Zolpidem Plan Limits

[ResCon]

Pt has a script for Zolpidem 10mg PRN Qty 21/D.S. 21. The pt requested a refill on the 21st day since the last fill, yet I still got this rejection: "Plans limits exceeded. Check qty and days supply."

Called Medco, and apparently they only allow 31 pills per 24 day period. I explained the pt only got 21 as that is the qty on the script, and is for 21 days. Rep explained that we could submit and dispense for a qty of 10 to make 31, but that would start a new 24 day period (what?). Despite the fact that doc specifically stated on the script "21 days," Medco is saying it doesn't matter what the doctor intended, as each time we fill a qty of equal to or less than 31 pills of zolpidem the pt has to wait another 24 days for insurance to pay (or in this case apply to the pt's deductible).

This seems really weird to me. Zolpidem isn't even an expensive drug. What's the point in making the utilization rules so strict? So now I have a patient who's paying out of pocket retail price for 3 days of zolpidem when the pt is legitimately out of the med prescribed, took it as prescribed, while the insurance is waiving it's disapproving finger.

Am I missing something here?

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[Ackj]

If they can get #31/24 days, that's more than one per day. They got 21 days worth, so they're only 3 tabs short of the refill. Get a new RX for #31, and give them 3 of them to hold them over until you can fill the new RX, at which point they would receive the remaining #28. From then on, they can fill the whole 31 tabs at a time.

Alternatively, have them pay cash, since it's pretty cheap. We have a few oddball plans that allow #30/50 days, so we can only bill their insurance roughly every other month, but the cash price copay is low enough that they don't freak out. A good night's sleep is worth the $20 or so.

 

[xiphoid2010]

To above, my understanding of the law is if the RX says days supply 21, then you can't dispense 31 days worth without calling MD. Especially talking about a control. 3day emergency supply is an option, but you cant do it every 3 weeks.

To OP, since insurance won't budge, paying out of pocket or call MD for quantity change would be the other options.

 

[Ackj]

To above, my understanding of the law is if the RX says days supply 21, then you can't dispense 31 days worth without calling MD. Especially talking about a control. 3day emergency supply is an option, but you cant do it every 3 weeks.

To OP, since insurance won't budge, paying out of pocket or call MD for quantity change would be the other options.

Yeah, I mentioned getting a new rx, no way you're just going to give them an extra #10. Once you fill in this 3 day gap, they'd be set from then on, since the new rx would not be for 21 anymore, so the 3 day supply would be a one time thing, not weekly.

 

[BidingMyTime]

To above, my understanding of the law is if the RX says days supply 21, then you can't dispense 31 days worth without calling MD. Especially talking about a control. 3day emergency supply is an option, but you cant do it every 3 weeks.

To OP, since insurance won't budge, paying out of pocket or call MD for quantity change would be the other options.

Depends on the state, in some states, the law does allow for a pt to get all their refills at once, including on controls (not CII's obviously)

A lot of the insurances, especially state public aid, are limiting sleepers.

I've also had the same situation as the OP, the only way to prevent it in the future is to fill a 30 day supply of medicine. If the law requires calling the doctor, I'm sure most doctors would be understanding of this situation. There is little practical reason not to trust a pt with a 30 day supply of medicine, if they are trusting them with a 21 day supply.

 

[PharmDstudent]

Most likely, the doctor based the 21 day supply off of some a different company's goofy insurance plan requirement. Stupid PBMs.

 

[ResCon]

Thanks for the helpful responses. The pt was cool with paying for 3 days supply OOP and new script came in. Weird utilization rule for a cheap generic drug.