It should be clear to the patient that they are receiving two NDCs when dispensing. Some pharmacies prefer to place both products in the same vial (separated with clean cotton) and include an auxiliary sticker that notifies the patient that ‘This is the same medication you have been getting. Color, size, or shape may appear different’. Note that dispensing two products in one vial could lead to misbranding the product dispensed, as there is likely only going to be only one NDC with the manufacturer and item description listed on the label. To avoid unintended allergic responses, do not use recycled cotton from manufacturer stock bottles (e.g., sulfasalazine, penicillin, etc.). Pharmacies may want to consider using two separate vials, each labeled with the correct NDC, manufacturer, and item description accurately reflecting its contents. While this method does not require cotton, it should still include an auxiliary sticker to inform the patient.
Processing the claim appropriately can be a complex endeavor. The data logged in the pharmacy dispensing software and submitted to the third-party payors has important downstream purposes. Incorrect data reflecting the claim can cause problems with FDA recalls and PBM audits.
Let’s consider an example where the pharmacy is dispensing #30 atorvastatin 20 mg tablets and only has #20 tablets of old manufacturer NDC ‘A’ and needs #10 tablets of new manufacturer NDC ‘B’ to complete the fill. Many pharmacies would process a single claim transaction with only one of the NDCs being filled. In this example, NDC ‘A’ would likely be billed as this NDC represents most of the fill. This can cause many problems including the following:
- If there is ever an FDA recall on NDC ‘B’ that requires a claim utilization report for the pharmacy to find impacted patients, you may not be able to find this claim. Recalls may be rare, but patient safety can be at risk
- The claim may be considered in violation of PBM contracts – identification and enforcement by PBMs may be difficult
- The pharmacy may have an inventory shortage on a future PBM invoice audit
The best practice to avoid these issues would be to process two separate claim transactions. This way each NDC is appropriately accounted for in your pharmacy software and adjudicated to the PBM. This may require the utilization of the Submission Clarification Code (SCC) value of 62. In Section 3.1.12 Submission Clarification Code (SCC) of the NCPDP Telecommunication FAQ document defines this value as being,
“Shortened Days Supply of Same Drug, Strength and Dosage Form with Multiple NDCs Dispensed.
Used to request an override to plan limitations and/or copay benefits when there are multiple claim billing transactions for same drug and strength due to NDC change(s)”
This will tie the claims together to help align with the plan benefit parameters. When using this override on a plan that recognizes the code, the pharmacy should receive Approved Message Code (548-6F) value 023, “Prorated copayment applied based on days supply. Plan has prorated the copayment based on days supply,” according to the NCPDP Telecommunication FAQ document linked above.
PAAS Tips:
- Pharmacies may need to contact PBM helpdesks if they do not recognize SCC-62 to resolve an early refill and/or duplicate copays
- Pharmacies will need to assess their own risk tolerance and practicality of using SCC-62
- While great in theory, the application may be cumbersome in workflow and not work well in your setting
- Consider the frequency of manufacturer changes and costs for determining your own policies
- Prescriptions for multiple package sizes require additional considerations
Billing and Filling: Glucagon Emergency Products
Glucagon emergency products are typically low audit risk – when billed correctly. Billing the wrong unit of measure, like “EA” instead of “mL”, is an easy target for auditors to flag. Below is a table to aid in billing the correct unit of measure.
PAAS Tips:
Why Adhering to Your Return to Stock Policy Is So Important
Pharmacies often struggle with patients not picking up prescriptions on a timely basis. The lag time could be caused by several reasons – cost concerns, transportation issues, mental health factors, or miscommunication are just a few of the possibilities. While pharmacies are sympathetic to patient situations, it is prudent to be aware of the consequences for not following a strict return to stock policy.
PBM return to stock policies range from 10 to 30 calendar days. Accordingly, PAAS National® advises pharmacies…
to abide by the most stringent 10-day policy to eliminate risk of full claim recoupment during an audit. Unfortunately, these discrepancies are often not appealable. PAAS has created the Return to Stock tool to assist pharmacies with staying up to date on each major PBM’s requirement.
PAAS Tips:
Interested in a customized FWA/HIPAA Compliance Policy and Procedure program? Contact PAAS National® at info@paasnational.com or (608) 873-1342 to get started today!
Medicare Prescription Drug Coverage and Your Rights (CMS-10147)
When a pharmacy receives an NCPDP Reject Code 569 <Provide Notice: Medicare Prescription Drug Coverage and Your Rights> on a Medicare Part D claim, the pharmacy “must” provide the patient with the CMS-10147 form, also known as the Medicare Prescription Drug Coverage and Your Rights notice. The notice instructs enrollees about their right to contact their Part D plan to request a “coverage determination” or prior authorization.
