Fraud Waste and Abuse

Substance Abuse Programs

Policy 0008

02/01/2000 Introduced
02/01/2005 Reapproved
11/01/2009 Reapproved
02/21/2018 Revised

Evidence-based Advertising of Pharmaceuticals

Policy 0012

02/01/2000 Introduced
02/01/2005 Revised
11/01/2009 Revised
12/01/2013 Revised
02/13/2019 Reapproved
02/21/2021 Revised

AMCP supports the establishment by state boards of pharmacy of counseling, treatment, prevention, and rehabilitation programs for pharmacists, pharmacy technicians and student pharmacists who are subject to physical or mental impairment due to the influence of drugs – including alcohol – or other causes, when such impairment has potential to adversely impact their abilities to function properly in a professional capacity.  AMCP supports the empowerment of state boards of pharmacy to use discretionary powers in determining employment waiver requests relating to the licensure of impaired pharmacists and pharmacy technicians.

Therapeutic Purpose Inclusion on Prescriptions and Medication Orders

Policy 0027

11/01/1999 Introduced
03/01/2004 Reapproved 
12/01/2008 Reapproved
10/01/2012 Revised
03/27/2017 Reapproved
02/13/2019 Revised
10/29/2019 Revised

Supply Chain Integrity

(Title prior to 02/21/2021 revision: Pharmaceutical Counterfeiting)

Policy 0505

10/01/2005 Introduced
02/01/2010 Reapproved
02/21/2021 Revised

AMCP encourages all entities involved in the pharmaceutical supply chain to assure that product integrity and stability is maintained throughout the continuum of the distribution system. AMCP supports the purchase and handling of products in ways that enhance the transparency and integrity of the product supply chain and encourages pharmacists to identify instances of product counterfeiting or adulteration. AMCP encourages efforts to provide consumers and health care professionals with information on how to avoid counterfeit or adulterated products and how to recognize, respond to, and report encounters with suspicious products.  

Drug Abuse/Illicit Drug Use

Policy 0604

04/01/2006 Introduced
12/01/2010 Reapproved
04/07/2015 Reapproved
03/29/2022 Revised

AMCP is concerned about reports of fraud, waste and abuse within the prescription drug benefit. Fraud, waste and abuse are unacceptable within any health care system, and result in unnecessary payments and costs to patients and public and private payers. AMCP supports efforts that would reduce the instance of fraudulent activity, such as lifting the current “any willing provider” requirement and amending current law and allowing plans to suspend payments to pharmacies upon a credible allegation of fraud.

(See AMCP Managed Care Pharmacy Practice Positions - Fraud, Waste and Abuse in the Medicare Part D Prescription Drug Benefit)

Fraud, Waste and Abuse in Prescription Drug Benefit

Policy 1105

10/01/2011 Introduced

Fraud

• AMCP supports efforts by both federal and state governments that enhance law enforcement’s ability to combat the actions of individuals who falsify prescription information or providers who write prescriptions for patients who intend to abuse the drugs.
• AMCP supports efforts to encourage the adoption of electronic prescribing systems, which could reduce the incidence of fraud at the pharmacy point-of-sale.
• AMCP is opposed to requirements that managed care organizations contract with any pharmacy willing to meet the terms and conditions of an organization’s contract, also known as “any willing provider” requirements. Without such requirements, a managed care organization may refuse to contract with a pharmacy that is suspected of fraudulent activity, such as a pharmacy that files claims and receives payments for prescriptions that are never filled.

Waste

• AMCP supports exemptions from these laws that would allow a health plan or PBM to suspend payment when there is credible evidence of fraud.
• AMCP supports efforts to make generic substitution an easy process for pharmacists and prescribers.
• AMCP opposes regulations that would unnecessarily place a burden on either party in order to make a substitution.
• AMCP supports allowing managed care organizations the flexibility to design pharmacy benefits that encourage the use of therapeutic treatment options that are most appropriate in terms of both patient outcomes and costs to both the patient and payer.

Abuse

• AMCP supports measures to prevent abuse of prescription drugs as well as prescription drug benefit plans.
• AMCP supports programs that gather dispensing information about controlled substances so that the pharmacist has a resource for checking “pharmacy and doctor shopping” patterns.
• AMCP supports sensible changes to current law that would allow Part D plan sponsors to help combat the problem of prescription drug abuse.

(See AMCP Managed Care Pharmacy Practice Positions - Fraud, Waste and Abuse in Prescription Drug Benefits)

Management of Opioids

Policy 1306

06/01/2013 Introduced
04/23/2018 Revised
02/13/2019 Revised

Prescription opioid medications can be effective for the treatment and management of severe acute pain; however, these medications are associated with serious risks to patients, including misuse, overdose, and death. To ensure the safe and appropriate use of opioid medications, the Academy of Managed Care Pharmacy (AMCP) supports policies that facilitate the ability of health plans and pharmacy benefit managers (PBMs) to effectively manage the use of opioids in their patient populations. Policies that address opioid use must strike an appropriate balance between the potential benefits and associated risks to patients. AMCP supports the ongoing development and use of prescription drug monitoring programs (PDMPs) and the expansion of PDMP access to include health plans and pharmacy benefit managers (PBMs). Allowing these organizations access to PDMPs will enhance their ability to recognize and assist patients who may be at risk for misuse or diversion of opioids and other controlled substances. AMCP supports mandatory electronic prescribing (e-prescribing) for opioids and other controlled substances as a means to reduce the potential for prescription forgery and errors and identify and minimize overprescribing.

AMCP further advocates for sensible changes to existing federal and state laws to authorize implementation of safeguards, including Risk Evaluation and Mitigation Strategy (REMS) programs, education on overdose prevention and treatment, naloxone distribution programs, and programs that facilitate proper disposal of unused prescription medications.

006/01/2013 Introduced*

04/23/2018 Revised (*subject originally included policy on abuse deterrent and tamper resistant formulations, those subjects now included in Policy 1802)

Therapeutic Purpose Inclusion on Prescriptions and Medication Orders

Policy 0027

11/01/1999 Introduced
03/01/2004 Reapproved 
12/01/2008 Reapproved
10/01/2012 Revised
03/27/2017 Reapproved
02/13/2019 Revised

Abuse Deterrent and Tamper Resistant Formulations

Policy 1802

04/23/2018 Introduced