Cvs Change to broken pack insulin pen policy

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FarmD711

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Just gonna leave this here

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Is this just CVS’s way of selling more insulin?

“A sealed carton” is very different than a “prepackaged sealed carton”. Just put the pen in a labeled carton and sell it. Make it official by putting tamper resistant tape on the carton
 
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Didn't walgreens got in trouble for doing exactly this?

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Walgreens paying $209M settlement for Not Opening Insulin Pen Boxes

Looks like this should clear up any confusion.. lol Walgreens to pay $269 million on claims it overcharged federal programs Wall Street Journal (01/23/19) Thomas, Patrick Walgreens Boots Alliance has agreed to pay more than $269 million to settle federal and state lawsuits that accused it of...
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Wtf, so if they're using 10 units a day... dispense a whole box? What if insurance only allows 30 day supply? Then we back to square 1 when the insurance audits drop.
 
The issue is imputed over utilization based on day supply (excuse to audit and do chargebacks)

Walmart recently introduced a "third party day supply" to avoid this issue. Even though a claims processor might limit day supply to 30 days max, you can keep the real day supply the same so messaging and auto-fill work correctly. Third party day supply cannot be changed after the initial fill either.
 
Sine Cura said:
The issue is imputed over utilization based on day supply (excuse to audit and do chargebacks)

Walmart recently introduced a "third party day supply" to avoid this issue. Even though a claims processor might limit day supply to 30 days max, you can keep the real day supply the same so messaging and auto-fill work correctly. Third party day supply cannot be changed after the initial fill either.
Click to expand...

That's actually pretty genius although I wonder if they will get away with it. Seems weird to me to have a "real" day supply and a "billed" day supply.
 
My company enacted this policy months ago, according to guidance from the FDA and insurance companies. If a full box exceeds the insurances' max days supply, we are to put the max days allowed as the days supply. We then put **true days supply is x days** at the end of the sig to prevent patient confusion and to allow staff to quickly track refills properly. We are expected not to refill it too soon, and manually keep track of last fill date. Not perfect and kinda a pain, but have had no issues so far and have passed a recent caremark audit on it.
 
rickyroxy said:
Didn't walgreens got in trouble for doing exactly this?

forums.studentdoctor.net

Walgreens paying $209M settlement for Not Opening Insulin Pen Boxes

Looks like this should clear up any confusion.. lol Walgreens to pay $269 million on claims it overcharged federal programs Wall Street Journal (01/23/19) Thomas, Patrick Walgreens Boots Alliance has agreed to pay more than $269 million to settle federal and state lawsuits that accused it of...
forums.studentdoctor.net forums.studentdoctor.net
Click to expand...

That was before the FDA judgement that came down. Our corporate was told by insurers that as long as we are tracking refill dates and aren't filling them unreasonably early (ex not just blindly refilling every 30 days if days supply is actual 75 days, etc), we will be in the clear. Been doing it this way for months at my company with no issues so far....just involves paying more attention.
 
Isn't the real issue here that insurances should be required to accept day's supply other than 30? If they are going to require 30 days supply then they should be required to pay for it every 30 days. Watch how fast they update their system in that case.

Wishful thinking, I know.
 
forums.studentdoctor.net

Insulin pen, box: open box or not? Rite Aid Old Memo of 2013?

Laws need changed first and with people thinking pharmacists need to only review so per day, law changes are far away. True, though with as much money as he (and Amazon) has, its still concerning. Look what big Pharma did with Congress to the DEA on last month's 60 Minutes story.
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I'm just going to leave this here
 
owlegrad said:
Isn't the real issue here that insurances should be required to accept day's supply other than 30? If they are going to require 30 days supply then they should be required to pay for it every 30 days. Watch how fast they update their system in that case.

Wishful thinking, I know.
Click to expand...
They won't allow the patient to put it on readyfill at the register. Only staff can do it manually.....
 
