Best Practices for Billing Vaginal Creams to Avoid Recoupment

Here is an example prescription:

1. Premarin^® vaginal cream, quantity: 30 gram, sig: 1 gram vaginally three times weekly
2. 30 gram ÷ 3 gram per week = 10 weeks or 70-day supply
3. Don’t assume plan max of 30 days, try to bill as 70-day supply as per estimate
4. If plan limit is 30 days, then follow the “ILQ process”
5. Suggest sig on dispensing label of ‘Use 1 gram vaginally three times weekly (70 days)’ to alert patient and pharmacy staff of how long the dispensed product should last

PAAS Tips:

• PBMs look for calculable instructions (e.g., grams per application or max grams per week/month)
• Instructions for “pea-sized amount” or “X number of inches” are not sufficient for audit purposes
  • For a pea-sized amount, work with prescribers to clarify if 0.25 grams would be appropriate (half of a finger-tip unit)
• Ensure an accurate days’ supply is submitted on claims – many PBMs will allow > 90 days for these products due to normal utilization
• These vaginal creams only come in one package size and instructions rarely support a days’ supply of 30
• Do NOT default the days’ supply to 30
• See PAAS’ Can You Bill as 30 Days? resource on the PAAS Member Portal (paasnational.com) for step-by-step guidance on the “Insurance Limits Quantity” (ILQ) process
• Vaginal creams should be treated as “refill on demand” only and NOT included on LTC cycle fill or retail medication synchronization programs
• Self-audit your vaginal creams for accurate days’ supply and appropriate instructions – refer to our June 2021 Newsline article, Self-Audit Series #5: Topical Prescriptions