Early Refills of Titrated Medications Lead to Recoupments

Example 1:

Prescription written for Victoza^® 18 mg/3 mL. Quantity 9 mL. Directions of inject 0.6 mg once daily for one week, then increase to 1.2 mg once daily for one week, then increase to 1.8 mg once daily.

The actual days’ supply of the first fill is 37. Each fill thereafter is a 30-day supply. If you refill the claim 25 days after the first fill, you are at risk of a “refill too soon.”

Example 2:

First prescription written for Mounjaro^® 2.5 mg/0.5 mL. Quantity 2 mL. Directions of inject 2.5 mg once weekly for 4 weeks.

Second prescription written for Mounjaro^® 5 mg/0.5 mL. Quantity 2 mL. Directions of inject 5 mg once weekly for 4 weeks.

Third prescription written for Mounjaro^® 7.5 mg/0.5 mL Quantity 2 mL. Directions of inject 7.5 mg once weekly for 4 weeks.

Each prescription filled should last the patient 28 days. If you fail to place the 5 mg and 7.5 mg prescriptions on hold and fill all three at once, the 5 mg and 7.5 mg prescriptions are likely to be recouped for “refill too soon,” “therapeutic duplicate,” “over utilization,” or “clinical misuse.”

PAAS Tips:

• Ensure the accurate days’ supply is billed on all titrated medications.
• If plan limits do not allow the correct days’ supply, follow PAAS’ Can You Bill It As 30 Days? guidance and do not refill until the actual days’ supply is nearing depletion.
• If receiving multiple prescriptions for the same medication with different strengths, place those not being used first on hold until the patient requires a refill.
• Not all patients will do well on the starter dose and may never require the additional medication.
• Filling those medications early may lead to waste.
• If the titration dose and maintenance dose are on the same prescription, consider the following options to accurately bill/dispense the medication:
• Enter the prescription into the system with the SIG representing the full titration and maintenance dose, making sure to adjust the days’ supply (and/or quantity) on subsequent refills.
  • Note: refills may process automatically, resulting in a wrong days’ supply or quantity. A wrong days’ supply would likely cause an early refill on the third dispensing, forcing the pharmacy to rebill the second claim.
• Enter the prescription in the system as two separate prescriptions, one for the titration and one for the maintenance dose. The titration can reference the maintenance dose in the SIG for patients and staff guidance.
• Review any DUR rejections and properly document resolutions.
• See the December 2023 Newsline article, Documentation Deep Dive: Meeting Auditors’ Standards in DUR and SCC, for more.