Addressing “Weird” Days’ Supply

Days’ supply errors are one of the easiest audit triggers a PBM can pursue. Algorithms can be set for any days’ supply that does not correspond with typical dispensing of a medication and have an audit sent almost as soon as the claim adjudicates. We know that days’ supply should be billed based on the mathematically calculable directions, but what happens when the days’ supply does not fall in the easily calculable 30- or 90-day spectrum? What if it is “weird?”

The answer is …

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that you should still attempt to bill your claim for the correct days’ supply! Many plans have built-in overrides in place for medications that are known to be greater than 90-day supply, like Prolia®. This medication is typically administered once every six months and should be billed for a 180-day supply. Do NOT assume that the claim will not go through. PAAS National® has seen many claims adjudicate correctly at this days’ supply. A patient may end up with a higher copay, but that is because they are receiving six months’ worth of medication.

Other “weird” days’ supply medications to be aware of:

  • Vaginal Creams: Typical directions vary, but a majority of the time they are only used a couple of times a week making a tube last much longer than 30 days, sometimes as much as 210 days.
  • Annovera® should be billed as 1 each for a 364-day supply (thirteen 28-day cycles).
  • Dexcom receiver should be billed as 1 each for a 365-day supply.
  • Tobramycin inhalation solution is typically used as one single-dose ampule twice daily for 28 days, then stop for 28 days, and should be billed as 280 mL (56 vials) for a 56-day supply.
  • Bowel preps: 1- or 2-day supply based on whether or not the patient is doing a “split” prep.
  • Vaccines: NCPDP billing guidance states all vaccines should be billed as a 1-day supply.

PAAS Tips:

  • Always attempt to bill the actual days’ supply calculated first. If the correct days’ supply does not go through, call the plan help desk and ask for a days’ supply override.
  • If the plan cannot (or will not) issue a days’ supply override, bill for the plan maximum, and note the plan limit on the hard copy (ILQ=90 or ILQ=30).
  • Review our Can You Bill It As 30 Days? document under Proactive Tips on our website.
  • Be careful with auto-fill or med sync programs – do not run for a 30-day supply when the actual days’ supply is 130.
  • Utilize separate fields for “billed” and “actual” days’ supply if needed and if your pharmacy system supports them.
  • Note the actual days’ supply on the patient label to help flag pharmacy employees not to refill early.
  • Days’ supply should be billed for the length of therapy needed (e.g., birth control with 3 weeks on and one week off is a 28-day supply, not a 21-day supply).
  • Products billed weekly should not be billed as a 30-day or 90-day supply. They should be billed as a 28-day supply (4 weeks) or an 84-day supply (12 weeks) respectively.

Jenevra Azzopardi, CPhT
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