Mailing Prescriptions? How to Ensure Audit Success

PBMs will require proof of delivery that contains information clearly showing what was in the package delivered. Most PBMs require a link between the delivery confirmation (via a tracking number) and the prescription record to show which prescription was being delivered. There should also be a patient signature or tracking detail from the carrier showing the date and location where the medication was ultimately received.

Notably, not all PBM agreements allow the mailing of prescriptions, while others may restrict mailing to a percentage. Humana and OptumRx typically prohibit mailing under retail agreements, and OptumRx further restricts delivery to within 100 miles by W-2 pharmacy employees. Caremark only allows up to 20% of their claims to be mailed.

Another consideration for pharmacies is ensuring you are licensed in any state you are mailing to. Many states have laws that require pharmacies to obtain a non-resident license to ship, mail, deliver, or dispense prescription medications into their states. Auditors look for these [expensive] claims to take advantage of well-meaning pharmacies who may not know of these requirements. Pharmacies located on state borders making deliveries into another state may also run into this problem as well.

PAAS Tips:

• Have a system that links the tracking number to the prescription record to indicate the contents being shipped.
• Print confirmation of delivery and keep it in a readily retrievable manner for audit – some carriers only keep tracking information for as little as 120 days, depending on the service used.
• Before mailing/delivering prescriptions out of state, it is a good idea to check with that state’s Board of Pharmacy to see if there are any licensure requirements for doing so.
• Be aware of your contract obligations and which PBMs do not allow mailing prescriptions to patients.
• For all DMEPOS items and supplies billed to Medicare Part B, proof of refill request and an affirmative response is required to occur and be documented prior to shipment.
• PAAS’ Proof of Refill Request and Affirmative Response for DMEPOS Items can be downloaded from our portal.
• If you do not require signatures upon delivery, consider providing the patient with a copy of our Signature Log Trifold Mailer to sign, fold up, and mail back to the pharmacy.
• Some PBMs, like Navitus Health Solutions, require a signature regardless of tracking information.
  • Have a follow-up plan in place if you do not receive the signed Signature Log Trifold Mailer back from patients.
• See the March 2025 Newsline article, Will Your Signature Logs Pass an Audit? for information on what auditors look for when patients pick up their medications or have them delivered.