All Indiana Health Coverage Programs Pharmacy Providers. Most Common Billing Unit Discrepancies That Result in Manufacturer Drug Rebate Disputes

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1 Indiana Hlth Coverage Programs P R O V I D E R B U L L E T I N BT APRIL 1, To: Subject: All Indiana Hlth Coverage Programs Pharmacy Providers Note: The information in this bulletin is not directed to those providers rendering services in the riskbased managed care (RBMC) delivery system. Overview For a drug manufacturer s products (legend and over-the-counter) to be covered by the Indiana Hlth Coverage Programs (IHCP), the manufacturer must have entered into and have in effect a rebate agreement with the federal government. The agreement states that the manufacturer agrees to pay ch state a portion of the money that the state expended for that manufacturer s individual products ch quarter. This is based on the number of units of ch drug the state submits to the manufacturer for rebates. Therefore, IHCP providers must submit the correct number of units on ch claim. The grtest number of manufacturer disputes is attributed to the number of units the state charges the manufacturer. Billing units for some drug products may seem sy to determine, such as tablets or capsules that are billed as ch. Correct billing units for injectable products and other products may not be sy to determine. IndianaAIM has claims processing logic edits designed to identify potentially misbilled units. Even with such edits, some products have had a large number of manufacturer rebate disputes. The purpose of this bulletin is to highlight products that analysis has shown to cause manufacturer disputes because of potentially misbilled units. EDS 1 P. O. Box 7263

2 Indiana Hlth Coverage Programs Note: Incorrectly billed units require more administrative time and resources of the state and rebating drug manufacturers and slows down the return to the state of the rebate-related proceeds. Also, manufacturers retain the right to audit specific providers billing records, in the event of unresolved disputes. Careful adherence to correct billing units should help ensure that this is not required. According to drug rebate records, Tables 1.1 and 1.2 relate those products most commonly disputed by rebating manufacturers. Table 1.2 lists the correct unit definition for drugs with substantial dispute activity. Definitions The IHCP accepts only three billing units. They are the following: Each () The billing unit for capsules, tablets, kits, and unreconstituted vials. Milliliters () The billing unit for liquid dosage form having a uniform concentration. Grams () The billing unit for products packaged by weight, such as ointments, crms, and powders that cannot be reconstituted for injection. Factors Most Commonly Associated with Rebate-Related Disputes Analysis consistently revls the following factors as the most common causes of rebate disputes: Incorrect billing units, such as, billing for the number of milliliters in a vial instd of billing ch to specify the entire contents of the vial Note: This example is an illustration only. Some products are billed by and some by ch vial. Provider data entry errors including those involving decimal or fractional quantities EDS 2

3 Indiana Hlth Coverage Programs Units billed exceed what would be expected as being within a normal range for the product; for example, the billed units appr inconsistent with what a normally dispensed quantity would be Charge amounts that suggest a generic might have been dispensed when a brand name National Drug Code (NDC) was submitted on the claim Providers should contact the Indiana Point-of-Service (POS)/ Prospective Drug Utilization and Review (Pro-DUR) Help Desk at if there is a question about what constitutes the correct unit for a drug being billed to the IHCP. All efforts to help minimize the number of manufacturer disputes are appreciated. Plse compare current billing practices to the indicated billing unit in the following tables to ensure consistency. Table 1.1 s for Commonly Billed Products Oral Antibiotic Suspensions Enbrel 25mg Kit Gammagard s/d 5 vl w/set Nordette 28 Tab Norplant System Kit Novoseven 4800mcg Rdy-To-Use IV Antibiotic Minibags Recombinate AHFU vial Birth Control Pills Glucagon F 1 mg Emergency Kit Premarin 1.25mg Cycle Pak Norplant System (kit) (vial/set) (kit) (kit) (mcg) (AHFUnit) (tablet) (kit) (tab) (kit) Table 1.2 contains a list of specific drug products and the correct billing unit..9% Sodium Chloride Soln 2% Xylocaine Viscous Sol Acetaminophen 160mg/5 Elixir EDS 3

