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.

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  • 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)
    • 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.
        • 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.
  • 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.

Dana Westberg, CPhT