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this is going to be chaos at a busier CVS store
 
The store where I used to work never broke open boxes, several others didn't either. Been that way for years.
 
I thought the FDA guidance on this was for LTCF. Did they specify community too?
 
owlegrad said:
That's actually pretty genius although I wonder if they will get away with it. Seems weird to me to have a "real" day supply and a "billed" day supply.
Click to expand...

This is way better than "calling the insurance help desk for an override on day supply" or "calling the prescriber to request they do a prior authorization for quantity/day supply limit"
 
This opening vs not opening insulin pens is the dumbest thing ever and I hope WAG goes after the federal government to recoup the $270M that they paid
 
Pronounce Doxazosin said:
This opening vs not opening insulin pens is the dumbest thing ever and I hope WAG goes after the federal government to recoup the $270M that they paid
Click to expand...

Exactly, it is the artificial insurance day supply limit that causes this issue, then they have the nerve to fine pharmacies for the problem they themselves created. How about this, make the smallest dispensable quantity of any drug have an unlimited day supply, problem solved.

I wondered when some company would have to implement a "real" and a "fake" day supply to deal with this stupidity, almost as dumb as still allowing prescriptions to be ordered over the phone is the year 2020.
 
Actually I always thought the sig "use per sliding scale. insulin dosing requires individualization" was the dumbest ****ing thing

What your sliding scale then?

Isn't a prescription for... an individual?

Almost as dumb as prescribers telling patients to increase the dose but not following up with an updated script, then the customer comes bitching they can't get their **** early.
 
Days supply is so vague and can mean so many different things depending on your lens. One could argue it’s the number of days worth of medication ingestion (30 tablets at one a day is 30 days) OR the number of days from first ingestion to last ingestion of the medications dispensed (2 tablets at 1 tablet stat then repeat in 3 days, 4 days supply ) OR its the therapeutic “duration” of the medication until the next dose is inevitably due (4 tablets at 1 a week = 28 days supply even though the last one is taken at day 21) meanwhile the clinical effects and actual duration of the medication in the body can often last much much longer.

what’s the right days supply for an annual flu shot? 1? 30? 90? 180? 365? ... you shouldn’t be due for the next one until next flu season but it’s only administered once on one day...
 
Most people working in retail pharmacy consider it the # of days to elapse before the pt would need to replenish the Rx if taken correctly (if it needs to be repeated). Or you just put 1 for one-offs like meters and Narcan

Claims processors typically impose qty/timing/lifetime limits for shots on the back end anyway (max 1 in 365 days or max 1/lifetime or no flu shots until Sept).
 
Sine Cura said:
Most people working in retail pharmacy consider it the # of days to elapse before the pt would need to replenish the Rx if taken correctly (if it needs to be repeated). Or you just put 1 for one-offs like meters and Narcan

Claims processors typically impose qty/timing/lifetime limits for shots on the back end anyway (max 1 in 365 days or max 1/lifetime or no flu shots until Sept).
Click to expand...

oh I’m aware what they do but as in your reply that’s three different use cases for the singular field leveraged by multiple parties.

wheres ncpdp in this? What’s the standard?
 
I never realized it was ambiguous. If an injection is once monthly I thought the days supply was 30. That’s usually how insurance companies want it processed at any rate.

I don’t know how you would process a once-in-a-lifetime vaccine using that logic though lol.
 
You just apply a "common-sense" algorithm when entering day supply. You'll never get disputed claim for DS = 1 for any vaccine. How else would you enter DS for Shingrix? Impose min 60 DS for the first one then ∞ for the next?
 
I’m not saying it’s hard to use common sense to figure out an “acceptable” value to enter for this field for a claim or one that has little to no audit risk.

it’s just very clear that depending on the prescription and even the same prescription for different plans, different rules are in place. This objectively creates a slew of different definitions or descriptions in what a days supply for any given prescription/claim represents.

In some scenarios the “best” entry can depend on if you view it from a pure clinical, pure compliance, or pure payer satisfaction lens.

