Audit Risk: Pre-Printed Prescription Forms

PAAS National^® has seen pre-printed prescription forms considered invalid when they have cascading or overly broad substitutions. For example, if a topical medication is not covered, the form states the prescriber allows the pharmacy to substitute the next topical medication on the form and so on until one is covered. These medications tend to be more expensive than an alternative the plan may prefer and are a red flag for audit when the pharmacy is seen transmitting claims, reversing them, and billing a different product in rapid succession. Many PBM provider manuals have now added language requiring pharmacies to have a verbal conversation with the prescriber before making any substitutions, which would need to be proven with a clinical note documented on the prescription.

PAAS Tips:

• Check the provider manual of the PBMs that you are billing to see if they prohibit the use of pre-printed forms. Currently, Elixir, Prime Therapeutics, CVS/Caremark, and Express Scripts all contain language about pre-printed forms and/or inappropriate therapeutic substitutions.
• Clinical notes should contain the date, name and title of who you spoke with, summary of what was discussed, and pharmacy employee initials.
• Pre-printed prescription forms with high-cost medications and/or cascading substitution could be a red flag and require further scrutiny.
• Prescriptions should be specific to an individual patient’s needs and not generalized.
• Eliminate the use of pre-printed prescription forms
  • Placeholder prescriptions for pharmacy-initiated dispensings (e.g., vaccines, OTC COVID-19 tests) has not been a concern