GLP-1 duplication of therapy, savings delivered $5,000 credit and PBM changed their internal processing to fix this issue across their book of business
Challenge
- PBIRx discovered that a member was utilizing 2 different GLP-1 medications, using 2 different MDs and 2 different pharmacies
- This concern was brought to the attention of the PBM and discovered the pharmacy was allowed to place a soft edit override
- PBM stated they would look into the claims and forward the issue to Fraud, Waste, and Abuse (FWA) department
- After months of inquiries and emails, the PBM determined there was no FWA involved and attempted to drop the case; however, PBIRx persistently argued that this was a case of waste (as these medications are not to be used together) and a potential safety issue to all members that use this PBM as Drug Utilization Review (DUR) and Utilization Management (UM) were not being performed.
- One of the main operations that PBMs offer, and that clients pay for in fees, is DUR and UM, and if these operations were performed as expected this duplication of therapy issue would have been discovered by the PBM
Solution
- After continuous pursuit and pressure from PBIRx®, the PBM has changed the criteria for processing GLP-1s and now duplication of therapy within the GLP-1 class of medication is not allowed, and pharmacists can no longer place a soft edit override at adjudication
- PBIRx was also able to negotiate $5,000 credit from the PBM to the client
Result
Credit to the Client
$5,000
PBM criteria now updated for ALL clients in the PBM’s book of business to prevent duplication of GLP-1 therapy
