Dose consolidation encourages pharmacy providers to dispense one larger strength of a drug rather than two smaller strengths. Tablet splitting allows providers to halve a single higher-strength tablet to create two doses of medication. Provider participation in these strategies is voluntary, but reimbursement is available through Pharmaceutical Care (PC) if these services are provided. (For the pharmacy provider to obtain PC reimbursement for tablet splitting, he or she is required to split the tablets for the recipient.) These polices apply only to brand name drugs; generic drugs are not included.

Dose consolidation and tablet splitting strategies encourage providers to prescribe a more cost-effective form of a medication.

Dose Consolidation

The dose consolidation policy encourages pharmacy providers to dispense one larger strength of a brand name drug rather than two smaller strengths (e.g., thirty tablets of Norvasc 10 mg are dispensed instead of sixty tablets of Norvasc 5 mg). Attachment 1 of this Wisconsin Medicaid and BadgerCare Update is a list of selected brand-name drugs for dose consolidation.

A recipient may receive the following benefits with dose consolidation:

• A reduction in the number of tablets taken per day, thereby simplifying the recipient’s drug regimen.
• A decrease in the chance of missing a dose.

Dose consolidation may only be completed if a pharmacy provider contacts the prescriber to authorize a new prescription for a consolidated dose. A discussion between the pharmacy provider and the prescriber will determine if dose consolidation is clinically appropriate for the recipient. For example, if a pharmacy provider receives a prescription that states, “Prevacid 15 mg; One capsule twice daily,” the provider may contact the prescriber to recommend a change in strength to one capsule daily of Prevacid 30 mg.

If approval is given, the prescriber should document the change in the recipient’s medical record. After the prescriber agrees that dose consolidation can occur, the pharmacy provider may submit a claim to PC to receive reimbursement for dose consolidation.

Tablet Splitting

Tablet splitting allows providers to halve a single higher-strength tablet of a brand-name drug to create two half tablets of equal dosage. Tablet splitting is allowed when a half tablet of a higher strength tablet provides the same dose of medication as the prescriber ordered in a lower-strength tablet. Attachment 2 is a list of selected brand-name drugs that may be split.

Tablet splitting may only be completed if a pharmacy provider contacts the prescriber to authorize a new prescription to dispense half tablets. A discussion between the pharmacy provider and the prescriber will determine if tablet splitting is clinically appropriate for the recipient. For example, when a pharmacy provider receives a prescription that states, “Lipitor 10 mg; One tablet daily,” the provider may contact the prescriber to recommend tablet splitting to one-half tablet daily of Lipitor 20 mg.

If approval is given, the prescriber should document this change in the recipient’s medical record. After the prescriber agrees that tablets can safely be split, the pharmacy provider should split the tablets and may submit a claim to PC to receive reimbursement for tablet splitting.

Prospective Drug Utilization Review

When a claim is submitted for a brand-name drug with the potential for dose consolidation or tablet splitting, Wisconsin Medicaid may respond with a prospective Drug Utilization Review (DUR) alert to notify the pharmacy provider of a dose consolidation or tablet splitting opportunity. Wisconsin Medicaid encourages pharmacy providers who receive prescription orders with the potential for dose consolidation, tablet splitting, or a DUR alert, to contact the prescriber and ask if the dose may be consolidated or tablets split when appropriate for the recipient.

If the pharmacy provider is unable to contact the prescriber at the point of sale, he or she may contact the prescriber to request dose consolidation or tablet splitting when the recipient requests a refill. Pharmacy providers should indicate in the DUR response the action that was taken if they were unable to contact the prescriber.

Pharmacy providers will not receive DUR alerts for every opportunity; however, they will receive alerts for drugs included in Attachment 1 and Attachment 2. The pharmacy provider is required to respond to DUR alerts to indicate whether or not they consolidated a dose or split tablets.

Additional dose consolidation or tablet splitting opportunities may exist for brand-name drugs that are not listed in Attachment 1 or 2. Pharmacists should evaluate each opportunity and consider the clinical appropriateness for the recipient. When an opportunity exists and the prescriber has authorized dose consolidation or tablet splitting, a pharmacy provider may submit a claim for PC for that prescription.

Alerts

From August 28, 2006, through September 5, 2006, pharmacy providers will receive an informational DUR alert on claims for dose consolidation or tablet splitting. (Providers may receive PC reimbursement on and after August 28, 2006.) Beginning September 6, 2006, claims for drugs with the potential for dose consolidation and tablet splitting will be denied and the pharmacy provider will be required to respond to the message by overriding the alert and resubmitting the claim or by submitting a new claim that indicates the dose consolidation or tablet splitting.

