Forms created by the pharmacy for the prescriber can be more problematic, as they may give the impression that the pharmacy is soliciting prescriptions or influencing the prescriber to choose one specific NDC over others. Cookie-cutter forms that contain only a small list of high AWP items, with each option featuring identical quantities, sig, and refills, are likely to attract PBM scrutiny.

Additionally, PAAS National^® has seen pre-printed prescription forms recouped during audits when they have cascading or overly broad substitutions. For example, if a topical medication is not covered, and the form provides a blanket allowance for the pharmacy to substitute the next topical medication on the list until one is covered, it could raise concerns about the pharmacy’s [conflicted] influence in the prescribing process. These medications are often more costly than preferred alternatives and can raise red flags for audits if the pharmacy is observed submitting claims, reversing them, and quickly billing for a different product. Many PBM provider manuals have now added language explicitly 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.

Here is a summary of the three big PBM positions:

• Caremark: Pre-printed forms resulting in the dispensing of products that are not the most cost-effective items are prohibited (even if they are different salts, bases, or have different release characteristics)
• Express Scripts: Pharmacies using forms with multiple medications and substitution language must consult (and document) consultation with prescriber prior to dispensing the appropriate medication
• OptumRx: Dispensing or distributing Prescription Drugs/Drug Products which are not based on valid prescriptions for individually identified Members or are otherwise on pre-populated or templated prescriptions is prohibited. Such pre-populated prescriptions may also not include options for substitute products without individualized prescriber authorization or annotation.

PAAS Tips:

• Not all template prescriptions will draw the ire of PBMs
• PAAS has seen enforcement mostly focused on:
  • High AWP products where a cheaper alternative is available
  • Compounded pain/scar creams with broad substitution language
  • High AWP dietary supplements

Many pharmacies have implemented a Point-of-Sale system (POS) in their pharmacies to ease the burden of storing paper signature logs and having easy access when asked to reproduce them. However, with the cost to implement and the extra costs in having an electronic system for deliveries, some pharmacies are still using both a POS system and paper signature logs for home/facility delivery. It is important that all elements are present on both the POS signature log as well as the delivery log.

PAAS Tips:

• Patients refusing to sign can be a challenge that pharmacies should consider addressing more aggressively
  • Try explaining that their insurance requires a legible signature for proof of receipt
    • This is an opportunity to explain that PBM’s are ruthless on audits and that a missing signature means you could be out hundreds or thousands of dollars each time they refuse to sign
  • If a patient still refuses to sign for expensive medications, offer to reverse the claim and bill it without their insurance
  • Do not sign/print the patient’s name for them, or use their initials to give the appearance of the patient signing
• Point-of-Sale electronic logs should contain:
  • Prescription number
  • Date filled or fill number
  • Date of pick-up
  • Signature of the patient or representative who picked up the medication
• Delivery logs should contain:
  • Patient name
  • Prescription number
  • Date filled or fill number
  • Date delivered (handwritten by the person receiving the delivery)
  • Delivery address
  • Signature of the patient or representative who received the delivery
• See the July 2024 Newsline article, Ensuring Audit Readiness: What PBMs Look for in Signature Logs and Proof of Delivery for more information on delivery and mailing requirements.

Atypical Dispensing Patterns

Communications labeled Atypical Dispensing Patterns point out pharmacy claims that are seemingly “abnormal” (relative to an unknown standard) and notify pharmacies that they are being watched. These letters are educational only with no direct call to action and should be interpreted as a warning letter to prevent future enforcement actions.

Notice of Breach

Communications labeled Notice of Breach include a list of specific claims in the previous month that have created a contract violation or “breach” that must be resolved. These letters have aggressive language and indicate that Caremark may terminate the pharmacy’s network participation unless the pharmacy cures the breach and develops/implements a written Corrective Action Plan (CAP).

Breach letters are issued almost exclusively due to the dispensing of NDCs included on Caremark’s Aberrant Product List and only when the pharmacy has crossed an arbitrary threshold of 25% (by claim count or dollar amount) within a one-month period. The NDCs on this list are generally products with a high AWP that have lower cost alternatives that could be dispensed in their place.

