Be on the Lookout for Eye Drops Requiring Extra Billing Consideration

Correctly billing eye drops requires a little extra thought and consideration, but it does not have to be a daunting task. Follow these simple steps and remember to be on the lookout for the unique eye drops listed below.

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  1. Ensure the prescription has calculable directions including which eye, or eyes, the drops are being utilized in, the frequency for which they are used, and a specified quantity (e.g., mL, bottles, vials)
  2. Calculate the days’ supply using PBM published guidelines regarding appropriate drops per milliliter; refer to the PAAS Eye Drop Guidance tool on the Member Portal for a listing of eight top PBMs and their required drops/mL
  • If a PBM does not provide published guidance, use 20 drops/mL for solutions and 15 drops/mL for suspensions and emulsions
  1. Adjust the days’ supply billed, when necessary, to account for manufacturer product labeling such as manufacturer beyond use dating (available at U.S. National Library of Medicine DailyMed website)
Medication Available Package Sizes Manufacturer Beyond Use Date
AzaSite® 1% solution 2.5 mL 14 days
Rhopressa® 0.02% solution 2.5 mL 42 days
VyzultaTM 0.024% solution 2.5 mL, 5 mL 56 days
Xalatan® 0.005% solution 2.5 mL 42 days
  1. Ensure drops available in single-use vials are calculated based on the number of vials needed per day, not drops/mL
Medication NDC Package Size Special Considerations
Restasis® 0.05% emulsion 00023-9163-30

00023-9163-60

 Carton of 30 vials

Carton of 60 vials

 The emulsion from one single-use vial is to be used immediately after opening for administration to one or both eyes; the remaining contents should be discarded immediately

Caution: Restasis® is also available in a 5.5 mL multi-dose preservative-free bottle NDC 00023-5301-05
Xiidra® 5% solution 00078-0911-12 Carton of 60 vials The solution from one single-use container is to be used immediately after opening and can be used to dose both eyes; the remaining contents should be discarded immediately
Zioptan® 0.0015% solution 82584-0609-30 Carton of 30 vials The solution from one individual vial is to be used immediately after opening for administration to one or both eyes; the remaining contents should be discarded immediately

PAAS Tips:

  • Prescriptions written for “1 bottle” are handled differently from one PBM to the next
    • Auditors will often use a vague quantity (or directions, drug formulation, etc.) to their advantage and flag the claim for recoupment
    • Avoid time-consuming appeal procedures across all PBMs by contacting the prescriber’s office and clarifying vague or ambiguous information prior to billing (i.e., quantity from “1 bottle” to number of milliliters)
  • If the treatment duration (e.g., “use for 10 days”) is less than the calculated days’ supply, submit the true calculated days’ supply
  • If discard instructions (e.g., “discard after 10 days”) are included on the prescription and it is a smaller days’ supply than the calculate days’ supply, submit the claim with a days’ supply matching the treatment duration
  • Refer to the March 2024 Newsline regarding special billing considerations for MieboTM ophthalmic solution

Sara Hathaway, PharmD
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