order claims of as little as 10% of total ESI claims. Pharmacies may need to provide proof that claims were delivered or picked up to avoid future contract termination.
ESI also is requiring that pharmacies use “best efforts to achieve formulary compliance.” Having a high percentage of non-formulary or brand drugs may be considered a violation of their Provider Manual. One of the notices specifically identified a high percentage of claims for products manufactured by Horizon Pharma. ESI stated that this was evidence that the pharmacy was not operating as a traditional retail pharmacy that dispenses a variety of drugs.
Humana Slamming Pharmacies for Invalid Faxed and Oral Prescriptions
Humana is going after pharmacies every way they can these days. Many states have specific elements that need to be present in the fax header of a faxed prescription. PAAS has seen numerous audits where the Humana auditor is marking a fax as an invalid hard copy if it is missing these required fax header elements.
Some examples are:
Please be aware of your state requirements for faxed prescriptions. Contact your board of pharmacy for more information.
Humana is also going after pharmacies for invalid oral prescriptions. Some state laws require an oral order be promptly reduced to writing. PAAS sees some pharmacies use a fill sticker as a hard copy. Other pharmacies will reduce an oral order to type-writing. PAAS thinks that these procedures are fine, however, Humana has interpreted reduced to writing to mean hand-writing and has found a new way to line their pockets.
While these discrepancies are appealable, they are a hassle as you must obtain a physician statement on clinic letterhead to get paid for that prescription. Avoid chargebacks from Humana for oral orders by hand writing them if your state requires you to reduce an oral order to writing.
Opioids – Don’t Get Sucked In!
“Two pharmacists sentenced to 19 and 20 years in prison and ordered to pay $5 million in restitution to the state of Georgia to combat the opioid epidemic,” reads the news heading from the Department of Justice story based upon the criminal activity of two pharmacists.
“Rosemary Ofume and Donatus Iriele have each been ordered to pay $2.5 million in community restitution… The defendants… formerly owned the Medicine Center Pharmacy in Atlanta, Georgia. They were sentenced… to 19 and 20 years in prison, respectively, for illegally dispensing controlled narcotics to customers of the AMARC ‘pill mill’ pain clinic.”
“The defendants used their pharmacy to supply pills to patients of a known ‘pill mill’ and then laundered millions of dollars to conceal their crimes,” said U.S. Attorney Byung J. “BJay” Pak.
“All health care professionals are put on notice to remember: you are to do no harm. And if you intentionally ignore this charge, you are going to be treated the same as a street-corner drug dealer in this war on opioid abuse,” said Dennis M. Troughton Sr., Director, Georgia Drugs & Narcotics Agency.
Last month, we reported that a Kentucky pharmacist was sentenced to eight years in federal prison for conspiring to distribute oxycodone and money laundering by filling forged prescriptions from outside of the state. Michael Ingram, who owned and operated Hometown Pharmacy of Georgetown, KY, was ordered to forfeit an amount in excess of $450,000.
The bottom line is – Don’t get sucked into distributing opioids for the allure of making a profit. If you know of any health care professionals who are circumventing their duties to do no harm, report them to the Department of Justice or the DEA.
The CVS Caremark and Aetna Deal
While it hasn’t gone through yet, some say the deal to merge CVS Caremark and Aetna will be bad for health care. “It’s going to face many hurdles,” said Adam Fein, president of Pembroke Consulting. Some House Democrats are calling for a hearing to examine the merger, which still faces the Federal Trade Commission. Some antitrust experts have stated that the deal could result in higher drug prices and less consumer choice. Aetna could simply drive their prescription business to CVS pharmacies, and charge more to patients who fill their drugs elsewhere.
The $69 billion merger could have major implications for patients. The deal would combine medical benefits and pharmacy benefits, and hopefully allow better treatment of those patients – a result yet to be seen after the 2015 merger of United Health Care and OptumRx, which resulted in a deal with the Walgreens 8,000 plus pharmacies to fill 90-day supply prescriptions at home delivery copay amounts, while independent and other community pharmacies saw copay clawbacks!
Larry Merlo, the CEO of CVS Health said, “While the traditional health care system could be overseeing people’s care, it isn’t,” and described the potential merger as, “an opportunity to meet a huge unmet need.” But some are asking if they wanted to change the health care landscape, why haven’t they done so already? Others say that the rumored interest of Amazon to enter the pharmaceutical supply industry is behind the potential merger.
According to the New York Times, “Some worry that the nation’s health care system will come to resemble a series of kingdoms, where consumers are locked into separate ecosystems of pharmacies, doctors and health care clinics depending on their insurance provider.” B. Douglas Hoey, CEO of the National Community Pharmacists Association said, “You may be bounced from kingdom to kingdom.” PAAS wonders if you could even be locked out of a (contract) kingdom? Aetna has over 22 million members that they can direct to CVS!
CVS Health and Aetna say that fewer people will fall through the cracks, getting high-quality and low-cost medical care at their corner drug store. Is CVS planning on ramping up their over 1,000 Minute Clinics for walkin medical care?
If the deal goes through, Aetna’s CEO is said to receive about $500 million in exit pay and stock options, so it’s a good deal for at least one person. Time will tell whether or not the deal is good for patients, and how it will affect independent pharmacies.
OptumRx Prohibits Mailing Prescriptions
Optum has recently faxed out notices reminding pharmacies that they should not solicit members for mail delivery or mail any covered prescription services to members. This includes US mail or shipping via any common carrier (FedEx, UPS, DHL).
Unless you have a specialized mail-order contract with OptumRx, this will be considered a violation of contract.
These notices can be somewhat deceiving as they may only list a certain benefit plan and a few BINs. If you read the notice closely, it does state that mailing is subject to termination from all ORx networks.
Optum is not the only PBM that prohibits mailing prescriptions. Humana and Express Scripts also have this stipulation in their provider manuals. Caremark states that if you ship more than 25% of the prescriptions you bill to them in any month, you are no longer eligible to be contracted under the retail pharmacy network.
Please check your contract, provider manual, or PSAO for further information.