PAAS Tips:

• See Caremark’s Pharmacy Portal (https://rxservices.cvscaremark.com/) under Document Library>Audit (login required) for the most current Aberrant Product List
• Notify PAAS if you are in receipt of a letter so that we can support you in developing a response
• See the January 2023 Newsline article, Essential Elements of Corrective Action Plans for suggestions on how to develop a CAP

they can be worn for up to 15 days and are indicated for children 2 years and older. FreeStyle Libre 2 Plus Sensors can also be integrated with insulin pumps while FreeStyle Libre 3 Plus Sensors work with Automated Insulin Delivery (AID) systems. For more information on the types of insulin pumps and AID systems, see the FreeStyle Libre website. As a reminder, FreeStyle Libre 2 Sensors and FreeStyle Libre 3 Sensors can only be worn up to 14 days and are indicated for children 4 years and older. These sensors cannot be integrated with insulin pumps or AID systems.

The chart below should be a helpful tool for referencing Dexcom and FreeStyle CGM products, NDCs, their respective NCPDP billing units, and corresponding days’ supply.

PAAS Tips:

• See our March 2024 Newsline article, Continuous Glucose Monitor (CGM) Billing and Supply Allowance for additional Medicare Part B billing information
  • Use the CGM Supply Allowance Billing Calculator found on your DME MAC website to help determine when the next date of service can be billed
    • CGS
    • Noridian
  • Check out this similar tool myCGS for a complete claim history to be sure the patient has not received supplies from another supplier in the last 30 or 90 days
  • If the patient requires a replacement sensor, transmitter, or receiver due to a product failure, be sure to document and replace the item while reaching out to the manufacturer
• The NCPDP billing units shown in the chart above would apply to non-Medicare Part B claims
• Beware that any PBM, including Medicare Part B, will recoup or deny a claim if it is refilled too soon based on days’ supply guidelines above

1. Know the prescriber
   1. Is this a new prescriber in your area?
   2. Have you received electronic prescriptions from this prescriber before?
   3. Is the medication within their scope of practice?
   4. Can you verify prescriber information (e.g. phone, address) through public resources?
   5. Check your state PDMP for any controlled substance prescriptions that don’t add up.
2. Know the patient/caregiver
   1. Is this a new patient at your pharmacy?
   2. Does this patient live within your service area?
   3. How did you obtain the third-party billing information?
   4. Consider requiring a copy of photo identification for prescriptions picked up for new patients
   5. Large cash copays paid by a representative unknown to pharmacy may be a clue that they are trying to avoid detection
   6. Some level of skepticism, if all interactions are with a personal representative
3. Review the prescription for unusual items such as:
   1. Is dose regimen outside the norm?
   2. Does patient have indication to support use?
   3. Does the patient have other prescriptions from this prescriber? Can the patient confirm they are being treated by the prescriber?
   4. Are there multiple prescriptions issued for high-cost medications brand medications, particularly those that may be dispensed in their original, intact containers?

With fraudulent electronic prescriptions being on the rise, pharmacies should consider formulating a business policy to handle these situations. A key first step is conducting due diligence before concluding that a prescription is fraudulent. When validating with a prescriber, the pharmacy should request documentation [preferably in writing] that the prescription is fraudulent. If the prescription was billed to insurance and later reversed due to a determination of it being a fraudulent prescription, the hardcopy should still be retained in case of an audit. The prescriber should take the lead on notifying authorities and researching their stolen credentials, but pharmacies may have a corresponding responsibility to notify the state board of pharmacy and/or DEA (especially when prescriptions were dispensed). FWAC Members can utilize the custom content section of their Policy and Procedure Manual to create and upload a fraudulent prescription policy.

If a prescription is dispensed and later identified as fraudulent, pharmacies are obligated to reverse the claims and likely notify the third-party payor. During a PBM audit, fraudulent electronic prescriptions will be subject to financial recoupment and the onus will be on the pharmacy to prove that they were ‘duped’ as well and not in on the fraudulent activity.

PAAS Tips:

• DEA has a brief video about fraudulent e-prescriptions and a handout on general prescription fraud here
• When prescriptions are identified as fraudulent, document your due diligence efforts on the prescription or in your pharmacy management software