PHARMA INDUSTRY RISK FACTORS
Mail Order Pharmacy Risk Factors
- Duplicate billing & dispensing
- Automatic refills when not needed
- Exceeding contractual days supply
- Re-packaging & charging a higher price
- Unapproved drug switching
- Dispensing low cost generic & billing a higher cost generic
- Manipulation of MAC pricing
- Mail Order claims are adjudicated through a different process than the retail claims which has been found to have fewer edits
- PBM does not check for inflated re-packaging prices from the Mail Order facility
- PBM uses Mail Order facility to:
a. Market drugs to beneficiaries & physicians
b. Increase profitability with inconsistent manufacturer drug
price updates (Mail Order has been known to institute price
updates 3 to 6 months ahead of official price updates from
the drug manufacturers)
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