OptumRx® has employed a new strategy to recoup more money on your pharmacy claims. Often upon an audit, if a pharmacy submitted an incorrect days’ supply, the PBM will re-adjudicate the claim with the correct days’ supply.
The Department of Justice recently announced the sentencing for a California (CA) pharmacy owner and their co-conspirator for submitting fraudulent claims to Medicare and CA Medicaid for prescription drugs that were never dispensed to beneficiaries.
Flu shot season is just around the corner and PAAS National® wants to make sure you reduce your risk of audit recoupments. As busy as the flu season can be, it is important to follow the best practices and PAAS tips below to ensure you have all documentation in place.
Popularity for GLP-1 medications, like Ozempic®, continues to grow and, consequently, PAAS National® encounters these drugs on PBM audits frequently.
In late June, Teva Pharmaceuticals launched the first “generic” GLP-1 (Glucagon-Like-Peptide-1) receptor agonist in the United States, known as Liraglutide injection (6 mg/mL).
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.
Cyclosporine eye drops are used to increase tear production in individuals with certain eye conditions and dry eye disease.
PBMs monitor, and flag, migraine medications due to excessive cost, quantities submitted, days’ supply (and/or frequency of refills) and vague instructions.
PAAS National® has seen audits with full claim recoupments being requested as a result of missing dosage and frequency instructions, as well as incomplete dispensing records. To minimize the risk of a Spravato® claim being recouped during an audit, consider the following PAAS tips …
Anytime a pharmacy dispenses a quantity different than what the prescriber ordered, there should be a reason documented on the prescription for the decreased or increased quantity.
