OptumRx® Continues to Pocket More Money from Days’ Supply Issues

OptumRx^® will flag the initial fill of the prescription with an invalid days’ supply (1N) discrepancy and subsequently re-adjudicate the claim with the correct days’ supply. If the correct days’ supply increases the patient’s copay, the pharmacy will see the copay difference as recoupment. For example, an inhaler was billed with a 30-day supply and had a $20 copay, but it should have been billed as a 60-day supply (assuming no days’ supply limitation) and would have had a $40 copay. The recoupment difference would be $20. However, OptumRx^® does not stop here. Since they found a discrepancy on the claim under audit, they will continue to look at all associated refills over the life of that prescription. The interval of time between each fill will be scrutinized to see if the pharmacy has refilled the prescription too soon according to the accurate [60] days’ supply. OptumRx^® states in their provider manual on page 76 under Section H. Coverage Limitations,

“A Member may refill most Prescriptions when a minimum of seventy-five percent (75%) of the quantity is consumed based on the number of days supplied. This minimum quantity consumed amount is seventy percent (70%) for eye drops.”

In this example, let’s say the prescription was refilled every 30 days with a total of 6 refills. OptumRx^® will flag every other fill as a refill too soon (2Z) and charge back the full amount of the claim. Now the recoupment has gone from one incorrect days’ supply to six incorrect days’ supply (1N) and three refill too soon discrepancies, assuming the pharmacy never caught the error. This causes the recoupment to alternate between the patient’s copay difference and the full claim, and this can add up very fast!

To see a more detailed example of this situation, please see October 2024 Newsline article, Avoid OptumRx^® Double Chargeback Pitfalls – Review Your Days’ Supply.

PAAS Tips:

• Insulin, inhalers, topical medication, vaginal creams, and eye drops are frequently flagged for refill too soon or overbilled quantity
• Many PBMs have built-in overrides for the smallest package sizes, so be sure to submit the claim with an accurate days’ supply first
• Consider these resources on the Member Portal, under “Proactive Tips”
  • Can You Bill It As 30 Days?
  • Exceeding Days’ Supply Plan Limits for Unbreakable Packages
• Notate the actual days’ supply on the patient label to help notify the patient and pharmacy staff on the true days’ supply in the case of plan limits
• Check with your software vendor to see if additional days’ supply fields are available for internal tracking (i.e., billed days’ supply and actual days’ supply)
• Avoid med sync or cycle fill programs for products whose correct days’ supply cannot be submitted for the smallest package size – See April 2025 Newsline article, Audit Considerations for Med Sync Programs for more information
• Read more from October 2024 Newsline article, What to Do (and Not Do) When Your Days’ Supply is Rejected  
• The Audit Violations and Discrepancy Descriptions for 1N and 2Z can be found in the OptumRx® Provider Manual on page 146 and page 148, respectively
• Be proactive and utilize the PAAS RX Days’ Supply Calculator! Download the app for a free 7-day trial ($5.99/year thereafter) by visiting the Apple App Store or Android Google Play Store, or check out the website at PAASNational.com/app