Potential fraud and abuse
Challenge
- May 2025 – PBIRx noticed a significant amount of increased claims for Zenpep
- PBIRx monitored utilization for the next few months through monthly reports
- There were 49 total claims filled between May and Sept 2025
- 46 out of 49 claims were prescribed by one physician and filled through one independent pharmacy
- Total plan cost for 46 claims was $234,596.08 between May and Sept 2025
- For comparison, our total book of business for Zenpep for full 2025, was 259 claims and total plan cost $1,078,517.90
- Requested the PBM to review and investigate
- The PBM sent this for Fraud, Waste, and Abuse (FWA) review due to the increase and due to the potential off label indication/dosing and review off-label use and guidelines for use of the medication
- It was identified that these members did not have pancreatic insufficiency or Cystic Fibrosis and Zenpep was being prescribed off-label
- The client did not have Zenpep on any Utilization Management (UM) program
Solution
- PBIRx recommended client remove the pharmacy from their network and implement a UM program for Zenpep
- PBIRx recommended to exclude the pharmacy from the network
Result
Potential Cost Savings:
$40,000+ per month
Zenpep was added to high-cost drug program, where the member has a higher cost-share
