PBM Prescription Validation Requests – What Are They Looking At Now?
The July 2024 PAAS National® Newsline article, What’s New with Prescription Validation Requests in 2024? compared the top five drugs targeted in the first six months of 2024. The chart below shows the top drugs picked for claim reviews in the second half of 2024, and a recap of the first half of 2024.
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| July-December 2024 | January-June 2024 |
| Ozempic® | Ozempic® |
| Trelegy Ellipta | Nurtec® |
| Eliquis® | Mounjaro® |
| Epinephrine | Creon® |
| Creon® | Ubrelvy® |
As you can see (and probably not a surprise), Ozempic® is the top drug reviewed through all of 2024. Additionally, you can see how the PBMs shift their focus on which drugs they select to perform claim reviews on.
The top 5 comments noted by an analyst after claim review for the second half of 2024 are the same 5 from 2023:
- Document the reason for the cut quantity – auditor will want to know why the pharmacy dispensed less that what was prescribed
- Black out acquisition cost and/or profit margin values on the backtag
- A clinical notation is needed and requires 4 elements: Date, who you spoke with and their title, what they confirmed, and the pharmacy employee initials
- Verify the quantity prescribed and make a clinical notation on the hard copy – Unit of Measure (UOM) is not specified or does not make sense for the medication ordered
- No backtag/sticker attached, typically requested by the PBM and helpful for PAAS to review the billing elements
PAAS Tips:
- Keep your employees engaged and help lower audit risk by adding all employees to the portal and giving them permission to access helpful tools, resources and eNewsline. For more information review the September 2019 Newsline article, What Are You Waiting For? Make Sure ALL of Your Employees are Added to the PAAS Portal!
- Have a question on a certain topic or medication? Search past Newsline articles to find answers to your questions.
- December 2024 Newsline, Reap the Benefits of the PAAS National® Newsline Archive
- Contact PAAS if you would like a tour of your PAAS Member Portal, so you can maximize the benefits of your PAAS Audit Assistance
I have a Bachelor of Science degree from the University of Wisconsin-River Falls and have been a Certified Pharmacy Technician since 2001. Prior to joining the PAAS team, I was a floating technician, 3rd party district chargeback specialist, and district pharmacy training coordinator. Formerly, I was also an instructor for pharmacy technician certification classes.
PAAS’ personal, one-on-one connection will help your pharmacy become more successful in dealing with tiresome PBM audits. It is a pleasure knowing that my colleagues and I can help member pharmacies.
- PBM Prescription Validation Requests – What Are They Looking At Now? - January 16, 2025
- Optimizing Prescriber Statements: Best Practices and Tips - January 8, 2025
- Adjusting Quantity or Days’ Supply Disproportionately Will Cost You! - December 24, 2024
