Best Practices for Billing Vaginal Creams to Avoid Recoupment

PAAS National® analysts frequently receive questions regarding the proper billing of creams and ointments, an easy audit target for PBMs. This article focuses on vaginal creams due to their high cost, lack of sufficient instructions for use and plan limits that cause pharmacies problems. When a PBM auditor sees a claim for Premarin® or Estrace® vaginal cream, they see dollar signs and often take back 100% recoupment on not just one fill, but multiple refills. To help reduce the risk of an audit recoupment, please review the table and PAAS Tips below.

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Product Package Size Applicator Measurements
Estrace® (estradiol) 0.01% vaginal cream 42.5 grams 1 to 4 grams (1 gram increments)
Premarin® (conjugated estrogens) vaginal cream 30 grams 0.5 to 2 grams (0.5 gram increments)

Here is an example prescription:

  1. Premarin® vaginal cream, quantity: 30 gram, sig: 1 gram vaginally three times weekly
  2. 30 gram ÷ 3 gram per week = 10 weeks or 70-day supply
  3. Don’t assume plan max of 30 days, try to bill as 70-day supply as per estimate
  4. If plan limit is 30 days, then follow the “ILQ process
  5. Suggest sig on dispensing label of ‘Use 1 gram vaginally three times weekly (70 days)’ to alert patient and pharmacy staff of how long the dispensed product should last

PAAS Tips:

  • PBMs look for calculable instructions (e.g., grams per application or max grams per week/month)
  • Instructions for “pea-sized amount” or “X number of inches” are not sufficient for audit purposes
  • Ensure an accurate days’ supply is submitted on claims – many PBMs will allow > 90 days for these products due to normal utilization
  • These vaginal creams only come in one package size and instructions rarely support a days’ supply of 30
  • Do NOT default the days’ supply to 30
  • See PAAS’ Can You Bill as 30 Days? resource on the PAAS Member Portal ( for step-by-step guidance on the “Insurance Limits Quantity” (ILQ) process
  • Vaginal creams should be treated as “refill on demand” only and NOT included on LTC cycle fill or retail medication synchronization programs
  • Self-audit your vaginal creams for accurate days’ supply and appropriate instructions – refer to our June 2021 Newsline article, Self-Audit Series #5: Topical Prescriptions

Jennifer Ottman, CPhT