NCPDP Reject Code / Description	DOM Exception Code #	Exception Code Long Description
01-INV BIN NUMBER	4001	THE BIN NUMBER IS MISSING OR IS NOT = '610084'.
01-INV BIN NUMBER	4098	DO NOT USE
03-INV TRANSACTION CODE	4004	THE TRANSACTION CODE IS MISSING (ZEROS) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD IN VERSION 3.2.
03-INV TRANSACTION CODE	4005	THE TRANSACTION CODE IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD IN VERSION 5.1.
03-INV TRANSACTION CODE	4006	THE TRANSACTION CODE IS NOT ONE OF THE TRANSACTION CODES IN VERSION 3.2 OR 5.1 THAT THE CUSTOMER ACCEPTS FOR PROCESSING.
04-INV PROCESSOR CONTROL NUMBER	4007	M/I PROCESSOR CONTROL - MUST BE 'DRMSTEST' OR 'DRMSPROD'.
05-INV PHARMACY NUMBER	4008	THE NPI NUMBER WAS NOT SUBMITTED FOR THE PHARMACY.
05-INV PHARMACY NUMBER	4009	THE PHARMACY PROVIDER ID DOES NOT EXIST ON THE PROVIDER MASTER TABLE.
05-INV PHARMACY NUMBER	4018	THE PROVIDER NUMBER SUBMITTED IS NOT A PHARMACY PROVIDER TYPE.
05-INV PHARMACY NUMBER	4080	EDIT IGNORED
05-INV PHARMACY NUMBER	4365	THE PHARMACY PROVIDER IS ENROLLED IN THE NETWORK ON THE DATE OF SERVICE AND IS UNDER REVIEW
05-INV PHARMACY NUMBER	4370	THE PHARMACY ID ON THE REPLACEMENT OR CREDIT REQUEST DOES NOT MATCH THE PHARMACY PROVIDER NUMBER ON THE CLAIM THAT IS BEING REPLACED OR CREDITED.
05-INV PHARMACY NUMBER	4794	IF PHARMACY ID = ZEROES AND THE PAYEE CODE IS NOT EQUAL TO PAY EMPLOYEE; POST THE ERROR.
05-INV PHARMACY NUMBER	4795	BILLING PROVIDER ID INVALID
05-INV PHARMACY NUMBER	4796	PROVIDER LOC. CODE MISSING
05-INV PHARMACY NUMBER	4797	PROVIDER LOC. CODE INVALID
06-INV GROUP NUMBER	4751	EDIT IGNORED
07-INV CARDHOLDER ID	4010	THE MEMBER ID IS MISSING OR EQUAL TO SPACES.
07-INV CARDHOLDER ID	4011	THE MEMBER ID IS MISSING (ZERO).
07-INV CARDHOLDER ID	4434	MEMBER ID DOES NOT MATCH VALID VALUES
07-INV CARDHOLDER ID	4910	MEMBER ID NOT IN VALID FORMAT
08-INV PERSON CODE	4752	EDIT IGNORED
09-INV DATE OF BIRTH	4012	MISSING OR INVALID BIRTHDATE.
09-INV DATE OF BIRTH	4013	EDIT IGNORED
09-INV DATE OF BIRTH	4014	"NOT USED DOB ON CLAIM MUST BE WITHIN ONE YEAR OF PARTICIPANT'S ACTUAL DOB BE/MA"
09-INV DATE OF BIRTH	4424	EDIT IGNORED
09-INV DATE OF BIRTH	4593	K-BABY EDIT - BABY'S DATE OF BIRTH IS MISSING.
09-INV DATE OF BIRTH	4631	THE DOB IS NOT THE SAME ON THE CLAIM AS ON THE BENEFICIARY RECORD
10-INV PATIENT GENDER CODE	4596	K-BABY EDIT - BABY'S GENDER CODE MISSING OR INVALID.
10-INV PATIENT GENDER CODE	4753	EDIT IGNORED
11-INV PATIENT RELATIONSHIP CODE	4754	EDIT IGNORED
12-INV PATIENT LOCATION	4016	THE CLAIM WELFARE CUSTOMER LOCATION (PATIENT LOCATION) IS MISSING OR DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD
12-INV PATIENT LOCATION	4017	EDIT IGNORED
12-INV PATIENT LOCATION	4798	EDIT IGNORED
12-INV PATIENT LOCATION	4996	CLINICIAN ADMINISTERED DRUGS AND DEVICES- BILLED WITH PLACE OF SERVICE 11.
13-INV OTHER COVERAGE CODE	4019	THE OTHER COVERAGE CODE IS MISSING OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
13-INV OTHER COVERAGE CODE	4435	EDIT IGNORED
13-INV OTHER COVERAGE CODE	4799	MEMBER COVERED BY PRIVATE INS
14-INV ELIG CLARIFICATION CD	4022	EDIT IGNORED
15-INV DATE OF SERVICE	4023	INVALID OR MISSING DATE OF SERVICE. CLAIM TOO OLD TO PROCESS ELECTRONICALLY. CLAIMS WITH DOS OVER ONE YEAR AGO, MAY BE SUBMITTED VIA PAPER OR WEB PORTAL FOR RETRO ELIGIBILITY CLAIMS.
15-INV DATE OF SERVICE	4800	DATE RX FILLED CANNOT BE EARLIER THAN DATE WRITTEN
15-INV DATE OF SERVICE	4801	DATE DISP. AFTER BILLING DATE
15-INV DATE OF SERVICE	4859	DATE DISPENSED IS INVALID
16-INV RX/SERVICE REF NUMBER	4025	IF PRESCRIPTION NUMBER IS MISSING (ZEROS) OR NOT NUMERIC - THEN POST THE ERROR.
17-INV FILL NUMBER	4028	THE PRESCRIPTION REFILL NUMBER (FILL NUMBER) IS NOT NUMERIC.
18	4029	SUBMITTED DRUG QUANTITY IS EQUAL TO ZEROS
19-INV DAYS SUPPLY	4030	MISSING OR OVER ALLOWED DAYS SUPPLY FOR THIS DRUG.
19-INV DAYS SUPPLY	4385	"THE CLAIM’S SUBMITTED DAYS SUPPLY AMOUNT (DAYS SUPPLY) > PLAN HEADER DAYS SUPPLY LIMIT (OR MAINTENANCE DAYS SUPPLY LIMIT FOR MAINTENANCE DRUGS) AND A CUSTOM PLAN BENEFIT LIMIT RECORD EXISTS FOR THIS CUSTOMER - PLAN - AND BENEFIT LIMIT TYPE AND (THE CUSTOM PLAN ACCUMULATION CODE = ‘NO EDIT’ OR THE CUSTOM PLAN’S D
19-INV DAYS SUPPLY	4386	"THE CLAIM’S SUBMITTED DAYS SUPPLY AMOUNT (DAYS SUPPLY) > PLAN HEADER DAYS SUPPLY LIMIT (OR MAINTENANCE DAYS SUPPLY LIMIT FOR MAINTENANCE DRUGS) AND A CUSTOM PLAN BENEFIT LIMIT RECORD EXISTS FOR THIS CUSTOMER - PLAN - AND BENEFIT LIMIT TYPE AND THE CUSTOM PLAN ACCUMULATION CODE = ‘EDIT ACUTE ONLY’ AND THE CUSTOM
19-INV DAYS SUPPLY	4387	"THE CLAIM’S SUBMITTED DAYS SUPPLY AMOUNT (DAYS SUPPLY) > PLAN HEADER DAYS SUPPLY LIMIT (OR MAINTENANCE DAYS SUPPLY LIMIT FOR MAINTENANCE DRUGS) AND A CUSTOM PLAN BENEFIT LIMIT RECORD EXISTS FOR THIS CUSTOMER - PLAN - AND BENEFIT LIMIT TYPE AND THE CUSTOM PLAN ACCUMULATION CODE = ‘EDIT ALL DRUGS’ AND THE CLAIM’S
19-INV DAYS SUPPLY	4388	"THE PLAN’S MAX UNITS LIMIT < UNLIMITED UNITS (9999.999) AND THE CLAIM’S DRUG SUBMITTED QUANTITY > PLAN’S MAX UNITS LIMIT AND NO CUSTOM PLAN BENEFIT LIMIT RECORD EXISTS FOR THIS CUSTOMER - PLAN - AND BENEFIT LIMIT TYPE "
19-INV DAYS SUPPLY	4389	"THE PLAN’S MAX UNITS LIMIT < UNLIMITED UNITS (9999.999) AND THE CLAIM’S DRUG SUBMITTED QUANTITY > PLAN’S MAX UNITS LIMIT AND A CUSTOM PLAN BENEFIT LIMIT RECORD EXISTS FOR THIS CUSTOMER - PLAN - AND BENEFIT LIMIT TYPE AND THE CUSTOM PLAN MAX UNITS ACCUMULATION CODE = ‘NO EDIT’ AND THE CUSTOM PLAN’S UNITS LIM
19-INV DAYS SUPPLY	4390	"THE CUSTOM PLAN MAX UNITS ACCUMULATION CODE = ‘EDIT ACUTE ONLY’ AND THE CUSTOM PLAN’S MAINTENANCE DOSE < DEFAULT DAILY DOSE (9999.999) AND THE CLAIM’S CALCULATED DAILY DOSE > CUSTOM PLAN’S MAINTENANCE DOSE AND THE CLAIM’S DRUG SUBMITTED QUANTITY > PLAN’S MAX UNITS LIMIT"
19-INV DAYS SUPPLY	4391	"THE CUSTOM PLAN MAX UNITS ACCUMULATION CODE = ‘EDIT ALL DRUGS’ AND THE CLAIM’S DRUG SUBMITTED QUANTITY > CUSTOM PLAN’S MAX UNITS LIMIT"
19-INV DAYS SUPPLY	4392	"THE CLAIM’S DRUG DEA CODE = ‘2’ (SCHEDULE 2 - MOST ABUSED) AND (THE DRUG’S CATEGORY CODE = ‘Z’ (ATTENTION DEFICIT DISORDER) AND THE CLAIM’S SUBMITTED DAYS SUPPLY AMOUNT (DAYS SUPPLY) > 60 DAYS) OR (THE DRUG’S CATEGORY CODE NOT = ‘Z’ (ATTENTION DEFICIT DISORDER) AND THE CLAIM’S SUBMITTED DAYS SUPPLY AMOUNT (DA
19-INV DAYS SUPPLY	4393	"THE CLAIM’S DRUG DEA CODE = ‘3’ (SCHEDULE 3 – LESS ABUSED) AND THE CLAIM’S SUBMITTED DAYS SUPPLY AMOUNT (DAYS SUPPLY) > 30 DAYS"
19-INV DAYS SUPPLY	4394	"THE CLAIM’S DRUG DEA CODE = ‘4’ OR ‘5’ (SCHEDULE 4 – POTENTIAL ABUSE - SCHEDULE 5 - CONTROLLED) AND THE CLAIM’S SUBMITTED DAYS SUPPLY AMOUNT (DAYS SUPPLY) > 90 DAYS"
19-INV DAYS SUPPLY	4395	"THE CLAIMS DRUG DEA CODE = 0 OR 1 (SCHEDULE 0  NO DEA CONTROL - SCHEDULE 1 - RESEARCH) AND THE DRUGS THERAPEUTIC CLASS IS NOT IN AN EXEMPT HARD-CODED TABLE AND THE CLAIM SUBMITTED DAYS SUPPLY AMOUNT (DAYS SUPPLY) > 90 DAYS"
19-INV DAYS SUPPLY	4400	EDIT IGNORED
19-INV DAYS SUPPLY	4401	EDIT IGNORED
19-INV DAYS SUPPLY	4403	"A CUSTOM PLAN BENEFIT LIMIT RECORD DOES NOT EXIST FOR THIS CUSTOMER - PLAN - AND BENEFIT LIMIT TYPE AND THE CLAIM’S SUBMITTED DAYS SUPPLY AMOUNT (DAYS SUPPLY) > PLAN HEADER DAYS SUPPLY LIMIT (OR MAINTENANCE DAYS SUPPLY LIMIT FOR MAINTENANCE DRUGS)"
19-INV DAYS SUPPLY	4504	A 90 DAY MAINTENANCE DRUG'S DAYS SUPPLY MUST BE UP TO 31 DAYS OR 90 DAYS.
19-INV DAYS SUPPLY	4523	QUANTITY DISPENSED IS NOT A MULTIPLE OF THE DRUG'S PACKAGE SIZE.
19-INV DAYS SUPPLY	4536	WHEN BILLING A 90 DAY SUPPLY OF CYSTIC FIBROSIS DRUGS, ORAL CONTRACEPTIVES OR PRENATAL VITAMINS, THE DAYS SUPPLY MUST BE UP TO 31 DAYS OR BETWEEN 84-91.
19-INV DAYS SUPPLY	4741	72 HOUR EMERGENCY FILL-PROVIDER MUST CONTACT 1-877-537-0722 FOR PA FOR REMAINDER OF RX
19-INV DAYS SUPPLY	4742	DRUG NOT ALLOWED FOR 72 HOUR FILL
19-INV DAYS SUPPLY	4743	MORE THAN 3 DAYS SUPPLY NOT ALLOWED FOR 72 HR EMERGENCY RX.
19-INV DAYS SUPPLY	4744	MORE THAN TWO 72 HOUR FILLS ATTEMPTED THIS MONTH
19-INV DAYS SUPPLY	4852	DAYS SUPPLY IS BLANK OR INVALID
20-INV COMPOUND CODE	4033	"EDIT POSTED IF NOT 0 - 1 - 2 NOTE: COMPOUNDS (VALUE 2) ACCEPTED IN 5.1"
20-INV COMPOUND CODE	4605	EDIT IGNORED
21-INV PRODUCT/SERVICE ID	4034	THE NATIONAL DRUG CODE (NDC) IS MISSING - NON-NUMERIC - OR ALL ZEROS.
21-INV PRODUCT/SERVICE ID	4040	THIS NDC IS A NONPREFERRED PACKAGE SIZE. SEE PDL FOR PREFERRED PKG. SIZE
21-INV PRODUCT/SERVICE ID	4450	"THE PRODUCT/SERVICE ID QUALIFIER INDICATES THE PRODUCT/SERVICE ID IS AN NDC AND THE NDC IS MISSING OR NON-NUMERIC."
21-INV PRODUCT/SERVICE ID	4803	MISSING/INVALID NDC #.
22-INV DAW/PROD SELECTION CD	4036	EDIT IGNORED
22-INV DAW/PROD SELECTION CD	4037	THE DISPENSE AS WRITTEN DAW/PRODUCT SELECTION CODE DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
22-INV DAW/PROD SELECTION CD	4402	EDIT IGNORED
22-INV DAW/PROD SELECTION CD	4625	INVALID NTI DRUG DAW CODE - THE ONLY DAW CODE ACCEPTED IN DAW FIELD IS '7' FOR MISSISSIPPI NARROW THERAPEUTIC INDEX (NTI) DRUGS
22-INV DAW/PROD SELECTION CD	4804	EDIT IGNORED
23-MISSING INGRED COST SUBMITTED	4038	M/I INGREDIENT COST
23-MISSING INGRED COST SUBMITTED	4219	INGREDIENT COST OF THIS 340B DRUG MUST BE SUBMITTED
24	4755	EDIT IGNORED
25-INV PRESCRIBER ID	4026	INVALID PRESCRIBER NPI NUMBER- DOES NOT PASS ALGORITHM.
25-INV PRESCRIBER ID	4039	THE PRESCRIBER ID IS MISSING (SPACES).
25-INV PRESCRIBER ID	4042	MUST USE VALID DEA NUMBER OR MS MEDICAID PRESCRIBER NUMBER
25-INV PRESCRIBER ID	4770	MUST USE VALID DEA NUMBER OR 8-DIGIT MS MEDICAID PRESCRIBER NUMBER
25-INV PRESCRIBER ID	4805	8 DIGIT/NUMERIC ACROSS THE BOARD
25-INV PRESCRIBER ID	4979	DEA NUMBER ENTERED DOES NOT MEET DEA ALGORITHM
26-INV UNIT OF MEASURE	4876	EDIT IGNORED
28-INV DATE PRESCRIPTION WRITTEN	4043	THE DATE PRESCRIPTION WRITTEN IS MISSING OR INVALID
28-INV DATE PRESCRIPTION WRITTEN	4044	"THE CLAIM DATE PRESCRIBED IS LESS THAN THE DATE THE PARTICIPANT ELIGIBILITY ON THE PARTICIPANT MEMBER TABLE BEGAN MINUS 30 DAYS OR THE CLAIM DATE PRESCRIBED IS GREATER THAN THE DATE THE PARTICIPANT ELIGIBILITY ON THE PARTICIPANT MEMBER TABLE ENDED. "
28-INV DATE PRESCRIPTION WRITTEN	4045	THE DRUG IS A SCHEDULE II DRUG AND THE NUMBER OF DAYS SINCE THE DATE PRESCRIBED IS NO MORE THAN 30 DAYS PRIOR TO THE FIRST DATE OF SERVICE
28-INV DATE PRESCRIPTION WRITTEN	4046	EDIT IGNORED
28-INV DATE PRESCRIPTION WRITTEN	4860	THE DATE RX WRITTEN IS MISSING OR INVALID
29-INV NUM REFILLS AUTHORIZED	4047	EDIT IGNORED
29-INV NUM REFILLS AUTHORIZED	4425	AUTHORIZED REFILLS MISSING OR INVALID.
29-INV NUM REFILLS AUTHORIZED	4426	REFILL NUMBER IS GREATER THAN 5.
30-INV PA MED CERT CD & NUM	4065	"THE PLAN BENEFIT LIMITS INDICATE A COVERED DRUG AND THE MED CERT OVERRIDE INDICATOR OF THE PLAN BENEFIT LIMIT RECORD THAT INDICATED A COVERED DRUG = ‘Y’ (OVERRIDE) AND (THE CLAIM PRIOR AUTHORIZATION TYPE (DRUG CERT CODE) IS NOT EQUAL TO 2 (MEDICAL CERTIFY) OR CLAIM SUBMISSION CLARIFICATION CODE (DRUG RX OVERR
30-INV PA MED CERT CD & NUM	4066	"PLAN BENEFIT LIMIT OVERRIDE MEDICAL CERTIFICATION EQUALS Y (OVERRIDE) AND (CLAIM PA TYPE(DRUG CERT CODE) IS NOT EQUAL TO 2 (MEDICAL CERTIFY) OR CLAIM DRUG RX OVERRIDE CODE (SUBMISSION CLARIFICATION CODE) IS NOT EQUAL TO 7 (MEDICALLY NECESSARY)) AND PRIOR AUTHORIZATION INDICATOR IS NOT EQUAL TO PRIOR AUTHORIZ
30-INV PA MED CERT CD & NUM	4436	EDIT IGNORED
30-INV PA MED CERT CD & NUM	4437	INVALID BATCH TYPE CODE ?
30-INV PA MED CERT CD & NUM	4438	PREGNANCY INDICATOR INVALID
30-INV PA MED CERT CD & NUM	4875	PA 1ST CHAR MUST = 6 OR 8- NOT USED IN MS.
32-INV LEVEL OF SERVICE	4756	"POST EDIT IF NOT VALID VALUE: 00=NOT SPECIFIED 01=PATIENT CONSULTATION 02=HOME DELIVERY 03=EMERGENCY 04=24 HOUR SERVICE 05=PATIENT CONSULTATION ABOUT GENERIC PRODUCT SELECTION 2-10-03 CHANGED PDCS DESCRIPTION AND MOVED EOB 0207 TO NEW EXCEPTION CODE 4961 - SPECIFIC TO ILLEGAL ALIEN"
33-INV PRESCRIPTION ORIGIN CD	4757	EDIT IGNORED
34-INV SUBMISSION CLARIF CODE	4070	EDIT IGNORED
34-INV SUBMISSION CLARIF CODE	4444	EDIT IGNORED
35-INV PRIMARY CARE PROV ID	4071	THE PRIMARY CARE PROVIDER ID IS MISSING (SPACES).