There’s literally no easy answer. In the insulin case the payers should not be lazy and figure out how to fix their coverage determination.
 
Sine Cura said:
You just apply a "common-sense" algorithm when entering day supply. You'll never get disputed claim for DS = 1 for any vaccine. How else would you enter DS for Shingrix? Impose min 60 DS for the first one then ∞ for the next?
Click to expand...
No. Shingrix is only approved for use on the living. Second dose days supply is calculated using The Death Clock - When Am I Going To Die?

Edit: also the first dose days supply may be more or less than 60 days based on the month given.
 
zelman said:
No. Shingrix is only approved for use on the living. Second dose days supply is calculated using The Death Clock - When Am I Going To Die?

Edit: also the first dose days supply may be more or less than 60 days based on the month given.
Click to expand...
I hate to break it to all of you. The days supply for any vaccine is 1. It is consumed in at the point of service. Do you put 10 years for the days supply on colonoscopy preps? Do you put one year on flu shots?
This is why the profession is going down hill. Arguing about utter BS. Somebofy please show me the rejection or audit report for putting the wrong days supply on a shingrix claim. The hob-goblins of small minds....
 
Old Timer said:
I hate to break it to all of you. The days supply for any vaccine is 1. It is consumed in at the point of service. Do you put 10 years for the days supply on colonoscopy preps? Do you put one year on flu shots?
This is why the profession is going down hill. Arguing about utter BS. Somebofy please show me the rejection or audit report for putting the wrong days supply on a shingrix claim. The hob-goblins of small minds....
Click to expand...
Was my DeathClock.com link not enough of an indication that I was not serious?
 
Back to insulin...

In a govt funded plan where a pbm is aware of this situation, refuses to adjust claim determination and forces pharmacies to use 30 day supply while the pbm is actively aware that its much longer than 30 days....

If the patient is bouncing pharmacies every month so the pharmacies are unaware of the early fill but the PBM is, can the govt sue the PBM for fraud for knowing and enabling this patient to fill way more than necessary all while the PBM scores in on admin fees every month when they shouldn’t?

I feel if we raise the level of risk for the PBM maybe they’ll make the necessary changes that should be made on their end...
 
Old Timer said:
I hate to break it to all of you. The days supply for any vaccine is 1. It is consumed in at the point of service. Do you put 10 years for the days supply on colonoscopy preps? Do you put one year on flu shots?
This is why the profession is going down hill. Arguing about utter BS. Somebofy please show me the rejection or audit report for putting the wrong days supply on a shingrix claim. The hob-goblins of small minds....
Click to expand...

dont tell this to the overnight pharmacist that begins administering a shot at 11:59PM and the clock strikes midnight before the full shot has been administered. I’m gonna call the feds.

Depo-Provera should be one day supply too then huh ... we should all stop arguing about this I agree. It’s like the transferring of unfilled electronic controlled medications. We all know the right answer.
 
PharFromNormal said:
dont tell this to the overnight pharmacist that begins administering a shot at 11:59PM and the clock strikes midnight before the full shot has been administered. I’m gonna call the feds.

Depo-Provera should be one day supply too then huh ... we should all stop arguing about this I agree. It’s like the transferring of unfilled electronic controlled medications. We all know the right answer.
Click to expand...
Depo Provera would depnd on the directions. If it says every 3 months than, no.
 
Old Timer said:
Depo Provera would depnd on the directions. If it says every 3 months than, no.
Click to expand...

If not? Do you enter as 1 day supply? If the sig doesn’t have every 3 months but payer requires 90 day supply... you calling doc? Of course not. Is the obvious answer. My point isn’t to call common sense wrong. My point is to call out that the field means literally whatever the specific payer wants it to mean. That definition changes based on the scenario and payer. Do I see it as a huge issue, no common sense makes it easy to manage. Do I like to point out hypocrisy, yes.
 
