BMI Audit Finding of the Month: 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.

Audit Finding of the M..., pbm, pharmacy benefits managerRandy Light, Founder + Executive Advisor