Update: Isentress® and Dificid® Added to Dispense in Original Container Chart
OptumRx continues to focus audits on prescriptions that must be dispensed in their original container per the manufacturer’s [FDA approved] labeling and package insert.
Entries by Jenevra Azzopardi, CPhT
Oral Inhalers – What You Need to Know About Institutional Pack Sizes
Oral inhaler prescriptions are frequently targeted for audit by PBMs because of their cost, frequent billing errors (e.g., incorrect days’ supply), or prescribing errors (e.g., non-mathematically calculable directions or incorrect written quantity). Vague written quantities can cause recoupments when multiple package sizes exist, including institutional package sizes.
Mailing Prescriptions? How to Ensure Audit Success
While some pharmacies make mailing prescriptions a regular practice, others may only do so on a case-by-case basis. PBMs require signature logs to prove that a patient received their medication in a timely manner, but how is proof obtained when the patient is not standing in front of you at the pharmacy counter?
Forteo® Package Size Update – Compendia Adjustment Expected April 1, 2025
As previously reported by PAAS National®® in our December 2024 Newsline article, the FDA revised the product labeling for Forteo® (teriparatide injection) and its generics to accurately reflect the amount of drug delivered to the patient and not the overfill existing in the pen injector delivery device (from a 600 mcg/2.4 mL pen to a 560 mcg/2.24 mL […]
Unique Eyedrop Calculation Challenges
Pharmacy social media platforms host passionate discussions on the correct way to bill days’ supply for eyedrops almost every week. Do you use 15 drops/mL, 20 drops/mL, or something else? As it turns out, the “right answer” depends on the PBM you are billing and if the eyedrop is a solution or a suspension. Sound […]
Forteo® Package Size Update – Are You Billing the Correct Cost?
Forteo® (teriparatide injection) is a parathyroid hormone analog (PTH 1-34) used in the treatment of osteoporosis, specifically for postmenopausal women at high risk for fractures, men with primary or hypogonadal osteoporosis, and individuals with osteoporosis associated with sustained glucocorticoid therapy. It is designed to increase bone mass and reduce fracture risk in patients who have […]
Why the Unit of Measure Matters in Audits: A Small Factor with Big Consequences
A unit of measure (UOM) provides standards to define physical quantities. Without a UOM, a number is left open for interpretation, and while common sense often prevails for pharmacies, third-party auditors look for explicit instruction. With an ambiguous, or absent, UOM (primarily an issue with electronic prescriptions), an auditor may flag the claim as discrepant […]
Representative NDC on Electronic Prescriptions Do Not Infer Specificity
When electronic prescriptions were first introduced, they were supposed to be more convenient for patients and cause less errors at the pharmacy (due to the legible nature of the information being sent from the prescriber).
Insulin Pens: Understanding Dosing Increments and Audit Risks
PAAS National® continues to see auditors flag insulin pen prescriptions for containing a dosage that does not align with the product.
What to Do (and Not Do) When Your Days’ Supply is Rejected
Insurance companies require pharmacies to bill an accurate days’ supply based on mathematical calculations from the directions.
