Missing PBM Audit Notifications: How Are They Supposedly Sent?

Caremark

Caremark’s Provider Manual states “notices will be delivered in person by mail, via fax the Provider’s fax number or by email via the email address provided by Provider in Provider’s enrollment documentation or as otherwise indicated by Provider to Caremark and agreed to by Caremark or via Pharmacy Portal.” It goes on to say that it is the responsibility of the provider to notify Caremark when contact information needs to be updated. There can also be times when Caremark will communicate via phone to pharmacies, most commonly seen with desk audits.

OptumRx

OptumRx’s Provider Manual states “Provider understands Administrator relies on the information about its Provider, as well as each Pharmacy location provided by NCPDP and directly to Administrator, therefore, Provider: (1) Agrees to update in a timely manner all information in the NCPDP database whenever … and (2) Immediately notifies ORx and NCPDP of updated contact information at pharmacyprograms@optum.com,including changes in telephone numbers, fax numbers, email address.” In addition, it states OptumRx may communicate via telephone, mail, fax, and/or email when it comes to conducting their audits.

Express Scripts

Express Script’s Provider Manual states “All changes to Provider demographic information for independent Network Providers must be submitted by logging onto https://www.esiprovider.com and completing the online Change of Demographics form. Provider shall also submit updated demographic information directly to NCPDP and/or any other third party website as applicable”. It also states Express Scripts will communicate via fax, email, or USPS when initiating an audit.

Prime Therapeutics

Prime Therapeutics uses the information pharmacies input to their NCPDP profile as their sole means of communication. In the Provider Manual, it states to go directly to the NCPDP’s website https://online.ncpdp.org to submit changes. Prime Therapeutic’s system will incorporate all new NCPDP updates on a weekly basis.

Humana

Humana’s Provider Manual states “[Humana] will notify all pharmacies via traditional mail (UPS or certified mail). If you prefer to be notified via email, we can send letters via secure message. To notify HPSX of your notification preference, please send an email to pharmacyaudit@humana.com.”

Elixir

Elixir also utilizes NCPDP to elicit pharmacy contact information. The Provider Manual states “Independent pharmacies are required to maintain NCPDP Part I and II with accurate and current information at all times as Elixir utilizes this information during its review.” Furthermore, the provider manual states “email is the preferred method for Pharmacy communications by Elixir. Pharmacies will be notified of any audit communications via fax unless the Pharmacy FWA Department has been notified of email preference”. The email to communicate an update in audit communication preference is PharmacyAudits@elixirsolutions.com

PAAS Tips:

• Update your safe sender list and/or junk mail to ensure any audit notices sent via email are received
• Educate pharmacy staff to watch faxes and email carefully for any PBM communications – tossing an audit can be costly
• Consider using an electronic/paperless fax system that records/retains all incoming faxes
• Ensure your pharmacy’s NCPDP profile is kept up to date as this is a primary means for many PBMs to gather pharmacies’ contact information – this should be updated whenever a change occurs
  • Designate an email address that is routinely monitored to avoid missing timely audit communications