Prescription Quantity Changes Require Documentation

Anytime you dispense a quantity different from what was prescribed, you should note why. PAAS National®® has seen recoupments when quantities dispensed were decreased or increased from the original prescribed quantity.

Valid reasons for decreasing quantity include patient request, med sync program, “dispense in original container,” and plan limitations. In these situations, you should be documenting the reason on the prescription or within the pharmacy’s software. Many PBMs require this documentation, including OptumRx, Express Scripts, Elixir, CVS/Caremark, and MagellanRx, all of which have discrepancy codes related to “cut quantity.” The rationale behind these discrepancies is that the PBM believes the pharmacy is trying to acquire excessive dispensing fees and/or circumvent plan limitations. Having documentation stating otherwise is essential.

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Contractual obligations must also be taken into consideration when dispensing lesser quantities of a medication. If you are not already aware, PAAS has one of the largest troves of PBM contracts in the nation. PAAS has seen a prominent PBM recently insert language in their extended days’ supply agreements that require pharmacies to use “commercially reasonable efforts” to dispense an Extended Days’ Supply. Not only does the PBM frown upon cut quantities, but they also want pharmacies intervening to dispense more extended days’ supply prescriptions. Evidence to the contrary can result in required corrective action plans and decreased reimbursement on 30 days’ supply claims going forward (either at the point of sale, or through the reconciliation process). Indiscriminately changing patients to a 30 days’ supply resulting in increased reimbursement for the pharmacy can give the appearance of profiteering and be a slippery slope.

There are also some things to consider when increasing a quantity:

  • If your state allows you to change a patient to a 90 days’ supply without consulting the prescriber, document accordingly (e.g., increased to 90 DS per state regulation xxx.xx) and ensure you do not go over the original total quantity and refills prescribed.
  • If your state does not allow you to increase the quantity, you must contact the prescriber first and make a clinical note about the approval for a quantity increase.
  • If the prescriber ordered a quantity less than the smallest package size, you still cannot go over the total quantity and refills prescribed without consulting with the prescriber
    • For example, insulin pens written for a quantity of 3 mL with 2 refills. The total quantity prescribed is only 9 mL. You must clarify the quantity and refills with the prescriber to dispense a full box of 15 mL.

PAAS Tips:

  • Document the reason for any quantity change
    • Insurance Limits Quantity (ILQ)
    • Patient requests one-month supply
    • Med sync program
    • Must dispense in original container
  • Do not cut the quantity to work around negative reimbursement or to acquire additional dispensing fees
  • Do not cut the quantity to work around a plan limit rejection
  • If the quantity written is less than the package size, and there are not enough refills to cover the actual quantity, verify the quantity and refills to dispense with the prescriber
  • Clinical notes should contain four elements: date, name and title of who you spoke with, what was discussed, and your initials
Jenevra Azzopardi, CPhT