On-Demand Webinar: Caremark’s Bulk Purchasing Requirements and the Importance of Cultural Competency

On June 15, 2022 PAAS National® hosted Caremark’s Bulk Purchasing Requirements and the Importance of Cultural Competency webinar. PAAS Audit Assistance members have access to the recorded webinar, in addition to many other tools and resources on the PAAS Member Portal.

For easy viewing, we’ve split the webinar into two separate recordings.

The importance of Cultural Competency reviews:

  • Laws pertaining to Cultural Competency and Linguistically Appropriate Services
  • Enhancing patient experiences with Cultural Competency training

Caremark’s Bulk Purchasing Requirements reviews:

  • Caremark’s updates to bulk purchasing requirements
  • Purchasing scenarios that place your pharmacy at risk

New Tools Available! Biologic and Non-Biologic Injectable Medication Reference Charts

Ever wonder if you were billing the correct NDC for a Humira® prescription and had to spend precious time investigating? Or how about questioning if you were billing the correct package size for Gvoke® and had to consult multiple references just to try and figure out the answer? Perhaps you had audit on Ajovy® only to find your pharmacy facing recoupment because the auto-injector was billed but the script was written for the pre-filled syringe.

PAAS National® now has two new reference charts available to help you and your staff with billing these unique injectable products correctly. Check out the Biologic Injectable Medication Chart and Non-Biological Injectable Medication Chart under the Tools & Aids section of the PAAS Member Portal.

PAAS Tips:

  • Utilize the Biologic Injectable Medication Chart to:
    • Determine if there is an interchangeable biologic available in the marketplace
    • Cross reference the correct NDC for medications such as Humira® and Enbrel®
    • Review the available dosage forms for medications such as Simponi® and Emgality®
    • Verify the correct NCPDP billing unit for medications such as Cimzia® and Aimovig®
  • Utilize the Non-Biological Injectable Medication Chart to:
    • Review the available dosage forms for medications such as Abilify Maintena® and Gvoke®
    • Verify the correct NCPDP billing unit for medications such as Lovenox® and Xyosted®
    • Find USP guidance for the expiration date of multi-dose vials (not otherwise indicated by the manufacturer)
  • These injectable medications carry a high audit risk; billing the correct formulation, quantity, NDC and days’ supply is not only essential to receiving the appropriate payment at time of adjudication but also necessary to successfully pass an audit
  • Check out the Tools & Aids tab on the PAAS Member Portal for additional reference charts which have been skillfully and deliberately crafted to save pharmacy staff time and money; print these and post them near the pharmacy claims processing station for easy reference

A Need for a Compliance Program – Attest with Confidence

Since 2009, PAAS National® Fraud, Waste & Abuse and HIPAA Compliance program was designed to meet the CMS requirements, with the full support of our expert staff – pharmacists and technicians just like you, with years of experience helping community pharmacies with FWA and HIPAA compliance. Don’t be fooled by offers for training and exclusion checks – work with the best compliance program available to community pharmacies!

Consider the following:

Humana’s 2022 Notice of Program Requirements

Humana’s Compliance Policy for Contracted Healthcare Providers explicitly states pharmacies must have a compliance program that meets the seven elements outlined by CMS, including written policies, procedures and standards of conduct. Per the 2022 Pharmacy Compliance Education and Training Requirements FAQs: “Humana reserves the right to request documentation (e.g., policies and tracking records) confirming that your organization has an effective compliance program that meets the requirements outlined in the Compliance Policy and Standards of Conduct.”

PerformRx Pharmacy Compliance Attestation 2022/2023

PerformRx requires attestations to the following:

The pharmacy has implemented and maintains a compliance program that is consistent, at minimum, with applicable federal and state requirements, including, but not limited to the standards set forth in 42 CFR §423.504(b)(4)(vi) and other Centers for Medicare & Medicaid Services (CMS) guidance set forth in the Medicare Part D Prescription Drug Benefit Manual.

Be proactive. Be prepared. Be protected. Ensure you have all your compliance bases met so that when you attest to having one, you can provide proof if requested for credentialing or audit.

Don’t have an FWA/HIPAA Compliance Program? Contact PAAS and receive a $126 discount when you combine services with your audit assistance. Get started today! info@paasnational.com or (608) 873-1342.

Is Your Pharmacy Ready for an Unannounced Audit?

