We’ve been asked by clients and direct competitors, how COVID-19 is changing the landscape of PBM auditing and consulting. We’d like to address a couple of misconceptions and discuss how PillarRx is adjusting processes to accurately validate PBM performance during these changing times.

1. Reviewing PBM performance won’t take into consideration CMS’ changing parameters such as refill-too-soon

During periods of emergency declaration, CMS will mandate that sponsors make adjustments to some of their formulary edits to increase access to care. PillarRx proprietary software is built around algorithms that mimic PBM adjudication systems, any change mandated by CMS is adjusted within our own software prior to performing pharmacy claim audits. For example, where a plan design may have allowed at a 75% refill rate at retail, in accordance with CMS guidance sponsors are now expected to lift refill-too-soon and some extended day supply edits to allow members greater ease in accessing their medications. Be sure to document these temporary changes to your formulary edits as part of your emergency preparedness plan and ensure that your PBM auditor is taking this into consideration!

2. Prior authorizations will not be applied correctly

Prior authorizations and step therapies are important formulary utilization management tools that provide not only cost containment measures but also ensure the right medications are getting dispensed. The principles hold true during a time of emergency declaration as well and CMS expects them to continue to be monitored by sponsors. Validating the accuracy and timeliness of prior authorizations based on medication and dosing volumes is even more critical to maintain confidence that your members are getting access to the medications they need when they need them.

One change is that CMS is allowing Medicare Part D plan sponsors to waive prior authorizations for Part D drugs or services related to COVID-19. Any Medicare Part D program providers choosing to waive prior authorizations specific to COVID-19 treatments should be validated for consistency across all Medicare Part D members.

PillarRx’s software is adjustable, meaning Medicare Part D pharmacy claims were properly adjudicated. Conversely, those Medicare Part D plans to choose not to waive COVID-19 prior authorizations, PillarRx will validate results based on contractual agreements already in place. If your auditor isn’t reviewing 100% of your PBM claims and isn’t adjusting prior authorizations to reflect Medicare Part D programs and CMS permissible actions, your pharmacy spend could be severely impacted and you could be as risk for noncompliance.