Preventing Misfill Recoupments Through Documentation

when a pharmacy supplements or documents clinical notations that are not explicitly written on the prescription (and do not appear on the patients prescription label), it risks the claim being considered a “misfill”. OptumRx and Caremark are very particular about the directions on the patient label matching exactly what the prescription, and any relevant clinical notations, contains.

Some of the following are examples of those errors:

• Grams per application or area applied for topical medications
• Which eye(s) an eye drop is being administered into
• Number of snacks for pancreatic enzymes
• Max daily dose for insulin with sliding scale or titration

Victoza^® is another example of a problematic patient label issue, which typically has directions in MG, but is often typed on the patient label as ML.

PAAS Tips:

• Verify any ambiguous information on the prescription with the provider prior to dispensing
• Include clinical notation about the clarification including the 4 elements below:
• Date/Time of the call/conversation
• Name and title of who you spoke with
• Specific details about the clarification
• Initials or name of the pharmacy employee making the clarification

• For more insight on clinical notations, see July 2025 Newsline article, PBMs Are Criticizing Clinical Notes!
• Educate all staff to include relevant clinical notation information on patient labels that relate to the instructions for use
• Be sure the auditor is receiving all clinical notations when submitting prescriptions for an audit