CONFIDENTIAL AND PROPRIETARY
The quantity submitted should be the number of units (e.g., tablets, capsules, milligrams, or milliliters) dispensed according to the metric decimal quantity of the medication or product and in accordance with the actual medication specifications or NCPDP guidelines and the client-specific plan design limitations.
The days supply submitted should correlate to the number of days the medication will last the patient when taken according to directions and in accordance with the actual medication specifications and the client-specific plan design limitations.
Prescription claims for insulin products must be submitted for each individually prescribed insulin or insulin product. If the directions are “as directed,” missing, or indicate a sliding scale, the pharmacy should verify the maximum number of units prescribed daily with the prescriber or member, and document accordingly on the prescription hard copy.
Prescription claims for inhalers must be submitted with the appropriate metric decimal quantity per prescribed quantity and in accordance with the actual drug specifications and the client-specific plan design limitations.
Ophthalmic drop products should be calculated according to a standard of 15-20 drops/ml or according to the actual drug specifications and in accordance with client- specific plan design limitations.
“As directed” and prescriptions missing or without directions- Prescriptions indicated with “as directed” or missing directions must be clarified with the prescriber and/or member. The pharmacy must verify, document, and submit the appropriate quantity and days supply for the prescription claim. “As directed” and prescribed claims lacking instructional documentation or clarification are subject to chargeback.
U&C- Usual and Customary
The usual and customary price refers to the cash price including all applicable customer discounts, coupons or sale price which a cash-paying customer would pay at the pharmacy.
DAW (dispense as written) Codes Walgreens Health Initiatives recognizes the Standard NCPDP 5.1 Codes:
= No product selection indicated
Walgreens Health Initiatives – Pharmacy Manual