Billing insurance isn’t always simple, whether it’s formulary issues, step therapy or plan limitations, it’s common for a pharmacy to receive a rejection when trying to bill a patient’s insurance. For patients with Medicaid as secondary coverage, can you simply send the rejected claim to Medicaid? Caution should be exercised.
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Medicaid is typically referred to as the “the payor of last resort” because all options must be exhausted through a patient’s primary plan before submitting the full claim to Medicaid. Unfortunately, this isn’t as simple as identifying a primary claim that has rejected the prescription billed and then submitting the full claim to Medicaid so it will process. Pharmacies must first identify if this rejection can be resolved through the patient’s primary insurance (i.e., how would the pharmacy handle the claim if there was no secondary?). For example, if the primary payor is requiring prior authorization, that process must be sought either by receiving an approved prior authorization or a denied one (or changing the therapy to a covered drug product). Only then would it be appropriate to bill the patient’s Medicaid.
Be sure to utilize the Other Coverage Codes (OCC) appropriately. An OCC should be used when billing claims with multiple payors. This ensures the secondary payor reimburses the correct amount. Incorrect or inappropriate use of an OCC can lead to recoupments or even network termination if these errors are intentional. The codes below are typically recognized by third-party payors and used in NCPDP field 308-C8:
OCC
Description
2
Other coverage exists/billed – payment collected
3
Other coverage billed – claim not covered
4
Other coverage exists – payment not collected
8
Claim is billing for patient financial responsibility only (copay)
It is important to note that if a primary payor rejects a claim, the rejection codes are sent to the secondary payor. As previously mentioned, the first step when facing this predicament would be to resolve the coverage issue with the primary payor, whenever possible. Backing out of the claim and billing the secondary payor as primary may result in audit recoupment due to the secondary payor covering a cost that the primary payor might have paid. But what if OCC 3 is billed? The claim could still be at risk, as this depends on why exactly the primary insurance rejected the claim. Pharmacies should resolve primary payor rejections first by working through rejects like quantity limits, step therapy, formulary selections, or prior authorizations before billing the secondary payor.
PAAS Tips:
One exception to the rule is a multi-payor claim with conflicting coverage and reject code 606 indicating the payor prefers the brand/reference product.
Sometimes Medicaid will accept Brand DAW 9 billed to primary but rejected with reject code 22 – M/I Dispense as Written (DAW)/Product Selection Code, then pushed through to secondary (Medicaid) with DAW 9. Refer to the PAAS Tool Conflicting Coverage: When One Payor Covers Brand the Other Prefers Generic
Be sure to save denied prior authorization claims and document those denials on the prescriptions
Do not bill discount cards in place of primary insurance (in lieu of resolving primary insurance rejections).
Some copay cards and manufacturer coupons may accept reject codes due to formulary issues, but you must use the correct OCC.
Do not use a coupon or copay cards with a federal health benefits program, including Medicare, Medicaid, and TRICARE.
PAAS National® analysts have received numerous calls from pharmacies related to continuous glucose monitor (CGM) products made by Dexcom, particularly the G6/G7 sensors. There appears to be two different versions of Dexcom products – those labeled for “Retail” (pharmacy benefit) and those labeled for “DME” (medical benefit). Pharmacies report finding both products on wholesaler websites with different list prices and they aren’t sure which product they can buy, and which payors will pay for what product.
