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 …

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!

“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 https://rxservices.cvscaremark.com/ > 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

Author
Recent Posts

Eric Hartkopf, PharmD

Analyst at PAAS National^®

As an Analyst, I focus on providing pre- and post-audit assistance, answering various member service questions, and researching & drafting articles for the Third-Party Newsline. I work with many of our members involved with invoice audits.

I obtained my PharmD from the University of Wisconsin-Madison School of Pharmacy and worked for a major chain as well as various LTC and independent pharmacies, before coming to PAAS.

I am passionate about learning and teaching. I strive to learn something new about PBM audits every day, so that PAAS can be more knowledgeable to better serve our members! In 2018, I started traveling to state pharmacy conferences to present audit seminars and meet our wonderful members in person.

Latest posts by Eric Hartkopf, PharmD (see all)

U.S. Government Alleges Counterfeit HIV Drugs Hiding in Pharmacy-to-Pharmacy Purchases - November 6, 2024
Walgreens $107 Million Settlement for False Claims Act Violations - November 4, 2024
Audit Risks: Medication Home Delivery - October 19, 2024