Pharmacies are often startled with the limited amount of time a PBM offers prior to an onsite audit. However, PBM auditors, DEA agents, FDA inspectors and state Board of Pharmacy inspectors can also make unannounced visits.

Ensuring your staff members are prepared in case of an unannounced visit is essential. Since these visits occur without warning, the Pharmacist-in-Charge (PIC) and/or owner may not be working or available to assist. Keeping information in a central location and advising staff on how to handle these intimidating visits will make the process go much smoother.

PAAS National® has created a document to help pharmacies prepare for PBM visits. Located on our website, under the Tools & Aids Section, you can find our Onsite Credentialing Guidelines. This tool provides a list of frequently asked questions from auditors. The guide also includes references to the Policy and Procedure Manual for PAAS National® Fraud, Waste & Abuse and HIPAA Compliance members.

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PAAS Tips:

  • Anyone requesting access to PHI (or your professional service area) should be identified with a company issued picture ID and other validating information
    • Follow your pharmacy’s HIPAA policy for visitors. PAAS FWA/HIPAA members can document information on their Visitor’s Log located in their Policy and Procedure Manual
  • Check PAAS’ newest guide How to Be Prepared for An Onsite Audit located in our Tools & Aids Section
  • Make sure all staff are:
    • Up to date on FWA and HIPAA compliance training
    • OIG and GSA exclusion checked; required monthly, PAAS performs these checks daily for our FWA/HIPAA members and records are accessible on the PAAS Member Portal
  • Review and update your FWA/HIPAA Compliance Manual and the Onsite Credentialing Guidelines with your Compliance Officer and/or PIC
  • Keep copies of all documents requested by auditor or inspector
  • Keep copies of any documents you are requested to sign
  • Contact PAAS once your PBM visit is over as we can track this information to better serve all members based on your experience

Don’t have an FWA/HIPAA Compliance Program? Contact PAAS and receive a $126 discount when you combine services with your audit assistance. Get started today! info@paasnational.com or (608) 873-1342.

Beware: DEA and Wholesalers are Cracking Down on Controlled Substance Dispensing

Take note – the DEA is coming after pharmacies dispensing illegitimate controlled substance prescriptions. Pharmacists should all be aware of their corresponding responsibility and the need for a legitimate medical purpose when dispensing controlled substance prescriptions. A review of recent Department of Justice settlements provides guidance on some prescriptions that require additional scrutiny.

Consider the following dispensing activities to be of high risk:

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  • Dangerous drug cocktails (e.g., opioids with benzodiazepines, muscle relaxants, and/or stimulants)
    • Often known as the ‘Holy Trinity’ on the street: opioid, benzodiazepines, and muscle relaxant
  • High opioid doses that far exceed FDA dosage guidance
  • Controlled substance prescriptions for patients traveling long distances
  • A patient who uses multiple prescribers and multiple pharmacies to fill their controlled substances
  • Suspicious prescriptions from providers who are now sanctioned by state and federal authorities
    • When a prescriber is sanctioned, the DEA will look downstream at pharmacies that ultimately dispensed medications from the prescriber
  • Providing early refills of opioid prescriptions
  • Schedule II prescriptions for opioid dependence, which is not a legitimate medical purpose

Dispensing combinations of controlled substances that have no legitimate medical purpose, are highly addictive and specifically used to create or enhance abusive and euphoric effects, is a violation of 21 CFR 1306.04(a). Pharmacists have a responsibility to ensure the appropriateness of the prescriptions they are dispensing. While turning away business is never easy, being fined and sanctioned by the DEA is a much more painful process to endure.

Consider a few DEA settlements over the last couple years:

  1. Pharmacy Agrees to Pay $1.5 million to resolve allegations it filled illegitimate controlled substance prescriptions (May 2022)
  2. Pharmacist to pay $275,000 to settle claims related to the alleged unlawful dispensing of controlled substances (including the ‘holy trinity’) (November 2021)
  3. Pharmacy, pharmacist to pay $2.1 million for dispensing illegitimate prescriptions (March 2020) Note: This settlement was the fifth prosecution of pharmacies/pharmacists affiliated with a convicted pill-mill doctor

Drug wholesalers are also pulled into the fray with their responsibility to identify and report “suspicious orders” of controlled substances. McKesson, Cardinal Health, and AmerisourceBergen have all had settlements and/or civil penalties (as high as $150 million) related to Controlled Substance Act violations. In 2019, there were felony criminal charges filed against a distributor and its executives for illegal distribution of controlled substances. Their failure to effectively oversee suspicious orders caused them to go out of business.

