Pharmacy Benefits Manager Fraud - Have you been a victim?

From John Curry, February 14, 2007

The text below these two paragraphs was taken directly from the federal government's Health and Human Services administration. They have listed the common types of pharmacy benefits manager (PBM) fraud. Several of the illegal acts listed below (prescription drug splitting or shorting and failure to offer negotiated prices) can be detected by you the patient. If you suspect you have been a victim of PBM fraud, ask a few questions of the PBM, take notes of the conversation or record it, take down the name of the person you talk to along with the time and date of the conversation, and save any correspondence -- this will aid in an investigation of any wrongdoing.

The violations below are not only federal violations but some also fall under violations of the Ohio Revised Code. If you feel that one of these illegal acts has happened to you I would suggest you file a complaint with the Ohio Attorney General's (Marc Dann's) office at his toll free number 1-800-282-0515. John

"70.1.2 – PBM Fraud, Waste and Abuse

(Rev.2, 04-25-2006)

The following section describes examples of PBM fraud, waste and abuse. Because many Sponsors operate their own PBMs or perform the PBM function themselves, some of the examples cited in the Part D Plan section are applicable here. Examples of potential fraud, waste and abuse include but are not limited to:

1. •
Prescription drug switching: The PBM receives a payment to switch a beneficiary from one drug to another or influence the prescriber to switch the patient to a different drug.

1. •
Unlawful remuneration: PBM receives unlawful remuneration in order to steer a beneficiary toward a certain plan or drug, or for formulary placement. Includes unlawful remuneration from vendors beyond switching fees.

1. •
Inappropriate formulary decisions: PBMs or their P&T committees make formulary decisions where cost takes precedence over clinical efficacy and appropriateness of formulary drugs.

1. •
Prescription drug splitting or shorting: PBM mail order pharmacy intentionally provides less than the prescribed quantity and does not inform the patient or make arrangements to provide the balance but bills for the fully-prescribed amount. Splits prescription to receive additional dispensing fees.

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1. • Failure to offer negotiated prices: Occurs when a PBM does not offer a beneficiary the negotiated price of a Part D drug."