4 Indiana Hlth Coverage Programs Acetaminophen Unisert 120mg Acetylcysteine 10% Vial Acular.5% Eye Drops Albuterol.83mg/ Soln Albuterol Sulf 2mg/5 Syrp Aluminum Hydroxide Gel Conc Amethapred 125mg Univial Amethapred 40mg Univial AMOXICILLIN SUSP Amoxicillin 250mg Tab Chew Ampicillin 250mg/5 Susp APL 20000u Vial Aquasol 50000u/ Vial Arthritis Form Capsaicin Cr Artificial Trs Drops Artificial Trs Eye Oint Ativan 2mg/ Tube X Syr Ativan 2mg/ Vial Atrohist Pediatric Susp Bacit/Polymyxin Eye Ointment Bacitracin 500u/ Oint. Bactrim Suspension Bactroban 2% Ointment Banophen 12.5mg/5 Elix B-D Glucose Tablet Chew Benefix 500IU Vial Benzoyl Peroxide 2.5% Wash Benzoyl Peroxide 5% Gel Betamethasone VA.1% Lotion Betamethasone VA.1% Oint Bethaprim Suspension Bion Trs Eye Drops EDS 4

5 Indiana Hlth Coverage Programs Bisacodyl 10mg Suppository Bondamine-Dm Syrup Brevicon 28 Tab Bromanate Dx Syrup Bromophen Elixir Capsium Oleoresin.025% Cm Catapres-Tts Patch Cefazolin 1/D5w Bag Cernevit Multivitamin Vial Centrum-Liquid Certa-Vite Liquid Cetapred.25% Eye Ointment Children s Advil Susp Drop Children s Tylenol Drops Ciloxan.3% Ointment Clemastine.67mg/5 Syrup Cleocin Phos 150mg/ Vial Clindamycin Ph 1% Solution Clybetasol.05% Gel Cortisporin Ear Susp Cortisporin Eye Drops Cyproheptadine 2mg/5 Syrup D5-1/2 NS/KCL 20meq/L IV Sol Denavir 1% Crm Depo-Provera 100mg/Ml Vial Desmopressin.1mg/ Spray Desoximetasone.05% Crm Dextrose 2.5%-1/2 Ns IV Soln Dibucaine 1% Ointment Dicomal-Dh Syrup Digoxin 50mcg/ Elixir DSS/Casanthranol Syrup EDS 5

6 Indiana Hlth Coverage Programs Dyphenhydramine Elixir Efudex Crm 5% Efudex Solution 5% Ery 2% Pads Erythromycin 2% Gel Erythromycin 2% Pledgets Erythromycin 200mg/5 Susp Erythromycin Eye Ointment Erythromycin/Sulfisox Susp Ferrous Sulf 220mg/5 Elix Fiber-Eze Powder Flonase Nasal Spray.05% Floucinolone.025% Crm Flourouracil 50mg/ Vial Floxin IV 4mg/ Mini Bag Fluocinonide 0.05% Ointment Frain 2500u Syringe Furosemide 10mg/ Oral Sol Gentamicin 0.1% Crm Gentamicin 3mg/ Eye Drops Gentamicin 40mg/ Vial Geravim Liquid Gevrabon-Liquid Golytely Packet Guaifenesin 100mg/5 Syrup H-Cortisone/Iodoquinol Crm Hemorrhoidal Prep Ointment Hem-Prep Suppository Humalog 100u/ Vial Humalog Cartridge 100u/ Humatrope 24mg Cartridge Humatrope 5mg Vial EDS 6

