For example, some manufacturers have specific guidance for drops/mL due to a viscosity and drop size difference (e.g., Miebo^® [272 drops/3 mL], Vevye^® [200 drops/2 mL], and Vyzulta^® [81 drops/2.5 mL]), and you should calculate the days’ supply based on the manufacturers’ guidance.

Additionally, some eyedrops have a specific beyond use date in Section 16 Storage and Handling of the product labeling (e.g., AzaSite^® [14 days], Rocklatan^® [42 days], Rhopressa^® [42 days], Vyzulta^® [56 days], Xalatan^® [42 days]) and cannot have a days’ supply greater than the beyond use date. Do not assume that all eyedrops have a beyond use date of 28 days. This is NOT true in most cases.

If a prescriber indicates that patient should discard the eyedrop after using it for ’X’ number of days, this must be explicitly spelled out in the directions to the patient. For example, eye drops that are to be used in the right eye for two weeks after surgery then discarded for a new bottle to be used for the left eye should clearly indicate this in the directions before billing a 14-day supply. If multiple package sizes of the product exist, use the smallest bottle closest to the treatment duration as possible. The PBM will not pay for a patient to discard the remainder of a 15 mL bottle when a 5 mL bottle would have sufficed.

PAAS Tips:

• There is no industry accepted conversion for Gel or Ointment products
• Follow the individual PBM published guidelines when billing days’ supply
• OptumRx is the only PBM the explicitly states you may use treatment duration (e.g., “Use for ten days”) as the days’ supply
• The quantity prescribed should contain a unit of measure that corresponds to the billing unit; however, if written for a quantity of “1 bottle”, it should be interpreted as the smallest package size
• Login to the Member Portal under “Days’ Supply Charts” to find the most current version of PAAS’ Eye Drop Chart with major PBM drops per mL ratios
• Download the PAAS National^® Rx Days’ Supply Calculator from the App Store or Google Play
• Review the November 2024 article, 2024 Self-Audit Series #9: Eye Drop Days’ Supply for additional guidance

When used for ESRD patients, these oral-only medications will now be covered by Medicare Part B under the ESRD Prospective Payment System (PPS) bundled payment to dialysis facilities and should NOT be billed by pharmacies to a Medicare patient’s Part D plan (pharmacies will also not be able to bill Medicare B). If pharmacies are looking to continuing dispensing these medications, advanced coordination with dialysis facilities will be required to ensure pharmacies receive reimbursement.

Part D claims may reject with the following NCPDP reject codes:

• 75>Prior Authorization Required
• 569>Provide Notice: Medicare Prescription Drug Coverage and Your Rights
• A4>This product may be covered under the Medicare-B Bundled Payment to an ESRD Dialysis Facility

If Part D claims do not reject and pharmacy bills Part D incorrectly, then there will likely be future coordination of benefit (COB) “audits” where the Part D plan recoups the pharmacy payment, leaving the pharmacy to reconcile with the dialysis facility after the fact. PAAS National^® already sees these types of retroactive, COB audits when claims were billed to Part D but “should have” been billed to Part A for patients residing in a nursing home on a covered stay.

Phosphate binders remain coverable under Part D for other medically accepted indications for patients not on dialysis for ESRD. Pharmacies may want to obtain (and document) diagnosis codes to support these claims.

Numerous organizations, including NCPA, the American Society of Consultant Pharmacists (ASCP), and the American Society of Nephrology (ASN) provided feedback to CMS that this change in payment policy will negatively affect patients as many dialysis facilities do not have an in-house pharmacy and may supply these medications without the expertise of a pharmacist.

PAAS Tips:

• Educate billing staff about the likely rejects for phosphate binder medications for Part D patients
• Coordinate with dialysis facilities to ensure continuity of patient care and payment for pharmacy services

Remember that a future invoice audit from Caremark could cover purchases made between 02/01/2025 – 01/31/2026 which means that any purchases made during December 2024 will NOT be credited unless you provide notification to Caremark within 21 days after the purchase.

Section 8.05 of the Caremark Provider Manual outlines the requirement to provide notification of these bulk purchases for audit purposes – you must notify Caremark via mail or email as outlined below:

1. Pharmacy NCPDP
2. Contact email address
3. Drug name
4. NDC
5. Total quantity purchased
6. Name of wholesaler used

Email:   PharmacyAudit@CVSHealth.com

Mail:    

CVS Caremark
Attn: Bulk Purchase Notification, MC 020
9501 E. Shea Boulevard
Scottsdale, AZ 85260

Pharmacies do not need to include cost information when submitting. Some pharmacies have received a notification back stating that their purchase was “routine in nature” and would not be considered a bulk purchase, but PAAS would encourage pharmacies to continually inundated/notify Caremark and document these responses as they could become relevant (and useful) in an audit situation.

PAAS Tips:

• PAAS National^®® recommends keeping record of both your submission and any responses received from Caremark in the event of a future audit.
• Watch the June 15, 2022 on-demand webinar Caremark’s Bulk Purchasing Requirements for more background information

DUR messages are designed as a warning to avert potential patient harm and require pharmacist intervention before proceeding. These are the more obvious DURs to spot and handle. Soft DURs can be easily overlooked but still require thorough review. For example, a DUR indicating the prescription was filled at another pharmacy should generate questions regarding current therapy or possible duplicate therapies the patient may be unaware of.

SCCs might be necessary to use when a patient is requesting a refill due to an upcoming vacation, lost or stolen medication, or a change in therapy. Some PBMs are known for auditing high dollar claims with override codes, like Express Scripts and Prime Therapeutics. Auditors are looking for documentation, including rationale on the prescription, when the override codes are used, but what does this mean? Below is an example of appropriate DUR and SCC documentation.

DUR Documentation: HD/M0/1B – Verified with Dr. Jones they are aware this is a high dose/Told to fill prescription as is/Pharmacist’s initials/date

SCC Documentation: SCC 03 – Susan is going on vacation to Italy from 01/06/2025 to 01/20/2025 & requires a vacation supply of medicine/date

Simply documenting the override codes utilized does not provide the auditor with the explanation of why it was appropriate to use. When under audit, be sure to make all clinical notes visible for the auditor. Rescan hard copies into your pharmacy software system when handwriting notes if necessary; this can help ensure the notes will not be missed when under audit.

PAAS Tips:

• A full clinical note should have four elements:
  • Date
  • Name and title of person you spoke with
  • What was discussed
  • Initials of who made the call
• Professional service code “M0” requires consultation with the prescriber and a supporting clinical note
  • Consider other professional service codes like “MR” (Medication Review) or “R0” (Pharmacist consulted other source) if “M0” is not applicable
  • Rationale for these codes is still required to be documented
• Vacation overrides should include documentation of where the patient will be and the dates they will be gone documented, as shown in the example above
• If referencing a clinical note from a previous prescription, the full note should be carried over to the new prescription
• Use professional judgement for when a follow-up with the prescriber is necessary to ensure the validity of the DUR code submitted and update when appropriate
  • It’s good practice to reconfirm at least once per year, or when there is a change in therapy or prescriber