that the correct quantity cannot be determined without the proper UOM being present. To combat the discrepancy, pharmacies may need to obtain a letter from the prescriber to substantiate what the pharmacy billed was indeed the correct quantity. These letters are often difficult to obtain, especially when claims are several years old, prescribers have relocated, or your pharmacy doesn’t have a working relationship with the office.

If your pharmacy receives a prescription without a UOM, or a UOM that is ambiguous, PAAS recommends contacting the prescriber for clarification and documenting with a clinical note.

Examples:

1. You receive a prescription for Lantus^® Solostar^® pens, quantity 15, UOM “unspecified.”
   1. Did the prescriber intend for the prescription to be written as 15 mL, 15 pens, or 15 boxes?
2. You receive a prescription for Combigan^® solution, quantity 1, UOM “bottle.”
   1. Did the prescriber intend for the 5 mL, 10 mL, or 15 mL bottle?
3. You receive a prescription for Trelegy Ellipta, quantity 1, UOM “inhaler.”
   1. At first glance, this may seem like an acceptable prescription. However, Trelegy comes in two sizes. Did the prescriber intend for the 60 each retail package or the 28 each institutional size package? “Each” is the proper UOM per NCPDP guidelines.
4. You receive a prescription for Trelegy Ellipta, quantity 1, UOM “each.”
   1. The correct billing unit is “each,” but the quantity should either be 60 for the retail package or 28 for the institutional package. Third party auditors will often flag the “1 each” combination – contact the prescriber to avoid ambiguity.

The following table shows the medications PAAS typically sees UOM troubles with and the typical billing units that should be used:

Drug Type	Correct Billing Unit	UOM Needing Clarification
Eye Drops	mL, each*	bottle
Injectables	mL, each*	kit
Nasal Inhalers	mL, gm, each*	inhaler
Oral Inhalers	gm, each*	inhaler
Insulin	mL	each
Topicals	mL, gm	tube

*The “each” UOM may need to be clarified if the quantity doesn’t correspond to an “each” unit of measure (e.g., 10 each on an eye drop likely indicates 10 mL vs 10 bottles of 10 mL)

When in doubt, clarify the prescription. Do not leave the UOM interpretation to a third-party auditor who has no reason to give you the benefit of the doubt and every reason to interpret it to their advantage.

PAAS Tips:

• Ambiguous or missing UOM should be clarified with the prescriber with a clinical note added to the prescription before dispensing
• The best quantity clarification will contain the actual billing unit per NCPDP for the drug, leaving no room for misinterpretation
• Clinical notes should contain the date, name and title of who you spoke with, summary of discussion, and your initials
• Pay close attention to electronic prescription quantities which have the biggest potential for incorrect or “unspecified” UOM
• Other prescription origins (written, fax, and transfer) may need clarification for missing UOM
• Notating UOM on all telephone orders would be considered best practice
• Some PBMs may consider a quantity of “1” to be the smallest package size; therefore, clarify the quantity with the prescriber if dispensing a larger size

The Affordable Care Act required that Medicaid programs shift pharmacy reimbursement to an acquisition cost-based model. CMS Final Rule (CMS-2345-FC) set a compliance date for State Medicaid Programs to be effective no later than April 1, 2017.

The NADAC file was created to provide pricing files for state Medicaid agencies to utilize when creating their acquisition cost-based pricing methods for Fee-for-service (FFS) Medicaid plans. Some PBMs have started to use this data for reimbursement formulas on commercial and Medicare Part D claims as well (e.g., Capital Rx).

CMS has contracted with Myers & Stauffer, LC (a professional accounting firm) to conduct these retail pricing surveys. Outpatient pharmacies are randomly selected to receive these surveys, requesting invoices for purchases made over a one-month period. The data collected from these invoices are used to update the NADAC file on a weekly basis.

Again, these surveys are currently voluntary, and pharmacies are under no obligation to respond. However, this may change with a newly introduced bill, Drug Pricing Transparency in Medicaid Act of 2023 (H.R. 1613). If passed, this bill would make the surveys mandatory for pharmacies and simultaneously include updates to ban spread pricing in State Medicaid Plans. NCPA has a summary “one-pager” on H.R. 1613 that pharmacies can share with their legislators here.

