It’s crucial to adhere to the manufacturer coupon rules, not just for the benefit of your patients, but also to steer clear of potential PBM audit issues.
It used to be so easy. Back in the day (yes, I am getting old, I can say back in the day!), if you had a manufacturer coupon, you could bill it without any concerns.
Nowadays, you have to ensure you aren’t breaking any PBM rules in regard to manufacturer coupons.
Let’s review some rules together.
Doing Manufacturer Coupons Right
This review isn’t meant to be a substitute for any of your PBM contracts or an all-encompassing rule review. I am going to dive into the most common rules that pharmacies innocently break. I don’t want you to fall into any avoidable potholes.
Who issued the coupon?
This question is a great place to start. PBMs require that the coupon is funded by the manufacturer, not a wholesaler or a pharmacy. This reason is why Caremark bans coupons from companies like Phoenix PBM, Affordable Medical Solutions, and others. Coupons from these companies are funded by wholesalers and pharmacies. Always be sure to read your provider manual for the latest list of banned companies.
Is the product a drug, supplement, or a 510k device?
Again, due to Caremark, you must know the type of product the coupon is for. Caremark treats coupons for Rx Only supplements and devices differently than it does for FDA-approved drugs. Something you think is a drug might be classified as a 510k device. This confusion is common for many topicals or oral solutions. To use a manufacturer coupon with any Caremark claim, the product must be an FDA-approved DRUG.
What primary insurance does the patient have?
This restriction is ubiquitous across all PBMs. You cannot use a manufacturer coupon for any claim paid for with federal dollars. If the patient has Medicare, Tricare, or Medicaid, you cannot bill a manufacturer coupon for their copay. Also, if the patient has no primary insurance, you won’t be able to use many coupons because they require secondary coverage only. You’ll have to read the fine print of each coupon before you bill it.
What Happens If You Do It Wrong?
Caremark has the most egregious rules regarding coupons and, therefore, is the most aggressive when it comes to audits. If you bill a coupon when you shouldn’t have, you could lose your contract. Essentially, the PBM will say you wrongly waived the copay when you use an improper coupon.
Copays are seen as a barrier to getting a prescription. The PBM wants the patient to have skin in the game when getting a prescription. Manufacturer coupons eliminate the share of the cost and, therefore, make prescriptions easier to get. While the lower price is good for patients, PBMs say it drives up their costs and drug utilization. (’cause we all know that is bad *eye roll*)
The Consequences of Losing An Audit
If you are audited and are found to have used coupons incorrectly, you will be charged back the full amount of the prescription. This recoupment would mean you lose all paid money and essentially give away the prescription for free. You lose the entire amount the drug costs you.
In addition to potentially losing a large amount of money, the PBM could decide to cancel your contract. If it is only 1-2 claims, you are probably not at risk of losing a contract. However, if they see a pattern of behavior, you could lose your contract and be banned for several years. This loss of contract would devastate most independent pharmacies.
Manufacturer Coupon Case Studies
Let’s look at some of my favorite products and see if you can use a coupon or not.
Clemastine – NDC 73308-0358-12 – Daily Med Profile
You can use the coupon for Clemastine Syrup on Caremark because:
- The coupon company Drexi is not on the banned list.
- The product is on the market due to ANDA (you can see this on the Daily Med Profile).
- Medicare, Tricare, and Medicaid patients are not eligible.
Xyzbac – NDC 69597-0 314-30 – Daily Med Profile
You cannot use the coupon for Xyzbac on Caremark because:
- The product is a dietary supplement, not a drug. Even though it is a prescription product (and an awesome one!), its approval category makes it ineligible for Caremark. With other PBMs, you are okay with using a coupon.
Oxaprozin 300mg – NDC 73308-0403-60 – Daily Med Profile
You can use this manufacturer coupon on Caremark and other PBMs because:
- The company Drexi is not banned.
- The product is available through a NDA.
I want to help you stay compliant. You can submit any questions you have to drlisafaast.com, or members can submit them through the Pharmacy Badass University membership portal. If you want to ensure you are doing all PBM billing correctly, check out this PBM Audit Blog.
