Fraud, Waste, & Abuse

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PBMs employ a variety of state-of-the-art techniques when working with pharmacies and other stakeholders to combat fraud, waste, and abuse. Vigilance against fraud is paramount to ensure that scarce health care resources are used for legitimate purposes.

According to PCMA-sponsored research, approximately 1 percent of prescription costs are likely due to fraud, waste, and abuse — amounting to hundreds of millions of dollars in unnecessary costs for consumers and payers. Typical examples of fraud, waste, and abuse that are detected by PBMs include prescription claims submitted with the improper medication quantities, improper days’ supply, improper coding, duplicative claims, and other irregularities.

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