In general, all pharmacies must arrange for this form to be distributed to the patient. While retail pharmacies must provide the notice at point-of-sale, mail order and specialty pharmacies have up to 72 hours to provide it to the patient. Importantly, CMS recognizes the uniqueness of LTC settings and that there is no practical means to deliver the notice directly to the patient; as a result, if the pharmacy can resolve the matter and ensure the LTC patient receives the needed medication or an appropriate substitute, they do not need to deliver the notice. If the matter cannot be resolved, then the pharmacy must deliver the notice within 72 hours to the patient, patient’s representative, prescriber or appropriate staff person at the LTC facility.
The 569 reject will NOT be returned in the following scenarios:
While documentation is not required when distributing the CMS-10147, your pharmacy should have a policy and procedure in place addressing how and when the form is being distributed to patients. PBM field auditors may ask you questions about your process and will possibly want to see a copy of your form to ensure you have the most up-to-date version. OptumRx auditors may even look to see if you have a copy of the CMS-10147 posted in the pharmacy. However, the OptumRx Provider Manual does not require the form to be posted, and Chapter 18 of the Prescription Drug Benefit Manual does not obligate the pharmacy to post the notice.
PAAS Tips:
Proof of Patient Consent for a Refill Request: What You Need to Know
If you are a DMEPOS supplier billing Medicare Part B claims, then you should be familiar with the proof of refill request requirement. All DMEPOS items and supplies billed to Medicare Part B that are delivered or mailed require proof of refill request and an affirmative response to occur and be documented prior to shipment. PAAS National®’s Proof of Refill Request and Affirmative Response for DMEPOS Items form can be downloaded from the Member Portal.
For non-Part B claims, many PBM provider manuals include language requiring pharmacies to obtain (and retain) proof of member consent prior to delivery. However, enforcement of this requirement is often at the PBM’s discretion (i.e., variable). These policies, at least in part, originate from the 2020 CMS Call letter revisions concerning Part D Mail Order Auto-Ship Modifications. While PBM requests are uncommon, they may ask pharmacies to provide “proof of patient consent to refill” during audits‒ often catching pharmacies off guard. When PAAS National® sees this request, there is typically an underlying reason and it is a seemingly effortless way for the PBMs to recoup claims if the pharmacy does not have the proof. PBM audit algorithms are looking for Fraud, Waste and Abuse conducted by bad actors and will use data analysis as a reason to audit suspicious claims. See the PAAS Tips below for potential reasons why a PBM may ask for proof of refill request upon an audit, and how to ensure compliance of an automatic refill or medication synchronization program.
PAAS Tips:
“A” for Abandoned: The Short Life of DAW Code A and What it Means for Multi-Payor Claims
Just 11 short months ago, PAAS National® released the NEW Dispense As Written (DAW) Code Revealed Newsline article about DAW code value “A” (408-D8). DAW A was designed to be utilized on multi-payor claims when one payor required a multi-source brand (or reference biologic with an approved interchangeable biosimilar in the marketplace) and the other payor preferred the generic or interchangeable biosimilar. Today…we bring you news of DAW A’s demise.
The National Council for Prescription Drug Programs (NCPDP) has concluded DAW A was more trouble than it was worth. As stated in Version 69 of the NCPDP Telecommunication Version D and Above Questions, Answers and Editorial Updates (here in “NCPDP FAQ”), “the use of DAW A may create barriers, such as:
NCPDP’s original approval set in motion plans which would make DAW A “effective” as of October 2025 when it becomes incorporated into the Annual External Code List (ECL). However, information about the appropriate use of DAW A was available in advance of its “effective” date. The NCPDP FAQ (Version 65) had DAW A information added in May of 2024, and DAW A explanations were found within the April 2024-April 2025 ECL Publications. With early access to the definition of DAW A and utilization guidance from NCPDP, some software vendors and/or payors may have proactively implemented DAW A as a billing option.
With the recent decision to eliminate this code, DAW A should be “obsolete” as of July 2025; except, the removal of DAW A is not truly “effective” until October 2026 based on the innate timeline of the NCPDP Data Element Request Form (DERF) process. This means there will be one year (October 2025 through October 2026) where DAW A is “available”, but its utilization will be discouraged through adjudication messaging. NCPDP’s guidance states “Payors should reject all claims where value A is submitted with Reject Code (511-FB) value 8K: DAW Code Value Not Supported”.
With this shift, NCPDP has released updated guidance regarding DAW code utilization (specifically, new instructions on the appropriate use of DAW 9 utilization) in their newest NCPDP FAQ. Below are several key points from the FAQ document:
PAAS Tips:
When Precision Fails: The Hidden Issues in Insulin Pen Dosing Calculations
Undoubtedly, a calculator can be found near every data entry and verification station throughout the prescription workflow line. This is, in part, due to PBM requirements that prescriptions have a mathematically calculable set of instructions. Consequently, pharmacies should strive to bill every claim with an appropriate quantity and days’ supply to prevent claim recoupment issues (e.g., overbilled quantity, refill too soon, exceeding plan limitations, etc.). However, there are instances where the pharmacy has the math correct, but the answer is clinically incorrect.
