Solera Specialty Pharmacy: The Pharmacy Signed for the Doctor

Solera Specialty Pharmacy and its chief executive agreed to a $1.31 million civil Evzio settlement over allegations that the pharmacy used false prior authorizations to bill Medicare. The pharmacy admitted signing forms without physicians’ authorization, putting its own contact information in their place and supplying false clinical information to get the drug covered. For someone inside a pharmacy or reimbursement operation, the telling document is the form that made the insurer believe it was hearing from the prescriber.

The Department of Justice announced the Pompano Beach, Florida pharmacy’s settlement on July 13, 2022. The civil case began with a whistleblower who had worked for Kaléo, Evzio’s manufacturer. Her view of the business extended from the sales force into the pharmacies that obtained coverage and submitted claims.

Evzio Prior Authorization and the Doctor’s Identity

Solera admitted submitting false clinical information on Evzio prior authorizations to secure insurance approval. It dispensed the drug from January 2017 through May 2018, when Evzio was the highest-priced version of naloxone on the market and insurers frequently required approval before covering it.

Evzio is an injectable naloxone product used to reverse opioid overdoses. Its device supplies spoken instructions to the person administering it. The complaint described coverage criteria under which some plans required visual impairment, while others required a medical reason the patient could not use a cheaper naloxone product. What the pharmacy said about the patient could determine whether the insurer paid for this particular device.

The account of Solera’s admissions in the civil agreement makes the substitution concrete. Staff completed forms in place of prescribing physicians. In some instances, they signed without the physician’s authorization and listed the pharmacy’s contact information as though it belonged to the physician. The pharmacy supplied both the clinical story and the apparent source of that story.

This is the pharmacy side of pharmaceutical prior authorization fraud. The alleged scheme left taxpayers paying for coverage obtained with false clinical answers.

The Complaint’s Account of Invented Coverage Facts

The whistleblower’s broader Evzio complaint alleged that network pharmacies supplied invented information to obtain coverage. It named Solera among the network pharmacies, then described conversations about how unnamed pharmacies got claims approved:

The device spoke instructions aloud. The complaint alleged that a pharmacy secured coverage by inventing a patient’s blindness. A form could satisfy the insurer’s criteria while describing a patient the prescriber would not recognize.

How Prescriptions Reached the Pharmacy

The complaint alleged a route from blanket prescribing orders to patient lists, pharmacy authorizations and Medicare claims. Kaléo representatives allegedly persuaded physicians to issue standing orders for all their Medicare patients receiving opioid pain-management treatment. Practices then allegedly supplied patient names and contact information to network pharmacies.

During what the complaint called “activation days,” representatives allegedly spent extended periods in physicians’ offices facilitating that handoff. The pharmacies allegedly would contact patients, tell them their physician had ordered Evzio, obtain approval where required, dispense it and submit the claims.

The complaint also alleged that Physician Partners of America physicians refused to prescribe Evzio until Kaléo’s network included Patient Rx Solutions, a pharmacy they partly owned. Network inclusion allegedly let the physicians profit from their own prescriptions. The alleged specialty-pharmacy kickback was access to the prescription business.

The whistleblower also alleged that Kaléo instructed representatives to press for replacement prescriptions for a newer Evzio version even when patients still had unexpired, usable devices.

Why the Signature Matters at the Pharmacy Counter

The 2020 University of Portsmouth doctoral study Exploring U.S. Pharmacists’ Willingness to Fill Prescriptions Illegally found that 28.2% of respondents would complete a prior-authorization form with a forged physician signature in a hypothetical involving an overdue prescription and an unreachable doctor. Among those willing to do it, the most common reason given was the patient’s health.

The study explains the practical tension. Prior authorization interrupts dispensing while the payer seeks answers about treatment criteria and less costly options. The physician has the complete medical history needed to answer those questions. The pharmacist faces the patient waiting at the counter.

That distinction helps explain the significance of Solera’s admissions. The insurer received clinical information under the appearance of the prescriber’s authority. A successful approval says nothing about who actually answered the clinical questions.

The Same Payment Gate in Other Drug Cases

Insys’s civil False Claims Act settlement addressed allegations of false Subsys reimbursement submissions and payments for prescribing. The alleged sales effort reached both the prescription and the information used to obtain payment.

Kaléo’s own Evzio settlement in November 2021 addressed allegations that it directed prescriptions to preferred pharmacies submitting false claims. Solera’s later resolution put the pharmacy’s own authorization practices at the center of the case. A manufacturer’s referral decisions and a pharmacy’s submissions can expose different parts of the same business.

What Solera’s Integrity Agreement Required

Solera and its chief executive entered a three-year integrity agreement with the Department of Health and Human Services Office of Inspector General. The government required measures addressing prior authorizations and collection of Medicare beneficiaries’ copays, along with reviews by an independent review organization.

Copays were part of Solera’s admissions too. The pharmacy acknowledged repeatedly waiving Medicare beneficiaries’ Evzio copays without analyzing whether the patient had a genuine financial hardship. The oversight therefore reached both the information used to secure coverage and the pharmacy’s treatment of the patient’s share of the bill.

What Evidence Is Needed to Prove Fraud?

In a case like Solera’s, we work with you to connect the patient’s clinical information, the form sent to the insurer, the prescriber’s actual authorization and the resulting claim. Solera’s admissions make the comparison specific: whose signature appeared, whose contact details were supplied and what clinical information secured approval.

The broader complaint adds the commercial context: where the prescription came from, how the patient list reached the pharmacy and why another prescription followed while an earlier supply remained usable. A pharmacy employee may know the submission process. A manufacturer’s representative may know why the business kept arriving. We work with pharmaceutical whistleblowers to connect that knowledge to the claims and the people directing the work.

The Solera resolution allocated a whistleblower reward from the recovery to the former manufacturer employee who brought the qui tam case. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know Who Filled in the Form

If you know how a pharmacy obtained approval using clinical information the prescriber never supplied, speak to one of our whistleblower experts about how those authorizations got approved. We work with you to build your strongest pharmacy fraud whistleblower case and bring in pharmaceutical fraud whistleblower lawyers who understand pharmacy reimbursement and manufacturer referral arrangements. From the first account of a false form through the pursuit of a recovery, we stay on your side.