Consequently, wholesalers are increasing their constraints on controlled substance purchasing. There are more rigorous applications, wholesaler audits, and purchasing thresholds which cannot be exceeded. PAAS National® has also become aware of wholesalers (nearly immediately) terminating a pharmacy’s ability to purchase controlled substances. In its notice to the pharmacy, the wholesaler flagged the following practices:

  • Dispensing antagonistic combinations concurrently (benzodiazepines or opioids with amphetamines)
  • Dispensing therapeutic duplications (two benzodiazepines or two IR/ER opioids)
  • Dispensing opioids and benzodiazepines concurrently
  • Dispensing controlled substance prescriptions for prescribers with current, or historical, discipline – particularly as it relates to prescribing concerns
  • Lacking policies and procedures to ensure against the diversion of controlled substances

PAAS Tips:

  • Review the DEA Pharmacist’s Manual (updated in 2020)
  • Utilize your state’s controlled substance Prescription Drug Monitoring Program to identify early refills, polypharmacy, and multiple prescribers
  • Educate all staff on high risk dispensings

When Should I Obtain a Diagnosis Code for Ozempic?

Since Ozempic® was FDA approved December 5, 2017, PAAS National® has fielded many questions regarding dispensing this expensive injectable diabetic medication. The questions relate to dosing, calculations, billing, and off-label use. PAAS cannot overemphasize the importance of calculating the correct days’ supply. Use the chart below and prior PAAS articles to help pharmacy staff calculate the correct days’ supply.

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NDC Label Color Dose Administered Initial or Maintenance Dose Number of Pens Per Box Milligrams Per Pen Billing Quantity Per Box
00169-4132-12 Red 0.25 mg or

0.5 mg only

Initial Dose (0.25 mg) or

Maintenance Dose (0.5 mg)

1 pen 2 mg 1.5 mL
00169-4130-13 Blue 1 mg only Maintenance Dose 1 pen 4 mg 3 mL
00169-4772-12 Yellow 2 mg only Maintenance Dose 1 pen 8 mg 3 mL

Off-label use is a concern because of Wegovy™, which has the same analog name (semaglutide) as Ozempic®, but is FDA approved for weight loss. To reduce audit risk, pharmacies should be vigilant in attempting to identify when a prescriber is working around a plan exclusion or prior authorization by prescribing Ozempic® instead of Wegovy™. With the FDA’s approval of 2 mg weekly dosing for Ozempic in March 2022, this became more challenging as higher dosing is not necessarily indicative of off-label use. Keep in mind, federal programs like Medicare Part D and Medicaid do not pay for off-label use and claims billed for non-diabetic patients could be recouped. Consider obtaining a diagnosis code if any of the following apply when starting patients on Ozempic:

  • The prescription was originally written for WegovyTM
  • This is the first antidiabetic agent being prescribed for the patient
  • The prescription is written for the analog name
  • The prescription has an indication for weight loss

Pharmacies dispensing Ozempic prescriptions for weight loss may incur significant audit recoupments. Consider collaborating with prescribers to educate them on the risks to help ensure appropriate billing practices.

PAAS Tips:

  • Medicare gives preference to a “pay and chase” model when it comes to claims – they want beneficiaries to receive needed medications and will pay the claim at point-of-sale assuming the medication is being used in an FDA approved manner
  • According to the package insert for Ozempic®, 0.25 mg per week is considered the first step in the initiation of Ozempic® and would be considered a subtherapeutic dose as it is insufficient for glycemic control
  • The NCPDP billing unit for Ozempic® is “mL” however; the patient instructions are to inject “mg”
  • See November 2021 PAAS Newsline article, Beware: Same Ingredients, Different FDA Indications
  • See February 2022 PAAS Newsline article, Oh, Oh, Oh… Ozempic®
  • See March 2022 PAAS Newsline article Off-Label Use Not Covered Under Medicare Part D

Insulin Glargine (Winthrop) – Unbranded Biologic of Lantus®

Insulin glargine labeled by Winthrop U.S. came to market in May 2022, and with it a lot of additional confusion regarding pharmacy level substitution.

Keen eyed observers will notice that Winthrop is “a Sanofi company”, and that both Lantus® and insulin glargine (Winthrop) have the same Biologics Licensing Application (BLA) number BLA021081 – which makes it an “unbranded biologic” of Lantus®.

