Stop Breaking Insulin Pen Boxes– Your Questions Answered

Claim Processing

1. Will PBMs allow claims with a days’ supply greater than 90?

Many pharmacies report that claims will successfully process for greater than 90 days. Pharmacies should always start by submitting an accurate days’ supply for a full box and follow plan messaging, See Can You Bill It As 30 Days? for additional guidance.

2. Why is my reimbursement going down?

We suspect that pharmacies are processing more insulin pen claims for extended day’s supply (> 30 days). PBM contracts have more aggressive rates for extended days’ supply dispensing. Pharmacies may consider contacting their PSAO or the PBM to try to opt out of these networks. Submitting a false days’ supply (e.g. 30 days) when the product should really last 90 days, and the plan allows 90 days, is a contractual violation and would probably be considered fraudulent.

LTC Pharmacy

3. Does this apply to LTC practice?

Yes, FDA-approved labeling applies to all practice settings and pay types.

Audits

4. Will PBMs issue written guidance such as fax memos or update Provider Manuals?

There was no explicit guidance issued subsequent to the Walgreens’ DOJ decision, but most PBMs were quick to audit claims and enforce. We continue to encourage various audit departments to provide clear expectations on audit policies. On March 20, OptumRx sent a one-page memo entitled “Accurate Billing for Insulin Pens” confirming the FDA labeling update and reminding Network Pharmacies how to correctly submit claims. In particular, Optum states:

• Pharmacy Provider must request an override through the pharmacy help desk when rejected for plan limits and dispensing in the smallest commercially available package size (typically 15 mL per carton).
• If an override is not available and the days’ supply is altered, pharmacies must ensure the refill interval is based on the actual days’ supply, not the submitted days’ supply (or risk audit recoupments).

PAAS is not aware of additional PBM guidance; and much like MAC pricing, the more vague and opaque policies are, the more broadly they can be applied to benefit the PBM.