Aetna whistle-blower accuses CVS of 'spread pricing' in federal lawsuit

CVS Caremark, the pharmacy benefit management division of Woonsocket, R.I.-based CVS Health, stands accused of improperly reporting Medicare generic drug prices to CMS, according to a STAT report.

An actuary at health insurer Aetna filed a lawsuit against Caremark in the U.S. District Court for the Eastern District of Pennsylvania related to the company's actions as a pharmacy benefit manager. As the PBM for Aetna's commercial business lines and Medicare Part D business, the lawsuit alleges Caremark took actions resulting in Aetna or its affiliates making or presenting false Medicare claims and statements to CMS. According to the lawsuit, Caremark billed CMS for more prescription drugs than it paid to retail pharmacies in the Aetna network, keeping the remaining difference or "spread."

The lawsuit seeks damages and penalties on behalf of the federal government from the defendants' actions.

CVS Health denies the allegations.

"We believe this complaint is without merit and we intend to vigorously defend ourselves against these allegations," the company said in a statement to Becker's Hospital Review. "CVS Health complies with all applicable laws and CMS regulations related to the Medicare Part D program, and the government filed a notice of declination with regard to this complaint."

CVS Health also reiterated its commitment to lowering prescription drug costs, citing a recent announcement that drug price growth remained nearly flat last year for the company's PBM clients and annual out-of-pocket costs for PBM members also decreased.


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