PAAS National® analysts are seeing correct mathematical calculations, but incorrect days’ supply with insulin pens because pharmacies are missing two very important considerations:
Let’s look at an example using Toujeo® Max U-300 SoloStar® Pen. Imagine a patient was prescribed 1 box (6 mL) of Toujeo® Max with directions to inject 57 units nightly at bedtime. The pharmacy correctly determines each 6 mL box has 1,800 units. Since this pharmacy chooses to use priming units in their days’ supply calculation, they add in a 2-unit prime to their days’ supply equation. They determine 6 mL is a 30.5 days’ supply (rounding to a 30 or 31 days’ supply – either is allowable). The math is right; however, this days’ supply would be wrong!
How is it wrong? The first mistake is that Toujeo® Max U-300 SoloStar® can only deliver doses in 2-unit increments. Since the prescription was written for 57 units nightly, the pharmacy should have contacted the prescriber’s office to clarify the prescription to a dose which could be dialed by the Toujeo® Max pen. Second, Toujeo® Max uses a 4-unit prime, therefore, the assumption that it used a 2-unit prime was also wrong.
Going back to the example above, let’s figure out the correct days’ supply. In this alternate timeline, the pharmacy called the prescriber’s office and clarified the directions to inject 58 units nightly at bedtime. They documented the change within the prescription record with a full clinical note and updated the patient label with the new directions. Now, the days’ supply calculation is made using 1,800 units per box, 58 units per day plus the 4-unit prime making 6 mL a 29 days’ supply.
While the days’ supply in this scenario was only altered marginally, there can still be subsequent consequences for having the wrong days’ supply on a claim, no matter how significant the error. For example, an incorrect days’ supply could cause a patient’s copay to increase (or decrease) once corrected. Additionally, the pharmacy could receive penalty fees during an audit for an incorrect days’ supply or recoupment against the claim if there is a difference in the reimbursement or patient’s copay once the days’ supply is corrected. There could also be issues with an overbilled quantity, refill too soon, or with exceeding plan limitations which can all lead to significant recoupment.
Below is a reference table which shows insulin pens with unique dosing increments and a list of insulin pens which do not use the standard 2-unit prime.
PAAS Tips:
LTC Essentials: A Guide to Residence Codes, Pharmacy Service Types, and Submission Clarification Codes
With more pharmacies exploring the world of long-term care and LTC Pharmacy at Home dispensing increasing daily, PAAS National® has also been seeing audits on these claims. One area PBMs have been targeting surrounds…
erroneous billing of Patient Residence Codes, Pharmacy Service Types, and Submission Clarification Codes (SCC). Recoupments primarily focus on SCC issues.
Please see the following tables to determine if you are billing the correct codes and service types to avoid potential audit recoupment:
PAAS Tips:
Combo Shop Pharmacy Inventory Considerations
Independent pharmacies are diving into the long-term care world to improve care for their patients and maximize revenue. Pharmacies can run both retail and combo-shop LTC pharmacies under one roof; typically with the same computer system. However, even though the pharmacies have a single location, the processing of claims and sharing of drug inventory can be challenging.
With a new NCPDP number for the combo-shop LTC, pharmacies will have new wholesaler accounts for ordering medications. Combo-shop LTC locations often have access to lower-cost brands through their LTC agreements. While the two NCPDPs operate in the same location, in many aspects, they need to be treated as two separate “pharmacies”. This raises two key questions that PAAS National® has received from members:
PAAS recommends …
classifying a patient as either retail or LTC (i.e., not both based on reimbursement for individual prescriptions). When determining the classification, consider patient qualifications (e.g., for LTC Pharmacy at Home) and the patient reimbursement profile holistically. Billing prescriptions between the two NCPDP numbers and different Pharmacy Service Types simultaneously can raise red flags to the PBMs and draw scrutiny to claims.
The separation of inventory can also be important in the event of an invoice audit. If a pharmacy receives an invoice audit for the retail NCPDP number but brand drugs are being ordered via the LTC agreement (and used throughout the pharmacy for both LTC and retail), this could result in class of trade issue and a shortage/recoupment of claims that don’t have enough inventory to cover the dispensing.
PAAS Tips:
Filling Prescriptions with Two NDCs – What You Need to Consider
We’ve all been in the sticky situation of having a few straggling pills left associated with one NDC that would be ideal to get off the shelf and free up some space. Maybe this NDC used to be the preferred product and now it has changed, or the manufacturer was bought out by another company. What is the proper way to bill and dispense two different NDCs on the same fill? It’s important to take both physical dispensing and claim processing into consideration to avoid the additional risk of this situation.
