Prescription Drugs Did Not Get the Required Prior-Authorization
Audit Issue
The terms of our client’s group pharmaceutical plan specifically stated that benefits for certain drugs could not be paid unless prior-authorization was obtained on behalf of the participant.
Audit Finding
We confirmed that benefits were paid on more than 100 occurrences when the prior-authorization requirement was ignored by the Pharmacy Benefits Manager (PBM).
PBM Response
The PBM agreed with our findings noting that prior authorization criteria had been erroneously eliminated from its system without detection.
Financial Error
The PBM agreed to recoverable financial errors of more than $50,000.