Managed Care Pharmacy Benefit Services – Aetna

CaremarkPCS Health, LLC employed an unallowable pricing model using an end-of-year effective rate adjustment to reduce final payments to pharmacies, resulting in spread pricing and misrepresentation of costs to Aetna.

Aetna Better Health of Texas Inc. employed an unallowable pricing model (effective rate pricing) with Caremark that reduced payments to Caremark and created overpayments, leading to spread pricing.

Aetna incorrectly reported prescription expenses on its Financial Statistical Reports, overstating expenses in 2020 and 2021 due to misreported administrative fees, rebates, and offsets, and failure to capture rebates and adjustments.

Caremark must exclude Texas Medicaid and CHIP services from prohibited effective rate pricing adjustments; not engage in spread pricing; report accurate final prescription expenses to Aetna; provide HHSC and OIG access to records and systems.

Aetna must exclude Texas Medicaid and CHIP services from effective rate pricing adjustments; ensure its PBM does not engage in spread pricing; report accurate final prescription expenses to HHSC; ensure HHSC and OIG have access; increase oversight of the PBM function.

Aetna must reimburse the funds collected via effective rate adjustments to the state of Texas; exclude Texas Medicaid and CHIP services from effective rate pricing adjustments; report accurate final prescription expenses; follow HHSC reporting instructions.

Aetna must report affiliate administrative expenses at cost or with fair market value documentation; capture and report accurate Texas Medicaid and CHIP prescription expenses and administrative fees including rebates and offsets; follow HHSC instructions.