Plan limit rejections are intended to help control costs, provide clinical edits, and assist pharmacies in ensuring patient safety. When an initial claim adjudication is rejected for exceeding plan limits (e.g., Max Quantity Limit or Quantity vs Time Limit), pharmacies need to proceed with caution.
At the end of October 2021, Centene® executives said the company would be making a $30 billion request for proposals from outside contractors to take over the pharmacy benefit manager (PBM) side of their business. The request for proposal is expected to launch in 2022 and be awarded in 2023.
Unfortunately, telemedicine also continues to be an easy target for bad actors, with pharmacies being caught in the middle.
PAAS National® has seen a recent uptick in the number of prescriptions being found discrepant for missing the supervising physician when written by a mid-level practitioner (e.g. physician assistant or nurse practitioner).