7 Indiana Hlth Coverage Programs Hydrocortisone 1% Crm Hydrocortisone 1% Lotion Hydroquinine 3% Soln Hydroquinine 4% Crm Hydroquinine 4% Gel Hydroxyzine 10mg/5 Syrup Infant's Tylenol Drops Iophen Dm Liquid Kaopectate Kristalose Packet Kytril 1mg/ Vial Lactulose 10/15 Syr Lacri-Lube NP Ointment Leucovorin Calcium 350mg Vial Leukine 500mcg Vial Levobunolol.5% Eye Drops Levora-28 Tab Lindane 1% Shampoo Lithium Cit 8meq/5 Syrup Lotemax.5% Eye Drops M.V.I. 12 Combo Pkg Major Trs Drops Major Trs Eye Ointment Major-Con Drops Mapap 100mg/ Drop Mapap 160mg/5 Elixir Maxitrol Eye Ointment Metamucil Powder Milk of Magnesia Susp Monistat 7 100mg Vag Supp Monistat Crm Monistat Derm 2% Lotion EDS 7

8 Indiana Hlth Coverage Programs Morphine 2mg/ Syringe Nasalcrom 4% Natural Fiber Lax Powder Neocidin Eye Drops Neumega 5mg Vial Nitroglycerine 2% Ointment Norinyl Tab Norinyl Tab Nor-Qd Novolin N 100u/ Cartridge Nubain 10mg/Ml Ampul Nuprin 200mg Tab Nystatin Crm u/ Nystatin u/ Ointment Ocucoat PF Eye Drops Ogen Vag Crm Ortho-Diaphra Allflex 65mm Paregoric Liquid Pediapred 6.7mg/5 Soln Pediatric Decongestant Drop Penicillin Vk 125mg/5 Liq Phenergan Suppository Phenergan 25mg/Ml Ampule Phisohex 3% Clnser Phosphate Enema Phospholine Iodide.25% Phospholine Iodide.06% Drop Pilocarpin 2% Eye Drop Potassium Chloride 20% Liquid Potassium Gluconate Elixir Povidine-Iodine 10% Soln Prednisolone AC 1% Eye Drop EDS 8

9 Indiana Hlth Coverage Programs Premarin Vaginal Crm Refl Premarin Vaginal Crm/Appl Prochlorperazine 5mg/ Vl Procrit 10000u/ Vial Promethazine 50mg Supp Promethazine VC Expectorant Promethazine/Codeine Syrup Pulmicort 200mcg Turbohaler Rhinocort Aqua Nasal Spray Robinul.2mg/ Vial Rocephin 10mg Vial Rondec Syrup Silver Sulfadiazine 1% Crm Sodium Chloride 0.9% Ampule Sodium Chloride.9% Irrig Sodium Chloride.9% Soln Sodium Sulfacet/Sulfur Lotion Solu-Medrol 1000mg Vial Sulfamide 10% Eye Drops Synvisc-Syringe Trs Naturale Free Drops Theophylline 80mg/15 Elix Thera Liquid Thrombin-JMI 5mu Vial Timentin 3.1 Gm RTU Bag Tobramycin.3% Eye Drops Tobramycin 40mg/ Vial Tobrex Eye Ointment.3% Triamcinolone.025% Ointment Tri-Norinyl 28 Tab Triphasil 28 Tab Tri-Statin II Crm EDS 9

10 Indiana Hlth Coverage Programs Tri-Tannate Susp Trivora-28 Tab Ty-Pap W/Codeine Elixir Vancocin Hcl 500mg/100 Vancoed 1 Vial Vancomycin 1mg Vial Vancomycin Add-Vantage Vial Vasolate-HC Ear Drops Ventolin 90 Aerosol Inhaler Vita Drops Vita Drops w/iron Vitamin B mcg/ Vial vitamin E Xalatan 0.005% Xeloda 500mg Tab Zebeta Tab 5mg Zinc Gluconate 50mg Tab Zinc Sulfate 220mg Cap Zosyn 3/3.75g Pre-Mix Bag EDS 10