PBM Provider Manual Updates – What You Need to Know

Pharmacy Benefit Managers (PBMs) update their provider manuals on occasion (some more frequently than others) and although the changes are applicable to the practice of all pharmacies contracted with that PBM, it can be difficult to keep track of the method by which each PBM updates their manual and where to find it.

  • Caremark – Generally they mail out a paper, hardcopy of their provider manual to contracted pharmacies every other year, on even years, and amendments on odd years. An electronic copy can also be found at the bottom of the Document Library on the pharmacy provider website (log in required).
  • Express Scripts® updates their manual and posts the newest version online in the Pharmacist Resource Center (log in required) along with an itemized list of updates. Pharmacy staff can read the itemized list if they are looking for an efficient way to access and review the updates.
  • Humana – Their provider manual is publicly accessible via the Pharmacy Manuals and Forms page of their website, which affords all pharmacies quick and easy access to the relevant information.
  • OptumRx® updates their provider manual multiples times each year. The newest being Version 4.1 which was published at the being of October 2021. The provider manual for OptumRx® is publicly available under the Manuals and Guides sections of the Health Care Professionals website. However, OptumRx® does not provide a summary of changes or a quick reference guide. Below are several significant updates from recent versions of their provider manual.

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    • Contracted pharmacies must provide language interpreter services in accordance with their state’s requirements or regulations.
    • Examples of “computer records” are now included under desktop and telephone audits and investigational reviews; these examples include electronic prescriptions (new and refill authorizations) as well as electronically stored clarifications or notes.
    • Over the course of 2021 several major additions have been made to the discrepancy code list:
      • 1P and 4B – Previously, claims billed with an invalid prescriber DEA number received these codes. Now, they will be utilized for invalid NPI number as well.
      • 2L – This discrepancy has been utilized when a script was missing documentation to validate the clinical appropriateness on a claim with possible clinical issues (gender/age/drug). Now, it will also be used for “possible high dose” claims without documentation supporting the appropriateness of the dose.
      • 3B – This will be utilized on claims with missing or invalid Risk Evaluation & Mitigation Strategies (REMS) documentation. For additional REMS information, refer to the June 2021 Newsline article Would Your REMS Prescription Pass an Audit?
      • 4Q – In states where prescriptions issued by mid-level practitioners require information regarding the supervising doctor, this code will be used if the supervisor’s information is missing.


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PAAS Tips:

  • It is important to stay up to date on the requirements of each PBM you are contracted with
  • Becoming familiar with a PBMs pharmacy provider manual can help the pharmacy prevent recoupment when audited and remain proactive by ensuring pharmacy policies and procedures are in line with PBM requirements
  • If your pharmacy receives a PBM notification regarding a policy change, please forward the notice to PAAS National® via fax (608) 873-4009 or email info@paasnational.com

Meredith Thiede, PharmD
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