Template Forms Can Lead to Audit Problems

Forms created by the pharmacy for the prescriber can be more problematic, as they may give the impression that the pharmacy is soliciting prescriptions or influencing the prescriber to choose one specific NDC over others. Cookie-cutter forms that contain only a small list of high AWP items, with each option featuring identical quantities, sig, and refills, are likely to attract PBM scrutiny.

Additionally, PAAS National^® has seen pre-printed prescription forms recouped during audits when they have cascading or overly broad substitutions. For example, if a topical medication is not covered, and the form provides a blanket allowance for the pharmacy to substitute the next topical medication on the list until one is covered, it could raise concerns about the pharmacy’s [conflicted] influence in the prescribing process. These medications are often more costly than preferred alternatives and can raise red flags for audits if the pharmacy is observed submitting claims, reversing them, and quickly billing for a different product. Many PBM provider manuals have now added language explicitly requiring pharmacies to have a verbal conversation with the prescriber before making any substitutions, which would need to be proven with a clinical note documented on the prescription.

Here is a summary of the three big PBM positions:

• Caremark: Pre-printed forms resulting in the dispensing of products that are not the most cost-effective items are prohibited (even if they are different salts, bases, or have different release characteristics)
• Express Scripts: Pharmacies using forms with multiple medications and substitution language must consult (and document) consultation with prescriber prior to dispensing the appropriate medication
• OptumRx: Dispensing or distributing Prescription Drugs/Drug Products which are not based on valid prescriptions for individually identified Members or are otherwise on pre-populated or templated prescriptions is prohibited. Such pre-populated prescriptions may also not include options for substitute products without individualized prescriber authorization or annotation.

PAAS Tips:

• Not all template prescriptions will draw the ire of PBMs
• PAAS has seen enforcement mostly focused on:
  • High AWP products where a cheaper alternative is available
  • Compounded pain/scar creams with broad substitution language
  • High AWP dietary supplements