Old Timer said:
Depo Provera would depnd on the directions. If it says every 3 months than, no.
Click to expand...

That doesn’t really make sense though. If flu shots are annual and Depo Provera is quarterly why would the day supply for vaccines be 1 day and the other be 90 days?
 
Sine Cura said:
The issue is imputed over utilization based on day supply (excuse to audit and do chargebacks)

Walmart recently introduced a "third party day supply" to avoid this issue. Even though a claims processor might limit day supply to 30 days max, you can keep the real day supply the same so messaging and auto-fill work correctly. Third party day supply cannot be changed after the initial fill either.
Click to expand...

This is an interesting approach. While they may have labeled this new thing “third party day supply” I’d imagine in most retail dispensing systems the pre-existing days supply field is the de facto “third party day supply.” Seems like what they really did was add an additional field intended to be the actual day supply.

While it doesn’t really have any significant financial implications, I wonder if there’s a better way to also handle things like reconstituted antibiotics where you dispense the smallest container but the patient will recieve more than needed but instructed to discard the rest (I.e. 5mL bid x5 days; dispense 75mL). Engineering something to systematically check appropriate dosing on these can be a bit of a pain in the ass, since the simple quantity/days supply is wrong everytime. I know this convo is all about proper billing but these scenarios complicate the clinical’s too.

If you put 1DS for a flu shot, would you also expect a duplicate therapy alert if some nimwit offered a dementia patient a flu shot a week after and they said yes?
 
The thing is you will reject with the "real day supply" for processors that limit to 30 DS max. There is no way to tell what actually is being rejected in the back end

It is common to get DUR rejects for over-utilization of flu shots, Td boosters (i.e., a refugee wants a shot in early 2020 but their last shot was Oct 2019)
 
Sine Cura said:
The thing is you will reject with the "real day supply" for processors that limit to 30 DS max. There is no way to tell what actually is being rejected in the back end

It is common to get DUR rejects for over-utilization of flu shots, Td boosters (i.e., a refugee wants a shot in early 2020 but their last shot was Oct 2019)
Click to expand...

lol I’m aware. As said previously the required 30 day thing is a problem created by the pbm that they do have the ability to change but it likely requires capital they don’t want to spend and it might require plan sponsor approval/notification.

I wouldn’t suggest 365 as the ideal days supply for flu shots either. There are barely any patients getting their flu shot on the ideal day for the impending flu season. If you got one late in the season last year the ideal time next year is less than 365. With regards to less common scenarios like refugees etc. I think flagging on the atypical scenario is the intent to validate appropriateness.

To clarify because I interpret “DUR reject” as ones from the pbm... When I talk of DUR I don’t just mean rejects from the third party but also any native DUR to the application itself. You may have meant this too or not, I’m not sure. But for instance if you have a true cash patient, are you also experiencing these rejects if you are using a 1 day supply for vaccines
 
PharFromNormal said:
If you put 1DS for a flu shot, would you also expect a duplicate therapy alert if some nimwit offered a dementia patient a flu shot a week after and they said yes?
Click to expand...

Yes. It won’t flag “refill too soon” but duplicate therapy screens go back two years. So if a patient got a flu shot last year and wants one this year the computer flags a duplicate therapy warning.

Once DUR fatigue sets in you will learn to ignore it though.
 
owlegrad said:
Yes. It won’t flag “refill too soon” but duplicate therapy screens go back two years. So if a patient got a flu shot last year and wants one this year the computer flags a duplicate therapy warning.

Once DUR fatigue sets in you will learn to ignore it though.
Click to expand...

would love to know what company you work for... if your system is considering all scripts in the past 2 years with no consideration of duration of therapy or a variance range (I.e. included for only 150%-200% days supply after fill date)... I’d seriously be impressed by the incompetency. Having a few friends at cvs I can tell you with absolute certainty a flu shot from 1.5 years ago won’t pop against one filled today in their system. Just as a 30 day supply for lisinopril last filled and sold 1/1/2020 wont pop on a 30 day supply of lisinopril filled today.
 
