Avoid OptumRx® Double Chargeback Pitfalls – Review Your Days’ Supply

After the days’ supply has been adjusted, some of the subsequent [refilled] claims may be flagged as early refills – which result in a full chargeback. Now, if the interval between two fill dates is appropriate (i.e., not refilled early – typically 75% utilization of an accurate days’ supply for OptumRx^®), OptumRx^® will still look to chargeback any additional copay(s) that would have been incurred when the correct days’ supply was submitted (up to the plan limit for the actual days’ supply).

Here is an example where the patient has a $40 copay per 30 days billed:

Prescription is written for Symbicort^® 80 mcg retail package size of 10.2 grams with directions of 1 puff twice a day. Symbicort^® 80 mcg contains 120 puffs and therefore the calculated days’ supply would be 60. If the pharmacy accidently billed for a 30 days’ supply instead of 60 and the Symbicort^® was refilled monthly, OptumRx^® will flag every other fill as a refill too soon (2Z) and chargeback the full amount. On the dates of service flagged as invalid days’ supply only (1N), OptumRx^® will chargeback an additional copay that would have incurred had the pharmacy billed the claim correctly (assuming the plan didn’t limit the days’ supply to 30).

*1N – invalid days’ supply

*2Z – refill too soon

PAAS Tips:

• Insulin, inhalers, topical medications, and eye drops are frequently flagged for refill too soon or overbilled quantity
• Always submit claims with an accurate days’ supply first; many PBMs now have built-in overrides in place for smallest package sizes
• If plan limit is 30 days, then follow PAAS’ Can You Bill It As 30 Days?  
• Include a notation on the patient label to help notify the patient and pharmacy staff of the true days’ supply
• Check with your software vendor to see if additional days’ supply fields are available for internal tracking
• Avoid med sync or cycle fill programs for products whose correct days’ supply cannot be submitted for the smallest single package size
• The updated Audit Violation and Discrepancy Description for 1N can be found in the OptumRx Provider Manual on page 147
• Be proactive and utilize the PAAS Rx Days’ Supply Calculator. Download the app for a free 7-day trial ($5.99/year thereafter) by visiting the Apple App Store or Android Google Play Store, or check out the website at PAASNational.com/app
• Read more on What to Do (and Not Do) When Your Days’ Supply is Rejected in this month’s Newsline article