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      Payable Services FAQs

      Can I submit multiple claims for the same intervention?

      • If the pharmacist’s intervention results in a prescription medication being changed to an alternative medication, only one claim may be submitted per intervention (e.g. this change is only billable as Suboptimal Drug – Changed Drug and an Unnecessary Prescription Therapy claim may not be submitted).

      Can I bill for moving from a 30-day to a 90-day supply?

      • Changing a patient from a 30-day supply to a 90-day supply for cost savings is not payable as a Cost- effective Alternative claim.
      • This change is only billable for select plans as Adherence – Needs 90-Day Fill, Adherence – Needs Check-in + 90-day Fill, or Adherence – Needs 100-day or 90-day Fill.

      Can I bill for education and monitoring on an immunization?

      • Immunizations are only billable as Needs Immunization, which includes education and monitoring. New or Changed Prescription Therapy is not a payable claim for immunizations.

      Can I bill for getting a new copy of a prescription that wasn’t sent to the pharmacy?

      • Calling for a new prescription that the prescriber office forgot to send is not a payable claim.

      How do I bill for verifying information on a prescription?

      • If the pharmacist contacts the prescriber to verify the accuracy of a prescription, a payable intervention will only result if a change is made to the prescription order. If the original prescription does not indicate medication, medication strength, quantity or directions, then obtaining this information is not payable. If no change is made as a result of the pharmacist’s verification, this service is also not payable.
      • Severity Level 1 is most appropriate for claims resulting from verification of a new prescription with the prescriber (e.g. verifying dose, duration, etc). If this is verification of information on an existing prescription order, select the most reasonable and foreseeable severity level.

      How do I bill for obtaining correct directions?

      • If a pharmacist obtains correct directions for a medication that will help the patient avoid confusion, a Dose Too Low or Dose Too High claim may be submitted

      How do I bill for obtaining a new prescription?

      • If the pharmacist’s intervention results in a new prescription therapy, bill under the appropriate reason code such as Needs Drug Therapy.
      • If the pharmacist’s intervention results in a changed prescription therapy, bill under the appropriate reason code such as Suboptimal Drug Selection, Cost-effective Alternative, Drug Interaction etc.
      • If the pharmacist obtains a new prescription for a prescription medication that was already prescribed for the patient, it is considered a refill request and is not payable as a pharmacist-initiated claim.
        • Exception 1: see next entry for expired drug
        • Exception 2: If the patient was non-adherent due to lack of available refills, an Adherence - Underuse of Medication claim may be submitted for select plans.
        • Exception 3: If it has been 6 months or more since a prescription has been taken/obtained this is considered a new therapy and a Needs Drug Therapy claim can be submitted.

      Can I bill for getting a new prescription for an expired drug?

      • If a pharmacist obtains a new prescription for a drug that is expired, and no valid prescription is on file, a Needs Drug Therapy claim may be submitted.
      • Common drugs this may affect include: EpiPens, nitroglycerin and insulin.

      How do I bill for claims related to diabetic testing supplies?

      • Only the following types of interventions involving diabetic testing supplies are payable:
        • If the patient has a diagnosis of diabetes and is not currently using diabetes testing supplies but needs a prescription for diabetes testing supplies, one Needs Drug Therapy claim may be submitted.
        • If the pharmacist provides counseling on a new blood sugar testing regimen, one New or Changed OTC Therapy claim may be submitted regardless of whether the regimen was prescribed.
        • If the pharmacist resolves an adherence or incorrect administration problem involving the blood sugar testing regimen, one New or Changed OTC Therapy claim may be submitted regardless of whether the regimen is prescribed.
        • If the pharmacist obtains a prescription for testing supplies for cost-efficacy purposes, one Cost- effective Alternative claim can be submitted.
      • Claims related to diabetic testing supplies are payable with a Severity Level 1.
      • Separate MTM claims for each diabetic testing supply (meter, lancets and strips) are not payable and will be considered duplicate claims.

      How do I bill for a PPI/clopidogrel interaction?

