OptumRx Continues to Cause Headaches!
PBMs monitor, and flag, migraine medications due to excessive cost, quantities submitted, days’ supply (and/or frequency of refills) and vague instructions. OptumRx often flags …
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“as needed” migraine medications with “Prescription lacks specific, calculable directions (use as directed or missing directions).” While this discrepancy may be appealable with a prescriber statement containing a maximum daily dose (MDD), the MDD may not support the quantity and days’ supply billed on the claim. To avoid this headache, and lessen your audit risk, follow the PAAS National®® tips below to ensure you have a compliant prescription prior to billing and dispensing.
PAAS Tips:
- Confirm the dosage form prescribed is clearly indicated as many migraine medications come in multiple forms – oral, oral disintegrating, nasal spray, injectable
- Vague instructions for use such as “Use as Directed” and “as needed” should always be clarified
- Call the prescriber to verify the frequency of headaches per month on “as needed” migraine prescriptions and document a clinical note
- A clinical note should contain the date, name and title of individual providing information, what was confirmed and the pharmacy staff initials
- Review product labeling to identify the maximum daily/weekly/monthly dosing and have supporting documentation on the prescription if billing outside the maximum dose
- More information about migraine prescriptions can be found in the archive Newsline articles
Analyst at PAAS National®
I began working at an independent pharmacy in high school and really enjoyed being in the health care field. I provided clinical support to improve patient care and adherence to their medications. I have played a vital role in the pharmacy industry full-time for 23 years.
I have a Bachelor of Science degree from the University of Wisconsin-River Falls and have been a Certified Pharmacy Technician since 2001. Prior to joining the PAAS team, I was a floating technician, 3rd party district chargeback specialist, and district pharmacy training coordinator. Formerly, I was also an instructor for pharmacy technician certification classes.
PAAS’ personal, one-on-one connection will help your pharmacy become more successful in dealing with tiresome PBM audits. It is a pleasure knowing that my colleagues and I can help member pharmacies.
I have a Bachelor of Science degree from the University of Wisconsin-River Falls and have been a Certified Pharmacy Technician since 2001. Prior to joining the PAAS team, I was a floating technician, 3rd party district chargeback specialist, and district pharmacy training coordinator. Formerly, I was also an instructor for pharmacy technician certification classes.
PAAS’ personal, one-on-one connection will help your pharmacy become more successful in dealing with tiresome PBM audits. It is a pleasure knowing that my colleagues and I can help member pharmacies.
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