Please see a few important notes about unbranded biologics from FDA Purple Book FAQ #9:

  1. Unbranded biologics are not separately listed in FDA Purple Book
  2. Unbranded biologics are not the same as an interchangeable biosimilar
  3. Unbranded biologics are considered by FDA to be equivalent to its brand name biological product because it is the same product as the brand name biological product under the same BLA

Remember that pharmacy level substitution of a reference product is only allowed if biologic drugs are either (i) identified as interchangeable OR (ii) an unbranded biologic with the same BLA number. For biologic drugs that don’t fall into these two categories, you must obtain prescriber approval prior to substituting.

Here is a summary table of how to understand insulin glargine products:

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Prescription written as: Okay to substitute WITHOUT prescriber approval (if allowed by state law)

BLA 021081

Reference Product

Insulin glargine (Winthrop)

BLA 021081

Unbranded biologic


BLA 761201

Reference Product

Insulin glargine-yfgn (Mylan)

BLA 761201

Unbranded biologic


BLA 205692

Reference Product

Lantus® Yes Yes Yes Yes No
Semglee® Yes Yes Yes Yes No
Basaglar® No No No No Yes
Insulin glargine* Yes, however consider clinical context – has patient taken one product previously?

*Treat this like a situation where prescription is written as “albuterol sulfate HFA inhaler”

PAAS Tips:

  • Unbranded biologics should be treated in the same way as an authorized generic.
  • State pharmacy laws may limit biosimilar interchangeability, but this does not apply to unbranded biologics. For information about your state laws:
  • See updated Insulin Medication Chart under the Tools & Aids section of the PAAS Member Portal

Why PAAS Cultural Competency?

Developed by pharmacists for community pharmacies, PAAS National® brings you a tailored approach to Cultural Competency and Linguistically Appropriate Services using the PAAS Care Model. Your training history is documented, retrievable and easily tracked throughout the year. Simply put, the training is more realistic for pharmacy staff, and documented should you ever need evidence of completion – training, done better.

“We understand there is a need to address federal and state requirements and meet PBM credentialing requirements,” stated Trent Thiede, President at PAAS National®, “The PAAS CARE Model can be used in any patient interaction to help identify a patient’s cultural differences and guide the pharmacy on how to proceed.”

The PAAS CARE Model is an acronym for Competence Evaluation, Adherence, Realistic, Evaluate and Educate in the training module. Our adage of “Be aware to CARE” uses real-life, pragmatic examples to serve as a launching pad for enhancing patient experiences. PAAS’ unique approach to training ensures its content resonates with all pharmacy staff, making the goal of cultural competence achievable, across the board.

Plus, if you are already a PAAS Fraud, Waste & Abuse and HIPAA Compliance member, your employees will have the ease of completing their FWA, HIPAA and Cultural Competency training on one screen. No clicking to multiple programs or browsers to access the yearly training for your staff.

If you would like more information about PAAS Cultural Competency Training Program starting at $99/year, please visit paasnational.com/culturalcompetency or contact PAAS National® at (608) 873-1342 or info@paasnational.com.

Beyond-Use Date vs. Nursing Home Storage Policy – Avoid this Recoupment Trap!

Manufacturers go through rigorous testing to bring their products to market and part of the tedious approval process includes stability, sterility, and beyond-use date (BUD) testing. Pharmacies should be familiar with a product’s stability, sterility, and BUD information since these timeframes may come into play when determining the correct quantity and days’ supply to bill. Insulin pens and vials are the most commonly billed products where the BUD may influence the days’ supply. For example, a single vial of Lantus® or NovoLog® is good for 28 days once the top is punctured; therefore, a single vial of either of these insulins should always be billed for 28 days or less. Alternatively, a single vial of Levemir® is good for 42 days once it has been punctured; therefore, a single vial of Levemir® should always be billed for 42 days or less. For additional BUD information, refer to Section 16 of the manufacturer product labeling, or see PAAS’ various Days Supply Charts found in the Tools & Aids section of the PAAS Member Portal.

