PAAS Tips:

• Bill one 8-count box of CeQur Simplicity^TM patches as “8 EA”; the proper days’ supply will be determined by the patient’s insulin utilization and should never be more than a 32-day supply per 8 patches
  • Example: CeQur Simplicity^TM, #8 + 11 refills; use with Novolog U-100 insulin up to 12 units TID; change patch every 4 days; bill #8 as a 32 days’ supply
• Since 20 units are required to prime each patch, that leaves a maximum of 180 units of usable insulin if the patch is filled to capacity. If more than 180 units of insulin are required over the 4-day wearable period, the patch can be replaced earlier than four days
  • Example: CeQur Simplicity^TM, #8 + 11 refills; use with NovoLog® U-100 insulin up to 20 units TID
    • Over 4 days, the patient could use up to 20 units x 3x/day x 4 days = 240 units
    • Since each patch has 180 units of usable insulin, the patient may run out of insulin before the 4-day wear time limit is reached and would need to change it more frequently (180 units ÷ 60 units/day = 3 days per patch)
    • Bill #8 as a 24 days’ supply
• CeQur Simplicity^TM patches are disposable and NOT durable, therefore, the patches and the insulin to be used within the patch are not covered under a patient’s Medicare Part B/DMEPOS benefit
• When billing the insulin used inside CeQur Simplicity^TM, be sure to include the 20 units of insulin required to prime each patch in the days’ supply calculation; below is an example:
  • Prescription: NovoLog® U-100, 20 mL + 11 refills; administer up to 12 units three times daily using CeQur Simplicity^TM patch
  • Amount of insulin needed per patch: (12 units TID) x (4 days/patch) + 20 priming units = 164 units
  • Amount of insulin needed for the corresponding # CeQur patches: 8 patches x 164 units/patch = 1,312 units total (13.12 mL) per 32 days
  • Suggested billing: 10 mL = 24 days’ supply -OR- 20 mL = 48 days’ supply
• Be sure the patient receives one CeQur Simplicity^TM Inserter when they begin using the CeQur Simplicity^TM patch; the patient should call the manufacturer if a replacement inserter is needed

you verify how your software currently bills Forteo^® and its generics. Make sure that when submitting a claim, the metric quantity aligns with what is displayed in your software system’s compendia and that the correct cost for one pen is included in your transmission. Once the compendia updates the metric quantity to 2.24 mL, ensure your drug file is updated to accurately reflect your cost for one pen accordingly.

PAAS Tips:

• Plans may reject claims based on package size, so know how to access and edit your drug file if needed
• Know which package size is assigned in your pharmacy system drug file to avoid possible over- or underpayments when 2.4 mL or 2.24 mL are billed
• Wholesaler ordering websites may not list products in the same NCPDP billing unit or package size
  • Check to see if the item numbers associated with Forteo® and its generics have changed
• Questions about billing quantity or unit of measure? Send us a question through the Ask a PAAS Expert on the Member Portal

PAAS Tips:

• Members with the PAAS Fraud, Waste & Abuse and HIPAA Compliance program can:
  • Find information about internal audits in Section 5.1 of your Policy & Procedure Manual
  • Use the Internal Auditing and Monitoring Plan found in Appendix B of your Policy & Procedure Manual
• Consider reviewing the additional PAAS resources which may be applicable to multiple categories of medications:
  • Audit Flags
  • Can You Bill It As 30 Days?
  • Exceeding Days’ Supply Plan Limits for Unbreakable Packages
• Need a second opinion regarding your self-audit findings? Contact us and the first available analyst will reach out to further discuss your concerns.

– the claim was too old to reprocess and is now stuck in your system as a reversed/unpaid claim! Without authorization or assistance from the insurance helpdesk, it can’t be re-billed. To avoid unnecessary stress, PAAS recommends leaving the identified billing errors as is, and discussing with your assigned PAAS analyst. Since each PBM has its own auditing processes and procedures, the steps to resolve a billing error vary.

You may be wondering, “Well, when is it okay to reverse a prescription if we’ve identified an error?” A prescription under audit should never be reversed, unless the PBM auditor has given explicit approval to do so. For claims not under audit, PAAS recommends sticking to a 30-day timeframe, as each PBM and/or Plan may have a unique billing window. If that claim is outside of 30 days, you’ll want to contact the insurance helpdesk and have them help you through the reversal and correction process.

Keep in mind that Prescription Validation Requests are an exception, as they often specifically indicate the allowance to reverse and correct a claim. You will want to be sure you are appropriately filling out the documentation provided by the PBM to indicate that the claim was reversed and rebilled.

PAAS Tips:

• If you find yourself with a reversed claim that is now stuck and unable to be rebilled, call the PBM helpdesk and ask if they can:
  • Open a billing window that would allow you to rebill, or
  • Help submit a paper claim via a Universal Claim Form (UCF)
• PBMs may have their own UCF, or alternatively these can be purchased from NCPDP’s vendor, CommuniForm LLC.

Forms created by the pharmacy for the prescriber can be more problematic, as they may give the impression that the pharmacy is soliciting prescriptions or influencing the prescriber to choose one specific NDC over others. Cookie-cutter forms that contain only a small list of high AWP items, with each option featuring identical quantities, sig, and refills, are likely to attract PBM scrutiny.

Additionally, PAAS National^® has seen pre-printed prescription forms recouped during audits when they have cascading or overly broad substitutions. For example, if a topical medication is not covered, and the form provides a blanket allowance for the pharmacy to substitute the next topical medication on the list until one is covered, it could raise concerns about the pharmacy’s [conflicted] influence in the prescribing process. These medications are often more costly than preferred alternatives and can raise red flags for audits if the pharmacy is observed submitting claims, reversing them, and quickly billing for a different product. Many PBM provider manuals have now added language explicitly requiring pharmacies to have a verbal conversation with the prescriber before making any substitutions, which would need to be proven with a clinical note documented on the prescription.

Here is a summary of the three big PBM positions:

• Caremark: Pre-printed forms resulting in the dispensing of products that are not the most cost-effective items are prohibited (even if they are different salts, bases, or have different release characteristics)
• Express Scripts: Pharmacies using forms with multiple medications and substitution language must consult (and document) consultation with prescriber prior to dispensing the appropriate medication
• OptumRx: Dispensing or distributing Prescription Drugs/Drug Products which are not based on valid prescriptions for individually identified Members or are otherwise on pre-populated or templated prescriptions is prohibited. Such pre-populated prescriptions may also not include options for substitute products without individualized prescriber authorization or annotation.

PAAS Tips:

• Not all template prescriptions will draw the ire of PBMs
• PAAS has seen enforcement mostly focused on:
  • High AWP products where a cheaper alternative is available
  • Compounded pain/scar creams with broad substitution language
  • High AWP dietary supplements