PAAS National® analysts continue to see a large volume of Caremark invoice audits. Remember that Caremark will only review aggregate purchases over the selected date range plus the 30 days prior to. If pharmacies want Caremark to consider purchases made prior to the selected date range, then there must be a “bulk purchase notification” on file in accordance with Section 8.05 of the Caremark Provider Manual.
In the fourth quarter of 2023, two of the “Big 3” PBMs announced that they will introduce new reimbursement methods for network pharmacies in the coming year(s) based on Cost Plus formulas in place of the typical AWP Minus terms.
No pharmacy should be forced to dispense prescriptions below their acquisition cost.
PBM audits regularly target eye medications looking to recoup on claims for incorrect days’ supply or early refills.
PAAS National® analysts have noticed an increase in PBM audits focusing on copay collection. These audits requested a copy of the pharmacies’ policies and procedures addressing copay collection and financial hardship.
Pharmacies often see PBM audit letters requesting documentation to validate paid claims, but not very many see letters sent to their patients.
A September 30, 2023, Department of Justice press release outlined a recent settlement between the U.S. government and a specialty pharmacy based in Delaware.
There are two RSV vaccines FDA-approved for people ages 60 years and older – AbrysvoTM and Arexvy®.
Some pharmacies are wondering if they are allowed to continue prescribing OTC COVID-19 tests.
The top audit discrepancy year after year is invalid days’ supply or refill too soon – which are essentially the same issue.
