V-Go® All-In-One Insulin Delivery Patch
The V-Go® all-in-one insulin delivery patch is a disposable device approved for use in patients with Type 2 diabetes.
Entries by Eric Hartkopf, PharmD
Caremark Notice of Breach – Aberrant Practices and Trends
PAAS National® analysts have recently assisted multiple pharmacies that received faxed notifications from Caremark that their pharmacy has “breached” the PBM Agreement by exceeding an arbitrary 25% threshold (by $ or # of claims) on the Aberrant Product List for their total claims dispensed in January 2024.
Caremark Invoice Audits – Purchases from Other Pharmacies
Caremark invoice audits continue to plague many pharmacies and often result in substantial audit findings and, occasionally, network termination.
Qualified Medicare Beneficiary (QMB) Program
Pharmacies may bill prescriptions from time to time for patients with dual eligibility, possessing both Medicare and Medicaid benefits.
Walgreens Reaches $360 Million Settlement with Humana Regarding Inflated Prescription Drug Prices
In January 2024, Walgreens and Humana reached a $360 million settlement to resolve ongoing lawsuits where Humana argued that Walgreens violated the PBM agreement by artificially inflating prescription drug prices for years.
Insulin Substitution Review: Understanding Purple Book Terminology
PAAS National® frequently gets questions about whether pharmacies may substitute various medications and if such substitutions require the approval of the prescriber.
Caremark Bulk Purchase Notification
PAAS National® analysts continue to see a large volume of Caremark invoice audits. Remember that Caremark will only review aggregate purchases over the selected date range plus the 30 days prior to. If pharmacies want Caremark to consider purchases made prior to the selected date range, then there must be a “bulk purchase notification” on file in accordance with Section 8.05 of the Caremark Provider Manual.
Major PBMs Announce “Cost Plus” Pharmacy Networks
In the fourth quarter of 2023, two of the “Big 3” PBMs announced that they will introduce new reimbursement methods for network pharmacies in the coming year(s) based on Cost Plus formulas in place of the typical AWP Minus terms.
Be Conscientious When Refusing to Dispense (or Bill Insurance)…
No pharmacy should be forced to dispense prescriptions below their acquisition cost.
Days’ Supply Considerations for Eye Medications
PBM audits regularly target eye medications looking to recoup on claims for incorrect days’ supply or early refills.