35-INV PRIMARY CARE PROV ID	4072	M/I PRIMARY CARE PROVIDER ID
36	4758	EDIT IGNORED
38-INV BASIS OF COST	4759	EDIT IGNORED
39-INV DIAGNOSIS CODE	4242	INVALID DIAGNOSIS CODE. ONLY VALID ICD-10 CODES ALLOWED FOR DATE OF SERVICE ON OR AFTER 10/01/2015
39-INV DIAGNOSIS CODE	4760	EDIT IGNORED
40-PHARM NT CONT W PLAN ON DT SRV	4075	PHARMACY IS NOT ENROLLED AS A MEDICAID PROVIDER ON DATE OF SERVICE.
40-PHARM NT CONT W PLAN ON DT SRV	4175	PHARMACY NOT A VALID PROVIDER SPECIALTY OF 146 FOR BILLING 340B CLAIMS.
40-PHARM NT CONT W PLAN ON DT SRV	4302	CLAIM BILLED AS 340B DRUG BUT PHARMACY FILE INDICATES PROVIDER HAS NOT OPTED-IN TO BILL AS 340B COVERED ENTITY
40-PHARM NT CONT W PLAN ON DT SRV	4806	EDIT IGNORED
40-PHARM NT CONT W PLAN ON DT SRV	4807	EDIT IGNORED
40-PHARM NT CONT W PLAN ON DT SRV	4861	PROV. INELIG. TO BILL FOR DOS
40-PHARM NT CONT W PLAN ON DT SRV	4862	"PHARMACY NOT CONTRACTED WITH PLAN ON DATE OF SERVICE - CHECKS IF THE PHARMACY IS ON FILE AND IF THE DATE RANGE FOR THE PLAN INCLUDES THE DATE OF SERVICE ON THE CLAIM; IF NOT - THEN POST THE ERROR EDIT WILL POST FOR NON-590 PROVIDERS SUBMITTING 590 CLAIMS NOTE: THIS IS A GENERIC EDIT THAT POSTS FOR NON-INCAID OR NON
41-SUBMIT BILL TO OTHER PROCESSOR	4062	THE PAYER ID DOES NOT MATCH THE CARRIER CODE ON THE CARRIER TABLE.
41-SUBMIT BILL TO OTHER PROCESSOR	4077	PT. HAS OTHER INSURANCE. SUBMIT CLAIMS TO OTHER INSURANCE PRIOR TO BILLING MEDICAID. SEE 'BILLING TIPS' @ HTTP://WWW.MEDICAID.MS.GOV/PHARMACY.ASPX
41-SUBMIT BILL TO OTHER PROCESSOR	4268	SERVICE NOT AUTHORIZED FOR CHIP BENEFICIARY
41-SUBMIT BILL TO OTHER PROCESSOR	4307	BENEFICIARY INCLUDED ON MS CHIP ENCOUNTER CLAIM, BUT IS NOT IN COE 099 OR MS CHIP LOCK IN.
41-SUBMIT BILL TO OTHER PROCESSOR	4377	EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR	4378	EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR	4380	EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR	4382	EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR	4383	EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR	4384	EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR	4396	EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR	4397	THE COVERAGE TYPE IS 17 AND THE OTHER INSURANCE INDICATOR IS 4 AND THE OTHER AMOUNT PAID IS ZERO AND CARRIER FOUND AND NOT DAW AND THE ADJUDICATION DATE IS GREATER THAN FDOS + 3 DAYS.
41-SUBMIT BILL TO OTHER PROCESSOR	4398	THE COVERAGE TYPE IS 17 AND THE OTHER INSURANCE INDICATOR IS 0 AND THE OTHER AMOUNT PAID IS GREATER THAN ZERO.
41-SUBMIT BILL TO OTHER PROCESSOR	4399	THE COVERAGE TYPE IS 17 AND THE OTHER INSURANCE INDICATOR IS 2 AND THE OTHER AMOUNT PAID IS ZERO.
41-SUBMIT BILL TO OTHER PROCESSOR	4418	THE COVERAGE TYPE IS NOT 17 AND THE OTHER INSURANCE INDICATOR IS 2 AND THE OTHER AMOUNT PAID IS ZERO.
41-SUBMIT BILL TO OTHER PROCESSOR	4419	THE COVERAGE TYPE IS 17 EXISTS AND THE CARRIER IS EQUAL '09200 ' - '09201 ' - '09212' AND THE OTHER AMOUNT PAID IS GREATER THAN ZERO AND/OR THE OTHER INSURANCE INDICATOR IS NOT EQUAL ‘2’ AND/OR THE CARRIER NOT FOUND AND/OR THE PAYER-ID DATE EXISTS.
41-SUBMIT BILL TO OTHER PROCESSOR	4427	"IF PARTICIPANT HAS TPL AND TPL AMOUNT LESS THAN 5% OF SUBMITTED INGREDIENT COST AND OTHER INSURANCE INDICATOR = 2 - 3 OR 4"
41-SUBMIT BILL TO OTHER PROCESSOR	4433	THE COVERAGE TYPE IS NOT 17 AND THE OTHER INSURANCE INDICATOR IS 0 -1 -3 -4 AND THE OTHER AMOUNT PAID IS ZERO.
41-SUBMIT BILL TO OTHER PROCESSOR	4601	CLIENT SPECIFIC EDIT (MS): CLAIMS FILED FOR BENEFICIARIES THAT QUALIFY FOR MEDICARE PART B COVERAGE WHERE THE DRUG ON THE CLAIM IS A MEDICARE PART B COVERED DRUG. MEDICAID EOMB ATTACHMENT
41-SUBMIT BILL TO OTHER PROCESSOR	4602	CLIENT SPECIFIC EDIT (MS): CLAIMS FILED FOR BENEFICIARIES THAT QUALIFY FOR MEDICARE PART B COVERAGE WHERE THE DRUG ON THE CLAIM IS A MEDICARE PART B COVERED DRUG
41-SUBMIT BILL TO OTHER PROCESSOR	4630	THIRD PARTY COVERAGE AND NO AMOUNT WAS RECOVERED FOR COVERAGE CODE 01,03,04,06 AND 07
41-SUBMIT BILL TO OTHER PROCESSOR	4815	BENEFICIARY ON ENCOUNTER CLAIM IS NOT LOCKED IN TO THE CORRECT CCO
41-SUBMIT BILL TO OTHER PROCESSOR	4846	SERVICE NOT AUTHORIZED FOR MISSISSIPPI CAN BENEFICIARY
41-SUBMIT BILL TO OTHER PROCESSOR	4863	MEMBER COVERED BY PRIVATE INS
41-SUBMIT BILL TO OTHER PROCESSOR	4880	MUST BILL HOSPICE. IF HOSPICE PAYS THE CLAIM, IT WILL BE CONSIDERED PAID IN FULL. IF HOSPICE REJECTS DUE TO NONCOVERAGE SUBMIT A '03' IN OTHER COVERAGE CODE FIELD 308-C8
41-SUBMIT BILL TO OTHER PROCESSOR	4962	CLAIM INDICATES OTHER COVERAGE BUT MAINFRAME FILES DON'T HAVE COB/TPL INFO ON FILE. PAY THE CLAIM BUT POST THE EXCEPTION. NO EOB REQUIRED.
50-NON-MATCHED PHARMACY NUMBER	4081	THE SERVICE PHARMACY PROVIDER ID DOES NOT EXIST ON THE PROVIDER MASTER TABLE.
50-NON-MATCHED PHARMACY NUMBER	4440	AN ADJUSTMENT REQUEST RECORD HAS A SERVICING PHARMACY (ALT ID) EQUAL TO SPACES.
50-NON-MATCHED PHARMACY NUMBER	4442	AN ADJUSTMENT REQUEST RECORD HAS TARGETED A HISTORY RECORD FOR ADJUSTMENT - BUT THE BILLING PROVIDER NUMBER ON THE ADJUSTMENT REQUEST RECORD DOES NOT MATCH THE BILLING PROVIDER NUMBER ON THE HISTORY RECORD
50-NON-MATCHED PHARMACY NUMBER	4951	PROVIDER NOT ELIGIBLE TO BILL SPECIALTY DRUGS
51-NON-MATCHED GROUP ID	4082	B - GROUP RECORD NOT ON FILE
51-NON-MATCHED GROUP ID	4083	BENEFICIARY GROUP'S 'PLAN ID' DOES NOT EXIST ON THE DATE OF SERVICE
51-NON-MATCHED GROUP ID	4084	EDIT IGNORED
51-NON-MATCHED GROUP ID	4085	EDIT IGNORED
52-NON-MATCHED CARDHOLDER ID	4086	NON-MATCHED MEMBER ID. MEMBER NOT FOUND ON ELIGIBILITY FILE.
52-NON-MATCHED CARDHOLDER ID	4369	THE PARTICIPANT ID ON THE REPLACEMENT OR CREDIT REQUEST DOES NOT MATCH THE PARTICIPANT ID ON THE CLAIM THAT IS BEING REPLACED OR CREDITED.
53-NON-MATCHED PERSON CODE	4088	PERSON CODE IN FIELD 303-C3 MUST BE 001 (CARDHOLDER)
54-NON-MATCHED PRODUCT/SERVICE ID	4089	NON-MATCHED NDC (NOT ON DRUG FILE)
54-NON-MATCHED PRODUCT/SERVICE ID	4981	NOT A SPECIALTY DRUG, AS THIS DRUG HAS A NADAC PRICE
55-NON-MATCHED PRODUCT PKG SIZE	4761	EDIT IGNORED
56-NON-MATCHED PRESCRIBER ID	4090	PHYSICIAN LIC# NOT ON FILE (LOCKIN)
56-NON-MATCHED PRESCRIBER ID	4220	PRESCRIBER IS NOT A MEDICAID PROVIDER. PRESCRIBER HAS 90 DAYS FROM THE DATE OF FIRST CLAIM SUBMITTED TO MEDICAID TO ENROLL AS PROVIDER UNTIL CLAIMS DENY.
56-NON-MATCHED PRESCRIBER ID	4421	EDIT IGNORED
56-NON-MATCHED PRESCRIBER ID	4535	PRESCRIBER IS NOT A MEDICAID PROVIDER
56-NON-MATCHED PRESCRIBER ID	4977	PHARMACY NPIS &/OR DUMMY PRESCRIBER NPIS ARE NOT ALLOWED IN PRESCRIBER FIELD
57-NONMATCHED PA/MED CERT	4762	EDIT IGNORED
58-NON-MATCHED PRIMARY PRESCRIBER	4763	EDIT IGNORED
59	4764	EDIT IGNORED
60-PROD/SVC NOT COVERED-PAT AGE	4092	BENEFICIARY'S AGE IS LESS THAN THE MINIMUM AGE RECOMMENDED BY MFG. PRESCRIBER MAY SUBMIT 'MEDICAL NECESSITY PA FORM FOR EPSDT ELIGIBLE BENE.'
606-BRAND DRUG REQUIRED	4122	GENERIC PRODUCT IS NON-PREFERRED. DISPENSE THE PREFERRED BRAND RATHER THAN THE NON-PREFERRED GENERIC. (SMART PA)
606-BRAND DRUG REQUIRED	4373	NONPREFERRED GENERIC/ NO PA REQUIRED FOR PREFERRED BRAND
61-PROD/SVC NOT COVRD-PAT GENDER	4094	DRUG NOT INDICATED FOR GENDER.
62-PAT/CARD HOLDER NAME MISMATCH	4765	THE NAME ON THE CLAIM DOES NOT MATCH THE NAME ON THE BENEFICIARY'S MEDICAID CARD. CHECK CARD.
63-INSTIT PAT PROD/SVC ID NOT COV	4766	EDIT IGNORED
64-CLM SUB DOES NOT MTCH PRI AUTH	4096	"(THE CLAIM PA NUMBER MISSING OR THE CLAIM PA NUMBER DOES NOT MATCH THE PA NUMBER) AND THE PA REQUIRES A MATCHING PA NUMBER ON THE CLAIM"
65-PATIENT NOT COVERED	4097	PATIENT NOT COVERED – CHECKS THE COVERAGE DATA ON THE ELIGIBILITY FILE TO SEE IF THE CLAIM FDOS IS IN RANGE. ALSO CHECKS THE RELATIONSHIP TO DETERMINE IF THE MEMBER IS COVERED AND CHECKS TO SEE IF IT IS A COVERED MEMBER ID. IF NOT COVERED FOR ANY OF THESE REASONS; THEN POST THE ERROR.
65-PATIENT NOT COVERED	4101	"THE CLAIM DRUG COVERAGE CODE IS FAMILY BUT THE PARTICIPANT RELATIONSHIP CODE IS NOT SELF - SPOUSE - CHILD - OR OTHER OR (THE CLAIM DRUG COVERAGE CODE IS INDIVIDUAL AND THE PARTICIPANT RELATIONSHIP CODE IS NOT SELF) OR (THE CLAIM DRUG COVERAGE CODE IS SUBSCRIBER SPOUSE AND THE PARTICIPANT RELATIONSHIP CODE IS NOT
65-PATIENT NOT COVERED	4429	IF THE PARTICIPANT IS PRODUCTION AND THE CLAIM WAS MARKED AS A TEST CLAIM BECAUSE IT CONTAINED A TEST PROVIDER
65-PATIENT NOT COVERED	4501	RESERVED FOR FUTURE USE
65-PATIENT NOT COVERED	4518	RESERVED FOR FUTURE USE
65-PATIENT NOT COVERED	4597	BENEFICIARY (K-BABY'S MOTHER) IS NOT FEMALE OR IS NOT AT LEAST 8 YRS OLD ON DOS OR IS NOT ELIGIBLE FOR MEDICAID ON DOS
65-PATIENT NOT COVERED	4617	EDIT IGNORED
65-PATIENT NOT COVERED	4808	EDIT IGNORED
65-PATIENT NOT COVERED	4810	DATE RX FILLED CANNOT BE AFTER DATE SUBMITTED
65-PATIENT NOT COVERED	4811	NO DRUG COVERAGE FOR SLMBS OR COE=11 OR 14 (NO DRUGS COVERED THRU POS FOR SPECIFIED LOW-INCOME (SLMB) MEDICARE BENEFICIARIES OR THOSE RESIDING IN A LONG TERM HOSPITAL).
65-PATIENT NOT COVERED	4812	EDIT IGNORED
65-PATIENT NOT COVERED	4813	MEMBER HAS OTHER INSURANCE BUT NO OTHER PAYOR AMT OR OTHER PAYOR DATE SUBMITTED ON THE CLAIM
65-PATIENT NOT COVERED	4814	EDIT IGNORED
65-PATIENT NOT COVERED	4864	EDIT IGNORED
65-PATIENT NOT COVERED	4865	FILLED AFTER COVERAGE EXPIRED
65-PATIENT NOT COVERED	4866	FILLED AFTER COVERAGE TERMINATED
65-PATIENT NOT COVERED	4911	FILLED BEFORE COVERAGE EFFECTIVE – IF THE CLAIM’S FDOS FALLS BEFORE THE OLDEST COVERAGE BEGINNING DATE IN THE COVERAGE TABLE (ELIGIBILITY FILE); THEN THE ERROR IS POSTED.
65-PATIENT NOT COVERED	4950	BENEFICIARY NOT COVERED FOR OUTPATIENT PHARMACY BENEFITS FOR DATE OF SERVICE. (HPE SERVICE MODIFIER).
65-PATIENT NOT COVERED	4956	BENEFICIARY NOT COVERED FOR PHARMACY BENEFITS. (PUBLIC INSTITUTION MODIFIER).
65-PATIENT NOT COVERED	4958	PATIENT NO LONGER COVERED BECAUSE DECEASED
65-PATIENT NOT COVERED	4985	EDIT WILL POST IF MEMBER IS NOT COVERED BY MEDICAID EVEN IF ELIGIBLE UNDER A SPECIFIC PLAN
66-PATIENT AGE EXCEEDS MAXIMUM	4103	DRUG HAS A MAXIMUM AGE SPECIFIED ON A CUSTOM RECORD AND THE AGE OF THE MEMBER EXCEEDS THIS MAXIMUM.
66-PATIENT AGE EXCEEDS MAXIMUM	4105	EDIT IGNORED
67-FILLED BEFORE COV EFFECTIVE	4106	EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED	4041	MEDICAL DEVICES NOT COVERED
70-PRODUCT/SERVICE NOT COVERED	4111	EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED	4113	"A =DESI DRUG (LESS THAN EFFECTIVE DRUG) - NON-REIMBURSABLE"
70-PRODUCT/SERVICE NOT COVERED	4114	PRODUCT NOT COVERED. (IF MEDICAL SUPPLY SUBMIT DME CLAIM)
70-PRODUCT/SERVICE NOT COVERED	4115	I= DEFAULT CODE – NOT COVERED ON PLAN
70-PRODUCT/SERVICE NOT COVERED	4116	PRODUCT NOT COVERED. IF AGE < 21 PRESCRIBER MAY SUBMIT PA REQUEST =  MEDICAL NECESSITY PA FORM FOR EPSDT ELIGIBLE BENE. (IF MEDICAL SUPPLY SUBMIT DME CLAIM)
70-PRODUCT/SERVICE NOT COVERED	4117	NON-REBATED NDC IS NOT COVERED. EXCEPTIONS MAY BE MADE FOR CHILDREN < 21. PRESCRIBER MAY SUBMIT 'MEDICAL NECESSITY PA FORM FOR EPSDT ELIGIBLE BENE.'
70-PRODUCT/SERVICE NOT COVERED	4118	EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED	4119	EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED	4121	"IF THE PRODUCT/SERVICE ID QUALIFIER INDICATES THAT THE PRODUCT/SERVICE ID FIELD CONTAINS A NDC AND THE CLAIM ALLOWED CHARGE EQUALS $0.00 AND THE GROUP PRICING DAW CODE ON THE GROUP PRICING TABLE EQUALS SPACES."
70-PRODUCT/SERVICE NOT COVERED	4124	EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED	4629	PRENATAL VITAMIN - ONLY COVERED FOR PREGNANT FEMALES
70-PRODUCT/SERVICE NOT COVERED	4853	EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED	4943	BILL INJECTABLE CII DRUGS ON MEDICAL CLAIM
70-PRODUCT/SERVICE NOT COVERED	4947	BILL VIA MEDICAL CLAIM. PA REQUIRED FOR POS BILLING
72-PRIMARY PRESCRIBER NOT COVERED	4771	EDIT IGNORED
73-REFILLS NOT COVERED	4128	EDIT IGNORED
73-REFILLS NOT COVERED	4129	EDIT IGNORED
73-REFILLS NOT COVERED	4130	EDIT IGNORED
73-REFILLS NOT COVERED	4131	EDIT IGNORED
74-OTH CAR PMT MEETS/EXCEEDS PYBL	4772	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4002	DO NOT USE
75-PRIOR AUTH REQUIRED	4003	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4015	PRESCRIBING PROVIDER NOT A VALID PROVIDER TYPE FOR BILLING POS CLAIMS. VALID PROVIDER TYPES FOUND ON SYSTEM LIST 4001 AND IF ORP, THEN SYSTEM LIST 4002.
