From Headache to Hassle Free: Best Practices in Migraine Medication Billing

is flagging migraine medications as 1N-Incorrect Days Supply: Submitted Days’ Supply on Claim is Incorrect. Prior Authorization Required for Correct Days’ Supply. The auditor has calculated the days’ supply strictly based on the prescription instructions, without accounting for the fact that the medication is prescribed to be taken as needed. Consider the following example:

Prescription is written for Ubrelvy^® 100 mg, #16 tablets. Instructions are to take 1 tablet at onset and repeat in 2 hours if needed. Pharmacy billed this claim as a 30-day supply based on a plan limit rejection (when the pharmacy billed #16 for an 8 days’ supply); however, the auditor also calculated the days’ supply to be 8, and stated this prescription, as written, would require prior authorization.

PBMs simply don’t allow pharmacists to use their professional judgement to determine the days’ supply. Prescribers should be contacted to obtain the specific number of headaches per week/month they anticipate the patient to treat, or the maximum number of tablets the patient may use per week/month. This information should be obtained prior to dispensing, documented on the prescription, and included on the patient label.

Injectable, maintenance migraine medications have their own set of audit risks. Pharmacies must bill the days’ supply according to the exact instructions. If the patient is to inject “monthly”, the claim should be billed as a 30-day supply. When the patient is injecting “every 4 weeks,” the claim should be billed as a 28-day supply. While you may not think two days can make a difference, understating the days’ supply can create an opportunity for the PBM to argue a refill was too early.

PAAS Tips:

• Obtain utilization (headache frequency or maximum dosing over time) information directly from prescribers – patient notes are often not accepted by PBMs
  • Update the patient label accordingly
• A complete clinical note should include:
  • Date and time
  • Name and title of individual providing information
  • Specific information clarified
  • Pharmacy staff initials
• As needed migraine medications should only be refilled upon patient request