Qualified Medicare Beneficiary (QMB) Program
Pharmacies may bill prescriptions from time to time for patients with dual eligibility, possessing both Medicare and Medicaid benefits.
Entries by Eric Hartkopf, PharmD
Walgreens Reaches $360 Million Settlement with Humana Regarding Inflated Prescription Drug Prices
In January 2024, Walgreens and Humana reached a $360 million settlement to resolve ongoing lawsuits where Humana argued that Walgreens violated the PBM agreement by artificially inflating prescription drug prices for years.
Insulin Substitution Review: Understanding Purple Book Terminology
PAAS National® frequently gets questions about whether pharmacies may substitute various medications and if such substitutions require the approval of the prescriber.
Caremark Bulk Purchase Notification
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.
Major PBMs Announce “Cost Plus” Pharmacy Networks
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.
Be Conscientious When Refusing to Dispense (or Bill Insurance)…
No pharmacy should be forced to dispense prescriptions below their acquisition cost.
Days’ Supply Considerations for Eye Medications
PBM audits regularly target eye medications looking to recoup on claims for incorrect days’ supply or early refills.
Best Practices for Financial Hardship Waivers
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.
PBM Audits: Letters to Patients for Prescription Verification
Pharmacies often see PBM audit letters requesting documentation to validate paid claims, but not very many see letters sent to their patients.
Specialty Pharmacy Paying the Price: $20 Million Settlement for Kickbacks and Copay Waivers
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.