It should be clear to the patient that they are receiving two NDCs when dispensing. Some pharmacies prefer to place both products in the same vial (separated with clean cotton) and include an auxiliary sticker that notifies the patient that ‘This is the same medication you have been getting. Color, size, or shape may appear different’. Note that dispensing two products in one vial could lead to misbranding the product dispensed, as there is likely only going to be only one NDC with the manufacturer and item description listed on the label. To avoid unintended allergic responses, do not use recycled cotton from manufacturer stock bottles (e.g., sulfasalazine, penicillin, etc.). Pharmacies may want to consider using two separate vials, each labeled with the correct NDC, manufacturer, and item description accurately reflecting its contents. While this method does not require cotton, it should still include an auxiliary sticker to inform the patient.
Processing the claim appropriately can be a complex endeavor. The data logged in the pharmacy dispensing software and submitted to the third-party payors has important downstream purposes. Incorrect data reflecting the claim can cause problems with FDA recalls and PBM audits.
Let’s consider an example where the pharmacy is dispensing #30 atorvastatin 20 mg tablets and only has #20 tablets of old manufacturer NDC ‘A’ and needs #10 tablets of new manufacturer NDC ‘B’ to complete the fill. Many pharmacies would process a single claim transaction with only one of the NDCs being filled. In this example, NDC ‘A’ would likely be billed as this NDC represents most of the fill. This can cause many problems including the following:
The best practice to avoid these issues would be to process two separate claim transactions. This way each NDC is appropriately accounted for in your pharmacy software and adjudicated to the PBM. This may require the utilization of the Submission Clarification Code (SCC) value of 62. In Section 3.1.12 Submission Clarification Code (SCC) of the NCPDP Telecommunication FAQ document defines this value as being,
“Shortened Days Supply of Same Drug, Strength and Dosage Form with Multiple NDCs Dispensed.
Used to request an override to plan limitations and/or copay benefits when there are multiple claim billing transactions for same drug and strength due to NDC change(s)”
This will tie the claims together to help align with the plan benefit parameters. When using this override on a plan that recognizes the code, the pharmacy should receive Approved Message Code (548-6F) value 023, “Prorated copayment applied based on days supply. Plan has prorated the copayment based on days supply,” according to the NCPDP Telecommunication FAQ document linked above.
PAAS Tips:
Update: Isentress® and Dificid® Added to Dispense in Original Container Chart
OptumRx continues to focus audits on prescriptions that must be dispensed in their original container per the manufacturer’s [FDA approved] labeling and package insert. If the prescription claim detail shows that a pharmacy dispensed a medication in a quantity different from the original package size (and not a multiple), the audit risk is significant and discrepancies can be difficult to appeal.
OptumRx’s latest targets are Isentress® and Dificid®.
Section 16 How Supplied/Storage and Handling of the product labeling state the following:
PAAS National® continues to express frustration and disdain with OptumRx’s audit practices. OptumRx would rather develop audit algorithms to profit from this dispensing behavior than put in hard-stop rejections to stop claims at the Point-of-Sale (something they would do if they were really concerned with patient safety).
Unfortunately, the FDA has also been lackadaisical by allowing inconsistent and vague manufacturer labeling. Store in the original container does not necessarily mean Dispense in the original container – how is a pharmacist to know if the FDA has approved the product to be dispensed in a vial in these situations? It’s simply not clear. Consider Section 16 from Linzess®: “Keep LINZESS in the original container. Do not subdivide or repackage. Protect from moisture. Do not remove desiccant from the container. Keep bottles tightly closed in a dry place.” This direction is very clear to dispensing pharmacists. PAAS has made several requests [to the FDA] to standardize the manufacturer Storage and Labeling requirements for products that must be dispensed in the original container– from a patient safety, and pharmacist awareness, perspective. The FDA, unfortunately, defers to the manufacturer submission for labeling and package insert information language, but they have intervened on other labeling requirements when patient safety is involved (e.g., insulin pens).
PAAS continues to reach out to manufacturers as PBM audit issues arise, with mixed results. For example, Auvelity® has the same language “Store AUVELITY in original bottle”; however, the manufacturer indicated to PAAS that, “When a quantity less than the amount available in the manufacturer’s original bottle is prescribed, transferring the tablets to a pharmacy vial does not conflict with the AUVELITY labeling.” The manufacturers of Isentress® and Dificid® would only reiterate that the products must be “stored in the original container”.
Due to the difficulty of appealing these type of discrepancies, PAAS has added them to the Dispense in Original Container Chart to help protect our members and support conservative dispensing practices. Unfortunately, the burden falls on the pharmacy to ensure FDA dispensing requirements are met even if the PBM does not put a hard stop in place on these medications.
PAAS Tips: