Table 2.
Part D Claims Rejections in the Nursing Home Setting, by Drug (2010)
| Drugs With Most Submitted Claims | Total Claims | Total Rejects | Rejection Rate | Proportion of Rejections in Each Category | ||
|---|---|---|---|---|---|---|
| Product Not Covered | Utilization Management | Administrative Rejections | ||||
| Furosemide tablets | 130,266 | 17,909 | 14% | 0% | 54% | 46% |
| Warfarin sodium tablets | 114,642 | 21,563 | 19% | 0% | 68% | 32% |
| Omeprazole capsules extended release | 114,211 | 17,206 | 15% | 3% | 48% | 48% |
| Levothyroxine sodium tablets | 112,796 | 14,904 | 13% | 0% | 44% | 56% |
| Simvastatin tablets | 107,584 | 13,983 | 13% | 0% | 46% | 53% |
| Lisinopril tablets | 102,540 | 12,995 | 13% | 0% | 43% | 57% |
| Aricept tabletsa | 88,376 | 10,830 | 12% | 0% | 44% | 55% |
| Metoprolol tartrate tablets | 80,082 | 10,663 | 13% | 0% | 53% | 47% |
| Hydrocodone bitartrate and acetaminophen tablets | 74,248 | 11,597 | 16% | 0% | 62% | 37% |
| Amlodipine besylate tablets | 66,494 | 8778 | 13% | 0% | 47% | 53% |
| Namenda tabletsa | 64,225 | 8847 | 14% | 0% | 49% | 51% |
| Seroquel tabletsa | 61,708 | 11,825 | 19% | 0% | 61% | 39% |
| Citalopram tablets | 52,595 | 7341 | 14% | 0% | 54% | 46% |
| Klor-Con extended-release tabletsa | 49,715 | 6820 | 14% | 7% | 44% | 49% |
| Mirtazapine tablets | 47,542 | 6060 | 13% | 0% | 55% | 45% |
| Risperidone tablets | 46,897 | 8643 | 18% | 0% | 55% | 45% |
| Sertraline hydrochloride tablets | 46,216 | 7278 | 16% | 0% | 50% | 50% |
| Lexapro tabletsa | 44,524 | 6553 | 15% | 5% | 47% | 48% |
| Plavix tabletsa | 39,735 | 5070 | 13% | 0% | 48% | 51% |
| Lantus injectiona | 36,675 | 5298 | 14% | 1% | 71% | 28% |
| Percent of all 2010 claims/rejections | 38% | 29% | ||||
| Drugs With Highest Rejection Rates (More Than 5000 Claims) | Total Claims | Total Rejects | Rejection Rate | Product Not Covered | Utilization Management | Administrative Rejections |
| Flomax capsulesa | 8766 | 5414 | 62% | 3% | 17% | 80% |
| Procrit injectiona | 5418 | 2996 | 55% | 9% | 80% | 11% |
| Pantoprazole sodium tablets extended release | 9355 | 4565 | 49% | 51% | 23% | 26% |
| Ventolin inhalation aerosola | 5067 | 2049 | 40% | 18% | 20% | 62% |
| Cozaar tabletsa | 5354 | 1917 | 36% | 21% | 26% | 52% |
| Fluticasone propionate nasal spray | 13,602 | 4812 | 35% | 0% | 19% | 80% |
| Ipratropium bromide albuterol sulfate inhalation solution | 15,652 | 5518 | 35% | 25% | 50% | 25% |
| Xalatan opthalmic solutiona | 7271 | 2517 | 35% | 3% | 40% | 57% |
| Potassium chloride oral solution | 5771 | 1869 | 32% | 76% | 11% | 14% |
| Oxycodone and acetaminophen tablets | 15,012 | 4857 | 32% | 1% | 37% | 63% |
| Oxycodone hydrochloride tablets | 5874 | 1825 | 31% | 2% | 40% | 58% |
| Morphine sulfate tablets extended release | 6200 | 1832 | 30% | 1% | 46% | 53% |
| Fentanyl transdermal patch | 25,022 | 7154 | 29% | 1% | 44% | 55% |
| Actonel tabletsa | 8981 | 2348 | 26% | 24% | 21% | 55% |
| Lidoderm patcha | 15,351 | 3948 | 26% | 0% | 77% | 23% |
| Nexium extended-release capsulesa | 6789 | 1718 | 25% | 11% | 48% | 41% |
| Detrol LA capsulesa | 5425 | 1347 | 25% | 14% | 41% | 46% |
| Propoxyphene napsylate and acetaminophen tablets | 8891 | 2144 | 24% | 19% | 41% | 40% |
| Abilify tabletsa | 14,778 | 3426 | 23% | 0% | 59% | 41% |
| Geodon capsulesa | 5609 | 1272 | 23% | 0% | 58% | 42% |
| Percent of all 2010 claims/rejections | 5% | 9% | ||||
a
Indicates medication is a brand name drug.
Source: Authors’ analysis of data provided by Omnicare, Inc, the nation’s largest long-term care pharmacy. Data include all paid and rejected Part D claims from the month of March in each study year.