Beware: Caremark is Monitoring High Quantity Utilization and Atypical Dispensing Habits

Beyond traditional desktop, on-site, investigational or invoice audits, Caremark performs various compliance reviews. These compliance reviews may include:

PAAS National® has recently reviewed a second round of these Rx Claim Review notices from members. While new for Caremark, PAAS has identified multiple versions of the letter primarily focusing on two areas of concern:

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  1. Dispensed quantities of medications that are significantly higher than the average fill size
    1. Primarily seen with Diclofenac Gel 1%, Lidocaine 3% cream, Ketoconazole 2% cream and diabetic testing supplies (i.e., lancets, needles, strips, and syringes)
  2. Atypical dispensing activity (e.g., disparate prescriber to pharmacy ratio)
    1. Primarily seen with Duexis® and Pennsaid®

The brief, and poorly worded, letter states the pharmacy should evaluate the claims in question and consider whether the dispensing of these medications is appropriate. It concludes with “your cooperation is appreciated and will greatly assist us in our review”. Due to the ambiguous direction, pharmacies are unsure if they need to respond or provide any additional information or documentation to Caremark.

PAAS Tips:

  • The notices PAAS has reviewed do not require a formal response
  • Caremark wants the pharmacy to evaluate the claims
    • For claims listed as having a high quantity utilization, pharmacy can verify the quantity and days’ supply dispensed for appropriateness
    • For claims listed as having atypical dispensing habits, pharmacy should validate the claims are billed under the correct prescriber, that there is a valid physician-patient relationship, and that the prescriptions are not being solicited
  • Every pharmacy’s situation is different and PAAS can help provide perspective and next steps
  • See Caremark Expands “Aberrant” Language & Restricts Bulk Purchases from February 2022 Newsline for additional information on Aberrant Practices and Trends
Jennifer Ottman, CPhT