As PBMs continue to monitor claims for migraine medications, PAAS National® continues to receive questions about billing and the audit risks associated with these claims. When billing a medication to treat or prevent a migraine, pharmacies often struggle with having the correct documentation recorded for audit purposes. Submitting accurate quantities and days’ supply, along with appropriate documentation to support these claims, are the biggest issue PAAS comes across during an audit. PBMs monitor, and flag, these claims due to excessive cost, quantities submitted, days’ supply and/or frequency of refills.
- Check to be sure the dosage form is present and clearly indicated whether that be an oral tablet, oral disintegrating tablet (ODT), nasal spray or subcutaneous (SQ) injection
- Vague instructions for use such as “Use as Directed” and “as needed” should always be clarified
- Prescriptions written for more than one package of any dosage form should have the estimated number of headaches per week or per month, per the prescriber, documented on the prescription and on the patient label. This information allows the pharmacy to calculate an accurate days’ supply when submitting the claim.
- Pay close attention to the FDA labeling for:
- Indications and usage – some medications are used for the treatment of a migraine and others as a preventative treatment
- Dosage and Administration – review the recommended dose, can the patient repeat a dose, is there a maximum number of migraines that can be treated per week/month
- Be sure to bill the appropriate days’ supply. Ex: Provider orders 16 tablets of Nurtec ODT for preventative treatment. Using 1 tablet every other day would make this a 32 days’ supply, not 30 days’ supply
- Here are some examples:
|Drug||FDA approved indications/usage||Recommend dose||Can patient repeat the dose?||Maximum daily dose||Billing Unit per package|
|Migranal Nasal Spray||Acute treatment||One spray in each nostril (must prime with 4 pumps prior to each use and discard 8 hours after it is primed)||Yes, 15 minutes later||No more than 4 sprays (2 mg) per 24 hours.
No safety studies for doses
|Nurtec ODT tablets||Acute treatment||75 mg daily||No||No more than 18 doses in a
|Preventative treatment||75 mg every other day|
|Ubrelvy tablets||Acute treatment||50 mg or 100 mg||Yes, at least 2 hours after initial dose||200 mg/24 hours and no more than 8 migraines in 30-day period||10 or 16 each|
Please reach out to PAAS (608) 873-1342 or firstname.lastname@example.org with any questions on how to bill for different migraine medications so you don’t end up with a headache!
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