Caremark Enforcement: Aberrant Quantities & Volumes

PAAS is starting to see Caremark enforce their new policy about Aberrant Quantities and Volume that we first wrote about in a December 2019 article Important: Caremark Provider Manual Updates for 2020!. These notifications state that pharmacies have breached the Provider Agreement and the pharmacy is receiving a formal breach notice as a warning.

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

Join today!

Caremark updated the Provider Agreement in November 2019 (effective January 1, 2020) to require pharmacies to dispense less than 25% of claims (by claim count or dollar amount) of select medications they consider to be at high risk for Fraud, Waste or Abuse. Exceeding this 25% threshold is deemed “aberrant” dispensing. Caremark states they will monitor pharmacies on a monthly basis and if you violate the 25% threshold after receiving a breach notice, you will be subject to claim recoupment and/or network termination.

While The Aberrant Drug List is unique to Caremark, all PBMs are auditing for these types of medications. PAAS has seen numerous examples of pharmacies losing claims during audits for soliciting prescriptions of these “special” dosage strengths. We advise pharmacies to be extremely cautious about this type of dispensing as it echoes the issue of repacking NDCs at inflated AWPs from the mid-2000s.

PAAS Tips:

  • The Aberrant Drug List was updated March 6, 2020
  • Current list is available on Caremark’s Pharmacy Portal at https://rxservices.cvscaremark.com
Eric Hartkopf, PharmD
Latest posts by Eric Hartkopf, PharmD (see all)