OptumRx Targeting Medications Requiring Dispensing in Original Containers

Recent audit results coming into PAAS National® are showing OptumRx auditors have their sights set on several medications that are required to be dispensed in the original container.

PAAS has notified members of common medications (e.g., Creon® and Linzess®) being targeted for recoupment on audits when dispensed outside manufacturer guidelines. However, several new medications have been added to their target list …

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– numerous HIV medications, Carafate® (sucralfate) suspension, Effient® (prasugrel) and Tekturna HCT® are just some of the recent medications flagged.

Please visit the Member Portal for the most current Dispense in Original Container Chart, that is updated as information is available.

Without PBM hard stops in place at claim adjudication (which is complete malarky), the burden falls on the pharmacy to ensure FDA dispensing requirements are met. Don’t fall into the trap and face recoupment because you billed a claim that was not divisible by the package size (e.g., dispensing 28 tablets with a 30-count bottle size – only billed in multiples of 30).

Pharmacies that service long-term care and assisted living facilities, or provide special packaging for patients on a sync program, tend to be at the highest risk for billing these claims incorrectly. Often, the manufacturer has not provided any stability information that supports breaking the stock bottle, therefore this medication should not be dispensed using special packaging.

PAAS Tips:

  • Post the Dispense in Original Container for staff to utilize at data entry and filling stations
  • When receiving a prescription for a quantity less than the package size of these medications, contact the prescriber and inform them of the dispensing requirements and request authorization to increase the quantity and document with a clinical note
  • Communicate with facilities and patients, who utilize special packaging, on the requirements for dispensing full bottles with certain medications
  • Contact your pharmacy’s software vendor to see if NDCs can be flagged with alerts at data entry to ensure the quantity billed matches the package size
    • Alternatively, consider flagging inventory shelves for medications with special packaging/dispensing requirements
  • Self-audit claims on a weekly or monthly bases to ensure appropriate dispensing

Dana Westberg, CPhT