2024 Self-Audit Series #1: Insulin Prescriptions
Starting this month, we will be refreshing our Self-Audit Series with new and updated information. Each month will focus on different prescription types and provide pharmacies with information PAAS National® analysts are currently seeing on PBM audits. These articles can be an excellent training tool for new employees, and a great refresher for all pharmacy staff, to avoid audit discrepancies.
PAAS Tips:
- Dosage Form/Strength/Substitution
- Prescription should clearly indicate vials or pens – this should not be assumed.
- Concentration of the insulin should be clearly stated if more than one exists (e.g., U-100 vs U-500).
- See the February 2024 Newsline, Insulin Substitution Review: Understanding Purple Book Terminology
- Consider the pen device administrable dosing increments (0.5, 1, 2 or 5-unit increments)
- See the March 2024 Newsline, Dosing Increments for Insulin Pens
- Quantity
- Pharmacies should never assume they know what the prescriber intended for quantity; if unclear, be sure to clarify and document appropriately.
- Quantity of “one” is not sufficient for audit purposes and requires clarification.
- Unit-of-measure for the quantity prescribed must identify mL, pens, boxes, or units.
- Auditors will look at the overall quantity prescribed, so increasing to dispense a full box of pens must be authorized by the prescriber and documented, or additional quantity taken out of the refills authorized, where allowed by state law.
- If the prescription is for 9 mL with 2 refills (and your state allows you to accelerate refills), the pharmacy can still only dispense one 15 mL box without calling the prescriber for additional authorization.
- Instructions for Use
- Incomplete or unclear instructions should be clarified and documented prior to dispensing.
- Sliding scales or titration prescriptions must include a max daily dose the patient can use.
- Patient label must match prescription instructions, including max daily dose if clarified.
- Days’ Supply
- Calculate days’ supply based off the directions on the prescription.
- Follow instructions on our Can You Bill It As 30 Days? guideline if days’ supply for smallest package size (1 box for pens) exceeds plan limit.
- Do not assume the days’ supply indicated on electronic prescriptions is correct, this field will not be taken into consideration by auditors.
- Priming units for insulin pens are typically 2 units per injection; however, some pens require different priming units. Document priming units if used in days’ supply calculation.
- See the May 2023 Newsline, Nuances of Insulin Pens and How They May Differ.
- Insulin vials do not require priming.
- Be mindful of expiration dates for vials and pens – days’ supply should not exceed this date.
- Do not bypass plan limits by altering the days’ supply to get a paid claim. Follow the plan guidance and obtain a prior authorization if necessary.
- Route of Administration
- Insulin pens should always be self-administered.
- Rapid-acting insulin vials may be used for injection or in an insulin pump.
- Long-acting, pre-mixed, and concentrated insulin is not FDA approved for use in a pump
- Confirm Medicare B coverage for insulin used in pump.
- See PAAS’ Considerations for Billing Insulin Vials: Medicare Part B vs Part D flowchart for more information.
- Pharmacies should never assume they know what the prescriber intended for quantity; if unclear, be sure to clarify and document appropriately.
- Resource for Insulin Pens and Vials
- PAAS National® provides members with a practical Insulin Medication Chart
- This chart includes package size and dosage form, units/mL, total units per package and beyond use dates for pens and vials.
- PAAS National® provides members with a practical Insulin Medication Chart
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