      • If a pharmacist’s recommendation results in the PPI being changed to another PPI, the claim is not payable.
      • If a pharmacist’s recommendation results in the PPI being discontinued or changed to a medication in another class (e.g. H2 blocker), a Drug Interaction claim may be submitted only if the PPI is labeled as Rx Only. If the PPI is available OTC, a New or Changed OTC Therapy claim may be submitted.
      • If a pharmacist’s recommendation results in the clopidogrel being discontinued or changed to a different medication, a Drug Interaction claim may be submitted.
      • If a pharmacist’s recommendation results in only a change in administration time of either the clopidogrel or PPI, the claim is not payable.

      How can I bill for services involving OTC medications?

      • Medications not labeled with Rx only or where an equivalent dose is available OTC (e.g., omeprazole 20 mg regardless of dosage form) must be submitted as New or Changed OTC Therapy regardless of whether the patient has been prescribed the OTC product.
      • This policy applies to any service involving an OTC medication including, but not limited to, obtaining a prescription for cost efficacy purposes, newly initiating the therapy, non-adherence to the medication, discontinuing the medication or initiating a dose change.
        • Exception 1: If a prescription medication is changed to an OTC product, any applicable claim requiring a prescriber consultation the patient is eligible for may be submitted.
        • Exception 2: see previous entry for diabetic testing supplies.

      Can I bill for obtaining a prescription for an OTC medication for cost efficacy purposes?

      • If the patient is newly starting the medication from a pharmacist-initiated intervention, the claim should be submitted as a single New or Changed OTC Therapy claim.
      • If the pharmacist obtains a prescription for an OTC medication the patient was already taking to help the patient save on medication costs the service is not payable.

      Can I bill for recommending preventative OTCs?

      • A pharmacist’s recommendation for OTC products such as Biotene or eye drops to treat side effects from prescription drugs is only payable if there is a patient-specific reason to recommend (e.g., known history of dry mouth from specific medication).

      Can I bill for helping a patient with a prescriber recommended OTC medication?

      • If a pharmacist assists a patient in selecting an OTC that was originally recommended by a prescriber, a New or Changed OTC Therapy claim may be payable as long as the medication is clinically relevant.

      How do I bill for recommending baby aspirin?

      • A pharmacist’s recommendation for aspirin 81 mg may be submitted with a severity level higher than level 1 with patient-specific reasoning.
      • Regardless of whether or not it is prescribed, claims involving aspirin should be submitted as a New or Changed OTC Therapy claim.

      Can I bill for recommending CoQ-10?

      • A pharmacist’s recommendation to add CoQ-10 to the patient’s regimen is never payable for muscle pain associated with statin use. Rather, the statin dose should be reduced, discontinued or changed to another cholesterol-lowering agent.

      Can I bill for recommending fish oil?

      • A pharmacist’s recommendation to add fish oil to a patient’s therapy is only payable if the patient has documented elevated triglycerides.

      Can I bill for recommending vitamins?

      • A pharmacist’s recommendation to add a multivitamin to a patient’s medication regimen is only payable if a clinically significant deficiency is known.
      • The same policy applies for vitamins A, C, D, E, etc.

      Can I bill for recommending herbals?

      • A pharmacist’s recommendation to add herbals is only payable if the product has clinical evidence to support the treatment of the patient’s symptoms.
        • Examples: melatonin for sleep, black cohosh for menopausal symptoms.
      • When discontinuing one or more herbal product, only one claim may be submitted per situation/discussion.
        • Example: If four herbal medications are discontinued during a CMR, only one New or Changed OTC Therapy claim may be submitted.

      Can I bill for recommending glucose tablets?

      • Recommending glucose tablets is considered a dietary recommendation and is not payable.

      Can I bill for recommending alcohol swabs?

      • Recommending alcohol swabs for use with insulin injections is not payable.

      Can I bill for recommending medical devices?

      • Recommending an item, such as canes, walkers, compression stockings, nebulizer machines and diabetic shoes, is not payable.

      When should I bill a service with a Severity Level 7?

      • A Severity Level 7 should only be used when the patient presents an immediate, life-threatening intervention.
      • NOTE: If the appropriate billing option is not available when starting a claim from a patient profile, do not select a different Reason/Action/Result code to attempt billing for the service.