Beginning in January of 2020, at least one of the major PBMs began monitoring its network pharmacies for the billing of specific NDC numbers the PBM considered “Aberrant”. The list of NDCs was sent to network pharmacies in November of 2019 and has since been updated in November of 2020. The communication states that billing Aberrant NDCs in amounts of more than 25% of total volume (volume as a measure of price, quantity of dosage units, or quantity is not clear) over a 30-day period will result in a breach of contract in which the pharmacy will have 30 days to cure. The communication states this is only one aspect the PBM monitors however, and that Providers must review their contractual duties to maintain compliance. Boesen &Snow has recently begun working with a pharmacy that received a termination notice due to the billing of four claims, that’s right only four prescriptions. The PBM is basing the contract breach on the quantity of medication billed for each claim and not as a percentage of total volume. PBM contract language states the PBM will review the quantities billed for Aberrant NDCs based upon the prescribing habits of local providers and plan sponsor formularies and will make a “reasonable determination” as to if the quantity is excessive or in breach. While it is recommended pharmacies avoid billing Aberrant NDCs altogether, it may be unavoidable at times and accurate documentation is needed to validate the quantities billed. If you have received a breach of contract or termination letter due to the billing of Aberrant NDCs, contact the PBM audit team at Boesen & Snow Law today for assistance.
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