Documentation is Essential for Prescription Quantity Changes

Anytime a pharmacy dispenses a quantity different than what the prescriber ordered, there should be a reason documented on the prescription for the decreased or increased quantity.

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PBMs want to know why the pharmacy is dispensing a quantity that is different from what was prescribed. PAAS National® has seen a few PBMs try to recoup on reduced quantities if the pharmacy did not have a valid reason documented. See the chart below for examples of discrepancy codes that will appear on audit results. The PBMs believe the pharmacy may be trying to work around negative reimbursement (e.g., lower reimbursement on EDS networks), acquire excessive dispensing fees and/or circumvent plan limitations.

PBM Definition Code
Caremark Quantity billed is less than that prescribed and less than that allowed resulting in additional refills and undue dispensing fees CQ – Cut Quantity
Elixir Quantity billed is less than prescribed, resulting in frequent fills and dispensing fees and/or circumventing plan limitations SPL – Split Quantity
Express Scripts Quantity dispensed was reduced from that authorized by prescriber and allowed under prescription drug plan CQ – Cut Quantity
MagellanRx Quantity cut with no documentation on RX RXCQ – Cut Quantity
MedImpact No documentation for dispensing a quantity less than prescribed 2Y – Quantity
OptumRx No documentation for dispensing a quantity less than prescribed 2Y – Quantity

 

PAAS Tips:

  • Document the reason for any decreased quantity
    • Insurance Limits Quantity (ILQ)
    • Patient requests one-month supply
    • Med sync program
    • Must dispense in original container per manufacturer
  • Document the reason for any increased quantity
    • Increased to 90 days’ supply per state regulation xxx.xx
      • Do not dispense more than the originally total quantity and refills that were prescribed
    • If your state does not allow you to increase the quantity, contact the prescriber first and document authorization for an increased quantity
    • If the prescriber ordered a quantity less than the smallest package size, do not exceed the total quantity and refills that were prescribed without consulting with the prescriber
      • For example, insulin pens written for a quantity of 3 mL with 2 refills. The total quantity prescribed is only 9 mL. You must clarify the quantity and refills with the prescriber to dispense a full box of 15 mL
    • A clinical note should contain four elements:
      1. Date (and preferably time),
      2. name, and title of who you spoke with,
      3. what was discussed, and
      4. your initials
    • Having documentation to support billing a quantity different than what was prescribed is essential for audit protection

Jennifer Ottman, CPhT
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