75-PRIOR AUTH REQUIRED	4020	SUBMITTED CLAIM IS FOR MORE THAN ONE TABLET SPLITTING DEVICE AND ONLY ONE DEVICE IS ALLOWED. (SMART PA)
75-PRIOR AUTH REQUIRED	4021	ONE TABLET SPLITTING DEVICE ALLOWED PER YEAR. CLAIMS HISTORY INDICATES A HISTORY OF ANOTHER TABLET SPLITTING DEVICE IN THE PAST 365 DAYS. (SMART PA)
75-PRIOR AUTH REQUIRED	4024	MUST HAVE A HISTORY OF ABILIFY 5 MG, 10 MG, 15 MG, 20 MG OR 30 MG IN THE PAST 31 DAYS FOR APPROVAL OF A TABLET SPLITTING DEVICE. (SMART PA)
75-PRIOR AUTH REQUIRED	4027	AGE IS LESS THAN THE RECOMMENDED MINIMUM AGE FOR THIS DRUG. MUST SUBMIT AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. ALL NONPREFERRED AGENTS MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4052	AMBIEN 10 MG, EDULAR 10 MG, AMBIEN CR 12.5 MG AND INTERNEZZO 3.5 MG AR NOT RECOMMENDED FOR USE IN WOMEN. USE LOWER STRENGTH. (SMART PA)
75-PRIOR AUTH REQUIRED	4054	LINDANE SHAMPOO AND LINDANE LOTION REQUIRE A MANUAL REVIEW. LINDANE SHAMPOO AND LOTION ARE RECOMMENDED FOR USE IN PATIENTS WEIGHING >/= 50 KG OR 110 POUNDS. APPROVAL ALSO REQUIRES A TRIAL OF PREFERRED PERMETHRIN 5% CREAM IN THE PAST 90 DAYS.(SMART PA)
75-PRIOR AUTH REQUIRED	4058	FEMALE BENEFICIARIES ARE LIMITED TO 1 CANISTER OF ZOLPIMIST PER 51 DAYS. (SMART PA)
75-PRIOR AUTH REQUIRED	4059	SEDATIVE HYPNOTICS ARE LIMITED TO EITHER ONE DRUG CHANGE OR ONE DOSE CHANGE WITHIN A 12 MONTH PERIOD. QUANTITY ON THIS CLAIM PLUS PRESCRIPTION HISTORY IN THE PAST YEAR EXCEEDS THIS LIMIT. (SMART PA)
75-PRIOR AUTH REQUIRED	4060	EPIDIOLEX IS INDICATED FOR AGE >/= 2 YEARS. MUST SUBMIT AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. ALSO REQUIRES A DIAGNOSIS OF DRAVET SYNDROME OR LENNOX-GASTAUT SYNDROME IN THE PAST 2 YEARS. (SMART PA)
75-PRIOR AUTH REQUIRED	4061	EPIDIOLEX REQUIRES A DIAGNOSIS OF DRAVET SYNDROME OR LENNOX-GASTAUT SYNDROME IN THE PAST 2 YEARS FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4067	A DIAGNOSIS OF SCHIZOPHRENIA, OR SCHIZOEFFECTIVE DISORDER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4069	A DIAGNOSIS OF SCHIZOPHRENIA, SCHIZOEFFECTIVE DISORDER OR BIPOLAR DISORDER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF RISPERDAL CONSTA OR ABILIFY MAINTENA ER. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4073	ENTRESTO REQUIRES A DIAGNOSIS OF HEART FAILURE IN THE PAST 2 YEARS FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4076	AGES 21 YEARS & OLDER REQUIRES A DIAGNOSIS OF ADD/ADHD IN THE PAST 2 YEARS FOR APPROVAL OF PREFERRED ATOMOXETINE. NO DIAGNOSIS FOUND ON FILE. BRAND STRATTERA IS NONPREFERRED. (SMART PA)
75-PRIOR AUTH REQUIRED	4079	COMBIVENT RESPIMAT IS NON-PREFERRED AND REQUIRES A HISTORY OF AT LEAST 1 CLAIM WITH COMBIVENT RESPIMAT IN THE PAST 90 DAYS FOR APPROVAL. NO RX FOR COMBIVENT RESPIMAT FOUND IN PHARMACY CLAIMS. REFER TO THE PDL FOR A LIST OF PREFERRED AGENTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4087	FERTILITY TREATMENT IS NOT COVERED BY MEDICAID, HOWEVER OTHER INDICATIONS WILL BE CONSIDERED FOR COVERAGE. SUBMIT A PRIOR AUTHORIZATION REQUEST.
75-PRIOR AUTH REQUIRED	4093	AGE IS LESS THAN THE RECOMMENDED MINIMUM AGE FOR THIS DRUG. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL
75-PRIOR AUTH REQUIRED	4095	ONFI AND SYMPAZAN ARE INDICATED FOR AGE >/= 2 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. NON-PREFERRED ONFI AND SYMPAZAN MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4099	GENERIC RECTAL MESALAMINE IS NON-PREFERRED. CANASA IS THE PREFERRED RECTAL PRODUCT. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRRED INFLAMMATORY BOWEL DISEASE AGENTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4100	MUST HAVE TRIAL OF ANY TWO PREFERRED BPH AGENTS AND DIAGNOSIS OF BPH AND ABSENCE OF ED. PRESCRIBER MUST SUBMIT STATEMENT THAT HE/SHE IS NOT TREATING PATIENT FOR ED (SMART PA)
75-PRIOR AUTH REQUIRED	4102	A HISTORY OF 1 CLAIM WITH PREFERRED VOLAREN GEL IN THE PAST 6 MONTHS OR A DIAGNOSIS OF EITHER POSTHERPETIC NEURALGIA OR DIABETIC NEUROPATHY IN THE PAST YEAR IS REQUIRED FOR APPROVAL OF LIDODERM. (SMART PA)
75-PRIOR AUTH REQUIRED	4108	A DIAGNOSIS OF CYSTIC FIBROSIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. ALL AGENTS MUST ALSO MEET AGE LIMIT REQUIREMENTS. KALYDECO, ORKAMBI & SYMDEKO REQUIRE A MANUAL PA FOR APPROVAL. OTHER NON-PREFERRED AGENTS REQUIRE A HISTORY OF 1 CLAIM WITH THE REQUESTED AGENT IN THE PAST 105 DAYS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4112	KALYDECO, ORKAMBI, AND SYMDEKO REQUIRE A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4125	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4127	RX EXCEEDS 8 RX/MONTH FOR B2I/B2R BENE. IF AGE < 21, ADDITIONAL RXS ALLOWED WITH PRIOR AUTHORIZATION.
75-PRIOR AUTH REQUIRED	4132	PRIOR AUTHORIZATION REQUIRED
75-PRIOR AUTH REQUIRED	4133	"IF THE DUR AMOUNT LIMIT ACCUMULATOR EQUALS ‘ALL’ AND THE DUR AMOUNT LIMIT TOTAL (A CALCULATED FIELD) IS GREATER THAN THE DUR AMOUNT LIMIT FROM THE PLAN BENEFITS LIMIT TABLE AND THE DUR AMOUNT LIMIT STATUS ON THE PLAN’S BENEFITS LIMIT TABLE EQUALS ‘P’ AND THERE IS NO PRIOR AUTHORIZATION INDICATED ON THE CLAIM."
75-PRIOR AUTH REQUIRED	4134	BILLED QTY IS GREATER THAN APPROVED QTY ON PA.
75-PRIOR AUTH REQUIRED	4135	IF THE PRIOR AUTHORIZATION USED DAYS PLUS THE CLAIM PAID DAYS IS GREATER THAN THE PRIOR AUTHORIZATION APPROVED DAYS.
75-PRIOR AUTH REQUIRED	4136	"A DISPENSE AS WRITTEN CODE 1 OVERRIDE IS NOT FOUND AND THE CLAIM PRESCRIBED DATE IS GREATER THAN OR EQUAL TO NOVEMBER 28 - 2001 (13847 IN MILLENNIUM DATE FORMAT) AND THE CLAIM DISPENSE AS WRITTEN CODE IS EQUAL TO 1 (PHYSICIAN DAW)"
75-PRIOR AUTH REQUIRED	4137	RANITIDINE CAPSULES REQUIRE PRIOR AUTHORIZATION. USE RANITIDINE TABLETS.
75-PRIOR AUTH REQUIRED	4138	A HISTORY OF 1 CLAIM WITH PREFERRED VOLAREN GEL IN THE PAST 6 MONTHS OR A DIAGNOSIS OF POSTHERPETIC NEURALGIA IN THE PAST YEAR IS REQUIRED FOR APPROVAL OF ZTLIDO. (SMART PA)
75-PRIOR AUTH REQUIRED	4139	A HISTORY OF 1 CLAIM IN THE PAST 105 DAYS WITH THE SAME ORAL CONTRACEPTIVE AS ON THE INCOMING CLAIM IS REQUIRED FOR APPROVAL OF A NON-PREFERRED ORAL CONTRACEPTIVE. (SMART PA)
75-PRIOR AUTH REQUIRED	4140	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4141	"IF THE CUSTOM PLAN MAX UNITS ACCUM EQUALS A (ALL DOSES) AND THE CLAIM SUBMITTED QUANTITY IS GREATER THAN CUSTOM PLAN MAX UNITS AND THE CUSTOM PLAN MAX UNITS STATUS EQUALS P (PA REQUIRED) AND THE PRIOR AUTHORIZATION INDICATOR IS NOT EQUAL TO ( PRIOR AUTHORIZED OR COVERED )."
75-PRIOR AUTH REQUIRED	4142	"IF THE CUSTOM PLAN MAX NUMBER OF REFILLS IS NOT EQUAL TO UNLIMITED (999) AND THE PLAN BENEFIT LIMIT OVERRIDE PA EQUALS I (OVERRIDE INITIAL RX) AND THE CLAIM REFILL INDICATOR GREATER 0 AND THE CUSTOM PLAN MAX NUMBER OF REFILLS LESS THAN (<) THE CLAIM REFILL INDICATOR AND THE PRIOR AUTHORIZATION INDICATOR IS
75-PRIOR AUTH REQUIRED	4143	"THE PLAN BENEFIT LIMITS INDICATE NOT COVERED AND THE CLAIM PA TYPE CODE NOT = ‘8’ (PA OVERRIDE) AND THE PLAN BENEFIT LIMIT OVERRIDE PA EQUALS I (OVERRIDE INITIAL RX) AND THE CLAIM REFILL INDICATOR IS EQUAL TO 0 AND THE PLAN BENEFIT LIMT MED CERT INDICATOR = ‘Y’ (OVERRIDE) AND THE CLAIM PA INDICATOR NOT = P
75-PRIOR AUTH REQUIRED	4144	"IF THE CUSTOM PLAN MAX NUMBER OF REFILLS IS NOT EQUAL TO UNLIMITED (999) AND THE PLAN BENEFIT LIMIT OVERRIDE PA EQUALS Y (OVERRIDE) AND THE CUSTOM PLAN MAX NUMBER OF REFILLS LESS THAN CLAIM REFILL INDICATOR AND THE PRIOR AUTHORIZATION INDICATOR IS NOT EQUAL TO ( PRIOR AUTHORIZED OR COVERED )."
75-PRIOR AUTH REQUIRED	4145	PRIOR AUTH REQUIRED.
75-PRIOR AUTH REQUIRED	4146	"IF THE PLAN BENEFIT LIMIT OVERRIDE PA EQUALS I (OVERRIDE INITIAL RX) AND THE CLAIM REFILL INDICATOR EQUALS 0 AND THE PRIOR AUTHORIZATION INDICATOR IS NOT EQUAL TO ( PRIOR AUTHORIZED OR COVERED )."
75-PRIOR AUTH REQUIRED	4147	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4148	CLAIM IS FOR NON-PREFERRED BRAND DEPO-PROVERA. USE PREFERRED GENERIC MEDROXYPROGESTERONE ACETATE IM. (SMART PA)
75-PRIOR AUTH REQUIRED	4149	"IF THE DAILY DOSE (DERIVED BY TAKING CLAIM SUBMITTED QUANTITY / CLAIM DAYS SUPPLY) GREATER THAN CUSTOM PLAN MAINTENANCE CLAIM DOSE AND THE CUSTOM PLAN MAINTENANCE INDICATOR EQUALS PAY AND THE PRIOR AUTHORIZATION INDICATOR IS NOT EQUAL TO ( PRIOR AUTHORIZED OR COVERED )."
75-PRIOR AUTH REQUIRED	4151	"IF THE CUSTOM PLAN MINIMUM DAILY DOSE UNITS IS NOT EQUAL TO 0 AND THE DAILY DOSE (DERIVED BY TAKING CLAIM SUBMITTED QUANTITY / CLAIM DAYS SUPPLY) IS LESS THAN THE CUSTOM PLAN MINIMUM DAILY DOSE AND THE PRIOR AUTHORIZATION INDICATOR IS NOT EQUAL TO ( PRIOR AUTHORIZED OR COVERED )."
75-PRIOR AUTH REQUIRED	4152	"THE CLAIM PARTICIPANT AGE IS NOT LESS THAN THE CUSTOM PLAN DRUG MAXIMUM AGE AND THE PRIOR AUTHORIZATION INDICATOR IS NOT EQUAL TO ( PRIOR AUTHORIZED OR COVERED ) AND THE CUSTOM PLAN AGE EDIT STATUS EQUALS PA REQUIRED AND THE CLAIM’S PRIOR AUTHORIZATION TYPE CODE NOT = PA OVERRIDE (‘8’)."
75-PRIOR AUTH REQUIRED	4153	BENEFICIARY’S AGE IS LESS THAN THE RECOMMENDED MINIMUM AGE FOR THIS DRUG. PRIOR AUTHORIZATION REQUIRED
75-PRIOR AUTH REQUIRED	4154	"THE (CUSTOM PLAN DAYS SUPPLIED ACCUM IS NOT EQUAL TO N (NONE) AND THE CUSTOM PLAN DAYS SUPPLIED IS NOT EQUAL TO WORK DEFAULT DAYS (999)) AND THE CUSTOM PLAN DAYS SUPPLIED ACCUM EQUALS C (ACUTE DOSE ONLY) AND THE CUSTOM PLAN MAINTENANCE CLAIM DOSE LESS THAN THE WORK DEFAULT DOSE (9999.999) AND THE DAILY DOS
75-PRIOR AUTH REQUIRED	4155	"IF THE CUSTOM PLAN DAYS SUPPLIED ACCUM EQUALS A (ALL DOSES) AND THE CLAIM SUBMITTED DAYS IS GREATER THAN THE CUSTOM PLAN DAYS SUPPLIED AND THE CUSTOM PLAN DAYS SUPPLIED STATUS EQUALS P (PA REQUIRED) AND THE PRIOR AUTHORIZATION INDICATOR IS NOT EQUAL TO ( PRIOR AUTHORIZED OR COVERED )."
75-PRIOR AUTH REQUIRED	4156	"AN ENTRY ON THE CUSTOM RECORD EXISTS AND THE DUR UNITS ACCUMULATOR CODE ON THE CUSTOM RECORD IS NOT EQUAL TO N AND THE DUR UNITS AMOUNT ON THE CUSTOM RECORD IS GREATER THAN +0.000 AND LESS THAN +99999.999 AND ((THE DUR UNITS ACCUMULATOR CODE ON THE CUSTOM RECORD EQUALS C (ACUTE)) AND (IP DAILY DOSE IS GREATER T
75-PRIOR AUTH REQUIRED	4157	"AN ENTRY EXISTS ON THE CUSTOM RECORD AND DUR DAYS SUPPLY ACCUMULATOR CODE ON THE CUSTOM RECORD IS NOT EQUAL TO N AND DUR DAYS SUPPLY AMOUNT ON THE CUSTOM RECORD IS GREATER THAN +0 AND LESS THAN +999 AND ((DUR DAYS SUPPLY ACCUMULATOR CODE ON THE CUSTOM RECORD EQUALS C (ACUTE)) AND (IP DAILY DOSE IS GREATER THAN THE
75-PRIOR AUTH REQUIRED	4158	"AN ENTRY EXISTS ON THE CUSTOM RECORD AND DUR MAX RX ACCUMULATOR CODE ON THE CUSTOM RECORD IS NOT EQUAL TO N AND DUR MAX RX AMOUNT ON THE CUSTOM RECORD IS GREATER THAN +0 AND LESS THAN +999 AND ((DUR MAX RX ACCUMULATOR CODE ON THE CUSTOM RECORD EQUALS C (ACUTE)) AND (IP DAILY DOSE IS GREATER THAN THE MAINTENANCE CL
75-PRIOR AUTH REQUIRED	4159	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4161	ARISTADA INITIO IS LIMITED TO 3 SYRINGES/YEAR TO ALLOW FOR INITIAL TREATMENT AND 2 RE-STARTS PER YEAR. REQUESTED RX EXCEEDS THIS LIMIT. A QUANTITY OF > 3 PER YEAR REQUIRES A MANUAL PA. (SMART PA)
75-PRIOR AUTH REQUIRED	4179	WITH A DAGNOSIS OF ADD/ADHD, 30 DAYS THERAPY WITH 2 DIFFERENT PREFERRED LONG ACTING STIMULANTS OR A HISTORY OF 1 CLAIM FOR A 30 DAY SUPPLY WITH THE SAME NON-PREFERRED LA STIMULANT AS THE INCOMING CLAIM IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4190	ALL ALZHEIMER'S AGENTS REQUIRE A HISTORY OF AN APPROVABLE DIAGNOSIS IN THE PAST 2 YEARS FOR APPROVAL. NON-PREFERRED ALZHEIMER'S AGENTS MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4216	A DIAGNOSIS OF SUBARACHNOID HEMORRHAGE IN THE PAST 45 DAYS IS REQUIRED FOR APPROVAL OF NIMODIPINE. (SMART PA)
75-PRIOR AUTH REQUIRED	4217	NIMODIPINE IS LIMITED TO 252 CAPSULES OR 2520 ML PER MAXIMUM 21 DAYS OF THERAPY. QUANTITY ON THE INCOMING CLAIM PLUS HISTORY IN THE PAST 21 DAYS EXCEEDS QUANTITY ALLOWED. (SMART PA)
75-PRIOR AUTH REQUIRED	4221	PA REQUIRED FOR NONPREFERRED BRAND/ NO PA REQUIRED FOR PREFERRED GENERIC
75-PRIOR AUTH REQUIRED	4223	ADEMPAS REQUIRES A WHO GROUP 1 DIAGNOSIS OF PULMONARY HYPERTENSION OR A WHO GROUP 4 DIAGNOSIS OF PULMONARY HYPERTENSION DUE TO CHRONIC THROMBOTIC AND/OR EMBOLIC DISEASE FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4224	HYDROXYZINE HCL TABLETS ARE NON-PREFERRED. PLEASE REFER TO PDL FOR A LIST OF PREFERRED HYDROXYZINE AGENTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4228	HYDROXYZINE HCL 10 MG TABLETS REQUIRE NO PA FOR AGES 6-12 YEARS. FOR ALL OTHER AGES, HYDROXYZINE HCL 10 MG TABLETS ARE NON-PREFERRED. PLEASE REFER TO PDL FOR A LIST OF PREFERRED HYDROXYZINE PAMOATE AGENTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4230	HISTORY OF AT LEAST 30 DAYS OF THERAPY WITH BRAND XENAZINE OR GENERIC TETRABENAZINE IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL OF AUSTEDO. PHARMACY CLAIMS INDICATES NO HISTORY WITH BRAND XENAZINE OR GENERIC TETRABENAZINE IN THE PAST 6 MONTHS. (SMART PA)
75-PRIOR AUTH REQUIRED	4240	TOBI PODHALER REQUIRES A MANUAL REVIEW FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4251	CIPRO HC REQ. PA FOR 9&UP. REFER TO PDL FOR PREFERRED MEDS FOR TX OF ACUTE OTITIS EXTERNA
75-PRIOR AUTH REQUIRED	4260	CUMULATIVE MAX UNIT OF 2 EXCEEDED IN 23 DAYS.
75-PRIOR AUTH REQUIRED	4264	CIPRODEX REQ PA FOR PATIENTS 15YRS & UP. REFER TO PDL FOR PREFERRED MEDS FOR TX OF ACUTE OTITIS EXTERNA
75-PRIOR AUTH REQUIRED	4273	A TRIAL WITH 2 DIFFERENT PREFERRED TOPICAL ANTIPARASITIC AGENTS IN THE PAST 90 DAYS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4278	ALL TRAMADOL PRODUCTS REQUIRE A MANUAL REVIEW FOR BENEFICIARIES < 18 YEARS OF AGE. MUST SUBMIT AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. NONPREFERRED AGENTS MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4279	ALL CODEINE & TRAMADOL PRODUCTS REQUIRE A MANUAL REVIEW FOR APPROVAL FOR BENEFICIARIES < 18 YEARS OF AGE. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER AND NONPREFERRED AGENTS MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4280	WITH A DIAGNOSIS OF NARCOLEPSY, NONPREFERRED SHORT ACTING STIMULANTS REQUIRE 30 DAYS OF THERAPY WITH BOTH MODAFINIL OR ARMODAFINIL AND A DIFFERENT PREFERRED SHORT ACTING STIMULANT INDICATED FOR THE TREATMENT OF NARCOLEPSY IN THE PAST 6 MONTHS. NO PREFERRED SA STIMULANT RX FOUND IN PHARMACY CLAIMS. (SMART PA)
75-PRIOR AUTH REQUIRED	4281	ALPRAZOLAM ER HAS A CUMULATIVE QUANTITY LIMIT OF 31 TABLETS/26 DAYS.
75-PRIOR AUTH REQUIRED	4282	WITH A DIAGNOSIS OF NARCOLEPSY, NONPREFERRED LONG ACTING STIMULANTS REQUIRE 30 DAYS OF THERAPY WITH BOTH MODAFINIL OR ARMODAFINIL AND A DIFFERENT PREFERRED LONG ACTING STIMULANT INDICATED FOR THE TREATMENT OF NARCOLEPSY IN THE PAST 6 MONTHS. NO PREFERRED LA STIMULANT RX FOUND IN PHARMACY CLAIMS. (SMART PA)
75-PRIOR AUTH REQUIRED	4292	AMPYRA REQUIRES CLINICAL REVIEW. (SMART PA)
75-PRIOR AUTH REQUIRED	4295	USE BRAND TERAZOL 3, IT IS THE PREFERRED DRUG.
75-PRIOR AUTH REQUIRED	4296	A HISTORY OF THERAPY WITH A COMBINATION CARBIDOPA AGENT IN THE PAST 45 DAYS IS REQUIRED IS FOR APPROVAL OF LODOSYN AND INBRIJA. NO PRESCRIPTION FOR A COMBINATION CARBIDOPA AGENT FOUND IN PHARMACY CLAIMS. (SMART PA)
75-PRIOR AUTH REQUIRED	4301	RX EXCEEDS MONTHLY BRAND LIMIT. ADDITIONAL BRAND PRESCRIPTIONS ALLOWED FOR BENFICIARIES UNDER AGE 21 WITH PRIOR AUTHORIZATION.
75-PRIOR AUTH REQUIRED	4306	A DIAGNOSIS OF HUNTINGTON'S CHOREA IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4310	ZONTIVITY REQUIRES A CLINICAL REVIEW FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4312	A DIAGNOSIS OF A MYOCARDIAL INFARCTION (MI) OR PERIPHERAL ARTERY DISEASE IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF ZONTIVITY. (SMART PA)
75-PRIOR AUTH REQUIRED	4313	A DIAGNOSIS OF A MYOCARDIAL INFARCTION (MI) OR PERIPHERAL ARTERY DISEASE WITH NO HISTORY OF A STROKE, TIA OR INTRACRANIAL HEMORRHAGE (ICH) IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF ZONTIVITY. (SMART PA)
75-PRIOR AUTH REQUIRED	4315	A DIAGNOSIS OF MYOCARDIAL INFARCTION (MI) OR PERIPHERAL ARTERY DISEASE AND A DIAGNOSIS OF A STROKE, TIA OR INTRACRANIAL HEMORRHAGE (ICH) IN THE PAST 2 YEARS AND CONCURRENT THERAPY WITH ASA &/OR CLOPIDOGREL IS REQUIRED FOR APPROVAL OF ZONTIVITY.
75-PRIOR AUTH REQUIRED	4366	A DIAGNOSIS OF NARCOLEPSY, OBSTRUCTIVE SLEEP APNEA, OR SHIFT WORK SLEEP DISORDER OR A DIAGNOSIS OF BIPOLAR DEPRESSION IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF ARMODAFINIL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4367	A DIAGNOSIS OF NARCOLEPSY, OBSTRUCTIVE SLEEP APNEA, OR SHIFT WORK SLEEP DISORDER OR A DIAGNOSIS OF ADD/ADHD, DEPRESSION, SLEEP DEPRIVATION OR MYOTONIC DYSTROPHY SYNDROME IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF MODAFINIL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4368	NEWLY RELEASED DRUG, MANUAL PRIOR AUTHORIZATION IS REQUIRED
75-PRIOR AUTH REQUIRED	4372	CLAIM IS FOR SIMVASTATIN 80 MG AND CLAIMS HISTORY INDICATES LESS THAN 12 MONTHS OF THERAPY IN THE PAST 18 MONTHS. (SMART PA)
75-PRIOR AUTH REQUIRED	4381	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4405	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4406	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4407	A HISTORY OF 30 DAYS OF THERAPY WITH A EITHER A STIMULANT, A PREFERRED NON-STIMULANT OR SHORT-ACTING CLONIDINE IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL OF NON-PREFERREED KAPVAY OR CLONIDINE ER. (SMART PA)
75-PRIOR AUTH REQUIRED	4408	DAKLINZA, EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI, AND ZEPATIER REQUIRE A MANUAL CLINICAL REVIEW. (SMART PA)
75-PRIOR AUTH REQUIRED	4409	GENERIC PRODUCT IS NON-PREFERRED. DISPENSE THE PREFERRED BRAND RATHER THAN THE NONPREFERRED GENERIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4410	CF-RESERVED SMART PA
75-PRIOR AUTH REQUIRED	4411	CF-RESERVED SMART PA
75-PRIOR AUTH REQUIRED	4412	CF-RESERVED SMART PA
75-PRIOR AUTH REQUIRED	4422	DAYS SUPPLY ON INCOMING SHORT-ACTING NARCOTIC CLAIM IS > 5 DAYS. CANNOT HAVE AN OPIATE PRESCRIPTION FOR MORE THAN A 5 DAY SUPPLY IN THE PAST 30 DAYS WHILE ON BUPRENORPHINE THERAPY. (SMART PA)
75-PRIOR AUTH REQUIRED	4423	A MAXIMUM CUMMULATIVE TOTAL OF 10 DAYS OF OPIATE THERAPY IS ALLOWED DURING ANY 60 DAY PERIOD WHILE ON BUPRENORPHINE THERAPY. PHARMACY CLAIMS HISTORY INDICATES THERAPY WITH BOTH AN OPIOID AND A BUPRENORPHINE PRODUCT FOR > 10 DAYS IN THE PAST 60 DAYS. (SMART PA)
75-PRIOR AUTH REQUIRED	4446	DUR EDIT POSTED WITH A CONFLICT CODE OF HD (HIGH DOSE) - PA REQUIRED
75-PRIOR AUTH REQUIRED	4447	"THE IN PROCESS BILLING PROVIDER ID NOT EQUAL HISTORY BILLING PROVIDER ID AND FIRST DATE OF SERVICE ON THE CURRENT CLAIM MUST BE AFTER THE FIRST DATE OF SERVICE ON THE HISTORY CLAIM. AND FIRST DATE OF SERVICE ON THE CURRENT CLAIM MUST BE BEFORE THE DATE CALCULATED TO BE THE HISTORY CLAIM’S FIRST DATE OF SERVICE PL
75-PRIOR AUTH REQUIRED	4448	DRUG TO DRUG INTERACTION
75-PRIOR AUTH REQUIRED	4451	DAYS SUPPLY ON INCOMING LONG-ACTING NARCOTIC CLAIM IS > 5 DAYS. CANNOT HAVE AN OPIATE PRESCRIPTION FOR MORE THAN A 5 DAY SUPPLY IN THE PAST 30 DAYS WHILE ON BUPRENORPHINE THERAPY. (SMART PA)
75-PRIOR AUTH REQUIRED	4452	A MAXIMUM CUMMULATIVE TOTAL OF 10 DAYS OF OPIATE THERAPY IS ALLOWED DURING ANY 60 DAY PERIOD WHILE ON BUPRENORPHINE THERAPY. PHARMACY CLAIMS HISTORY INDICATES THERAPY WITH BOTH AN OPIOID AND A BUPRENORPHINE PRODUCT FOR > 10 DAYS IN THE PAST 60 DAYS. (SMART PA)
75-PRIOR AUTH REQUIRED	4453	30 DAYS OF THERAPY WITH TWO DIFFERENT PREFERRED ANDROGENIC AGENTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4454	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED SSRI'S IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4455	90 DAYS STABLE THERAPY WITH A DIAGNOSIS OF CANCER OR HISTORY WITH AN ANTINEOPLASTIC IS REQUIRED FOR APPROVAL. REFER TO THE PDL FOR A LIST OF PREFERRED LONG ACTING NARCOTIC AGENTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4456	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED NSAIDS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4457	30 DAYS THERAPY WITH A PREFERRED COX-II AND A PREFERRED NSAID IN THE PAST 6 MONTHS, OR 30 DAYS THERAPY WITH A PREFERRED COX-II AND A DX OF GI BLEED, GERD, PUD, GI PERFORATION, COAG DISORDER IN THE PAST 2 YEARS, OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4458	AGE IS LESS THAN THE RECOMMENDED MINIMUM AGE FOR THIS DRUG. A SIGNED AGE WAIVER IS REQUIRED FOR ALL AGENTS IF AGE < RECOMMENDED . NONPREFERRED AGENTS MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4459	GENERIC SUMATRIPTAN INJECTABLE IS NONPREFERRED. DISPENSE PREFERRED BRAND IMITREX INJECTABLE. (SMART PA)
75-PRIOR AUTH REQUIRED	4460	1 CLAIM WITH 2 DIFFERENT PREFERRED ORAL TRIPTANS IN THE PAST 90 DAYS IS REQUIRED FOR APPROVAL. MUST ALSO MEET THE FDA RECOMMENDED MINIMUM AGE REQUIREMENT. (SMART PA)
75-PRIOR AUTH REQUIRED	4461	REFER TO THE PDL. REQUESTED AGENT DOES NOT MEET THE AGE LIMIT AND REQUIRES AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. ALL AGENTS MUST MEET DIAGNOSIS CRITERIA AND NONPREFERRED AGENTS MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4462	PATIENT HAS A HISTORY OF ATRIAL FIBRILLATION, OR HISTORY OF A HIP OR KNEE REPLACEMENT IN THE PAST 30 DAYS. USE OF ELIQUIS STARTER PACK IS CONTRAINDICATED WITH THIS DIAGNOSIS. (SMART PA)
75-PRIOR AUTH REQUIRED	4463	A DIAGNOSIS OF ADD/ADHD IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF THE REQUESTED NONPREFERRED STIMULANT. NO DIAGNOSIS FOUND ON FILE. NONPREFERRED STIMULANTS MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4464	CLAIM IS FOR NON-PREFERRED BRAND FOCALIN. GENERIC DEXMETHYLPHENIDATE IS PREFRRED. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED SHORT-ACTING STIMULANTS. (SMARTPA)
75-PRIOR AUTH REQUIRED	4465	WITH A DAGNOSIS OF ADD/ADHD, 30 DAYS THERAPY WITH 2 DIFFERENT PREFERRED SHORT ACTING STIMULANTS OR A HISTORY OF 1 CLAIM FOR A 30 DAY SUPPLY WITH THE SAME NON-PREFERRED SA STIMULANT AS THE INCOMING CLAIM IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4466	A DIAGNOSIS OF ADD/ADHD OR NARCOLEPSY IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF ALL NONPREFERRED STIMULANTS. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4467	REQUESTED NON-PREFERRED CYSTIC FIBROSIS AGENT REQUIRES A HISTORY OF 1 CLAIM WITH THE REQUESTED AGENT IN THE PAST 105 DAYS FOR APPROVAL. NO RX FOUND IN PHARMACY CLAIMS HISTORY. (SMART PA)
75-PRIOR AUTH REQUIRED	4468	AGE IS > 17 YEARS. GUANFACINE ER, CLONIDINE ER AND KAPVAY ARE LIMITED TO BENEFICIARIES </= 17 YEARS OF AGE. GUANFACINE ER, CLONIDINE ER AND KAPVAY MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4469	ENTRESTO IS INDICATED FOR AGE >/= 18 YEARS OF AGE. MUST SUBMIT AN AGE WAIVER SIGNED BY THE PRESCRIBER FOR APPROVAL. ALSO REQUIRES A DIAGNOSIS OF HEART FAILURE IN THE PAST 2 YEARS. (SMART PA)
75-PRIOR AUTH REQUIRED	4470	PATIENT IS FEMALE. REQUESTED ANDROGENIC AGENT IS RECOMMENDED FOR USE IN MALES ONLY. HAVE MD SUBMIT PA REQUEST WITH MEDICAL JUSTIFICATION. (SMART PA)
75-PRIOR AUTH REQUIRED	4471	A DIAGNOSIS ON FILE FOR OSTEOARTHRITIS, RHEUMATOID ARTHRITIS, FAMILIAL ADENOMATOUS POLYPOSIS OR ANKYLOSING SPONDYLITIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4476	AGE IS LESS THAN THE RECOMMENDED MINIMUM AGE AND ALL NONPREFERRED AGENTS MUST ALSO MEET PDL CRITERIA. PREFERRED AGENTS REQUIRE AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4477	AGE IS LESS THAN THE RECOMMENDED MINIMUM AGE OF 7 YEARS FOR TREATMENT OF GENERALIZED ANXIETY DISORDER. APPROVAL REQUIRES AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4478	DULOXETINE REQUIRES A DIAGNOSIS OF GENERALIZED ANXIETY DISORDER IN THE PAST 2 YEARS FOR AGES 7 - 17 YEARS. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4479	1 CLAIM WITH 2 DIFFERENT PREFERRED CEPHALOSPORINS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4480	AGE IS LESS THAN THE RECOMMENDED MINIMUM AGE AND ALL NONPREFERRED AGENTS MUST ALSO MEET PDL CRITERIA. PREFERRED AGENTS REQUIRE AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4481	REQUESTED AGENT DOES NOT MEET AGE LIMIT AND REQUIRES AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. KALYDECO, ORKAMBI & SYMDEKO ALSO REQUIRE A MANUAL PA FOR APPROVAL. OTHER NON-PREFERRED AGENTS REQUIRE A HISTORY OF 1 CLAIM WITH THE REQUESTED AGENT IN THE PAST 105 DAYS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4482	INCOMING CLAIM IS FOR A NON-PREFERRED TOBRAMYCIN PRODUCT. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED CYSTIC FIBROSIS AGENTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4483	REQUESTED NON-PREFERRED BPH AGENT IS NOT INDICATED FOR USE IN FEMALES. (SMART PA)
75-PRIOR AUTH REQUIRED	4484	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED BPH AGENTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4485	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED ANTICONVULSANTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AND A DIAGNOSIS OF A SEIZURE DISORDER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4486	A DIAGNOSIS OF KIDNEY TRANSPLANT, RHEUMATOID ARTHRITIS OR OTHER APPROVABLE DIAGNOSIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF AZATHIOPRINE. (SMART PA)
75-PRIOR AUTH REQUIRED	4487	EUCRISA REQUIRES A HISTORY OF 1 CLAIM WITH A TOPICAL STEROID OR ELIDEL IN THE PAST YEAR FOR APPROVAL. NO RX FOR A TOPICAL STEROID OR ELIDEL FOUND IN PHARMACY CLAIMS HISTORY. (SMART PA)
75-PRIOR AUTH REQUIRED	4488	A DIAGNOSIS OF PARKINSON'S DISEASE IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4489	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED ANTIPARKINSON'S AGENTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4490	INCOMING CLAIM FOR DILTIAZEM ER IS NONPREFERRED. GENERIC DILTIAZEM ER CAPSULES 24 HR ARE PREFERRED. REFER TO THE PDL FOR A LIST OF OTHER PREFERRED LONG-ACTING CALCIUM CHANNELS BLOCKERS. (SMART PA)
75-PRIOR AUTH REQUIRED	4491	AKYNZEO AND VARUBI REQUIRE A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4492	A HISTORY OF 1 CLAIM WITH A DIFFERENT PREFERRED ANTIEMETIC IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4493	NEUPOGEN SYRINGES ARE NON-PREFERRED. PLEASE DISPENSE PREFFERRED NEUPOGEN VIALS. (SMART PA)
75-PRIOR AUTH REQUIRED	4494	REQUESTED COLONY STIMULATING FACTOR IS NON-PREFERRED AND REQUIRES A MANUAL PA FOR APPROVAL. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED AGENTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4495	DUPIXENT REQUIRES A MANUAL REVIEW FOR APPROVAL. (SMARTPA)
75-PRIOR AUTH REQUIRED	4496	CIALIS REQUIRES CLINICAL REVIEW FOR DIAGNOSIS OF BPH IN THE PAST 2 YRS, WITH NO HISTORY ERECTILE DYSFUNCTION IN THE PAST 2 YRS, AND A WAIVER SIGNED BY THE PHYSICIAN INDICATING TREATMENT IS NOT FOR ERECTILE DYSFUNCTION, AND NO TRIAL OF 30 DAYS WITH 2 DIFFERENT PREFERRED BPH AGENTS IN PAST 6 MONTHS (SMART PA)
75-PRIOR AUTH REQUIRED	4497	CLAIM IS FOR NON-PREFERRED NUVIGIL OR PROVIGIL. PLEASE DISPENSE PREFERRED ARMODANAFIL OR MODANAFIL OR REFER TO THE PDL FOR A LIST OF PREFERRED LONG-ACTING STIMULANTS. (SMARTPA)
75-PRIOR AUTH REQUIRED	4498	A DIAGNOSIS OF ALLERGY OR URTICARIA IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4499	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED 2ND GENERATION ANTIHISTAMINES IN THE PAST 12 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4500	INCOMING CLAIM IS FOR A NON-PREFERRED CYTOMEGALOVIRUS ANTIVIRAL. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED CYTOMEGALOVIRUS ANTIVIRALS. (SMART PA)
75-PRIOR AUTH REQUIRED	4502	CLAIM IS FOR NON-PREFERRED CARBAMAZEPINE XR OR TRILEPTAL SUSPENSION. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED ANTICONVULSANTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4505	A DIAGNOSIS OF CHRONIC RENAL FAILURE IN THE PAST 2 YRS IS REQUIRED FOR APPROVAL OF PREFERRED MIRCERA. (SMART PA)
75-PRIOR AUTH REQUIRED	4506	A DIAGNOSIS OF ULCERATIVE COLITIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. GENERIC BUDESONIDE EC ALSO APPROVES WITH A DIAGNOSIS OF CROHN'S DISEASE IN THE PAST 2 YEARS. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4507	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED INFLAMMATORY BOWEL AGENTS IN THE PAST 6 MONTHS OR 90 DAYS OF STABLE THERAPY WITH THE SAME AGENT IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4508	BRAND QUDEXY XR IS NONPREFERRED. GENERIC TOPIRAMATE IR IS PREFERRED. REFER TO THE PDL FOR A LIST OF PREFERRED ANTICONVULSANTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4509	A DIAGNOSIS OF A SEIZURE DISORDER IN THE PAST 2 YEARS AND A HISTORY OF 90 DAYS STABLE THERAPY WITH THE REQUESTED AGENT IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4510	A DIAGNOSIS OF A SEIZURE DISORDER IN THE PAST 2 YEARS AND A HISTORY OF 90 DAYS STABLE THERAPY WITH THE SAME AGENT IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4511	A DIAGNOSIS OF IDIOPATHIC PULMONARY FIBROSIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4512	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED BLADDER RELAXANT PREPARATIONS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4513	A DIAGNOSIS OF CANCER OR CHRONIC RENAL FAILURE IN THE PAST 2 YEARS OR A HISTORY WITH AN ANTINEOPLASTIC IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE AND NO RX FOR AN ANTINEOPLASTIC FOUND IN PHARMACY CLAIMS. (SMART PA)
75-PRIOR AUTH REQUIRED	4514	A HISTORY WITH PREFERRED PROCRIT OR EPOGEN IN THE PAST 6 MONTHS OR 1 CLAIM WITH THE SAME AGENT IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4515	KAPVAY AND CLONIDINE ER REQUIRE A DIAGNOSIS OF ADD/ADHD IN THE PAST 2 YEARS. NON-PREFERRED KAPVAY AND CLONIDINE ER MUST ALSO MEET PDL CRITERIA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4516	REQUIRES A DIAGNOSIS OF GLAUCOMA IN THE PAST 2 YEARS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4517	30 DAYS OF THERAPY WITH 2 PREFERRED GLAUCOMA AGENTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4519	A DIAGNOSIS OF DIABETES MELLITUS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4522	A DIAGNOSIS OF DIABETES AND 30 DAYS OF THERAPY WITH A PREFERRED INSULIN OR RELATED AGENT IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4524	A DIAGNOSIS OF ALLERGIC RHINITIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL.(SMART PA)
75-PRIOR AUTH REQUIRED	4525	1 CLAIM WITH 2 DIFFERENT PREFERRED INTRANASAL CORTICOSTEROIDS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4526	AN APPROPRIATE DIAGNOSIS ON FILE IN THE PAST 2 YEARS, 30 DAYS THERAPY WITH A STATIN OR COMBO PRODUCT IN THE PAST YEAR, OR 90 DAYS STABLE THERAPY WITH SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4527	A DIAGNOSIS OF PREGNANCY IN THE PAST 280 DAYS, 30 DAYS THERAPY WITH 2 DIFFERENT PREFERRED BILE ACID SEQUESTRANTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH WELCHOL IS REQUIRED FOR APPROVAL. WELCHOL. (SMART PA)
75-PRIOR AUTH REQUIRED	4528	30 DAYS THERAPY WITH 2 DIFFERENT PREFERRED FIBRIC ACID DERIVATIVES IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4529	30 DAYS THERAPY WITH 2 DIFFERENT PREFERRED NON-STATIN LIPOTROPICS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4530	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED STATIN/STATIN COMBINATIONS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4531	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED OPHTHALMIC ALLERGY AGENTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL (SMART PA)
75-PRIOR AUTH REQUIRED	4532	A TRIAL OF 1 CLAIM FOR 2 DIFFERENT PREFERRED OPHTHALMIC ANTI-INFLAMMATORY AGENTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL (SMART PA)
75-PRIOR AUTH REQUIRED	4533	MENTAL HEALTH INJECTABLE DRUGS ONLY COVERED THROUGH POS FOR BENEFICIARIES RESIDING IN LONG TERM CARE FACILITIES. ALL OTHER PTS. BILL ON MEDICAL CLAIM.
75-PRIOR AUTH REQUIRED	4534	GENERIC VALGANCICLOVIR SOLUTION APPROVES FOR < 12 YEARS OF AGE. AGES 12 YEARS AND OLDER REQUIRE A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4537	REQUESTED SHORT ACTING NARCOTIC IS NON-PREFERRED. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED SHORT ACTING NARCOTIC AGENTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4538	BRAND NAME TRILIPIX, TRICOR AND NIASPAN ARE NONPREFERRED. REFER TO THE PDL FOR A LIST OF OTHER PREFERRED LIPOTROPIC NON-STATIN AGENTS. (SMARTPA)
75-PRIOR AUTH REQUIRED	4539	1 CLAIM WITH 2 DIFFERENT PREFERRED ORAL TRIPTANS IN THE PAST 90 DAYS IS REQUIRED FOR APPROVAL. MUST ALSO MEET THE FDA RECOMMENDED MINIMUM AGE REQUIREMENT. AXERT AND TREXIMET REQUIRE NO PA FOR AGES 12-17. (SMART PA)
75-PRIOR AUTH REQUIRED	4540	QVAR REQUIRES ONE CLAIM WITH QVAR IN THE PAST 90 DAYS OR 30 DAYS THERAPY WITH 1 DIFFERENT PREFERRED SINGLE-ENTITY INHALED GLUCOCORTICOID IN THE PAST 6 MONTHS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4541	AGES 18 YEARS AND OLDER REQUIRE EITHER A HISTORY OF CRANIAL IRRADIATION IN THE PAST 2 YEARS OR A DIAGNOSIS OF A FDA APPROVED INDICATION IN THE PAST 2 YEARS FOR APPROVAL OF A GROWTH HORMONE. (SMART PA)
75-PRIOR AUTH REQUIRED	4542	A HISTORY OF 28 DAYS OF THERAPY WITH A PREFERRED GROWTH HORMONE AGENT IN THE PAST 6 MONTHS OR 84 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4543	A HISTORY OF 1 CLAIM WITH A PREFERRED HEPATITIS C TREATMENT IN THE PAST 6 MONTHS OR A HISTORY OF 1 CLAIM WITH THE SAME AGENT AS THE INCOMING CLAIM IN THE PAST 12 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4544	A HISTORY OF 1 CLAIM WITH 2 DIFFERENT PREFERRED ORAL ANTIFUNGALS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL OF A NON-PREFFERED AGENT. GRISEOFULVIN TABLETS WILL APPROVE FOR AGES 12 - 17 YEARS AND LAMISIL GRANULES WILL APPROVE FOR AGES 4-12 YEARS WITHOUT PRIOR AUTHORIZATION. (SMART PA)
75-PRIOR AUTH REQUIRED	4545	1 CLAIM WITH A DIFFERENT PREFERRED ORAL FLUOROQUINOLONE IN THE PAST 30 DAYS IS REQUIRED FOR APPROVAL. REFER TO THE PDL FOR A LIST OF PREFERRED ORAL FLUOROQUINOLONES. (SMART PA)
75-PRIOR AUTH REQUIRED	4546	A DIAGNOSIS ON FILE FOR OSTEOPOROSIS/OSTEOPENIA IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4547	A HISTORY OF 1 CLAIM WITH 2 PREFERRED OSTEOPOROSIS AGENTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4548	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED PANCREATIC ENZYMES IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4549	A DIAGNOSIS ON FILE IN THE PAST 2 YEARS FOR AN APPROVED INDICATION IS REQUIRED FOR APPROVAL OF A NONPREFERRED PLATELET AGGREGATION INHIBITOR. (SMART PA)
75-PRIOR AUTH REQUIRED	4550	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED PLATELET AGGREGATION INHIBITORS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4551	XARTEMIS XR REQUIRES A CLINICAL REVIEW. (SMART PA)
75-PRIOR AUTH REQUIRED	4552	TRIAZOLAM IS LIMITED TO 10 CUMULATIVE UNITS IN THE PAST 25 DAYS. QUANTITY ON CLAIM PLUS PRESCRIPTION HISTORY EXCEEDS THIS AMOUNT. (SMART PA)
75-PRIOR AUTH REQUIRED	4553	ZOLPIMIST IS LIMITED TO 1 CANISTER PER 25 DAYS FOR MEN. QUANTITY ON CLAIM PLUS PRESCRIPTION HISTORY EXCEEDS THIS AMOUNT. (SMART PA)
75-PRIOR AUTH REQUIRED	4554	REVATIO SUSPENSION IS NOT APPROVED FOR 12 YEARS OF AGE AND OLDER. (SMART PA)
75-PRIOR AUTH REQUIRED	4555	A DIAGNOSIS OF PULMONARY HYPERTENSION, PATENT DUCTUS ARTERIOSUS, PERSISTENT FETAL CIRCULATION, OR HISTORY OF A HEART TRANSPLANT IN THE PAST 2 YEARS OR 90 DAYS STABLE THERAPY IS REQUIRED FOR APPROVAL OF REVATIO SUSPENSION FOR AGES < 12 YEARS. NO DIAGNOSIS OR STABLE THERAPY FOUND. (SMART PA)
75-PRIOR AUTH REQUIRED	4556	A DIAGNOSIS OF PULMONARY HYPERTENSION IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF ALL PAH AGENTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4557	30 DAYS OF THERAPY WITH 1 DIFFERENT PREFERRED PAH AGENT IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4558	SEDATIVE HYPNOTICS ARE LIMITED TO 31 CUMULATIVE TOTAL UNITS IN 25 DAYS. QUANTITY ON THE INCOMING CLAIM PLUS PRESCRIPTION HISTORY EXCEEDS THIS AMOUNT. (SMART PA)
75-PRIOR AUTH REQUIRED	4559	A HISTORY OF AT LEAST 1 CLAIM FOR 2 DIFFERENT PREFERRED SEDATIVE HYPNOTIC AGENTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4560	A DIAGNOSIS OF MULTIPLE SCLEROSIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. AMPYRA AND MAVENCLAD REQUIRE A MANUAL PA FOR APPROVAL. OTHER NON-PREFERRED MS AGENTS ALSO REQUIRE 1 CLAIM WITH 2 DIFFERENT PREFERRED MS AGENTS IN THE PAST 6 MONTHS OR 3 CLAIMS WITH THE SAME AGENT FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4561	1 CLAIM WITH 2 DIFFERENT PREFERRED MS AGENTS IN PAST 6 MONTHS OR A HISTORY OF 3 CLAIMS WITH THE SAME AGENT AS ON THE IMCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4562	TRIAZOLAM IS LIMITED TO A CUMMULATIVE DAYS SUPPLY OF </= 60 UNITS PER 365 DAYS. QUANTITY ON CLAIM PLUS PRESCRIPTION HISTORY EXCEEDS THIS AMOUNT. (SMART PA)
75-PRIOR AUTH REQUIRED	4563	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED ANTIHYPERURICEMICS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4564	A NON-PREFERRED LONG-ACTING NARCOTIC IS NOT ALLOWED WHILE ON A BUPRENORPHINE PRODUCT. REFER TO THE PDL FOR A LIST OF PREFERRED LONG ACTING NARCOTICS. (SMART PA)
75-PRIOR AUTH REQUIRED	4565	XOPENEX IS INDICATED FOR AGE >/= 6 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4566	A HISTORY OF 1 CLAIM FOR ALBUTEROL INHALATION SOLUTION IN THE PAST 30 DAYS IS REQUIRED FOR APPROVAL OF LEVALBUTEROL INHALATION SOLUTION. (SMART PA)
75-PRIOR AUTH REQUIRED	4567	BROVANA AND PERFOROMIST ARE INDICATED FOR AGE >/= 18 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4568	A HISTORY OF 1 CLAIM WITH A DIFFERENT PREFERRED BETA AGONIST SOLUTION IN THE PAST 6 MONTHS OR 3 CLAIMS WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4569	ZYFLO AND ZYFLO CR ARE INDICATED FOR AGE >/= 12 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4570	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED LEUKOTRIENE MODIFIERS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4571	REPATHA AND PRALUENT REQUIRE A MANUAL PA FOR APPROVAL. (SMARTPA)
75-PRIOR AUTH REQUIRED	4572	SEREVENT IS INDICATED FOR AGE >/= 4 YEARS. MUST SUBMIT AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4573	XADAGO IS USED IN COMBINATION WITH LEVODOPA/CARBIDOPA FOR TREATMENT OF PARKINSONS DISEASE. APPROVAL OF XADAGO REQUIRES ONE CLAIM WITH LEVODOPA/CARBIDOPA IN THE PAST 30 DAYS. PHARMACY HISTORY INDICATES NO PAID CLAIM FOR LEVODOPA/CARBIDOPA IN THE PAST 30 DAYS. (SMARTPA)
75-PRIOR AUTH REQUIRED	4574	XADAGO REQUIRES A HISTORY OF THERAPY WITH A PREFERRED SELEGILINE PRODUCT IN THE PAST 45 DAYS FOR APPROVAL. PHARMACY HISTORY INDICATES NO HISTORY OF THERAPY WITH A PREFERRED SELEGILINE PRODUCT IN THE PAST 45 DAYS. (SMARTPA)
75-PRIOR AUTH REQUIRED	4575	A HISTORY OF 1 CLAIM WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL OF A NONPREFERRED ANTIRETROVIRAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4576	COMPOUNDS NOT ALLOWED - ALL LINE ITEMS FOR A COMPOUND CLAIM MUST HAVE A VALID PRIOR AUTHORIZATION ('MATCHED' OR 'COVERED' STATUS) ON THE PA ASSOCIATED WITH THE LINE ITEM.
75-PRIOR AUTH REQUIRED	4579	A HISTORY OF 1 CLAIM WITH A PREFERRED ALBUTEROL INHALER IN THE PAST 30 DAYS IS REQUIRED FOR APPROVAL OF XOPENENX HFA INHALER. MUST ALSO MEET MINIMUM AGE REQUIREMENT OF >/= 4 YEARS OF AGE. (SMART PA)
75-PRIOR AUTH REQUIRED	4580	CLAIM IS FOR A NON- PREFERRED ALBUTEROL INHALER. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED SHORT ACTING BETA AGONIST (SABA) INHALERS. (SMART PA)
75-PRIOR AUTH REQUIRED	4581	CLAIM IS FOR NON-PREFERRED BRAND XENAZINE. PLEASE DISPENSE PREFERRED GENERIC TETRABENAZINE. (SMART PA)
75-PRIOR AUTH REQUIRED	4582	A TRIAL OF AT LEAST 1 CLAIM FOR 2 DIFFERENT PREFERRED TOPICAL ANTIFUNGALS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4583	A DIAGNOSIS OF A SEIZURE DISORDER IN THE PAST 2 YEARS AND A HISTORY OF 90 DAYS STABLE THERAPY WITH GENERIC TOPIRAMATE ER IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4584	A HISTORY OF 1 CLAIM WITH A PREFERRED ATOPIC DERMATITIS AGENT IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. PLEASE REFER TO THE PDL FOR A LIST OF PREEFERRED AGENTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4585	30 DAYS OF THERAPY WITH TOPIRAMATE IR IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL OF NONPREFERRED GENERIC TOPIRAMATE ER. NO THERAPY WITH TOPIRAMATE IR FOUND IN CLAIMS HISTORY. (SMART PA)
75-PRIOR AUTH REQUIRED	4586	EUCRISA IS INDICATED FOR AGE >/= 2 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. ALSO REQUIRES A HISTORY OF 1 CLAIM WITH A TOPICAL STEROID OR ELIDEL IN THE PAST YEAR FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4588	A DIAGNOSIS OF PLAQUE PSORIASIS, PSORIATIC ARTHRITIS OR ANKYLOSING SPONDYLITIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. NO DIAGNOSIS FOUND. ALSO REQUIRES A HISTORY OF 90 DAYS THERAPY WITH HUMIRA IN THE PAST YEAR FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4589	THE NDC SUBMITTED ON THE CLAIM IS NOT A COVERED TABLET SPLITTING DEVICE. (SMART PA)
75-PRIOR AUTH REQUIRED	4590	A HISTORY OF 90 DAYS THERAPY WITH HUMIRA IN THE PAST YEAR IS REQUIRED FOR APPROVAL. NO 90 DAYS THERAPY WITH HUMIRA FOUND IN CLAIMS HISTORY. (SMART PA)
75-PRIOR AUTH REQUIRED	4591	A TRIAL WITH A STATIN OR STATIN COMBO IN THE PAST YEAR IS REQUIRED FOR APPROVAL OF GENERIC FENOFIBRATE. DISPENSE PREFERRED ANTARA. (SMART PA)
75-PRIOR AUTH REQUIRED	4592	CLAIMS FOR NONPREFERRED PROTON PUMP INHIBITORS WILL NOT BE APPROVED. PLEASE REFER TO CURRENT PDL FOR A LIST OF PREFERRED PROTON PUMP INHIBITORS. (SMART PA)
75-PRIOR AUTH REQUIRED	4598	GIAZO IS INDICATED FOR USE IN MALES ONLY. (SMART PA)
75-PRIOR AUTH REQUIRED	4599	USE HYDROXYZINE PAMOATE, THIS IS THE PREFERRED DRUG. HYDROXYZINE TABLETS ARE NON PREFERRED.
