How Saving a Patient Money can Cost Your Pharmacy the Entire Paid Claim Amount or Worse, Your Pharmacy’s PBM Contract.
Most who have worked in a pharmacy for some time can remember the Purple Pill Card, the Nexium Savings Coupon with the catchy name and bright purple colors. Not only did this program have catchy marketing, but it also saved patients a portion of their copayment. This was a great way for patients to afford their medication more easily. Manufacturer coupons have been around for some time and can be a great method of saving patients some money. Did you know that not all Manufacturer Coupons are created equally? While Manufacturer Coupons are prohibited from being applied to both Federal and State funded benefits, were you aware that you are in violation of your PBM contract if you apply a Manufacturer Coupon to non-FDA approved medications or devices? While you may be able utilize a Manufacturer Coupon on a paid claim to save your patient money, you may be putting yourself at risk for audit recoupments and possibly the termination of your PBM contract for prohibited waivers of a Patient Pay Amount. The main rule when applying a Manufacturer Coupon to a paid claim for a medication in which you are unsure of the FDA approval status or device status, you must verify the medication before submitting the Manufacturer Coupon.
The FDA Provides searchable databases online which can be used to verify approval status. Databases include the FDA Orange Book for FDA Approval Status, the FDA Purple Book for Biologics and Biosimilars, and the 510k Premarket Notification Database for devices that may be FDA approved but are disallowed from Manufacturer Coupons by the PBMs. The PBMs also list specific Manufacturer Coupon Programs that are strictly prohibited from use. Contact Boesen and Snow Law today for guidance in the proper utilization of Manufacturer Coupons and PBM audits.