New Year, New Insurance, New Formularies!

the opportunity to also ensure profile accuracy when adjusting the patients’ billing information. Is the patient’s address and phone number up to date? Do they have any allergies you may not have listed? Since a pharmacy employee is already in their profile adjusting the insurance information, it may be beneficial to verify that the demographics on file are still accurate.

While it is important to have current information for purposes of patient safety and accuracy, it’s also a requirement for some PBMs. Section 10.08 of Caremark’s Provider Manual highlights this requirement for maintaining up to date Part D patient information on their profiles. Often during an on-site visit, Caremark auditors will ask to see a covered Part D patient’s profile, looking specifically for patient demographics and allergy information. While PAAS National^® has not seen any significant recourse due to missing information on Part D patient profiles, consider validating these elements when updating insurance information.  

New Year also means new formularies! Be cautious of incoming refills utilizing a DAW 9 as a new formulary could require the generic or a different drug entirely. PAAS suggests challenging a historical DAW 9 (by trying to bill the claim with the generic) with any new plan year, change in insurance or new prescription being authorized.

PAAS Tips:

• Be on the lookout for person codes or insurance cards with patient specific ID numbers
• If a claim is rejected due to a mismatch in the patient’s date of birth submitted on the claim (versus the date of birth on file with the insurance company), call the patient to verify the correct date of birth.
  • If your system is correct and the insurance plan has documented the incorrect date of birth, be sure the patient contacts their plan (or Human Resources Department for employee-sponsored plans) and updates their information.
  • Changing the date of birth in your system to be incorrect (but match the PBM) is not advisable and can lead to dispensing errors and future claim issues.
• If you see a blank field in the allergies section of a patient’s profile, confirm allergy information with the patient and update their file accordingly.
• If your system has “no known allergies” listed for a patient, periodically verify that this is still accurate, as some patients develop allergies and sensitivities to medications, ingredients and foods as they age.
• Be sure to include not only food allergies, but allergies to dyes as well. Some examples are as follows:
  • Progesterone capsules can be made using peanut oil
  • Some flu shots may not be appropriate for patients with egg allergies
  • Many medications have dyes in them to produce their coloring
  • Gelatin allergy is crucial to document on a patient’s file, as many capsules are composed of gelatin