Combivent® Respimat® Still Causing Confusion

In 2013, Combivent® Inhalation Aerosol inhalers made by Boehringer Ingelheim Pharmaceuticals were discontinued and phased out because they contained chlorofluorocarbons or CFCs (harmful substances that work to decrease the ozone layer above the Earth). The original Combivent® inhaler was then replaced by Combivent® Respimat®.

The new inhaler was not an exact replacement of the old one. The original Combivent® inhaler (14.7 g) had dosing of two inhalations four times a day with the total number of inhalations not to exceed 12 puffs in 24 hours. The updated Combivent® Respimat® (4 g) has a recommended dosage of only ONE puff four times a day with a total number of inhalations not to exceed 6 puffs in 24 hours.

This dosing change has caused problems for pharmacies over the years. Prescribers have been known to still send prescriptions to the pharmacy with the old directions. If the pharmacy fails to clarify the directions, patient safety could be a concern and the claim is sure to be flagged for audit.

Another problem PAAS National® has seen is related to billing the correct days’ supply on a claim. Combivent® Respimat® contains 120 metered doses. If a prescription is written for one puff four times a day, then the days’ supply is 30. If the prescription notes the patient may take up to 6 puffs per day, then the days’ supply is 20.

What happens if the plan will not allow a 20-day supply? The first instinct of many pharmacies is to rebill the claim as a 30-day supply, but this would be incorrect and would likely flag for an audit. The insurance company will see you originally tried to bill a 20-day supply and will want to know why it was changed. This may be interpreted as claims data manipulation and a circumvention of the plan limits. The proper thing to do in this case is follow any reject instructions, possibly obtaining a prior authorization for the correct dosing. See our January 2022 Newsline, Manipulating Quantity or Days’ Supply to Bypass Plan Limits Will Cost You, for further information.

PAAS Tips:

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  • Verify inappropriate directions with the prescriber and make a clinical note
  • Always submit an accurate days’ supply based on the quantity prescribed and the maximum daily dose
  • Do not workaround a plan limit to get a paid claim – follow the plan’s instructions in the reject message
  • With a 20 day’s supply, some plans may require the pharmacy call for an override or obtain a prior authorization for that dosing interval
  • Workarounds may save time and take care of a patient’s immediate need, but those short-term gains will invariably lead to long term pain with audit recoveries. PAAS has even seen network terminations for habitual offenders
  • Review our April 2021 Newsline article, Self-Audit Series #3: Inhaler Prescriptions to help your pharmacy develop practical and efficient strategies to identify claims that may be at risk for audit recovery
  • Review our Oral Inhalers chart found on the PAAS Member Portal under “Days Supply Charts”
Jenevra Azzopardi, CPhT
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