PharFromNormal said:
would love to know what company you work for... if your system is considering all scripts in the past 2 years with no consideration of duration of therapy or a variance range (I.e. included for only 150%-200% days supply after fill date)... I’d seriously be impressed by the incompetency. Having a few friends at cvs I can tell you with absolute certainty a flu shot from 1.5 years ago won’t pop against one filled today in their system. Just as a 30 day supply for lisinopril last filled and sold 1/1/2020 wont pop on a 30 day supply of lisinopril filled today.
Click to expand...

Any CVS pharmacists want to back me up?

I work for PharMerica but every pharmacy system I have ever worked with behaves how I described. It’s possible your friends are blowing past the DUR so fast they aren’t seeing it.

When I worked at CVS the system did DUR screens for 2 years. It wasn’t uncommon to get duplicate therapy warnings for scripts that hadn’t been filled in months and months. Again if your friends say this isn’t happening they are probably just blowing past the soft stop DURs so fast they aren’t reading them. *shrug*
 
owlegrad said:
Any CVS pharmacists want to back me up?

I work for PharMerica but every pharmacy system I have ever worked with behaves how I described. It’s possible your friends are blowing past the DUR so fast they aren’t seeing it.

When I worked at CVS the system did DUR screens for 2 years. It wasn’t uncommon to get duplicate therapy warnings for scripts that hadn’t been filled in months and months. Again if your friends say this isn’t happening they are probably just blowing past the soft stop DURs so fast they aren’t reading them. *shrug*
Click to expand...

literally just called them in a store, they were checking a fill for a patient, patient also has the same med different strength on their profile from 9 months ago. Both 30 day supply. No duplicate therapy alert. Asked them if it was a soft stop or maybe something they blew by... no. they literally thought I was crazy when I kept pressing to ensure there was no alert, they thought it would have been ridiculous if there was. They have come across old scripts in the past but when they looked into them they were still “waiting bin” status and never marked as sold or RTS’d, they couldn’t remember the last time they came across that though.
 
PharFromNormal said:
literally just called them in a store, they were checking a fill for a patient, patient also has the same med different strength on their profile from 9 months ago. Both 30 day supply. No duplicate therapy alert. Asked them if it was a soft stop or maybe something they blew by... no. they literally thought I was crazy when I kept pressing to ensure there was no alert, they thought it would have been ridiculous if there was. They have come across old scripts in the past but when they looked into them they were still “waiting bin” status and never marked as sold or RTS’d, they couldn’t remember the last time they came across that though.
Click to expand...

Well I could be misremembering or it is possible (although unlikely) that CVS improves their DUR engine.
 
owlegrad said:
Well I could be misremembering or it is possible (although unlikely) that CVS improves their DUR engine.
Click to expand...

Less keystrokes seems like a nice corporate rationale for labor savings...

But wait back to flu shots... if this is true... I’m not sure why you would see this as an improvement. You expect. Duplicate therapy alert to warn on that patient getting another flu shot, remember?
 
PharFromNormal said:
Less keystrokes seems like a nice corporate rationale for labor savings...

But wait back to flu shots... if this is true... I’m not sure why you would see this as an improvement. You expect. Duplicate therapy alert to warn on that patient getting another flu shot, remember?
Click to expand...

What you wouldn’t want is 2019 flu season shot triggering a warning for 2020 flu season shot. In that sense it is an improvement. As for a flu shot from this flu season triggering a warning for a flu shot this season I would be very surprised if the system didn’t trigger a warning. Not to mention I doubt most insurances would be willing to pay for the same flu shot twice in the same season.

As for an improved DUR system saving time...I mean yeah but in practice it’s the opposite. Fill a script for zestoretic sometime and enjoy the duplicate therapy warning you get.
 
owlegrad said:
What you wouldn’t want is 2019 flu season shot triggering a warning for 2020 flu season shot. In that sense it is an improvement. As for a flu shot from this flu season triggering a warning for a flu shot this season I would be very surprised if the system didn’t trigger a warning. Not to mention I doubt most insurances would be willing to pay for the same flu shot twice in the same season.

