Caremark Notice of Breach – Aberrant Practices and Trends

PAAS National® analysts have recently assisted multiple pharmacies that received faxed notifications from Caremark that their pharmacy has “breached” the PBM Agreement by exceeding an arbitrary 25% threshold (by $ or # of claims) on the Aberrant Product List for their total claims dispensed in January 2024.

Affected pharmacies must …

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“cure the breach” by not exceeding this threshold in any subsequent month and develop and implement a written Corrective Action Plan (CAP) to support this goal. Notably, submission of the written CAP is optional. The letter includes a threat that non-compliance may result in network termination. Importantly, there is no request or requirement for pharmacies to reverse previously billed and dispensed claims.

Caremark suggests that pharmacies perform a monthly review of the most current Aberrant Product List and educate pharmacy staff about the aberrant product list, with a specific emphasis on purchasing personnel, to avoid inadvertent breaches due to unawareness.

Caremark created an Aberrant Product List in November 2019 and states that while these products are a covered benefit, pharmacies may only dispense up to (but no more than) 25% of their Caremark claims in a given month. The list has grown from 7 to 15 pages over the past 4 years and includes specific NDCs that are high cost.

PAAS Tips:

  • See Caremark’s Pharmacy Portal > Document Library > Audit (login required) to find the most current Aberrant Product List
  • The 25% threshold is based on dollar value or number of claims for aberrant products (against Caremark’s book of business), making the calculation slightly complex
    • Most pharmacies will trigger based on the dollar value of aberrant product claims
  • See January 2023 Newsline article, Essential Elements of Corrective Action Plans for suggestions on how to document a CAP
  • Notify PAAS National® at (608) 873-1342, if you are in receipt of a letter so that we can support you in developing a response

Eric Hartkopf, PharmD