In September 2016, Eric Pusey’s Olyphant pharmacy received notification that he owed CVS Caremark $143,594.75.
The problem was with a series of prescriptions that Pusey had filled and charged to Caremark, a pharmacy benefit manager or PBM, a representative had written. The prescribing doctor had written instructions that the drug should be taken every six hours. What Pusey wrote on the patient’s bottle was “4 times a day.”
PBMs are pharmaceutical industry middlemen hired by insurance companies to oversee the prescription drug side of health care plans. When a patient picks up an expensive drug from a pharmacy and only pays a copay, it’s the PBM’s job to reimburse the pharmacy for the rest of the drug’s cost, plus a small dispensing fee.
In that role, it’s common for pharmacy benefit managers to audit individual pharmacies and ensure the drugs they’re being billed for were appropriately prescribed and dispensed. That’s what led to Pusey’s pharmacy being charged over $143,000.
Because the wording Pusey put on the bottle may have resulted in more medicine being taken and dispensed, Caremark wanted back the entire cost of the medicine, and six refills — which cost Pusey around $22,000 per bottle.
“That literally was putting me out of business,” Pusey said. “I mean that one audit, on that one set of prescriptions.”