PAAS Tips:

• NADAC files are published monthly here
• Consider responding if you are being paid below your cost on Medicaid claims; your actual costs can be added to the survey data
• Pharmacies may want to consider requesting a Non-Disclosure Agreement from Myers & Stauffer LC
• Steps to take with your documents if responding
  • Print “Confidential” on each invoice page
  • Only include the documents requested, no PHI should be included
• Contact the NADAC helpdesk, operated by Myers and Stauffer, at (855) 457-5264 or survey@mslcrps.com if you have additional questions about the survey

• Verify the prescription has mathematical instructions for use and clarify any ambiguous directions
• Download the PAAS National^® Rx Days’ Supply Calculator app
• Do not assume the days’ supply indicated on electronic prescriptions is correct, always calculate days’ supply according to instructions for use
• Best practice is for quantity prescribed to include a unit of measure; however, if written for a quantity of “1 bottle”, it should be interpreted as the smallest package size
• When billing a PBM not listed on the Eye Drop Guidance, PAAS recommends using 15 drops/mL for suspensions or emulsions, and 20 drops/mL for solutions, unless otherwise specified by the manufacturer
• Billing eye drops for LTC patients carries the same audit risk, refer to the following June 2022 Newsline article, Beyond-Use Date vs. Nursing Home Storage Policy – Avoid this Recoupment Trap
• Prescriptions with a treatment duration (e.g., “use for 10 days”) that is less than calculated days’ supply, should still be submitted per calculation

PAAS Audit Assistance members can search the Newsline archive for keyword “2024 self-audit” to read previous articles in this series. If you have any questions on accessing the Member Portal, or need help adding employees so they have access, please contact us.

Claims are flagged because a beneficiary is on either albuterol, albuterol/ipratropium combination, levalbuterol, or metaproterenol as a rescue or supplemental medication in addition to either formoterol or arformoterol. The presence of formoterol or arformoterol as an active medication for the beneficiary triggers a lower monthly maximum milligrams/month policy limit on the rescue or supplemental medication (i.e., albuterol, albuterol/ipratropium combination, levalbuterol, or metaproterenol).

Inhalation Drugs and Solutions	Standard Maximum	Reduced Maximum When Beneficiary is Also on Formoterol or Arformoterol
Albuterol	465 mg/month	78 mg/month
Albuterol/Ipratropium combination	186 units/month	31 units/month
Levalbuterol	232.5 mg/month – 465 units/month	39 mg/month – 78 units/month
Metaproterenol	2800 mg/month – 280 units/month	470 mg/month – 47 units/month

How to Avoid This Pitfall

Pharmacies supplying any one of these four inhalation drugs in the table above should be reviewing all evidence prior to billing the claim to Part B to verify which monthly limit is applicable for the claim; here are several considerations:

• Review the patient’s medication profile at your pharmacy to see if they are getting any medication with formoterol (e.g., formoterol nebulizer solution [Perforomist^®]; budesonide and formoterol inhaler [Symbicort^®, Breyna^TM]; glycopyrrolate and formoterol inhaler [Bevespi Aerosphere^®]; budesonide, glycopyrrolate, and formoterol [Breztri Aerosphere^®]; mometasone and formoterol [Dulera^®]; etc.) or arformoterol [Brovana^®] nebulizer solution
• Obtain medical records from the prescriber’s office from within 12 months prior to the date of the claim and review the records for any active formoterol or arformoterol
• Ask the patient or their representative if they are using any prescription products with formoterol or arformoterol

If the investigation to any of the above considerations shows active formoterol or arformoterol, be sure:

1. The order being billed for one of the four inhalation drugs in the table above falls within the reduced maximum supply limit, or
2. Contact the prescriber to adjust the order to be within the reduced maximum policy limit, or
3. Complete an Advanced Beneficiary Notice of Non-Coverage (ABN) prior to dispensing because the claim is not expected to be covered.

PAAS Tips:

• Refer to the December 2021 Newsline article, Advanced Beneficiary Notice of Non-coverage Changes, for more information about the use of an ABN
• The Same and Similar tool on the DME MAC website may not be helpful as some of the formoterol-containing items would not be billed to Medicare Part B (but instead, Part D) and because suppliers have 12 months to file a Part B claim, meaning the data may not be up to date