PAAS has spoken with Dexcom officials who confirmed the following:
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The products are the same but are intended for different channels
The “Retail” product is intended for pharmacy benefit and includes an NDC on the box
The “DME” product is intended for medical benefit (e.g., Medicare Part B) and does NOT include an NDC on the box
There is an authorized distribution list (ADL) that is not yet posted on Dexcom’s public website
Here is a list of Dexcom products with associated NDC (or SKU)
Government ONLY
Product Description
Dexcom SKU
G6 Medicare Touchscreen Receiver Kit
STK-FM-001
G6 Medicare Transmitter Kit, Dexcom
STT-OM-001
G6 Medicare Sensor 1-Pack, Dexcom
STS-OM-001
G6 Medicare Sensor Kit 3-Pack, US
STS-OM-003
G7 US Medicare Receiver Kit
STK-AT-013
G7 US Medicare Sensor/Transmitter 1-Pack
STP-AT-013
G7 15-Day US Medicare Sensor/Transmitter 1-Pack
STP-FT-013
DME Benefit ONLY
Product Description
Dexcom SKU
G6 Touchscreen Receiver Kit
STK-FE-001
G6 Transmitter Kit, Dexcom
STT-OR-001
G6 Sensor 1-Pack, Dexcom
STS-OR-001
G6 Bundled Transmitter Kit, Dexcom
BUN-OR-TX6
G7 US DME Receiver Kit
STK-AT-011
G7 US DME Sensor/Transmitter 1-Pack
STP-AT-011
G7 15-Day US DME Sensor/Transmitter 1-Pack
STP-FT-011
Retail Rx Pharmacy Benefit ONLY
Product Description
Dexcom SKU
“NDC”
G6 Receiver Kit (Retail)
STK-OE-001
08627-0091-11
G6 Retail Transmitter Kit
STT-OE-002
08627-0016-01
G6 Retail Sensor 3-Pack
STS-OE-003
08627-0053-03
G7 US Retail Receiver Kit
STK-AT-012
08627-0078-01
G7 US Retail Sensor 1-Pack
STP-AT-012
08627-0077-01
PAAS Tips:
Pharmacies must be careful when dispensing these products depending on whether the CGM is covered under the pharmacy or medical benefit
Caremark and Express Scripts require that network pharmacies purchase diabetic testing supplies directly from the manufacturer or an authorized distributor only
GLP-1 medications continue to come under scrutiny from PBM auditors for several reasons. High cost, off-label use, rising utilization, and billing irregularities make these easy audit targets. Pharmacies must remain diligent to ensure accuracy and appropriateness when dispensing these medications to avoid recoupments.
The latest in audit recoupments have come from…
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!
prescriptions for “microdosing”. Patients and prescribers have become aware of an internet sensation of injecting smaller doses for titration or maintenance therapy. The concept of using a certain number of clicks on the pen dial may be prescribed to obtain this microdose. Dosing at this level may be an attempt at reducing side effects or saving money.
GLP-1 pens are designed to deliver a specific, measured dose and the manufacturer instructions clearly indicate the pens should only be dialed to the appropriate dose and the number of clicks should not be counted. Pharmacies can refer to DailyMed for each medications’ package insert.
Manufacturers of these GLP-1 medications have not gone through the approval process from the FDA to ensure this practice is safe or effective. Consequently, PBMs may consider these prescriptions experimental or not medically appropriate. Pharmacies should consult with prescribers on the appropriate dosing and obtain new instructions, as needed.
PAAS Tips:
PAAS National® has written many Newsline articles regarding GLP-1 billing tips and recommendations – use ‘GLP-1’ in the Newsline Archive search box to pull up historical articles and consider the ones listed below:
https://paaswp.s3.amazonaws.com/wp-content/uploads/2025/08/04105935/iStock-1895226791.jpg13441920Dana Westberg, CPhThttps://paaswp.s3.amazonaws.com/wp-content/uploads/2021/03/24084106/Paas-National_Logo_RGB_transparency-224x300.pngDana Westberg, CPhT2025-08-12 10:55:302025-08-04 11:03:10GLP-1 Prescriptions Remain in the Crosshairs of Auditors
The CDC recently revised recommendations for COVID-19 vaccination by (i) removing the recommendation for pregnant women to receive the vaccine and (ii) that individuals ages 6 months to 17 years may receive the vaccine using a shared clinical decision-making (SCDM) approach. The SCDM recommendations are meant to be flexible and informed by the characteristics, values, and preferences of the individual patient (or guardian) and the clinical discretion of the health care provider.
There are now five vaccines that follow the SCDM approach rather than routine, catch-up, or risk-based approach where the default is to “vaccinate, unless contraindicated”.
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Meningococcal B (MenB) vaccination for adolescents and young adults aged 16–23 years
Hepatitis B (HepB) vaccination for adults aged 60 years and older with diabetes mellitus
Human papillomavirus (HPV) vaccination for adults aged 27–45 years
Pneumococcal conjugate vaccination (PCV20 or PCV21) for adults aged 65 years and older who have completed the recommended vaccine series with both PCV13 (at any age) and PPSV23 (which was administered at age ≥65 years)
COVID-19 for individuals 6 months to 17 years
Multiple organizations have objected to these changes and some have even filed lawsuits against the U.S. Department of Health and Human Services.
PAAS Tips:
While PAAS has NOT seen PBMs request documentation related to SCDM, we recommend that pharmacies document in the event of future audits
CDC has SCDM Job Aids for four of the five SCDM vaccine recommendations; however, no such COVID-19 Job Aid exists as of early July 2025 due to recency of the revised recommendation
We suggest pharmacies download the most current CDC adult and adolescent immunization schedules
Many pharmacies that PAAS National® assists with audits have similar sentiments, “Why us?” or “We just had an audit with [insert PBM here]”. It can feel like it is a never-ending cycle, with shifting standards depending on which PBM is conducting the audit. At PAAS, we understand these concerns — and we’re here to help.
To support pharmacies in managing and minimizing audit risk, the PAAS portal includes a valuable resource under the “Proactive Tips”, called Audit Flags. This resource can help pharmacies identify characteristics of prescriptions that frequently trigger audits and provide insight into why they’re being flagged. While high-cost medications are commonly targeted, there are many other lesser-known reasons a claim might attract attention. For example, did you know…
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!
that PBMs may analyze the geographical distance between the patient, prescriber, and pharmacy?
Additionally, the PAAS Self-Audit Article Series compliments this tool by offering actionable strategies to help reduce audit exposure. This series highlights different types of prescriptions that have historically led to PBM audits or recoupments and shares guidance to ensure your documentation and dispensing practices can withstand scrutiny. The series includes 12 different topics, each with links to relevant Newsline articles and additional resources for deeper learning.
Let PAAS help you stay ahead — with proactive tools and expert insights to protect your pharmacy. Access the additional resources available on the PAAS portal to better understand and manage audit risks. For additional support or questions, feel free to reach out to the PAAS team.
PAAS Tips:
Review Audit Flags to identify possible audit triggers that may be occurring in your pharmacy
Be prepared and confident BEFORE you receive an audit notice by reviewing the Self-Audit Article Series
https://paaswp.s3.amazonaws.com/wp-content/uploads/2025/08/04104611/iStock-2162411925.jpg11521920Erin McDonald, PharmDhttps://paaswp.s3.amazonaws.com/wp-content/uploads/2021/03/24084106/Paas-National_Logo_RGB_transparency-224x300.pngErin McDonald, PharmD2025-08-06 10:43:292025-08-04 10:46:54Why Are There So Many Audits?
As technology continues to reshape modern medicine, medical providers have embraced electronic prescribing to improve patient care. Unfortunately, as the healthcare landscape evolves, so do the tactics of bad actors seeking to exploit it.
Bad actors can use stolen login credentials from prescribers to gain access to electronic health record systems and initiate thousands of fraudulent e-prescriptions to pharmacies across the country within a very short period. For example, a 26-year-old Florida resident plead guilty in December 2024 and will serve two years and six months in federal prison for wire fraud and aggravated identity theft.
In response to this growing threat, the DEA is urging pharmacies to stay vigilant, as those that dispense fraudulent prescriptions may be held liable. For example, CVS agreed to pay $70,000 in 2023 to resolve allegations that the Controlled Substances Act (CSA) was violated at several of its locations.
According to an article published by Pharmacy Practice News, the DEA is on high alert. “Electronic prescription fraud is a real emerging trend that we’re seeing all across the country,” said Erin Hager, a DEA diversion investigator in the Phoenix-Tucson Tactical Division Squad. “What’s happening is … bad actors … who have been conducting prescription drug fraud are now utilizing the internet and electronic health record platforms to create electronic prescriptions that they can then send nationwide.”
What can pharmacies do to keep fraudulent prescriptions from being filled and dispensed? As mentioned in our February 2025 Newsline article, Electronic Prescription Fraud, we listed techniques to spot fraudulent e-prescriptions, like knowing the prescriber, the patient/caregiver, and reviewing the prescription for unusual items. The DEA has also released some helpful resources to help in preventing fraudulent prescriptions from being filled and dispensed, like the Pharmacists’ Guide to Prescription Fraud and the DEA Pharmacists’ Manual.
PAAS Tips:
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The DEA has an informative video about fraudulent e-prescriptions that can be found here
When in doubt, call the prescriber to confirm a prescription’s validity
If a prescription is identified as fraudulent, make documentation of this assessment on the prescription or in your pharmacy management software
For new patients, consider asking for their insurance card, rather than using the insurance look-up tool in your billing software. This allows pharmacies to confirm payor information and serves as another validation point.
https://paaswp.s3.amazonaws.com/wp-content/uploads/2023/02/03102850/iStock-1421859468.jpg12801920Heaven Bennett, CPhThttps://paaswp.s3.amazonaws.com/wp-content/uploads/2021/03/24084106/Paas-National_Logo_RGB_transparency-224x300.pngHeaven Bennett, CPhT2025-08-04 15:12:202025-07-25 15:14:46DEA Alert: Electronic Prescription Fraud on the Rise
Numerous pharmacies have received letters from AstraZeneca, the manufacturer of Farxiga® 5 and 10 mg, regarding “discrepancies” identified in a reconciliation of purchase and dispensing data from 2024.
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Similar to the LifeScan letters highlighted in the April 2025 article, Diabetic Test Strip Authorized Distributors – LifeScan Audits Continue!, there are two different versions of the AstraZeneca letter. The gentle version requests that pharmacies review wholesaler invoices and pharmacy dispensing records to ensure that claims are dispensed/billed properly, while the stronger version requests cooperation by providing data to AstraZeneca to include total tablets purchased and dispensed in 2024. Both versions point out that 2023 data show no such discrepancies.
The unsupported assertions of an invoice shortage should prompt pharmacies to perform an internal review of their own purchase and dispensing data to see if the claim has any merit. If shortages are uncovered, then pharmacies should attempt to determine the root cause(s) and implement appropriate corrective actions to prevent a recurrence.
A few possible reasons that should be considered include:
Excess supply on-hand from 2023
Return to Stock Errors
Claims with overbilled quantities
Purchases from other pharmacies that may not be visible to the manufacturer
Incorrect NDCs billed
Counterfeit product in the supply chain
Fraudulent billing of claims where no inventory was purchased
Failure to reverse claims that were not picked up
While not stated directly, the tone and wording of the letters imply that AstraZeneca suspects that pharmacies purchased/dispensed the Authorized Generic NDC and billed claims under the Brand NDC. This type of error causes manufacturers to pay inappropriate rebates and is considered fraudulent, if done intentionally.
The Authorized Generic version of Farxiga® (dapagliflozin), labeled by Prasco Laboratories, entered the market January 3, 2024, and has the identical appearance (color, shape, size, imprint) as the branded product indicating that it is the exact same tablets in the bottles – with different labeling, NDCs, and most importantly, prices.
Product
Labeler
NDC
AWPper unit
NADACper unit
Tablet Description
Farxiga® 5 mg
AstraZeneca
00310-6205-30 00310-6205-90
$23.99
$19.15
Color: Yellow Shape: Round Size: 7 mm Imprint: 5; 1427
Dapagliflozin Propanediol 5 mg
Prasco Laboratories
66993-0456-30
$22.12
$11.47
Farxiga® 10 mg
AstraZeneca
00310-6210-30 00310-3210-90
$23.99
$19.16
Color: Yellow Shape: Diamond Size: 11 mm Imprint: 10; 1428
Dapagliflozin Propanediol 10 mg
Prasco Laboratories
66993-0457-30
$22.12
$11.54
As of this publication it is unclear how AstraZeneca will proceed. If you have a letter, be sure to send it into PAAS right away so that we may guide you through next steps.
PAAS Tips:
AstraZeneca has a list of Authorized Distributors of Record on its website. The contractual requirements are unclear as to whether pharmacies are obligated to purchase Farxiga only from an Authorized Distributor; however, one way to ensure you are not purchasing counterfeit product would be to order only from one of these authorized distributors.
Make sure that inventory purchased from another pharmacy or via a third-party marketplace is performed in accordance with DSCSA and that these transactions are thoroughly documented
Ensure that claims are billed with the exact NDC that is purchased/dispensed – this is a contractual requirement of every payor, for every claim
Pharmacist visual verification of Farxiga® tablets alone is insufficient to prevent this error type – make sure you check the NDC of the stock bottle against the claim to confirm accuracy
Consider staff education on this possible error type and implementing barcode scanners to prevent mistakes
The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released its Semiannual Report to Congresssummarizing program integrity efforts from October 2024 through March 2025 which showed a return of $11 for every $1 spent. The OIG is the lead federal agency combating healthcare fraud, waste, and abuse in federal programs such as Medicare, Medicaid and providers will likely see increased activity based on President Donald Trump’s goals to pay for the One Big Beautiful Bill Act.
OIG Highlights from October 1, 2024 – March 31, 2025:
78 reports issued
946 investigations closed
1,503 excluded individuals and entities
298 criminal informations and indictments (formal accusations)
1,209 referrals (to prosecutors)
349 criminal actions (convictions)
395 civil actions
OIG oversight impacting pharmacies includes:
Medicare Part D improperly paid up to $465 million for drugs when payment was available under Medicare Part A over a 3-year period
Medicare may have improperly paid up to $454 million for 39 million OTC COVID-19 tests in excess of the monthly limit of eight tests per enrollee
Compounded prescriptions and HIV medications continue to be targets of FWA
https://paaswp.s3.amazonaws.com/wp-content/uploads/2025/07/25150339/iStock-2223053610.jpg14401920Eric Hartkopf, PharmDhttps://paaswp.s3.amazonaws.com/wp-content/uploads/2021/03/24084106/Paas-National_Logo_RGB_transparency-224x300.pngEric Hartkopf, PharmD2025-07-31 15:01:232025-07-25 15:03:53OIG Semiannual Report to Congress Shows 11:1 Return On Investment
Similar to the recent package size changes for Forteo®, NCPDP reports that the FDA has requested product labeling changes on four additional products which will be revised in compendia this summer. The FDA is not requiring manufacturers to obtain new NDCs and there are no clinical changes to the products.
Products with coming package size changes include:
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Alvogen’s teriparatide will have the strength corrected from 620 mg/2.48 mL to 560 mcg/2.24 mL to accurately reflect the intended delivery of 28 daily doses of 20 mcg. Products with revised labeling should be in the marketplace by mid-June 2025.
EMD Serono, Inc’s Gonal-f® RFF Redi-ject® (follitropoin alfa injection) will correct the currently rounded number volumes to more accurately reflect the volume delivered in a single patient use prefilled pen. Products with revised labeling should enter the marketplace in mid-June and mid-July 2025.
PAAS Tips:
Be careful when adjudicating claims and ensure that you bill for the quantity of the product in-hand
Pharmacies may need to contact PBM helpdesks if claims are paid incorrectly (overpay or underpay) or reject altogether
In the PAAS National® January 2025 Newsline article, PBM Prescription Validation Requests – What Are They Looking At Now? we discussed the PBM trends we saw in 2024. Below is a list of drugs reviewed and analyst comments that have been compiled through the first six months of 2025 along with a comparison from 2024. While we are not surprised that Ozempic® continues to be the top drug on the prescription validation requests, the others are not surprising either.
January-June 2025
July-December 2024
January-June 2024
Ozempic®
Ozempic®
Ozempic®
Invega®
Trelegy Ellipta
Nurtec®
Creon®
Eliquis®
Mounjaro®
Zepbound®
Epinephrine
Creon®
Nurtec®
Creon®
Ubrelvy®
The top 5 comments noted by an analyst after claim review for the first half of 2025 mirror those from 2024.
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A clinical notation is needed and requires the following 4 elements:
Date/time of the call/conversation
Name and title of who you spoke with
Specific details about the clarification
Initials or name of the pharmacy employee making the clarification
Black out acquisition cost and/or profit margin values on the backtag
Document the reason for the cut quantity – auditor will want to know why the pharmacy dispensed less than what was prescribed
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
No backtag/sticker provided, typically requested by the PBM and helpful for PAAS to review the billing elements
PAAS Tips:
Use our Self-audit Mindset tool found under the “Proactive Tips” tab to review your prescriptions prior to sending them to PAAS
Be sure to include a backtag or screenshot of billing information for a PAAS analyst to review
Be sure to add all employees to the Member Portal and give them permission to access helpful tools, resources and eNewsline
https://paaswp.s3.amazonaws.com/wp-content/uploads/2025/07/25145323/iStock-1818264966.jpg9601920Jennifer Ottman, CPhThttps://paaswp.s3.amazonaws.com/wp-content/uploads/2021/03/24084106/Paas-National_Logo_RGB_transparency-224x300.pngJennifer Ottman, CPhT2025-07-27 14:51:282025-07-25 14:54:02What’s New with Prescription Validation Requests in 2025?
When Medicaid is the Secondary Payor
Billing insurance isn’t always simple, whether it’s formulary issues, step therapy or plan limitations, it’s common for a pharmacy to receive a rejection when trying to bill a patient’s insurance. For patients with Medicaid as secondary coverage, can you simply send the rejected claim to Medicaid? Caution should be exercised.
Medicaid is typically referred to as the “the payor of last resort” because all options must be exhausted through a patient’s primary plan before submitting the full claim to Medicaid. Unfortunately, this isn’t as simple as identifying a primary claim that has rejected the prescription billed and then submitting the full claim to Medicaid so it will process. Pharmacies must first identify if this rejection can be resolved through the patient’s primary insurance (i.e., how would the pharmacy handle the claim if there was no secondary?). For example, if the primary payor is requiring prior authorization, that process must be sought either by receiving an approved prior authorization or a denied one (or changing the therapy to a covered drug product). Only then would it be appropriate to bill the patient’s Medicaid.
Be sure to utilize the Other Coverage Codes (OCC) appropriately. An OCC should be used when billing claims with multiple payors. This ensures the secondary payor reimburses the correct amount. Incorrect or inappropriate use of an OCC can lead to recoupments or even network termination if these errors are intentional. The codes below are typically recognized by third-party payors and used in NCPDP field 308-C8:
It is important to note that if a primary payor rejects a claim, the rejection codes are sent to the secondary payor. As previously mentioned, the first step when facing this predicament would be to resolve the coverage issue with the primary payor, whenever possible. Backing out of the claim and billing the secondary payor as primary may result in audit recoupment due to the secondary payor covering a cost that the primary payor might have paid. But what if OCC 3 is billed? The claim could still be at risk, as this depends on why exactly the primary insurance rejected the claim. Pharmacies should resolve primary payor rejections first by working through rejects like quantity limits, step therapy, formulary selections, or prior authorizations before billing the secondary payor.
PAAS Tips:
Dexcom G6/G7 Sensors: Retail vs DME
PAAS National® analysts have received numerous calls from pharmacies related to continuous glucose monitor (CGM) products made by Dexcom, particularly the G6/G7 sensors. There appears to be two different versions of Dexcom products – those labeled for “Retail” (pharmacy benefit) and those labeled for “DME” (medical benefit). Pharmacies report finding both products on wholesaler websites with different list prices and they aren’t sure which product they can buy, and which payors will pay for what product.
PAAS has spoken with Dexcom officials who confirmed the following:
Here is a list of Dexcom products with associated NDC (or SKU)
PAAS Tips:
GLP-1 Prescriptions Remain in the Crosshairs of Auditors
GLP-1 medications continue to come under scrutiny from PBM auditors for several reasons. High cost, off-label use, rising utilization, and billing irregularities make these easy audit targets. Pharmacies must remain diligent to ensure accuracy and appropriateness when dispensing these medications to avoid recoupments.
The latest in audit recoupments have come from…
prescriptions for “microdosing”. Patients and prescribers have become aware of an internet sensation of injecting smaller doses for titration or maintenance therapy. The concept of using a certain number of clicks on the pen dial may be prescribed to obtain this microdose. Dosing at this level may be an attempt at reducing side effects or saving money.