75-PRIOR AUTH REQUIRED	4603	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4606	NO DIAGNOSIS FOUND IN MEDICAL HISTORY IN THE PAST 2 YEARS. RESUBMIT CLAIM WITH DIAGNOSIS CODE DOCUMENTED ON PRESCRIPTION. (SMARTPA)
75-PRIOR AUTH REQUIRED	4607	PATIENT IS MALE AND BUPRENORPHINE APPROVED ONLY FOR PREGNANT FEMALES. (SMART PA)
75-PRIOR AUTH REQUIRED	4608	PATIENT IS FEMALE AND HAS NO HISTORY OF PREGNANCY IN THE PAST 280 DAYS. BUPREPNORPHINE TABLETS ARE APPROVED ONLY DURING PREGNANCY FOR FEMALES. (SMART PA)
75-PRIOR AUTH REQUIRED	4609	PATIENT IS FEMALE WITH A HISTORY OF A DELIVERY OR TERMINATION OF PREGNANCY IN PAST 280 DAYS. BUPRENORHINE APPROVED ONLY FOR PREGNANT FEMALES. (SMART PA)
75-PRIOR AUTH REQUIRED	4611	PRESCRIPTIONS FOR 2 MG STENGTH BUPRENORPHINE PRODUCTS HAVE A QUANTITY LIMIT OF 93 UNITS OR 3 UNITS/DAY. QUANTITY ON CLAIM EXCEEDS THIS AMOUNT. (SMART PA)
75-PRIOR AUTH REQUIRED	4612	A DAILY DOSE UP TO 24 MG/DAY IS ALLOWED DURING THE 1ST 60 DAYS OF INDUCTION THERAPY WITH A BUPRENORPHINE PRODUCT. ALL 4 MG PRODUCTS ARE LIMITED TO 1/DAY. BUNAVAIL IS NOT INDICATED FOR INDUCTION THERAPY. (SMART PA)
75-PRIOR AUTH REQUIRED	4613	PHARMACY HISTORY INDICATES PATIENT IS CURRENTLY ON OPIOID THERAPY. CONCOMITANT USE OF A LIQUID OR INJECTABLE BENZODIAZEPINE & AN OPIOID REQUIRES A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4614	A DAILY DOSE UP TO 16 MG/DAY IS ALLOWED DURING MAINTENANCE THERAPY WITH A BUPRENORPHINE PRODUCT. SUBOXONE 4 MG & 12 MG AND BUNAVAIL 2.1 MG & 6.3 MG ARE LIMITED TO 1/DAY. (SMARTPA)
75-PRIOR AUTH REQUIRED	4616	TO ALLOW FOR THE SHORT-TERM TREATMENT OF ANXIETY, A MAXIMUM OF 4 UNITS OF A BENZODIAZEPINE IN THE PAST 60 DAYS IS ALLOWED WHEN USED IN COMBINATION WITH AN OPIOID. PHARMACY HISTORY INDICATES > 4 UNITS OF A BENZODIAZEPINE IN THE PAST 60 DAYS WHICH REQUIRES A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4619	DOM WILL ONLY PAY 1 DISP FEE/MONTH FOR THE SAME BENE/SAME DRUG FOR BENEFICIARIES IN PLAN 200 OR 901
75-PRIOR AUTH REQUIRED	4620	INCOMING CLAIM IS FOR A NON-PREFERRED ANXIOLYTIC BENZODIAZEPINE THAT REQUIRES A MANUAL PA FOR APPROVAL. REFER TO THE PDL FOR A LIST OF PREFERRED ANXIOLYTIC BENZODIAZEPINES. (SMART PA)
75-PRIOR AUTH REQUIRED	4621	A DIAGNOSIS OF ADD/ADHD OR BINGE EATING DISORDER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF PREFERRED VYVANSE. NO DIAGNOSIS OF ADD/ADHD OR BINGE EATING DISORDER FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4622	30 DAYS THERAPY WITH 2 DIFFERENT PREFERRED LONG ACTING NARCOTIC AGENTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY IS REQUIRED FOR APPROVAL OF METHADONE AND OPANA ER. (SMART PA)
75-PRIOR AUTH REQUIRED	4623	METHADONE AND OPANA ER ARE LIMITED TO 62 TABLETS PER 25 DAYS. QUANTITY ON THE CLAIM EXCEEDS THIS AMOUNT. (SMART PA)
75-PRIOR AUTH REQUIRED	4624	PATIENT IS CURRENTLY ON AN OPIOID RX. CONCOMITANT USE OF A BENZO + OPIOID IS CONTRAINICATED AND REQUIRES A PA. FOR SHORT-TERM TREATMENT OF ANXIETY, A BENZO RX FOR UP TO 2 UNITS USED IN COMBINATION WITH AN OPIOID CAN BE FILLED IF OVERRIDDEN BY DISPENSING PHARMACIST. DUR SERVICE CODES: M0, 1G & AT. (SMART PA)
75-PRIOR AUTH REQUIRED	4632	GENERIC VENLAFAXINE ER TABLETS ARE NON-PREFERRED. GENERIC VENLAFAXINE ER CAPSULES ARE PREFERRED AND DO NOT REQUIRE PRIOR AUTHORIZATION FOR AGES 18 YEARS AND OLDER. (SMART PA)
75-PRIOR AUTH REQUIRED	4633	A HISTORY OF 1 CLAIM WITH PREFERRED VOLTAREN GEL IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. NO RX FOR VOLTAREN GEL FOUND IN PHARMACY HISTORY. (SMART PA)
75-PRIOR AUTH REQUIRED	4634	A DIAGNOSIS OF DIABETES INSIPIDUS OR SIADH ON FILE IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF DEMECLOCYCLINE. (SMART PA)
75-PRIOR AUTH REQUIRED	4635	A HISTORY OF 1 CLAIM FOR 2 DIFFERENT PREFERRED TETRACYCLINE PRODUCTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL OF A NONPREFERRED TETRACYCLINE. (SMART PA)
75-PRIOR AUTH REQUIRED	4636	A HISTORY OF 1 CLAIM WITH 2 DIFFERENT PREFERRED LOW POTENCY TOPICAL STEROIDS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4637	A HISTORY OF 1 CLAIM WITH 2 DIFFERENT PREFERRED MEDIUM POTENCY TOPICAL STEROIDS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4638	A HISTORY OF 1 CLAIM WITH 2 DIFFERENT PREFERRED HIGH POTENCY TOPICAL STEROIDS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4639	A HISTORY OF 1 CLAIM WITH 2 DIFFERENT PREFERRED VERY HIGH POTENCY TOPICAL STEROIDS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4640	CLAIM IS FOR NON-PREFERRED IRENKA OR DULOXETINE DR 40 MG. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED ANTIDEPRESSANTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4641	A HISTORY OF 30 DAYS THERAPY WITH A XANTHINE OXIDASE INHIBITOR IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL OF ZURAMPIC. PHARMACY CLAIMS INDICATE NO PREVIOUS THERAPY WITH A XANTHINE OXIDASE INHIBITOR. (SMART PA)
75-PRIOR AUTH REQUIRED	4642	ZURAMPIC IS USED IN COMBINATION WITH A XANTHINE OXIDASE INHIBITOR. APPROVAL OF ZURAMPIC REQUIRES 30 DAYS OF THERAPY WITH A XANTHINE OXIDASE INHIBITOR IN THE PAST 30 DAYS. PHARMACY HISTORY INDICATES NO PAID CLAIM FOR A XANTHINE OXIDASE INHIBITOR IN THE PAST 30 DAYS. (SMARTPA)
75-PRIOR AUTH REQUIRED	4643	BRAND AND GENERIC AIRDUO AND ARMONAIR INHALERS REQUIRE A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4644	THE QUANTITY ON THE CLAIM PLUS PRESCRIPTION HISTORY IN THE PAST 25 DAYS EXCEEDS THE QUANTITY LIMIT FOR THIS DRUG. (SMART PA)
75-PRIOR AUTH REQUIRED	4645	ELIDEL AND PROTOPIC 0.03% ARE INDICATED FOR AGE >/= 2 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA FOR APPROVAL OF NONPREFERRED PROTOPIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4646	PROTOPIC 0.10% IS INDICATED FOR AGE >/= 6 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA FOR APPROVAL OF NONPREFERRED PROTOPIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4647	30 DAYS OF THERAPY WITH 1 DIFFERENT PREFERRED BETA BLOCKER IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH BYSTOLIC IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4648	30 DAYS OF THERAPY WITH TWO DIFFERENT PREFERRED COMBINATION INHALED GLUCOCORTICOIDS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY IN THE PAST 105 DAYS WITH THE SAME AGENT BEING REQUESTED IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4649	30 DAYS THERAPY WITH 1 DIFFERENT PREFERRED SINGLE-ENTITY INHALED GLUCOCORTICOID IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY IN THE PAST 105 DAYS WITH THE SAME AGENT BEING REQUESTED IS REQUIRED FOR APPROVAL (SMARTPA).
75-PRIOR AUTH REQUIRED	4650	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED CALCIUM CHANNEL BLOCKERS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS ON THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4651	A DIAGNOSIS OF HYPERTENSION IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4652	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED ACE INHIBITORS OR ARB PRODUCTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4653	A DIAGNOSIS ON FILE IN THE PAST 2 YEARS FOR APPROPRIATE USE OF A SKELETAL MUSCLE RELAXANT IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4654	A HISTORY OF THERAPY WITH PREFERRED BRAND SUBOXONE FILM IN THE PAST 6 MONTHS OR PREVIOUS THERAPY WITH BUNAVAIL IN THE PAST 3 MONTHS IS REQUIRED FOR APPROVAL OF BUNAVAIL. (SMART PA)
75-PRIOR AUTH REQUIRED	4655	A HISTORY OF AT LEAST 1 CLAIM WITH 2 DIFFERENT PREFERRED SKELETAL MUSCLE RELAXANTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4657	A DIAGNOSIS OF AN ACUTE MUSCULOSKELETAL CONDITION IN THE PAST 3 MONTHS IS REQUIRED FOR APPROVAL OF CARISOPRODOL. (SMART PA)
75-PRIOR AUTH REQUIRED	4658	CLAIMS HISTORY MUST INDICATE NO PRESCRIPTIONS FILLED FOR MEPROBAMATE IN THE PAST 90 DAYS FOR APPROVAL OF CARISOPRODOL. (SMART PA)
75-PRIOR AUTH REQUIRED	4659	A HISTORY OF AT LEAST 1 CLAIM WITH CYCLOBENZAPRINE IN THE PAST 21 DAYS IS REQUIRED FOR APPROVAL OF CARISOPRODOL. (SMART PA)
75-PRIOR AUTH REQUIRED	4660	WITH A DIAGNOSIS OF NARCOLEPSY, 30 DAYS OF THERAPY WITH PREFERRED MODAFINIL OR ARMODAFINIL IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL OF A NON-PREFERRED STIMULANT. NO RX FOR MODAFINIL OR ARMODAFINIL FOUND IN PHARMACY CLAIMS. (SMART PA)
75-PRIOR AUTH REQUIRED	4661	CARISOPRODOL HAS A QUANTITY LIMIT OF 84 TABLETS EVERY 6 MONTHS. THE QUANTITY ON THE CLAIM PLUS PRESCRIPTION HISTORY EXCEEDS THE QUANTITY LIMIT FOR CARISOPRODOL. (SMART PA)
75-PRIOR AUTH REQUIRED	4662	A DIAGNOSIS OF PULMONARY HYPERTENSION, PATENT DUCTUS ARTERIOSUS OR PERSISTENT FETAL CIRCULATION IN THE PAST YEAR OR 90 DAYS STABLE THERAPY IS REQUIRED FOR APPROVAL OF REVATIO TABLETS FOR AGES < 1 YEAR. (SMART PA)
75-PRIOR AUTH REQUIRED	4663	A DIAGNOSIS OF HYPERTENSION IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF COREG. (SMART PA)
75-PRIOR AUTH REQUIRED	4664	AT LEAST 30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED ANGIOTENSIN RECEPTOR BLOCKER/DIURETIC COMBINATION PRODUCTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4665	AT LEAST 30 DAYS OF THERAPY WITH 1 PREFERRED ANGIOTENSIN RECEPTOR BLOCKER/CALCIUM CHANNEL BLOCKER COMBINATION PRODUCT IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4666	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED ANGIOTENSIN RECEPTOR BLOCKER PRODUCTS IN THE PAST 6 MONTHS OR 90 DAYS THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4667	NUTRESTORE REQUIRES A MANUAL PA. PHARMACY CLAIMS MUST INDICATE THE PATIENT IS ALSO RECEIVING ZORBTIVE FOR APPROVAL OF NUTRESTORE BY MANUAL REVIEW. (SMART PA)
75-PRIOR AUTH REQUIRED	4668	A HISTORY OF 1 CLAIM WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL OF LOTRONEX, GATTEX OR ZORBTIVE. ALL NEW PATIENTS REQUIRE MANUAL REVIEW. (SMART PA)
75-PRIOR AUTH REQUIRED	4669	REQUESTED GI AGENT IS INDICATED FOR AGE >/= 18 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4670	A DIAGNOSIS OF IBS-D IN THE PAST YEAR IS REQUIRED FOR APPROVAL OF VIBERZI. NO DIAGNOSIS FOUND. (SMART PA)
75-PRIOR AUTH REQUIRED	4671	A HISTORY OF 30 DAYS OF THERAPY WITH 3 DIFFERENT PREFERRED IBS-D AGENTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4672	A DIAGNOSIS OF OPIOID INDUCED CONSTIPATION IN THE PAST YEAR IS REQUIRED FOR APPROVAL OF AMITIZA 24 MCG, MOVANTIK, RELISTOR OR SYMPROIC. NO DIAGNOSIS FOUND. (SMART PA)
75-PRIOR AUTH REQUIRED	4673	A HISTORY OF 1 CLAIM WITH AN OPIOID IN THE PAST 30 DAYS IS REQUIRED FOR APPROVAL OF AMITIZA 24 MCG, MOVANTIK, RELISTOR OR SYMPROIC FOR TREATMENT OF OPIOID INDUCED CONSTIPATION. NO OPIOID RX FOUND IN THE PAST 30 DAYS IN PHARMACY CLAIMS HISTORY. (SMART PA)
75-PRIOR AUTH REQUIRED	4674	PATIENT HAS A HISTORY OF A GI OR BOWEL OBSTRUCTION IN THE PAST YEAR. USE OF AMITIZA, LINZESS, MOVANTIK, RELISTOR, SYMPROIC OR TRULANCE IS CONTRAINDICATED WITH THIS DIAGNOSIS. (SMART PA)
75-PRIOR AUTH REQUIRED	4675	A DIAGNOSIS OF CHRONIC PAIN IN THE PAST YEAR IS REQUIRED FOR APPROVAL OF AMITIZA 24 MCG, MOVANTIK, RELISTOR TABLETS OR SYMPROIC. NO DIAGNOSIS FOUND. (SMART PA)
75-PRIOR AUTH REQUIRED	4676	A DIAGNOSIS OF ACTIVE CANCER IN THE PAST YEAR IS REQUIRED FOR APPROVAL OF RELISTOR INJECTABLE. NO DIAGNOSIS FOUND IN MEDICAL HISTORY. (SMART PA)
75-PRIOR AUTH REQUIRED	4678	THE EXISTING PA IS OVERRIDDEN BY THE AUTOMATED PA FROM SMART PA.
75-PRIOR AUTH REQUIRED	4679	A DIAGNOSIS OF PALLIATIVE CARE IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL OF RELISTOR INJECTABLE. NO HISTORY OF PALLIATIVE CARE FOUND IN MEDICAL HISTORY. (SMART PA)
75-PRIOR AUTH REQUIRED	4680	30 DAYS OF THERAPY WITH AMITIZA 24 MCG IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4681	30 DAYS THERAPY WITH 2 PREFERRED BETA-BLOCKERS AND/OR COMBO AGENTS IN THE PAST 6 MO. OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. CLAIMS FOR COREG CR REQUIRE 30 DAYS OF THERAPY WITH CARVEDILOL THERAPY AND A PREFERRED BETA-BLOCKER THERAPY IN THE PAST 6 MONTHS. (SMART PA)
75-PRIOR AUTH REQUIRED	4682	30 DAYS THERAPY WITH 2 PREFERRED ACE INHIBITORS/DIURETIC COMBINATION PRODUCTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4683	30 DAYS THERAPY WITH 2 PREFERRED ACE INHIBITORS/CALCIUM CHANNEL BLOCKER COMBINATION PRODUCTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4684	30 DAYS THERAPY WITH 2 PREFERRED ACE INHIBITOR PRODUCTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. EPANED REQUIRES NO PA FOR AGES </=6 YEARS. (SMART PA)
75-PRIOR AUTH REQUIRED	4685	PHARMACY HISTORY INDICATES THE INCOMING SEDATIVE HYPNOTIC BENZODIAZEPINE RX OVERLAPS THERAPY WITH A PREVIOUSLY FILLED OPIOID RX. CONCOMITANT USE OF A SEDATIVE HYPNOTIC BENZODIAZEPINE WITH AN OPIOID REQUIRES A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4686	A DIAGNOSIS FOR HEART, KIDNEY OR LIVER TRANSPLANT , OR OTHER APPROVABLE DIAGNOSIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF CELLCEPT. (SMART PA)
75-PRIOR AUTH REQUIRED	4687	A DIAGNOSIS FOR KIDNEY TRANSPLANT OR PSORIASIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF MYFORTIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4688	A DIAGNOSIS OF HEART, KIDNEY OR LIVER TRANSPLANT, PSORIASIS, RA, OR APPROVABLE INDICATION IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF CYCLOSPORINE MODIFIED. (SMART PA)
75-PRIOR AUTH REQUIRED	4689	A TRIAL OF 7 DAYS WITH 2 PREFERRED PENICILLIN, 2ND OR 3RD GENERATION CEPHALOSPORINS, OR MACROLIDES IN THE PAST 3 MONTHS IS REQUIRED FOR APPROVAL.. (SMART PA)
75-PRIOR AUTH REQUIRED	4690	A HISTORY OF CIPROFLOXACIN SUSPENSION IN THE PAST 3 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4691	A HISTORY OF DOXYCYCLINE IN THE PAST 3 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4692	30 DAYS OF THERAPY WITH PREFERRED ENOXAPARIN IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4693	MALE PATIENTS WITH A HISTORY OF A LMWH RX IN THE PAST 3 MONTHS REQUIRE A DIAGNOSIS OF CANCER IN THE PAST 2 YRS FOR APPROVAL . (SMART PA)
75-PRIOR AUTH REQUIRED	4694	CARISOPRODOL WITH CODEINE REQUIRES A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4695	CLAIMS FOR > 17 DAYS THERAPY WITH NO HISTORY OF A LMWH RX IN THE PAST 3 MONTHS REQUIRE A DIAGNOSIS OF CANCER IN THE PAST 2 YRS, OR A HIP OR KNEE REPLACEMENT IN THE PAST 60 DAYS FOR APPROVAL. CLAIMS WILL APPROVE FOR FEMALES 8-50 YEARS OLD OF CHILDBEARING AGE. (SMART PA)
75-PRIOR AUTH REQUIRED	4696	A HISTORY OF 1 CLAIM WITH 2 DIFFERENT PREFERRED TRIPTANS IN THE PAST 90 DAYS IS REQUIRED FOR APPROVAL OF NON-PREFFERED ZECUITY. (SMART PA)
75-PRIOR AUTH REQUIRED	4697	A DIAGNOSIS OF ANGINA IN THE PAST TWO YEARS IS REQUIRED FOR APPROVAL OF RANEXA ER. (SMART PA)
75-PRIOR AUTH REQUIRED	4698	A TRIAL OF ONE CLAIM FOR A CALCIUM CHANNEL BLOCKER, BETA-BLOCKER, NITRATE OR COMBINATION AGENT IN THE PAST 30 DAYS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT IS REQUIRED FOR APPROVAL OF RANEXA ER. (SMART PA)
75-PRIOR AUTH REQUIRED	4699	ZUBSOLV IS NON-PREFERRED. BRAND SUBOXONE FILM IS THE PREFERRED BUPRENORPHINE AGENT. (SMART PA)
75-PRIOR AUTH REQUIRED	4700	PRODUCT IS EITHER NOT COVERED OR AGE IS LESS THAN FDA APPROVED MIN AGE. IF AGE < 21 PRESCRIBER MAY SUBMIT PA REQUEST = 'MEDICAL NECESSITY PA FORM FOR EPSDT ELIGIBLE BENE.' (IF MEDICAL SUPPLY SUBMIT DME CLAIM)
75-PRIOR AUTH REQUIRED	4701	A DIAGNOSIS ON FILE FOR COPD IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF ARCAPTA. (SMART PA)
75-PRIOR AUTH REQUIRED	4702	ARCAPTA IS INDICATED FOR AGE >/= 18 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4703	PATIENTS WITH A DIAGNOSIS OF DIABETES IN THE PAST 2 YRS REQUIRE A TRIAL WITH A PREFERRED ORAL ANTIDIABETIC AGENT IN THE PAST 180 DAYS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4704	UP TO A 3-DAY SUPPLY OF A SHORT ACTING OPIOID IS ALLOWED FOR TREATMENT OF ACUTE PAIN FOR PATIENTS CURRENTLY ON A BENZODIAZEPINE. PHARMACY HISTORY INDICATES PATIENT IS CURRENTLY ON A BENZODIAZEPINE. INCOMING SA OPIOID IS FOR > 3 DAY SUPPLY WHICH REQUIRES A MANUAL PA FOR APPROVAL.
