Community pharmacies are always looking for ways to provide better care for patients. A primary focus continues to be on customer service - whether it be cost savings on prescriptions, convenience of delivery or med-sync programs. When a patient presents to the pharmacy with a new prescription, the focus is on education and adherence. Wouldn’t it be nice to fill the first month AND the second month of medication for the patient at the same time? Not so fast!

Using Chantix^® (varenicline) for smoking cessation as an example, a patient starts with a titration pack for 28 days of increasing dose. Following the initial 28-day course, the 28-day continuing pack is prescribed with the maintenance dosing that the patient will continue. Smoking cessation is often a struggle for patients and compliance becomes very important for patient success. A pharmacy may be tempted to fill both prescriptions simultaneously, saving the patient a trip to the pharmacy as well as increasing the likelihood of compliance and success in quitting smoking.

However, this situation would be an easy target for PBMs to recoup the continuing pack due to “refill too soon,” “therapeutic duplication,” “overutilization,” or even “clinical misuse”. The billing of two separate NDCs may allow both claims to successfully adjudicate on the same day without a problem, but it is expected that the patient will wait for the plan-defined utilization threshold (after receiving the Chantix^® starter pack) before filling the continuing pack. Part of the rationale being if the patient doesn’t tolerate the starter pack, the PBM has paid for a second prescription that will not be used by the patient, leading to waste.



PAAS Tips:

• If multiple prescriptions for treatment initiation and continuation are brought or sent into the pharmacy, fill only one at a time to avoid potential audit recoupments.
• If the titration and maintenance doses are written on the same prescription, there are a few different ways to bill and dispense the prescription:
• Enter the prescription with the directions for the complete titration and maintenance dose and adjust the days’ supply and/or quantity on the refills.
• Enter the prescription as two separate prescriptions, one for the titration and the other for the maintenance dose. 

By Trenton Thiede, PharmD, MBA, President at PAAS National^®, expert third party audit assistance, FWA/HIPAA and USP 800 compliance.

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