GLP-1 pens are designed to deliver a specific, measured dose and the manufacturer instructions clearly indicate the pens should only be dialed to the appropriate dose and the number of clicks should not be counted. Pharmacies can refer to DailyMed for each medications’ package insert.
Manufacturers of these GLP-1 medications have not gone through the approval process from the FDA to ensure this practice is safe or effective. Consequently, PBMs may consider these prescriptions experimental or not medically appropriate. Pharmacies should consult with prescribers on the appropriate dosing and obtain new instructions, as needed.
PAAS Tips:
COVID-19 Vaccine Update: Shared Clinical Decision-Making
The CDC recently revised recommendations for COVID-19 vaccination by (i) removing the recommendation for pregnant women to receive the vaccine and (ii) that individuals ages 6 months to 17 years may receive the vaccine using a shared clinical decision-making (SCDM) approach. The SCDM recommendations are meant to be flexible and informed by the characteristics, values, and preferences of the individual patient (or guardian) and the clinical discretion of the health care provider.
There are now five vaccines that follow the SCDM approach rather than routine, catch-up, or risk-based approach where the default is to “vaccinate, unless contraindicated”.
Multiple organizations have objected to these changes and some have even filed lawsuits against the U.S. Department of Health and Human Services.
PAAS Tips:
Why Are There So Many Audits?
Many pharmacies that PAAS National® assists with audits have similar sentiments, “Why us?” or “We just had an audit with [insert PBM here]”. It can feel like it is a never-ending cycle, with shifting standards depending on which PBM is conducting the audit. At PAAS, we understand these concerns — and we’re here to help.
To support pharmacies in managing and minimizing audit risk, the PAAS portal includes a valuable resource under the “Proactive Tips”, called Audit Flags. This resource can help pharmacies identify characteristics of prescriptions that frequently trigger audits and provide insight into why they’re being flagged. While high-cost medications are commonly targeted, there are many other lesser-known reasons a claim might attract attention. For example, did you know…
that PBMs may analyze the geographical distance between the patient, prescriber, and pharmacy?
Additionally, the PAAS Self-Audit Article Series compliments this tool by offering actionable strategies to help reduce audit exposure. This series highlights different types of prescriptions that have historically led to PBM audits or recoupments and shares guidance to ensure your documentation and dispensing practices can withstand scrutiny. The series includes 12 different topics, each with links to relevant Newsline articles and additional resources for deeper learning.
Let PAAS help you stay ahead — with proactive tools and expert insights to protect your pharmacy. Access the additional resources available on the PAAS portal to better understand and manage audit risks. For additional support or questions, feel free to reach out to the PAAS team.
PAAS Tips:
Be prepared and confident BEFORE you receive an audit notice by reviewing the Self-Audit Article Series
DEA Alert: Electronic Prescription Fraud on the Rise
As technology continues to reshape modern medicine, medical providers have embraced electronic prescribing to improve patient care. Unfortunately, as the healthcare landscape evolves, so do the tactics of bad actors seeking to exploit it.
Bad actors can use stolen login credentials from prescribers to gain access to electronic health record systems and initiate thousands of fraudulent e-prescriptions to pharmacies across the country within a very short period. For example, a 26-year-old Florida resident plead guilty in December 2024 and will serve two years and six months in federal prison for wire fraud and aggravated identity theft.
In response to this growing threat, the DEA is urging pharmacies to stay vigilant, as those that dispense fraudulent prescriptions may be held liable. For example, CVS agreed to pay $70,000 in 2023 to resolve allegations that the Controlled Substances Act (CSA) was violated at several of its locations.
According to an article published by Pharmacy Practice News, the DEA is on high alert. “Electronic prescription fraud is a real emerging trend that we’re seeing all across the country,” said Erin Hager, a DEA diversion investigator in the Phoenix-Tucson Tactical Division Squad. “What’s happening is … bad actors … who have been conducting prescription drug fraud are now utilizing the internet and electronic health record platforms to create electronic prescriptions that they can then send nationwide.”
