Insurance Limits Quantity – Common Scenarios and Pitfalls

Another common scenario with insulin, the pharmacy receives a prescription for 30 mL of Lantus^® Solostar^® with directions of 90 units at bedtime. The actual days’ supply comes out to just over 33 days. If the insurance maximum is 30 days, the pharmacy should rebill this claim for 15 mL for a 16- or 17-day supply and document the reason for the cut quantity.

What if the actual days’ supply is still greater than the plan maximum when dispensing the smallest package size?

PAAS National^® frequently sees this problem with HFA inhalers such as Flovent HFA. The inhaler contains 120 puffs. If a prescription received has directions of 1 puff twice daily, the actual days’ supply is 60. If the plan limit is 30 days, the pharmacy should first call the help desk for a days’ supply override. If one is not able to be given, the pharmacy can then bill a 30-day supply, document the ILQ, but MUST NOT refill earlier than the actual 60-day supply or risk recoupment from a PBM during an audit.

This last scenario causes the most problems for pharmacies. Many systems are not set up to flag these prescriptions as early and rely on notes in the patient’s profile or in the label directions to remind pharmacy staff. Be aware of the recoupment possibilities and proactively take steps to ensure that the correct days’ supply is being billed.

PAAS Tips:

• Insulin, inhalers, topical medications, and eye drops are frequently flagged for refill too soon or overbilled quantity
• Always submit claims with an accurate days’ supply first; many PBMs now have built-in overrides in place for smallest package sizes
  • Be aware of soft rejections that may direct the pharmacy to use an SCC 10 override
  • See our October 2022 Newsline article: Breaking Insulin Pen Boxes: Where Are We Now?
• Include a notation on the patient label to help notify patient and pharmacy staff of the true days’ supply
• Check with your software vendor to see if additional days’ supply fields are available for internal tracking
• Avoid med sync or cycle fill programs for products whose correct days’ supply cannot be submitted for the smallest single package size
• Self-audit prescriptions with multiple pack sizes available for days’ supply and refill accuracy; see our Self-Audit Series of articles in our archive on the PAAS Member Portal
• Review our Can You Bill It As 30 Days? document under Proactive Tips on the PAAS Member Portal