As for an improved DUR system saving time...I mean yeah but in practice it’s the opposite. Fill a script for zestoretic sometime and enjoy the duplicate therapy warning you get.
Click to expand...

Called my cvs friend again because I couldn’t believe this... had them run a rx for zestoretic. No duplicate therapy alert. Is your system tripping alerts from the same script on itself? Lol... that’s what I assume you meant
 
PharFromNormal said:
Called my cvs friend again because I couldn’t believe this... had them run a rx for zestoretic. No duplicate therapy alert. Is your system tripping alerts from the same script on itself? Lol... that’s what I assume you meant
Click to expand...

Then CVS has improved their system since I worked there! Good for them.
 
PharFromNormal said:
lol I’m aware. As said previously the required 30 day thing is a problem created by the pbm that they do have the ability to change but it likely requires capital they don’t want to spend and it might require plan sponsor approval/notification.

I wouldn’t suggest 365 as the ideal days supply for flu shots either. There are barely any patients getting their flu shot on the ideal day for the impending flu season. If you got one late in the season last year the ideal time next year is less than 365. With regards to less common scenarios like refugees etc. I think flagging on the atypical scenario is the intent to validate appropriateness.

To clarify because I interpret “DUR reject” as ones from the pbm... When I talk of DUR I don’t just mean rejects from the third party but also any native DUR to the application itself. You may have meant this too or not, I’m not sure. But for instance if you have a true cash patient, are you also experiencing these rejects if you are using a 1 day supply for vaccines
Click to expand...

Well there has to be a cutoff on day supply somewhere. They don't have to limit any particular product to 30 days max though. Look at self-administered birth control in California. It is required that all plans (not just Medicaid) cover up to a years supply of birth control. However some employer-sponsored plans I've come across are outright flouting this regulation even after 3+ years (certain ones that use ESI or Optum as the claims processor). Guess who gets yelled at.

I was referring to the third-party DUR reject not the internal DUR engine. Data entry verification takes < 10 seconds. You should be spending more time on the DUR aspects and "logic" of the Rx (HURRRRR DURRRRR DON'T WRITE FOR SYRINGES WITHOUT THE GD INSULIN)
 
owlegrad said:
That doesn’t really make sense though. If flu shots are annual and Depo Provera is quarterly why would the day supply for vaccines be 1 day and the other be 90 days?
Click to expand...
Look, I have no time for nonsense and this is nonesense. Bill Depeo Provera for 1 day and bill flu shots for 365, which is an a-hole *****ic thing to do, because it is by the season and not by the year. If you get your flu shot late one year in January let's say, you are not condemed to waiting a year to get it and you are now forced to get it in January forever. If you got the 2019-2020 flu shot in January, you can gt the 2020-2921 flu shot in August and it will sail right on by.

This is like debating how mnay angels dance of the head of a pin. *****IC
 
Old Timer said:
Look, I have no time for nonsense and this is nonesense. Bill Depeo Provera for 1 day and bill flu shots for 365, which is an a-hole *****ic thing to do, because it is by the season and not by the year. If you get your flu shot late one year in January let's say, you are not condemed to waiting a year to get it and you are now forced to get it in January forever. If you got the 2019-2020 flu shot in January, you can gt the 2020-2921 flu shot in August and it will sail right on by.

This is like debating how mnay angels dance of the head of a pin. *****IC
Click to expand...

Hey don’t be mad at me that you weren’t making since or being consistent lol

Also how is correct day supply nonsense? Insurance companies will penalize us for not getting it right so I would say it is actually pretty important.

Also how is it like debating angels dancing on the head of a pin? One is a rhetorical question and the other determines if we will get reimbursed or not.
 
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