Vaginal Creams: Why 30 Days’ Supply Is Probably Not Appropriate

related to days’ supply issues. Do the directions on the hard copy give a calculable day supply? Are there grams per application? If not, the pharmacy should clarify with the prescriber prior to dispensing and put a clinical note on the hard copy. Directions like “one application twice weekly” or “use as directed, a pea-sized amount” would also not suffice for calculable directions, as they are not specific enough, and most PBMs will not assume “pea-sized” amount is 0.25 g. PAAS recommends communicating with the provider to clarify and adding a clinical note to the hard copy. Be sure that these clarifications (frequency and/or volume) are also reflected on an updated patient label prior to dispensing.

Once you determine the prescription contains calculable directions, the next step would be to bill the accurate day supply. Pharmacies can fall into the trap of assuming a days’ supply exceeding 90 days will surely be rejected based on historical experience; therefore, a 90 days’ supply is billed to the insurance. This places the pharmacy at risk for an invalid day supply discrepancy, as well as potential refilled too soon discrepancies on subsequent refills. Unbeknownst to many pharmacies, PBMs have begun to allow accurate [>90] days’ supplies to be billed for certain types of medications, including vaginal creams. Our recommendation is to always submit a claim with the true and accurate days’ supply first. If the plan rejects the days’ supply, PAAS recommends contacting the insurance help desk for an override. If the insurance does not have an override for the day supply, document this on the hard copy and bill for the maximum day supply allowed by insurance. To prevent accidental early refills, PAAS recommends adding a note on the pharmacy label in the directions, making both staff and patients aware of the actual day supply. The more visibility the note is, the less likely an early refill will be missed.  

PAAS Tips:

• Reminder that a clinical note should contain four elements
  • The date/time of the call
  • The name and title of the person you spoke with at the prescriber’s office
  • The clarification
  • Your initials
• Both products have a calibrated applicator for dosing, however each applicator is a different size
  • Estrace® is a 42.5 g tube with an applicator that can measure 1 to 4 grams in 1 g increments
  • Premarin® is a 30 g tube with an applicator that can measure 0.5 to 2 grams in 0.5 g increments
• Avoid putting vaginal creams on automatic refill or in a medication synchronization program if the pharmacy billed an inaccurate day supply due to a plan limit
• Review our new member benefit guidance Exceeding Days’ Supply Plan Limits for Unbreakable Packages