Consecutive Days' Supply

The majority of HMSA members' pharmacy benefits are based on a 30-day supply. A 30 -day supply is defined as a supply lasting the member for a period consisting of 30 consecutive days. Participating pharmacies should dispense a maximum 30-day supply or fraction thereof for first-time prescriptions of maintenance drugs if applicable to the member's plan. For subsequent refills, the pharmacy may dispense a maximum 90-day supply or fraction thereof after confirming that: (1) the member has tolerated the drug without adverse side effects that may cause the member to discontinue using the drug, and (2) the member's physician has determined that the drug is effective.

If the days supply field has an error on entry, it may trigger an erroneous high dose error. Thus, it is important that the days supply should reflect the number of consecutive days that are covered by the prescription.

Unbreakable Package Item Day Supply

Some medication dosage forms and packages are dispensed in their original containers. These unbreakable package items include eye drops, inhalers, creams, ointments, etc.

The online claims processing system will generate the copayment (if applicable to the member's plan) based on the following rules:

If days supply is:

• 0-59 days = one copayment
• 60-89 days = two copayments
• 90-119 days = three copayments
• If greater than or equal to 120 days = claim will deny (If a single unit of the smallest package size of the medication exceeds the maximum number of days the maximum does not apply.)

Note: Copayments do not apply to The HMSA Plan for QUEST Members or Medicare Members.

For mail order benefits, if days supply is:

• Up to 119 days = 1 mail order copayment
• If greater than or equal to 120 days = claim will deny (If a single unit of the smallest package size of the medication exceeds the maximum number of days the maximum does not apply.)

Insulin Days Supply

The days supply quantity for insulin is the lesser of the "consecutive days supply" calculation or the recommended "discard after" date of the medication. A best estimate for days supply for sliding-scale regimens will be accepted.

The on-line claims processing system will generate the copayment (if applicable to the member's plan) based on the following rules:

If days supply is:

• 0-59 days = one copayment
• 60-89 days = two copayments
• 90-119 days = three copayments
• If greater than or equal to 120 days = claim will deny (If a single unit of the smallest package size of the medication exceeds the maximum number of days the maximum does not apply.)

Note: Copayments do not apply to The HMSA Plan for QUEST Members.

For mail order benefits, if days supply is:

• Up to 119 days = 1 mail order copayment
• If greater than or equal to 120 days = claim will deny (If a single unit of the smallest package size of the medication exceeds the maximum number of days the maximum does not apply.)

Eye Drops Days Supply

The standard HMSA conversion for eye drops is 17 drops per mL. The drops per mL conversion is devised to standardize days supply calculations for pharmacy providers.

This conversion is based on the "normal" or "standard" drop measure as recognized by the United States Pharmacopeia and National Formulary, which state, "The pharmacopeial medicine dropper is 3 mm in external diameter at its delivery end, and when held vertically delivers 20 drops of water." It is notable that conversions for some ophthalmic formulations may differ slightly due to dropper size, liquid viscosity, etc. Thus, the HMSA conversion has allowed for a 15% variance to account for these differences and a limited number of doses lost during administration.

The following are frequently asked questions from pharmacies. The answers may help to clarify situations related to prescriptions for unbreakable package drugs:

What should I enter for the "days supply" for a 10mL bottle of eye drops if the directions read "one drop in the left eye twice a day"?

Based on the HMSA eye drop conversion of 17 drops per mL, the pharmacy would calculate an 85 days supply, which would generate two copayments for the member.

What should I enter for the "days supply" for a 10mL bottle of eye drops if the directions read "one drop in the left eye twice daily for 10 days"?

In such situations, it is prudent for the pharmacy to enter the days supply equivalent to the duration of therapy, as specified on the prescription. In this example, a 10-day supply would be entered, which would generate a single copayment for the member. It is not HMSA's intent to hold members responsible for multiple copayments for unbreakable package drugs used for short-term therapy. However, it would be prudent for the pharmacy to inform the physician if a smaller bottle is available which would meet the quantity needs based on the directions and duration of therapy.

What should I do if the prescription is written for a 10mL bottle with the following directions, "one drop in the left eye twice daily" and I am out of stock of the 10mL size, but have two 5 mL bottles?

The pharmacy can:

• Dispense two 5mL bottles with the appropriate calendar days supply, which will generate two copayments, or
• Dispense one 5mL bottle with the appropriate calendar days supply, which will generate one copayment.

The decision is based on the pharmacy, physician, and/or member's preference and consent. The pharmacy should document the "partial" out-of-stock issue on the prescription. It is not HMSA's intent for the pharmacy to deny service to a member based on a "partial" out-of-stock situation.

What should I dispense if the prescription is written for 60gm of a cream and the only sizes available from the manufacturer are 15 and 45 gm?

The pharmacy can:

• Dispense one 45gm tube plus one 15gm tube, or
• Dispense four 15gm tubes

The decision will be based on what the pharmacy has in stock. If both options are available, the pharmacy should opt for the combination that results in the lowest cost to the plan. The pharmacy should document the dispensing rationale on the prescription.

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