What’s New with Prescription Validation Requests in 2024?
In the PAAS National® January 2024 Newsline article PBM Validation Requests Rose 123% in 2023 – What You Need to Know, we discussed the PBM trends we saw in 2023. Below is a list of drugs reviewed and analyst comments that have been compiled through the first six months of 2024 for comparison.
Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!
Top 5 drugs reviewed in 2023 compared to first half of 2024:
| January-June 2024 | January-December 2023 |
| Ozempic® | Lantus® |
| Nurtec® | Humalog® |
| Mounjaro® | Creon® |
| Creon® | Levemir® |
| Ubrelvy® | Invega® |
While Creon® is still one of the top PBM targets, you can see that during the first half of 2024, the PBMs have shifted their focus from monitoring insulin claims to GLP-1s and migraine medications, demonstrating how PBM audit trends change over time. Be assured that the PBMs will continue to send claim reviews for insulin as well. While they may not show in the top 5 drugs of 2024 so far, Tresiba®, Humalog®, Levemir®, insulin lispro and Toujeo® were all right behind Ubrelvy® in the number of claim reviews the PBMs have issued to date in 2024.
The top 5 comments noted by an analyst after claim review mimic the same 5 from 2023:
- Document the reason for the cut quantity – auditor will want to know why the pharmacy dispensed less that what was prescribed
- Black out acquisition cost and/or profit margin values on the backtag
- A clinical notation is needed and requires 4 elements: Date, who you spoke with and their title, what they confirmed, and the pharmacy employee initials
- No backtag/sticker attached, typically requested by the PBM and helpful for PAAS to review the billing elements
- Verify the quantity prescribed and make a clinical notation on the hard copy – Unit of Measure (UOM) is not specified or does not make sense for the medication ordered
PAAS Tips:
- Share and review the following Newsline articles with your staff in relation to the top drugs reviewed and common concerns listed above
- January 2024, PBM Prescription Validation Requests Rose 123% in 2023 – What You Need to Know
- August 2023, Migraine Medications Continue to Cause Headaches for Nurtec® and Ubrelvy® FDA approved indications, recommended doses, whether the patient can repeat the dose, what the maximum daily dose can be and how to bill
- May 2023, Best Practices for Dispensing GLP-1 Medications and Reducing Recoupment Risk
- December 2023, Avoid the Creon Chargeback Catastrophe by Following THIS Billing Rule
- December 2023, Insufficient/Missing Clinical Notes Yield Audit Recoupments
- September 2022, Prescription Quantity Changes Require Documentation
- Be sure to include a backtag or screenshot for a PAAS analyst to review the billing elements
I have a Bachelor of Science degree from the University of Wisconsin-River Falls and have been a Certified Pharmacy Technician since 2001. Prior to joining the PAAS team, I was a floating technician, 3rd party district chargeback specialist, and district pharmacy training coordinator. Formerly, I was also an instructor for pharmacy technician certification classes.
PAAS’ personal, one-on-one connection will help your pharmacy become more successful in dealing with tiresome PBM audits. It is a pleasure knowing that my colleagues and I can help member pharmacies.
- Understanding Biologic Substitutions – New Tool Available! - November 12, 2024
- FDA Proposed Guidance for Biosimilar Updates - October 23, 2024
- Avoid OptumRx® Double Chargeback Pitfalls – Review Your Days’ Supply - October 1, 2024