Similar to current Wisconsin Medicaid prospective DUR alerts, the pharmacy provider will receive an alert conflict code in National Council for Prescription Drug Programs (NCPDP) field 439 and an explanation of the alert in NCPDP field 544. The alert conflict code for dose consolidation and tablet splitting is “SR.” The explanation of the alert will contain one of the following messages:

• “Dose consolidation opportunity.”
• “Tablet splitting opportunity.”

Pharmaceutical Care

As a reminder, claims for PC services may be submitted through the real-time pharmacy Point-of-Sale (POS) system or on the Noncompound Drug Claim form, HCF 13072 (fillable PDF, 82 KB) (Rev. 06/03). On POS claims, providers should indicate PC codes in the three fields shared with DUR plus the Level of Effort field. Providers are reminded that there are limitations on the frequency of PC billing and reimbursement. Wisconsin Medicaid will only reimburse for one PC dispensing fee per recipient, per provider, per day.

Responding to DUR alerts is not considered a PC service. Not all PC services for which a provider receives a DUR alert are reimbursable under the PC benefit.

The pharmacy should never charge the participant more than the amount indicated by Wisconsin SeniorCare, according to s. 49.688(5)(a), Wis. Stats. For SeniorCare participants in the spenddown or deductible level of participation, the amount indicated by SeniorCare includes the cost for PC. Pharmacy providers are required to receive the participant’s approval for PC claims when the participant is in the spenddown or deductible level of participation. If the participant refuses the PC service, the amount submitted on the claim must be reduced to not include the PC dispensing fee.

Dose Consolidation

For dose consolidation, pharmacy providers may receive up to four PC reimbursements per recipient, per pharmacy provider, per calendar year.

If the prescriber agrees that a recipient’s medication can safely be consolidated, the pharmacy provider may submit a drug claim, indicating PC for dose consolidation, to receive reimbursement for the service. Providers may only submit a claim for PC if they contact the prescriber to authorize a new prescription for a consolidated dose.

Attachment 3 contains the PC billing information for dose consolidation.

Tablet Splitting

For tablet splitting, pharmacy providers may receive up to three PC reimbursements per recipient, per pharmacy provider, per month. For the pharmacy provider to obtain PC reimbursement, he or she is required to split the tablets for the recipient.

If a prescription indicates that the recipient may take one-half tablet daily, and the pharmacy provider splits the tablets, the pharmacy provider may submit a claim for PC.

Providers are required to submit a claim for PC each time tablets are split. Even if the PC reimbursement limit for tablet splitting has been exceeded, providers are still required to submit a claim for PC services.

Attachment 4 contains the PC billing information for tablet splitting.

Documentation Requirements

Pharmaceutical Care documentation requirements for dose consolidation or tablet splitting have been simplified:

• The first time a pharmacy provider contacts the prescriber to request a new prescription for tablet splitting or dose consolidation, prescribers are required to document in the recipient’s medical record an initial change in dose.
• When a dose consolidation or tablet splitting claim for PC is submitted to Wisconsin Medicaid, pharmacy providers are required to document the following in the recipient’s file or on the prescription:
  • The date the prescriber was contacted.
  • The change to the prescription.
  • The name of the pharmacist who made the contact.
  • The name of the person in the prescriber’s office who authorized the change to the prescription.

International Classification of Diseases, Ninth Revision, Clinical Modification Coding Requirements

As a reminder, valid International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes are required on the drug claim for each PC intervention submitted. Providers are required to make a reasonable effort to report an ICD-9-CM code that identifies the medical condition most closely related to the PC intervention performed. This is generally the ICD-9-CM code associated with the drug dispensed as a result of the intervention. The diagnosis and associated ICD-9-CM code should be determined and reported to the level of specificity that the provider believes is necessary to perform the intervention.

Diagnosis code V70.0 (Routine general medical examination at a health care facility) is not a valid diagnosis code for claims for dose consolidation or tablet splitting.

Copayments for SeniorCare Participants

When a claim is submitted for a SeniorCare participant and the provider responds to a DUR message to acknowledge that tablets have been split, the participant’s copayment will be half of the brand name copayment.

For More Information

Providers should refer to the Drug Utilization Review and Pharmaceutical Care section of the Pharmacy Handbook for a description of minimum standards for submitting PC claims. Providers with questions about this Update may call Provider Services at (800) 947-9627 or (608) 221-9883.

Information Regarding Medicaid HMOs

This Update contains Medicaid fee-for-service policy and applies to providers of services to recipients on fee-for-service Medicaid only. For Medicaid HMO or managed care policy, contact the appropriate managed care organization. Wisconsin Medicaid HMOs are required to provide at least the same benefits as those provided under fee-for-service arrangements.

Attachment 1 — Dose Consolidation Drugs
Attachment 2 — Tablet Splitting Drugs
Attachment 3 — Pharmaceutical Care Billing Information for Dose Consolidation Prescriptions
Attachment 4 — Pharmaceutical Care Billing Information for Tablet Splitting