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Pharmacies billing for nursing home patients may come across yet another “date of importance” – the maximum time a product may be stored according to the facility’s storage policy. PAAS National® analysts see pharmacies billing eye drops, inhalers, and insulin products as a 28-day or 30-day supply even though the directions on the prescription, the manufacturer product sterility information, and the BUD all support a longer days’ supply. Using the Levemir® example from above, if a pharmacy had a prescription for a Levemir® vial 100 units/mL, injecting 12 units subcutaneously nightly (dispense 10 mL), a single vial would have 83.3 doses or 83 days of medication. However, the BUD of a single vial is only 42 days; therefore, this should be billed as a 42-day supply. If a nursing home facility has a policy to discard all insulin vials after 28 days, then a pharmacy would be tempted to bill this as a 28-day supply but be aware of the repercussions this billing process could have! Nursing home practices and policies do not invalidate FDA/manufacturer sterility testing. Adjusting the days’ supply to 28 days to follow the facility’s policy often leads to “invalid day supply” penalty fees and full recoupments on early refills since PBMs will not take into consideration nursing home policies when determining days’ supply.

PAAS Tips:

  • Always attempt to bill the true/accurate days’ supply on a claim.
  • Utilize PAAS tools to facilitate correct billing:
    • Insulin Medication Chart
    • Eye Drop Chart
    • Can You Bill It as 30 Days?
    • Oral Inhaler Chart
    • Additional billing resources are available in the Tools & Aids section of the PAAS Member Portal.
    • Find additional manufacturer storage information on DailyMed.
  • If there is no state law to substantiate a facility’s storage policy which is more restrictive than manufacturer’s storage guidance (i.e., billing eye drops, inhalers, insulins, etc. for 28 or 30 days due to facility policy when they truly would last longer according to directions and manufacturer sterility information):
    • Consider talking to the facility’s Director of Nursing about revising their policy so your pharmacy can avoid penalty fees and recoupment issues, or
    • Insist that the pharmacy must bill for the true days’ supply according to directions and product labeling. If the facility’s storage policy requires early fills, then the facility will have to pay for those early fills. This is unlikely to be well-received by any facility and may help open lines of communication about changing the facility’s policy.

DMEPOS Mini-Series #2 – Ostomy Supplies

PAAS National® often sees recoupments on ostomy supplies due to unsupported medical records. Insufficient documentation accounted for 86.8% of improper payments for ostomy supplies in 2019, around $65.5 million. Please see the tips provided below to help ensure Medicare B coverage and payment for a beneficiary’s ostomy supplies.

PAAS Tips:

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  • Coverage
    • Beneficiary must have a surgical created opening (stoma) to divert urine or fecal matter outside the body
    • The location, construction and skin condition surrounding the stoma must be discussed in the medical record
    • Diagnosis driven by the type of ostomy the beneficiary has:
      • Colostomy – opening into the colon (large intestine)
      • Ileostomy – opening into abdominal wall (small intestine)
      • Urostomy – opening into abdominal wall that connects to urinary tract
    • Ostomy supplies are not separately payable when in a covered home health stay
  • Continued Medical Need
    • Once the initial medical need has been met, the ongoing need for ostomy supplies is assumed to be met.
    • If the beneficiary continues to meet the medical guidelines, no further documentation is required
  • Coding Guidelines
    • Diagnosis must be documented in the medical record as well as submitted on the claim for coverage consideration
    • Barrier (also known as a Wafer or Faceplate) – protects skin from stoma output and keeps the pouch in place
      • Solid barrier
      • Liquid barrier – liquid OR spray and individual wipes OR swabs may be used but not both
    • Pouches – can be one-piece or two-piece
    • Tape and adhesive – an AU (Item furnished in conjunction with a urological, ostomy, or tracheostomy supply) modifier code must be billed for tape and adhesive
  • If a continent stoma:
    • use only one type of supply per day
    • can be a stoma cap, stoma plug, stoma absorptive cover or gauze pads
  • Covered diagnosis, Healthcare Common Procedure Coding System (HCPCS) codes, modifiers and maximum allowances per month can be found in the LCD and policy articles
  • Quantity of supplies needed depends on the type of stoma, condition of skin surface, location, and construction
  • If beneficiary resides in a nursing facility, pharmacies are limited to billing a one-month supply
  • If beneficiary resides in their home, pharmacies can bill for a 3-month supply and will need a narrative on the claim for the 3-month supply
  • See the June 2022 Newsline article CGS® and Noridian Self-Service Tools and Resources for Durable Medical Equipment, Prosthetics, Orthotics and Supplies for guidance on claim status, eligibility, same or similar items and more
    • Additional Resources
      • Jurisdictions JB and JC Portal – MyCGS
      • Jurisdictions JA and JD Portal