Why You Should Care About PBM Provider Manuals (and Where to Find Them)

Whether your pharmacy contracts directly with a PBM or the agreements are negotiated through a Pharmacy Services Administrative Organization (PSAO), the terms and conditions within the agreements are just the beginning of a pharmacy’s obligations. Additional expectations for the pharmacy are laid out in the PBM’s Provider Manual. Understanding and following the stipulations contained therein can help decrease your risk of audit recoupments and keep the pharmacy in good standing. However, these manuals vary significantly by PBM, often exceed 150 pages, and can get updated multiple times throughout the year – making it impossible for pharmacies to keep up with all the requirements. Making matters worse, PBMs do not accept a plea of ignorance and violating the provider manual can lead to claim recoupment, accusations of fraud, waste, or abuse, and even contract termination!

Through our Newsline and audit assistance, PAAS National® helps pharmacies stay abreast of these changing requirements as they relate to audits. To access the Provider Manuals directly, follow the links below: 

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  • Caremark produces (and mails) a biennial version to all contracted pharmacies on even years and supplements on odd years. An electronic copy can also be found on the pharmacy provider website (log in required).
  • Express Scripts tends to update their manual periodically throughout the year and they post the newest version online in the Pharmacist Resource Center (log in required) along with an itemized list of updates. Reviewing the itemized updates is an efficient way to stay on top of the changes Express Scripts implements.
  • Humana publicly posts their provider manual online on the Pharmacy Manuals and Forms page of their website.
  • OptumRx updates their provider manual several times throughout the year and has a copy publicly available under the Manuals and Guides section of their Health Care Professionals website.

PAAS Tips:

  • Be proactive and read PAAS’ Newsline in its entirety each month
    • The paper Newsline only contains half the content that PAAS produces each month – be sure to log-in to the PAAS Portal to view additional articles and PAAS Tips
    • Add additional employees to the PAAS Portal to increase eNewsline readership and ensure that small details don’t get missed
  • Have questions about a specific topic and don’t know where to start? PAAS analysts can guide you through the PBM requirements and refer you to appropriate sections of the PBM’s provider manual, when applicable

Sara Hathaway, PharmD