On January 30, 2023, President Biden’s administration announced that both the national emergency and public health emergency (PHE) for COVID-19 would be ending on May 11, 2023. This will have far-reaching implications for everyone in healthcare, including pharmacy.
While the PBMs took a break from auditing pharmacies in the early days of the pandemic, most gradually started up again by the end of 2020. They started with desk audits and slowly added back in larger virtual audits to take the place of the onsite audits. Most recently, PBMs have reinstated onsite audits. If you feel like you have been seeing more audits, it is likely because you are.
- January 2023, PAAS helped with 969 audits. A 30% increase year over year!
PBMs also made concessions in other audit areas due to the COVID-19 pandemic, including relaxed restrictions on mailing and delivery to patients during the PHE. They also made concessions allowing pharmacies to dispense prescriptions without obtaining a signature from the patient. While some PBMs and payors have already reinstated signature requirements, PAAS National® expects both of these situations to return to pre-pandemic requirements no later than May 11, 2023.
Some Public Health and Emergency Preparedness (PREP) Act authorities will end May 11, 2023, unless made permanent through state legislation. Check with your Board of Pharmacy and/or state pharmacy association to see what will still be allowed in your state. Requirements relevant to pharmacies that will be ending include coverage with no cost share for at-home COVID-19 tests/testing related-services for patients with Medicare, Medicare Advantage, and commercial insurance. Commercial insurers will also no longer be required to cover eight OTC tests per month. Health plans will no longer be required to reimburse out-of-network providers for tests/testing-related services, or cover vaccines for COVID-19 without cost-sharing when provided by out-of-network providers. They will also no longer be required to reimburse these vaccines at a “reasonable” rate.
It is difficult to know how the different health plans will handle these changes. Patients have grown accustomed to not paying any cost-share amount for these items. Adding cost-share may add to vaccine hesitancy concerns or hinder a patient’s ability to continue receiving COVID-19 vaccines and tests. Pharmacies will be on the front lines again helping patients navigate changing coverages.
- We recommend pharmacies start collecting signatures from patients for prescription pick-ups on or before May 11, 2023, if you have not already.
- PAAS Audit Assistance members can review the February 2023 Newsline article, Are Your Delivery/Signature Logs PBM Compliant for 2023?
- Check your state’s legislation to see what PREP Act authorities have been made permanent in your state.
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