PBMs Dramatically Increase Their Audit Focus on Copayment Collection. Is Your Pharmacy Prepared?

Over the past few weeks, multiple Pharmacy Benefits Managers (PBMs) have been dramatically increasing their focus on a pharmacy’s collection of copayments or other patient pay amounts from the PBMs’ patients. Express Scripts, Caremark and MedImpact are just some of the PBMs who have stepped up their focus on participating pharmacy’s copayment collection practices, and their ability to document the collection of copayments.

The PBM manuals generally prohibit the waiver of a patient’s copayment, but in recent months, have been amended to include prohibitions on advertising waivers and requirements that a pharmacy maintain evidence that it received the copayment for a particular patient. Some PBMs have even gone so far as to issue Special Alerts highlighting their increased focus on these issues. Based on these new provisions, several PBMs have (within the last two weeks) carried out multiple targeted audits of pharmacies’ copayment collection. In light of these developments, it is important for pharmacies to be prepared to prove their actual receipt of copayment (whether by cash, check, credit card or otherwise), and to demonstrate their policies and procedures in this regard. Frier Levitt can draft robust policies and procedures to help protect your pharmacy and ensure compliance with the PBM manuals and State and Federal laws. Contact us to speak to an attorney.