Caremark Aberrant Practices and Trends – Enforcement Extends Beyond the Aberrant Product List
PAAS National® analysts have worked with numerous pharmacies who have received communications related to Caremark’s proprietary Aberrant Product List or other alleged Atypical Dispensing Patterns. These letters are driven by Caremark’s Provider Manual section 3.02.03 which was expanded in 2022 as discussed in the Newsline article, Caremark® Expands “Aberrant” Language & Restricts Bulk Purchases.
These letters fall into two different categories:
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Atypical Dispensing Patterns
Communications labeled Atypical Dispensing Patterns point out pharmacy claims that are seemingly “abnormal” (relative to an unknown standard) and notify pharmacies that they are being watched. These letters are educational only with no direct call to action and should be interpreted as a warning letter to prevent future enforcement actions.
Notice of Breach
Communications labeled Notice of Breach include a list of specific claims in the previous month that have created a contract violation or “breach” that must be resolved. These letters have aggressive language and indicate that Caremark may terminate the pharmacy’s network participation unless the pharmacy cures the breach and develops/implements a written Corrective Action Plan (CAP).
Breach letters are issued almost exclusively due to the dispensing of NDCs included on Caremark’s Aberrant Product List and only when the pharmacy has crossed an arbitrary threshold of 25% (by claim count or dollar amount) within a one-month period. The NDCs on this list are generally products with a high AWP that have lower cost alternatives that could be dispensed in their place.
PAAS Tips:
- See Caremark’s Pharmacy Portal (https://rxservices.cvscaremark.com/) under Document Library>Audit (login required) for the most current Aberrant Product List
- Notify PAAS if you are in receipt of a letter so that we can support you in developing a response
- See the January 2023 Newsline article, Essential Elements of Corrective Action Plans for suggestions on how to develop a CAP
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.
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