75-PRIOR AUTH REQUIRED	4705	ONE SHORT ACTING OPIOID PRESCRIPTION FOR UP TO A 3-DAY SUPPLY EVERY 60 DAYS IS ALLOWED FOR TREATMENT OF ACUTE PAIN IN OPIOID NAÏVE PATIENTS WHO ARE CURRENTLY ON A BENZODIAZEPINE. PHARMACY CLAIMS INDICATE A PREVIOUS OPIOID RX WAS FILLED IN THE PAST 60 DAYS. REQUESTED SA OPIOID RX EXCEEDS THIS LIMIT. (SMART PA)
75-PRIOR AUTH REQUIRED	4706	AGE IS LESS THAN THE RECOMMENDED MINIMUM AGE AND ALL NONPREFERRED AGENTS MUST ALSO MEET PDL CRITERIA. PREFERRED AGENTS REQUIRE AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4707	A DIAGNOSIS OF ADD/ADHD IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF THE REQUESTED PREFERRED STIMULANT. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4708	30 DAYS OF THERAPY WITH 2 PREFERRED ATYPICAL ANTIPSYCHOTICS IN THE PAST YEAR OR 30 DAYS THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4709	A HISTORY OF 1 CLAIM WITH A 30 DAY SUPPLY OF ADDERALL XR OR A HISTORY OF 30 DAYS THERAPY WITH VYVANSE IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL OF BRAND ADDERALL XR. (SMART PA)
75-PRIOR AUTH REQUIRED	4710	A HISTORY OF 30 DAYS THERAPY WITH SHORT-ACTING GUANFACINE IN THE PAST 6 MONTHS OR 1 CLAIM WITH PREFERRED GUANFACINE ER IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL OF GUANFACINE ER. BRAND INTUNIV IS NON-PREFERRED. (SMART PA)
75-PRIOR AUTH REQUIRED	4711	COSENTYX IS INDICATED FOR AGE >/= 18 YEARS. MUST SUBMIT AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. ALSO REQUIRES A DIAGNOSIS OF PLAQUE PSORIASIS, PSORIATIC ARTHRITIS OR ANKYLOSING SPONDYLITIS IN THE PAST 2 YEARS AND 90 DAYS OF THERAPY WITH HUMIRA IN THE PAST YEAR. (SMART PA)
75-PRIOR AUTH REQUIRED	4712	FEMALES WITH A HISTORY OF A LMWH RX IN THE PAST 3 MONTHS WHO ARE NOT OF CHILDBEARING AGE 8 - 50 YEARS REQUIRE A DIAGNOSIS OF CANCER IN THE PAST 2 YRS FOR APPROVAL . (SMART PA)
75-PRIOR AUTH REQUIRED	4713	A DIAGNOSIS OF HYPERCALCEMIA WITH PARATHYROID CANCER OR PRIMARY HYPERPARATHYROIDISM, OR A DIAGNOSIS OF SECONDARY HYPERPARATHYROIDISM WITH STAGE 5 CHRONIC KIDNEY DISEASE IN THE PAST 2 YRS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4714	A DIAGNOSIS OF SECONDARY HYPERPARATHYROIDISM WITH STAGE 5 CHRONIC KIDNEY DISEASE REQUIRES 30 DAYS OF THERAPY WITH ZEMPLAR IN THE PAST 6 MONTHS FOR APPROVAL OF SENSIPAR. (SMART PA)
75-PRIOR AUTH REQUIRED	4715	A DIAGNOSIS OF WELL-DIFFERENTIATED/DEDIFFERENTIATED LIPOSARCOMA IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF IBRANCE. ALL OTHER DIAGNOSES REQUIRE A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4716	PHARMACY HISTORY INDICATES PATIENT IS CURRENTLY ON A BENZODIAZEPINE. CONCOMITANT USE OF A LONG ACTING OPIOID AND A BENZODIAZEPINE IS CONTRAINDICATED AND REQUIRES A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4717	NONPREFERRED NASAL TRIPTANS REQUIRE A HISTORY OF 1 CLAIM WITH 2 PREFERRED ORAL TRIPTANS AND 1 CLAIM WITH EITHER PREFERRED SUMATRIPTAN NASAL OR INJECTABLE IN THE PAST 90 DAYS FOR APPROVAL. PHARMACY CLAIMS INDICATE NO TRIAL WITH EITHER SUMATRIPTAN NASAL OR INJECTABLE. (SMART PA)
75-PRIOR AUTH REQUIRED	4718	A DIAGNOSIS OF THYROID, HEPATOCELLULAR, OR RENAL CELL CANCER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF LENVIMA. NO DIAGNOSIS OF THYROID, HEPATOCELLULAR, OR RENAL CELL CANCER FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4719	A DIAGNOSIS OF RECURRENT EPITHELIAL OVARIAN CANCER, FALLOPIAN TUBE CANCER, OR PRIMARY PERITONEAL CANCER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF LYNPARZA TABLETS. ALL OTHER DIAGNOSES REQUIRE A MANUAL PA FOR APPROVAL (SMART PA)
75-PRIOR AUTH REQUIRED	4720	RX EXCEEDS MONTHLY BRAND LIMIT OF 2. ADDITIONAL BRANDS ALLOWED FOR AGE <21. PRESCRIBER MAY SUBMIT 'MEDICAL NECESSITY PA FORM FOR EPSDT ELIGIBLE BENE.'
75-PRIOR AUTH REQUIRED	4721	A DIAGNOSIS OF RECURRENT EPITHELIAL OVARIAN CANCER, FALLOPIAN TUBE CANCER, OR PRIMARY PERITONEAL CANCER AND PHARMACY CLAIMS HISTORY WITH A PLATINUM-BASED CHEMOTHERAPY AGENT IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF LYNPARZA TABLETS. NO HISTORY WITH A PLATINUM-BASED CEHMO THERAPY AGENT FOUND. (SMART PA)
75-PRIOR AUTH REQUIRED	4722	NONPREFERRED NASAL TRIPTANS REQUIRE A HISTORY OF 1 CLAIM WITH 2 PREFERRED ORAL TRIPTANS AND 1 CLAIM WITH EITHER PREFERRED SUMATRIPTAN NASAL OR INJECTABLE IN THE PAST 90 DAYS FOR APPROVAL. PHARMACY CLAIMS INDICATE NO TRIAL WITH 2 PREFERRED ORAL TRIPTANS. (SMART PA)
75-PRIOR AUTH REQUIRED	4723	XARELTO 10 MG AND PRADAXA 110 MG ARE LIMITED TO 70 DAYS OF THERAPY PER YEAR. THE DURATION OF THERAPY ON THE INCOMING CLAIM PLUS PREVIOUS THERAPY IN CLAIMS HISTORY IS > 70 DAYS. (SMART PA)
75-PRIOR AUTH REQUIRED	4724	HISTORY OF 30 DAYS THERAPY WITH 2 DIFFERENT PREFFERED ANTICOAGULANTS IN THE PAST 6 MONTHS OR 1 CLAIM WITH THE SAME AGENT AS ON THE INCOMING CLAIM IN THE PAST 90 DAYS IS REQUIRED FOR APPROVAL. (SMARTPA)
75-PRIOR AUTH REQUIRED	4725	THE DURATION OF THERAPY WITH XARELTO 10 MG & ELIQUIS ARE LIMITED TO </= 12 DAYS FOR PATIENTS WITH HISTORY OF A KNEE REPLACEMENT IN THE PAST 30 DAYS. (SMART PA)
75-PRIOR AUTH REQUIRED	4726	A HISTORY IN THE PAST 30 DAYS OF HIP OR KNEE REPLACEMENT IS REQUIRED FOR APPROVAL OF XARELTO 10 MG. PRADAXA 110 MG REQUIRES A HISTORY OF HIP REPLACEMENT SURGERY IN THE PAST 30 DAYS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4727	</= 35 DAYS OF THERAPY WITH XARELTO 10 MG, PRADAXA 110 MG OR ELIQUIS IS ALLOWED FOLLOWING HIP REPLACEMENT SURGERY. DAYS OF THERAPY ON THE INCOMING CLAIM PLUS THERAPY IN PRESECRIPTION HISTORY EXCEEDS 35 DAYS OF THERAPY ALLOWED.
75-PRIOR AUTH REQUIRED	4728	A DIAGNOSIS OF CIRCADIAN RHYTHM SLEEP DISORDER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF HETLIOZ. (SMART PA)
75-PRIOR AUTH REQUIRED	4729	LAMISIL GRANULES ARE NOT INDICATED FOR AGES < 4 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. NO PA REQUIRED FOR AGES 4-12 YEARS. AGES >/=12 YEARS REQUIRE A TRIAL WITH 2 DIFFERENT PREFERRED ORAL ANTIFUNGALS IN THE PAST 6 MONTHS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4730	INCOMING CLAIM IS FOR A NON-PREFERRED TYPICAL ANTISPYCHOTICS. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED TYPICAL ANTIPSYCHOTIC AGENTS. (SMARTPA)
75-PRIOR AUTH REQUIRED	4731	NONPREFERRED LONG ACTING NARCOTIC AGENTS REQUIRE 30 DAYS THERAPY WITH 2 PREFERRED IN THE PAST 6 MONTHS OR A DIAGNOSIS OF CANCER OR HISTORY WITH AN ANTINEOPLASTIC AND 90 DAYS STABLE THERAPY FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4732	A DIAGNOSIS ON FILE FOR HEART, KIDNEY OR LIVER TRANSPLANT, PSORIASIS, RA, OR OTHER APPROVABLE INDICATION IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4733	A DIAGNOSIS FOR HEART, KIDNEY OR LIVER TRANSPLANT , OR OTHER APPROVABLE DIAGNOSIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF TACROLIMUS. (SMART PA)
75-PRIOR AUTH REQUIRED	4734	EVEROLIMUS IS INDICATED FOR AGE >/= 18 YEARS. MUST SUBMIT AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. EVEROLIMUS ALSO REQUIRES A DIAGNOSIS OF A KIDNEY OR LIVER TRANSPLANT IN THE PAST 2 YEARS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4735	SIROLIMUS IS INDICATED FOR AGE >/= 13 YEARS. MUST SUBMIT AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. SIROLIMUS ALSO REQUIRES A DIAGNOSIS OF KIDNEY TRANSPLANT IN THE PAST 2 YEARS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4736	SIROLIMUS REQUIRES A DIAGNOSIS OF A KIDNEY TRANSPLANT IN THE PAST 2 YEARS FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4737	A HISTORY OF 12 MONTHS OF THERAPY WITH SIMVASTATIN 80 MG IN THE PAST 18 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4738	CLAIM IS FOR SIMVASTATIN 80 MG. PATIENT HAS A DIAGNOSIS OF MYOPATHY IN THE PAST 12 MONTHS AND USE OF SIMVASTATIN IS CONTRAINDICATED WITH A DIAGNOSIS OF MYOPATHY. (SMART PA)
75-PRIOR AUTH REQUIRED	4739	CLAIM FOR SIMVASTATIN AT DOSE > 80 MG IS GREATER THAN THE FDA RECOMMENDED DOSE. (SMART PA)
75-PRIOR AUTH REQUIRED	4740	DRUG IS NON PREFERRED, REFER TO PDL DOCUMENT FOR A PREFERRED OPTION IN THIS CLASS OR SUBMIT A 'PREFERRED DRUG LIST EXCEPTION' PRIOR AUTHORIZATION. (NO SMART PA RULE EXISTS)
75-PRIOR AUTH REQUIRED	4745	NUTRITIONALS WITH NONPREFERRED PDL INDICATORS REQUIRE PA. PRODUCTS WITH PDL INDICATORS OF U OR WHICH ARE BLANK ARE NONCOVERED (MAY ALLOW PA IF MEDICALLY NECESSARY FOR AGE < 21)
75-PRIOR AUTH REQUIRED	4746	BANZEL, ONFI, AND SYMPAZAN REQUIRE 30 DAYS OF THERAPY WITH 1 DIFFERENT PREFERRED ANTICONVUSANT INDICATED FOR TREATMENT OF LENNOX-GASTAUT IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE REQUESTED AGENT FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4747	BANZEL, ONFI & SYMPAZAN REQUIRE A DIAGNOSIS OF LENNOX-GASTAUT IN THE PAST 2 YEARS FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. ALSO REQUIRES 30 DAYS OF THERAPY WITH 1 DIFFERENT PREFERRED ANTICONVULSANT INDICATED FOR LENNOX-GASTAUT IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4748	CLAIM IS FOR A NON-PREFERRED RIBAVIRIN AGENT. USE PREFERRED RIBAVIRIN TABLETS. (SMART PA)
75-PRIOR AUTH REQUIRED	4749	A DIAGNOSIS OF ADD/ADHD OR NARCOLEPSY IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF ALL PREFERRED STIMULANTS. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4750	RX EXCEEDS MONTHLY LIMIT. ADDITIONAL PRESCRIPTIONS ALLOWED FOR BENEFICIARIES UNDER AGE 21 WITH PRIOR AUTHORIZATION.
75-PRIOR AUTH REQUIRED	4767	BANZEL IS INDICATED FOR AGE >/= 1 YEAR. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4768	HISTORY OF THERAPY WITH PREFERRED PERMETHRIN 5% CREAM IN THE PAST 90 DAYS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4769	A DIAGNOSIS OF PARKINSON'S DISEASE IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF NUPLAZID. NO DIAGNOSIS OF PARKINSON'S DISEASE IS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4774	PHARMACY HISTORY INDICATES AT LEAST 90 DAYS CONCURRENT THERAPY WITH >/= 2 ANTIPSYCHOTICS. MUST SUBMIT CLINICAL JUSTIFICATION FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4788	PATIENTS WITH A DIAGNOSIS OF CIRCADIAN RHYTHM SLEEP DISORDER MUST ALSO HAVE A DIAGNOSIS OF TOTAL BLINDNESS IN THE PAST 2 YEARS FOR APPROVAL OF HETLIOZ. (SMART PA)
75-PRIOR AUTH REQUIRED	4791	BENEFICIARY MUST HAVE A DIAGNOSIS OF HIV IN THE PAST 2 YEARS OR 1 CLAIM FOR 2 DIFFERENT PREFERRED ORAL ANTIFUNGALS IN PAST 6 MONTHS FOR APPROVAL OF AN ORAL ANTIFUNGAL WITH LEVEL IIB RECOMMENDATION OR HIGHER FOR HIV OPPORTUNISTIC INFECTIONS. (SMART PA)
75-PRIOR AUTH REQUIRED	4792	BENEFICIARY MUST HAVE A DIAGNOSIS OF HIV OR HISTORY OF A TRANSPLANT IN THE PAST 2 YEARS OR A HISTORY OF AN IMMUNOSUPPRESSANT OR ONE CLAIM FOR 2 DIFFERENT PREFERRED AGENTS IN PAST 6 MONTHS FOR APPROVAL OF ITRACONAZOLE. (SMART PA)
75-PRIOR AUTH REQUIRED	4809	CLAIM IS FOR NONPREFERRED ARIPIPRAZOLE ODT OR CLOZAPINE ODT. REFER TO PDL FOR A LIST OF PREFERRED ATYPICAL ANTIPSYCHOTICS. (SMART PA)
75-PRIOR AUTH REQUIRED	4820	INSULIN PENS/CARTRIDGES ARE NONPREFERRED FOR LTC BENES (PLAN 200). DISPENSE INSULIN VIALS. (SEE SYSTEM LIST 5800 AND 5801)
75-PRIOR AUTH REQUIRED	4821	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4822	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4824	30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED ALZHEIMER'S AGENTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4825	30 DAYS OF THERAPY WITH EITHER 2 PREFERRED ANTIDEPRESSANT-OTHERS CLASS OR 30 DAYS WITH BOTH A PREFERRED ANTIDEPRESSANT-OTHER CLASS & A SSRI IN THE PAST 6 MONTHS, OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IN REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4826	A TRIAL OF 30 DAYS WITH A PREFERRED LONG ACTING BETA AGONIST INHALER IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4827	LENVIMA IS USED IN COMBINATION WITH EVEROLIMUS FOR TREATMENT OF RENAL CELL CANCER. APPROVAL OF LENVIMA FOR RENAL CELL CARCINOMA REQUIRES ONE CLAIM WITH EVEROLIMUS IN THE PAST 30 DAYS. PHARMACY HISTORY INDICATES NO PAID CLAIM FOR EVEROLIMUS IN THE PAST 30 DAYS. (SMARTPA)
75-PRIOR AUTH REQUIRED	4829	XOPENEX HFA INHALER IS INDICATED FOR AGE >/= 4 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED	4830	RHINOCORT AQ REQUIRES 1 CLAIM WITH 2 DIFFERENT PREFERRED INTRANASAL CORTICOSTEROIDS IN THE PAST 6 MONTHS OR A DIAGNOSIS OF PREGNANCY FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4838	CLAIM IS FOR NON-PREFERRED ASMANEX TWISTHALER OR PULMICORT RESPULES. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED INHALED GLUCOCORTICOIDS. (SMART PA)
75-PRIOR AUTH REQUIRED	4840	BOTH BRAND AND GENERIC AMLODIPINE/ATORVASTATIN COMBINATIONS ARE NON-PREFERRED. DISPENSE PREFERRED INDIVIDUAL COMPONENTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4851	LYNPARZA CAPSULES REQUIRE A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4858	APPROVAL OF LENVIMA FOR TREATMENT OF RENAL CELL CARCINOMA REQUIRES COMBINATION THERAPY WITH EVEROLIMUS AND HISTORY OF ONE CLAIM WITH AN ANTI-ANGIOGENIC AGENT IN THE PAST 2 YEARS. NO RX WITH AN ANTI-ANGIOGENIC AGENT FOUND IN PHARMACY CLAIMS. (SMARTPA)
75-PRIOR AUTH REQUIRED	4874	A DIAGNOSIS OF ALZHEIMER'S DISEASE IN THE PAST 2 YEARS AND 30 DAYS CONCURRENT THERAPY WITH BOTH DONEPEZIL AND NAMENDA IN THE PAST 6 MONTHS IS REQUIREED FOR APPROVAL OF NAMZARIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4878	UROXATRAL FOR FEMALE PATIENTS REQUIRES AN APPROVABLE DIAGNOSIS ON FILE IN THE PAST 2 YEARS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4879	DOXAZOSIN FOR FEMALE PATIENTS REQUIRES AN APPROVABLE DIAGNOSIS ON FILE IN THE PAST 2 YEARS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4883	XIIDRA AND CEQUA REQUIRE A HISTORY OF 4 CLAIMS WITH PREFERRED RESTASIS DROPPERETTES IN THE PAST 6 MONTHS FOR APPROVAL. 4 CLAIMS WITH PREFERRED RESTASIS DROPPERETTES NOT FOUND IN PHARMACY HISTORY. (SMART PA)
75-PRIOR AUTH REQUIRED	4884	RESTASIS MULTIDOSE VIALS ARE NON-PREFERRED. PLEASE DISPENSE PREFERRED RESTASIS DROPPERETTES. (SMARTPA)
75-PRIOR AUTH REQUIRED	4885	FINASTERIDE FOR FEMALE PATIENTS REQUIRES A DIAGNOSIS OF HIRSUTISM ON FILE IN THE PAST 2 YEARS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4886	TAMULOSIN FOR FEMALE PATIENTS REQUIRES AN APPROVABLE DIAGNOSIS ON FILE IN THE PAST 2 YEARS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4887	TERAZOSIN FOR FEMALE PATIENTS REQUIRES AN APPROVABLE DIAGNOSIS ON FILE IN THE PAST 2 YEARS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4888	CITALOPRAM IS INDICATED FOR AGES >/= 18 YRS. MUST SUBMIT AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. PATIENTS < 18 YEARS OF AGE WITH 90 DAYS OF STABLE THERAPY IN THE PAST 105 DAYS WILL BE APPROVED. (SMARTPA)
75-PRIOR AUTH REQUIRED	4889	THE MAXIMUM RECOMMENDED DOSE OF CITALOPRAM FOR PATIENTS < 60 YEARS OF AGE IS 40 MG/DAY. DOSE ON CLAIM EXCEEDS 40 MG. (SMARTPA)
