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:
  • Keeping the Diagnoses Straight for GLP-1 Products (February 2025)
  • Billing Ozempic^®0.25mg Weekly as Maintenance – What PBMs Say (January 2025)

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
• Read the March 2025 Newsline article, When the Margins Are Thin, Self-Audit for the Win for information on self-audit tips and links to PAAS resources on the portal

Be prepared and confident BEFORE you receive an audit notice by reviewing the Self-Audit Article Series

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:

1. Excess supply on-hand from 2023
2. Return to Stock Errors
3. Claims with overbilled quantities
4. Purchases from other pharmacies that may not be visible to the manufacturer
5. Incorrect NDCs billed
6. Counterfeit product in the supply chain
7. Fraudulent billing of claims where no inventory was purchased
8. 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	AWP per unit	NADAC per 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
  • See March 2025 Newsline article, The NEW Inventory Transfer Log and Why It Could Save You Big!
  • Document pharmacy to pharmacy (P2P) purchases on the Pharmacy Inventory Transfer Log
• 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

Product	NDC	Old Package Size	New Package Size	Compendia Date
Teriparatide (Alvogen)	47781-0652-89	2.48 mL	2.24 mL	July 1, 2025
Gonal-f® RFF Redi-ject®	44087-1117-01	1.5 mL	1.44 mL	July 1, 2025
	44087-1115-01	0.5 mL	0.48 mL	August 1, 2025
	44087-1116-01	0.75 mL	0.72 mL	August 1, 2025

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

has Terms and Conditions that need to be followed in order to be compliant in the program.

Each coupon or card has its own set of limitations/parameters for use. All coupons and copay cards are not allowed if a patient is enrolled in any Federal-paying prescription program (such as Medicaid, Medicare Part D, and Tricare) due to the Anti-kickback Statute (42 U.S.C. 1320a-7b). A question that is often asked is: “what if the drug isn’t covered by the federal plan?” The answer to this question would come down to the wording in the Terms and Conditions. Many cards will say it cannot be used for patients covered under Medicare or Medicaid. However, even though the drug isn’t covered, the patient is still enrolled in the federally funded program and the coupon or copay card should not be applied. 

What if the pharmacy uses a discount card (instead of the primary insurance) or bypasses the primary insurance plan altogether? The answer should be in the details. For example, Linzess^® has a copay savings card available (called the Linzess^® savings program). After finding terms and conditions for the card, the first sentence states, “This offer is valid only for patient with commercial prescription insurance coverage…”. It would likely be considered a violation of the program to directly bill a discount card instead of the patient’s primary insurance coverage (with the exception of discount cards embedded in plans) and could result in recoupment of the money paid to the pharmacy, and possibly termination from the coupon’s processor. Many coupons are processed by the same payers and PBMs, which could exclude you from multiple coupon cards/discount programs and possibly draw scrutiny to commercial claims and contracts unknowingly.

PAAS Tips:

• Always use the correct ‘Other Coverage’ code indicator
• Do NOT bypass any primary insurance requirements, such as prior authorization, plan limits, or step therapy
• Ensure the patient does not have a federally funded plan, such as Medicare, Medicaid or Tricare when applying coupons and discount cards
• Review past Newsline articles for more information on billing coupons
  • Billing Coupons for Medicare Part D Patients—When Is It Okay? (November 2024)
  • Federal Employees and Coupon Cards (February 2021)