What can pharmacies do to keep fraudulent prescriptions from being filled and dispensed? As mentioned in our February 2025 Newsline article, Electronic Prescription Fraud, we listed techniques to spot fraudulent e-prescriptions, like knowing the prescriber, the patient/caregiver, and reviewing the prescription for unusual items. The DEA has also released some helpful resources to help in preventing fraudulent prescriptions from being filled and dispensed, like the Pharmacists’ Guide to Prescription Fraud and the DEA Pharmacists’ Manual.
PAAS Tips:
AstraZeneca Letters re: Farxiga® Data Discrepancies
Numerous pharmacies have received letters from AstraZeneca, the manufacturer of Farxiga® 5 and 10 mg, regarding “discrepancies” identified in a reconciliation of purchase and dispensing data from 2024.
Similar to the LifeScan letters highlighted in the April 2025 article, Diabetic Test Strip Authorized Distributors – LifeScan Audits Continue!, there are two different versions of the AstraZeneca letter. The gentle version requests that pharmacies review wholesaler invoices and pharmacy dispensing records to ensure that claims are dispensed/billed properly, while the stronger version requests cooperation by providing data to AstraZeneca to include total tablets purchased and dispensed in 2024. Both versions point out that 2023 data show no such discrepancies.
The unsupported assertions of an invoice shortage should prompt pharmacies to perform an internal review of their own purchase and dispensing data to see if the claim has any merit. If shortages are uncovered, then pharmacies should attempt to determine the root cause(s) and implement appropriate corrective actions to prevent a recurrence.
A few possible reasons that should be considered include:
While not stated directly, the tone and wording of the letters imply that AstraZeneca suspects that pharmacies purchased/dispensed the Authorized Generic NDC and billed claims under the Brand NDC. This type of error causes manufacturers to pay inappropriate rebates and is considered fraudulent, if done intentionally.
The Authorized Generic version of Farxiga® (dapagliflozin), labeled by Prasco Laboratories, entered the market January 3, 2024, and has the identical appearance (color, shape, size, imprint) as the branded product indicating that it is the exact same tablets in the bottles – with different labeling, NDCs, and most importantly, prices.
As of this publication it is unclear how AstraZeneca will proceed. If you have a letter, be sure to send it into PAAS right away so that we may guide you through next steps.
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OIG Semiannual Report to Congress Shows 11:1 Return On Investment
The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released its Semiannual Report to Congress summarizing program integrity efforts from October 2024 through March 2025 which showed a return of $11 for every $1 spent. The OIG is the lead federal agency combating healthcare fraud, waste, and abuse in federal programs such as Medicare, Medicaid and providers will likely see increased activity based on President Donald Trump’s goals to pay for the One Big Beautiful Bill Act.
OIG Highlights from October 1, 2024 – March 31, 2025:
OIG oversight impacting pharmacies includes:
NCPDP Package Size Updates: Gonal-f® RFF Redi-ject® and Teriparatide (Alvogen)
Similar to the recent package size changes for Forteo®, NCPDP reports that the FDA has requested product labeling changes on four additional products which will be revised in compendia this summer. The FDA is not requiring manufacturers to obtain new NDCs and there are no clinical changes to the products.
Products with coming package size changes include:
Alvogen’s teriparatide will have the strength corrected from 620 mg/2.48 mL to 560 mcg/2.24 mL to accurately reflect the intended delivery of 28 daily doses of 20 mcg. Products with revised labeling should be in the marketplace by mid-June 2025.
EMD Serono, Inc’s Gonal-f® RFF Redi-ject® (follitropoin alfa injection) will correct the currently rounded number volumes to more accurately reflect the volume delivered in a single patient use prefilled pen. Products with revised labeling should enter the marketplace in mid-June and mid-July 2025.
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What’s New with Prescription Validation Requests in 2025?
In the PAAS National® January 2025 Newsline article, PBM Prescription Validation Requests – What Are They Looking At Now? we discussed the PBM trends we saw in 2024. Below is a list of drugs reviewed and analyst comments that have been compiled through the first six months of 2025 along with a comparison from 2024. While we are not surprised that Ozempic® continues to be the top drug on the prescription validation requests, the others are not surprising either.
The top 5 comments noted by an analyst after claim review for the first half of 2025 mirror those from 2024.
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