Welcome back. I know that there is a lot going on in our world right now, but I wanted to provide a quick update on some changes that could impact the billing of insulin pens.
In the past, insulin pens were dispensed by a pharmacy based on how many pens would last the corresponding days’ supply limit allowed by a member’s prescription drug plan. As these pens come prepackaged in a set quantity, pharmacies would break up the boxes, if needed, in order to provide the appropriate quantity to the member.
The wording stated to “dispense in the original sealed carton” and therefore breaking up boxes was no longer recommended. The FDA’s key reason for the change was for safety purposes. Open boxes may prevent members from receiving all the appropriate labeling or product pamphlets and could lead to adverse effects.
From a pharmacy standpoint this creates a challenge. Pharmacies are required to bill medications in quantities that are at or below what the limits are for a member’s prescription drug plan. Not allowing a pharmacy to open or break up a box could lead to them having to give more than what is allowed by the plan. The solution for situations where this happens is for the pharmacy to calculate the appropriate amount based on the specific directions on the prescription and then contact the member’s insurance if an override is needed. Based on the specific insurance company and benefit, the member’s copay may be adjusted to reflect the actual days’ supply of insulin they are receiving. This would be no different than other situations where a medication cannot be broken or split, and the member’s copayment reflects the true days’ supply of medication.
On a final note, I hope that you and all those around you are staying safe and well during these trying times in our nation. You have our commitment at ProAct that we are maintaining the highest level of service for you and your members. We will get through this together.