Excluded Prescription Drugs Paid as Covered Benefit While Discount Guarantee Doesn’t Add Up
For the month of September, BMI is pleased to present a recent finding from one of our prescription drug audits.
Audit Issue
Our client’s group pharmaceutical plan specifically excluded fertility drugs as a covered benefit. In addition, our client had contract language in their administrative services only (ASO) agreement that specified certain aggregate AWP generic discount guarantees.
TPA Response
The administrator confirmed our findings regarding several prescriptions for fertility drugs having been paid in error. BMI also identified a significant shortfall in the AWP generic discount guarantees.
Audit Finding
The administrator confirmed that a fertility drug exclusion edit was not in place that should have been. In addition, as a result of BMI’s findings and the administrator’s subsequent reconciliation, the administrator confirmed the shortfall in the AWP generic discount which identified recoverable dollars back to the client as a result of the shortfall.
Financial Error
The administrator agreed to combined financial recoveries of $70,000. The audit also identified an estimated future annual savings of $150,000 due to enhanced utilization management of hormone-enhancement drugs and an increased coverage in the prior-authorization program