Why PBMs Insist on Understanding Dispense Quantity Changes

patient requests, insurance limitations, med sync programs, or dispensing in the original container per manufacturer guidelines. Some reasons that are NOT valid include working around negative reimbursement rates, trying to collect more dispensing fees, or circumventing plan limitations. Many PBMs have a discrepancy code for lack of proper documentation to support these changes, making full recoupment possible.

Contractual obligations apply when filling prescriptions and should be considered when adjusting quantities. Opting out of extended days’ supply networks when/where possible may help alleviate some negatively reimbursed claims while still adhering to the agreement. If PBMs are notified of a pharmacy refusing to dispense a 90 days’ supply (while being contracted for extended days’ supply networks), they may issue a cease and desist letter that can result in required corrective action plans or even network termination if not corrected. One PBM in particular has language in their agreement that allows them to extend 90 days’ supply pricing to 30 days’ supply claims if the pharmacy is found to disproportionately dispense 30-day fills in comparison to peers.

Increasing the quantity dispensed requires a different set of considerations. Check your state law on whether you are allowed to increase the quantity without consulting the prescriber (i.e., accelerated refills). If so, document accordingly and ensure you are not dispensing more than the total quantity authorized on the prescription. If not allowed, contact the prescriber for approval and document a clinical note.

When a prescriber orders a quantity that is less than the smallest package size, contact the prescriber for approval to dispense a total quantity larger than originally prescribed and document a clinical note. For example, if NovoLog FlexPen^® was prescribed for a written quantity of 3 mL with 2 refills, the total quantity on the prescription is only 9 mL. The pharmacy should call the prescriber to clarify the quantity and refills (to comply with FDA labeling requirements and dispense a full box of 15 mL). It’s important to include what the new quantity prescribed AND refills are to avoid any ambiguity on what the total quantity approved on the prescription is (e.g., prescriber approved increasing quantity to 15 mL with two additional refills).

PAAS Tips:

• Always document the reason for any quantity change
• Check your state law before increasing the quantity without prescriber approval
• Be careful not to dispense more than was authorized on the prescription
• Verify quantity and refills with prescriber if quantity prescribed is less than a package size
• Do not change the quantity due to negative reimbursement, additional dispensing fees or working around plan limitations
• Clinical notes should contain four elements:
  • Date
  • Name and title of who you spoke with
  • What was discussed
  • Your initials