75-PRIOR AUTH REQUIRED	4890	THE MAXIMUM RECOMMENDED DOSE OF CITALOPRAM FOR PATIENTS 60 YEARS OF AGE AND OLDER IS 20 MG/DAY. DOSE ON CLAIM EXCEEDS 20 MG. (SMARTPA)
75-PRIOR AUTH REQUIRED	4904	A DIAGNOSIS OF CHRONIC IDIOPATHIC CONSTIPATION IN THE PAST YEAR IS REQUIRED FOR APPROVAL OF AMITIZA 24 MCG, LINZESS 72 MCG, LINZESS 145 MCG, MOTEGRITY, OR TRULANCE. NO DIAGNOSIS FOUND. (SMART PA)
75-PRIOR AUTH REQUIRED	4905	PATIENT HAS A HISTORY OF A GI OR BOWEL OBSTRUCTION IN THE PAST YEAR. USE OF AMITIZA 24 MCG, LINZESS 72 MCG, LINZESS 145 MCG, MOTEGRITY, OR TRULANCE IS CONTRAINDICATED WITH THIS DIAGNOSIS. (SMART PA)
75-PRIOR AUTH REQUIRED	4906	30 DAYS OF THERAPY WITH TWO PREFERRED AGENTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4914	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4915	A DIAGNOSIS OF PSEUDOBULBAR AFFECT IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4916	EDIT IGNORED
75-PRIOR AUTH REQUIRED	4920	INGREZZA REQUIRES A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4921	EPIDIOLEX REQUIRES 30 DAYS OF THERAPY WITH 1 DIFFERENT PREFERRED ANTICONVUSANT INDICATED FOR TREATMENT OF LENNOX-GASTAUT IN THE PAST 6 MONTHS OR 1 CLAIM WITH EPIDIOLEX IN THE PAST 30 DAYS FOR APPROVAL. NO RX FOUND IN PHARMACY CLAIMS. (SMART PA)
75-PRIOR AUTH REQUIRED	4922	ZOTRESS REQUIRES A DIAGNOSIS OF A KIDNEY TRANSPLANT OR A LIVER TRANSPLANT IN THE PAST 2 YEARS FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED	4924	A DIAGNOSIS OF CORONARY ARTERY DISEASE OR PERIPHERAL ARTERY DISEASE IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF XARELTO 2.5 MG. NO DIAGNOSIS FOUND ON FILE. ALSO REQUIRES A HISTORY WITH ASA AND EITHER AN ANTIPLATELET OR WARFARIN FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4925	XARELTO 2.5 MG IS USED IN COMBINATION WITH ASPIRIN. APPROVAL OF XARELTO 2.5 MG REQUIRES A HISTORY OF ASPIRIN IN THE PAST 30 DAYS. NO RX FOR ASPIRIN IN THE PAST 30 DAYS WAS FOUND IN PHARMACY CLAIMS. ALSO REQUIRES A HISTORY WITH EITHER AN ANTIPLATELET OR WARFARIN FOR APPROVAL (SMART PA)
75-PRIOR AUTH REQUIRED	4926	APPROVAL OF XARELTO 2.5 MG REQUIRES COMBINATION THERAPY WITH ASPIRIN AND 90 DAYS OF THERAPY WITH AN ANTIPLATELET AGENT IN THE PAST YEAR OR 30 DAYS OF THERAPY WITH WARFARIN IN THE PAST 30 DAYS. NO RX FOR EITHER AN ANTIPLATELET AGENT OR WARFARIN FOUND IN PHARMACY CLAIMS. (SMART PA)
75-PRIOR AUTH REQUIRED	4928	SHORT ACTING OPIOID PRESCRIPTIONS ARE LIMITED TO A MAXIMUM OF 2 7-DAY SUPPLIES IN A 30 DAY PERIOD. PHARMACY CLAIMS INDICATE PREVIOUS SHORT ACTING OPIOID PRESCRIPTIONS FILLED IN THE PAST 30 DAYS PLUS REQUESTED SA OPIOID RX EXCEED ALLOWED LIMIT. (SMART PA)
75-PRIOR AUTH REQUIRED	4929	SHORT ACTING OPIOID PRESCRIPTIONS ARE LIMITED TO A MAXIMUM OF 2 7-DAY SUPPLIES IN A 30 DAY PERIOD. REQUESTED SA OPIOID RX IS FOR > 7-DAY SUPPLY WHICH EXCEEDS ALLOWED LIMIT. (SMART PA)
75-PRIOR AUTH REQUIRED	4930	PHARMACY CLAIMS INDICATE REQUESTED OPIOID PRESCRIPTION IS THE 1ST OPIOID RX FILLED IN THE PAST 90 DAYS. NEW SHORT ACTING OPIOID PRESCRIPTIONS ARE LIMITED TO A MAXIMUM 7-DAY SUPPLY. REQUESTED SHORT ACTING OPIOID RX FOR > 7-DAY SUPPLY EXCEEDS THIS LIMIT. (SMART PA)
75-PRIOR AUTH REQUIRED	4932	REQUESTED SHORT ACTING OPIOID PRESCRIPTION IS >/= 90 MME PER DAY. OPIOID PRESCRIPTIONS FOR >/= 90 MME PER DAY REQUIRE A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4933	THE CUMULATIVE MME FOR THE REQUESTED SHORT ACTING OPIOID RX PLUS ALL OTHER ACTIVE OPIOID PRESCRIPTIONS IS >/= 90 MME PER DAY WHICH REQUIRES A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4934	THE CUMULATIVE MME FOR THE REQUESTED SHORT ACTING OPIOID RX PLUS ALL OTHER ACTIVE OPIOID PRESCRIPTIONS IS >/= 90 MME PER DAY. REFILLS FOR PATIENTS WHO HAVE NOT UTLILIZED 85% OF PREVIOUSLY FILLED OPIOIDS WILL REQUIRE A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4938	INCOMING LONG ACTING OPIOID IS THE 1ST OPIOID RX FILLED IN THE PAST 90 DAYS. NEW OPIOID PRESCRIPTIONS MUST BE FOR AN IMMEDIATE RELEASE OR SHORT ACTING PRODUCT. PHARMACY CLAIMS INDICATE NO PREVIOUS IR/SA OPIOID FILLED IN THE PAST 90 DAYS. (SMART PA)
75-PRIOR AUTH REQUIRED	4939	REQUESTED LONG ACTING OPIOID PRESCRIPTION IS >/= 90 MME PER DAY. OPIOID PRESCRIPTIONS FOR >/= 90 MME PER DAY REQUIRE A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4940	THE CUMULATIVE MME FOR THE REQUESTED LONG ACTING OPIOID RX PLUS ALL OTHER ACTIVE OPIOID PRESCRIPTIONS IS >/= 90 MME PER DAY WHICH REQUIRES A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4941	THE CUMULATIVE MME FOR THE REQUESTED LONG ACTING OPIOID RX PLUS ALL OTHER ACTIVE OPIOID PRESCRIPTIONS IS >/= 90 MME PER DAY. REFILLS FOR PATIENTS WHO HAVE NOT UTLILIZED 85% OF PREVIOUSLY FILLED OPIOIDS WILL REQUIRE A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4942	MAVENCLAD REQUIRES A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4945	A DIAGNOSIS OF NARCOLEPSY OR OBSTRUCTIVE SLEEP APNEA IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF NON-PREFERRED SUNOSI. NO DIAGNOSIS OF NARCOLEPSY OR OBSTRUCTIVE SLEEP APNEA FOUND ON FILE. SUNOSI ALSO REQUIRES 30 DAYS THERAPY WITH PREFERRED MODAFINIL OR ARMODAFINIL IN THE PAST 6 MONTHS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4946	FLUMIST IS NOT RECOMMENDED FOR THE 2017-2018 FLU SEASON BY CDC. PA REQUIRED IF INJECTION CANNOT BE USED BY BENEFICIARY
75-PRIOR AUTH REQUIRED	4948	SUNOSI REQUIRES 30 DAYS OF THERAPY WITH PREFERRED MODAFINIL OR ARMODAFINIL IN THE PAST 6 MONTHS FOR APPROVAL. NO RX FOR MODAFANIL OR ARMODAFINIL FOUND IN PHARMACY CLAIMS. (SMART PA)
75-PRIOR AUTH REQUIRED	4949	CONCOMITANT USE OF A GLP-1 AND A DPP-4 HYPOGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4952	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF 3 OR > ORAL HYPOGLYCEMICS IN THE PAST 30 DAYS. INCOMING SINGLE ENTITY HYPOGLYCEMIC IS THE 4TH ORAL HYPOGLYCEMIC AGENT. (SMART PA)
75-PRIOR AUTH REQUIRED	4953	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT WHICH REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF 2 OR > COMBINATION HYPOGLYCEMICS IN THE PAST 30 DAYS. INCOMING SINGLE ENTITY HYPOGLYCEMIC IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4954	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF BOTH A COMBINATION AGENT AND A SINGLE ENTITY HYPOGLYCEMIC IN THE PAST 30 DAYS. INCOMING SINGLE ENTITY HYPOGLYCEMIC IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4955	AUSTEDO CLAIMS FOR THE TREATMENT OF TARDIVE DYSKINESIA WILL REQUIRE A MANUAL PA FOR APPROVAL. (SMARTPA)
75-PRIOR AUTH REQUIRED	4957	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF A SULFONYLUREA PRODUCT, A MEGLITINIDE PRODUCT AND A 3RD HYPOGLYCEMIC (DIFFERENT STC) IN THE PAST 30 DAYS. INCOMING SINGLE ENTITY HYPOGLYCEMIC IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4959	PRADAXA 110 MG IS NOT INDICATED FOR KNEE REPLACEMENT SURGERY. (SMART PA)
75-PRIOR AUTH REQUIRED	4960	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF 2 OR > ORAL HYPOGLYCEMICS IN THE PAST 30 DAYS. INCOMING COMBINATION HYPOGLYCEMIC IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)(SMART PA)
75-PRIOR AUTH REQUIRED	4961	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF A COMBINATION HYPOGLYCEMIC IN THE PAST 30 DAYS. INCOMING COMBINATION HYPOGLYCEMIC IS THE 4TH ORAL HYPOGLYCEMIC. (SMARTPA)
75-PRIOR AUTH REQUIRED	4963	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF BOTH A SULFONYLUREA PRODUCT AND A MEGLITINIDE PRODUCT IN THE PAST 30 DAYS. INCOMING COMBINATION HYPOGLYCEMIC IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4964	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF A COMBINATION MEGLITINIDE PRODUCT IN THE PAST 30 DAYS. INCOMING COMBINATION SULFONYLUREA PRODUCT IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4965	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF A HYPOGLYCEMIC AND A COMBINATION MEGLITINIDE PRODUCT IN THE PAST 30 DAYS. INCOMING SULFONYLUERA IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4966	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF A MEGLITINIDE PRODUCT AND ANOTHER HYPOGLYCEMIC IN THE PAST 30 DAYS. INCOMING COMBINATION SULFONYLUERA IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4967	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVALTHERE IS A HISTORY OF A MEGLITINIDE PRODUCT AND 2 HYPOGLYCEMICS IN THE PAST 30 DAYS. INCOMING SULFONYLUREA IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4968	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF A MEGLITINIDE PRODUCT AND A COMBINATION HYPOGLYCEMIC IN THE PAST 30 DAYS. INCOMING SULFONYLUREA IS THE 4TH HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4969	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF A COMBINATION SULFONYLUREA PRODUCT IN THE PAST 30 DAYS. INCOMING COMBINATION MEGLITINIDE PRODUCT IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4970	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF A HYPOGLYCEMIC AND A COMBINATION SULFONYLUERA PRODUCT IN THE PAST 30 DAYS. INCOMING MEGLITINIDE IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4971	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF A HYPOGLYCEMIC AND A SULFONYLUERA PRODUCT IN THE PAST 30 DAYS. INCOMING COMBINATION MEGLITINIDE IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4973	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF A SULFONYLUREA PRODUCT AND 2 HYPOGLYCEMICS IN THE PAST 30 DAYS. INCOMING MEGLITINIDE IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4975	THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A MANUAL PA FOR APPROVAL. THERE IS A HISTORY OF A SULFONYLUREA PRODUCT AND A COMBINATION HYPOGLYCEMIC IN THE PAST 30 DAYS. INCOMING MEGLITINIDE IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
75-PRIOR AUTH REQUIRED	4976	CLAIM IS FOR A NONPREFERRED ANTIHYPERGLYCEMIC AGENT. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED ANTIHYPERGLYCEMIC AGENTS. (SMART PA)
75-PRIOR AUTH REQUIRED	4978	A HISTORY OF 90 DAYS STABLE THERAPY WITH RIOMET IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4980	A HISTORY OF 90 DAYS STABLE THERAPY IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL OF KOMBIGLYZE XR, ONGLYZA, OR TANZEUM. (SMART PA)
75-PRIOR AUTH REQUIRED	4982	ROSACEA AGENTS REQUIRE MANUAL PA WITH DIAGNOSIS FOR AGE 21 AND UP. ACNE VULGARIS AND SEBORRHEIC DERMATITIS AGENTS ARE LIMITED TO < 21 YEARS.
75-PRIOR AUTH REQUIRED	4983	A DIAGNOSIS OF IRRITABLE BOWEL SYNDROME CONSTIPATION (IBS-C) IN THE PAST YEAR IS REQUIRED FOR APPROVAL OF AMITIZA 8 MCG OR LINZESS 290 MCG. (SMART PA)
75-PRIOR AUTH REQUIRED	4984	PATIENT HAS A HISTORY OF A GI OR BOWEL OBSTRUCTION IN THE PAST YEAR. USE OF AMITIZA 8 MCG OR LINZESS 290 MCG IS CONTRAINDICATED WITH THIS DIAGNOSIS. (SMART PA)
75-PRIOR AUTH REQUIRED	4986	AMITIZA 8 MCG IS INDICATED FOR TREATMENT OF IRRITABLE BOWEL SYNDROME CONSTIPATION IN FEMALES ONLY. (SMART PA)
75-PRIOR AUTH REQUIRED	4987	30 DAYS OF THERAPY WITH TWO PREFERRED AGENTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4988	A DIAGNOSIS OF HIV/AIDS IN THE PAST YEAR IS REQUIRED FOR APPROVAL OF FULYZAQ OR MYTESI. NO DIAGNOSIS FOUND IN MEDICAL CLAIMS. (SMART PA)
75-PRIOR AUTH REQUIRED	4989	A DIAGNOSIS OF NON-INFECTIOUS DIARRHEA IN THE PAST YEAR IS REQUIRED FOR APPROVAL OF FULYZAQ OR MYTESI. NO DIAGNOSIS FOUND IN MEDICAL CLAIMS. (SMART PA)
75-PRIOR AUTH REQUIRED	4990	A HISTORY OF 1 CLAIM WITH AN ANTIRETROVIRAL IN THE PAST 30 DAYS IS REQUIRED FOR APPROVAL OF MYTESI OR FULYZAQ. NO RX FOR AN ANTIRETROVIRAL FOUND IN PHARMACY CLAIMS. (SMART PA)
75-PRIOR AUTH REQUIRED	4991	A DIAGNOSIS OF CARCINOID SYNDROME IN THE PAST YEAR IS REQUIRED FOR APPROVAL OF XERMELO. NO DIAGNOSIS FOUND IN MEDICAL CLAIMS. (SMART PA)
75-PRIOR AUTH REQUIRED	4994	A HISTORY OF 1 CLAIM WITH A SOMATOSTATIN ANALOG IN THE PAST 30 DAYS IS REQUIRED FOR APPROVAL OF XERMELO. NO RX FOR A SOMATOSTAIN ANALOG FOUND IN PHARMACY CLAIMS. (SMART PA)
75-PRIOR AUTH REQUIRED	4997	DIACOMIT IS INDICATED FOR TREATMENT OF DRAVET SYNDROME IN PATIENTS 2 YEARS OF AGE & OLDER TAKING CLOBAZAM. PATIENT DOES NOT MEET AGE REQUIREMENT. MUST SUBMIT AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. ALSO REQUIRES A DX OF DRAVET SYNDROME IN THE PAST 2 YRS & AN ACTIVE CLAIM FOR CLOBAZAM FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4998	DIACOMIT IS INDICATED FOR TREATMENT OF DRAVET SYNDROME IN PATIENTS 2 YEARS OF AGE & OLDER TAKING CLOBAZAM. DIACOMIT REQUIRES A DIAGNOSIS OF DRAVET SYNDROME IN THE PAST 2 YEARS FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. ALSO REQUIRES AN ACTIVE CLAIM FOR CLOBAZAM FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED	4999	DIACOMIT IS INDICATED FOR TREATMENT OF DRAVET SYNDROME IN PATIENTS 2 YEARS OF AGE & OLDER TAKING CLOBAZAM. DIACOMIT REQUIRES AN ACTIVE CLAIM FOR CLOBAZAM IN PHARMACY HISTORY FOR APPROVAL. NO CLOBAZAM RX FOUND IN PHARMACY CLAIMS. (SMART PA)
76-PLAN LIMITATIONS EXCEEDED	4063	HYDROCODONE TABS/CAPS ARE LIMITED TO 62 TOTAL CUMULATIVE UNITS OF ALL/ANY STRENGTHS IN THE PAST 31 ROLLING DAYS. IF HIGHER QTY NEEDED, MUST SUBMIT MAX UNIT OVERRIDE REQUEST TO DOM PA UNIT.
76-PLAN LIMITATIONS EXCEEDED	4064	HYDROCODONE LIQUID LIMITED TO 480 TOTAL CUMULATIVE MILLILITERS OF ALL/ANY STRENGTHS IN THE PAST 31 ROLLING DAYS. MUST SUBMIT MAX UNIT OVERRIDE REQUEST TO DOM PA UNIT.
76-PLAN LIMITATIONS EXCEEDED	4104	INSULIN LIMITED TO 60 ML CUMULATIVE TOTAL/MONTH FOR RAPID, INTERMEDIATE, AND LONG-ACTING FORMS. FOR >60ML QUANTITES, SUBMIT MAX UNIT OVERRIDE REQUEST TO PA UNIT
76-PLAN LIMITATIONS EXCEEDED	4107	B2I/B2R BENEFICIARIES, AGE 21 & OLDER-CLAIM EXCEEDS MONTHLY PRESCRIPTION LIMIT OF 8
76-PLAN LIMITATIONS EXCEEDED	4109	B2I/B2R BENEFICIARIES, AGE 21 & OLDER- CLAIM EXCEEDS MONTHLY BRAND LIMIT OF 5
76-PLAN LIMITATIONS EXCEEDED	4126	EDIT IGNORED
76-PLAN LIMITATIONS EXCEEDED	4160	H =CUSTOM REC; DAILY DOSE > MAINTENANCE CLAIM DOSE
76-PLAN LIMITATIONS EXCEEDED	4162	"(THE CUSTOM PLAN DAYS SUPPLIED ACCUM IS NOT EQUAL TO N (NONE) OR THE CUSTOM PLAN DAYS SUPPLIED IS NOT EQUAL TO WORK DEFAULT DAYS (999)) AND THE CUSTOM PLAN DAYS SUPPLIED ACCUM EQUALS C (ACUTE DOSE ONLY) AND THE CUSTOM PLAN MAINTENANCE CLAIM DOSE LESS THAN WORK DEFAULT DOSE (9999.999) AND THE DAILY DOSE IS GREATE
76-PLAN LIMITATIONS EXCEEDED	4163	G =CUSTOM REC; ACUTE DOSE - SUBMITTED DAYS > MAX DAYS SUP FOR SPEC CLAIM
76-PLAN LIMITATIONS EXCEEDED	4164	"(THE CUSTOM PLAN MAX UNITS ACCUM IS NOT EQUAL TO N (NONE) AND THE CUSTOM PLAN MAX UNITS IS NOT EQUAL TO WORK DEFAULT MAX UNITS (99999.999)) AND THE CUSTOM PLAN MAX UNITS ACCUM EQUALS C (ACUTE DOSE ONLY) AND THE CUSTOM PLAN MAINTENANCE CLAIM DOSE LESS THAN WORK DEFAULT DOSE (9999.999) AND THE DAILY DOSE IS GREATE
76-PLAN LIMITATIONS EXCEEDED	4165	D =CUSTOM REC; ALL DOSES - SUBMITTED UNITS > MAX UNITS FOR SPEC CLAIM
76-PLAN LIMITATIONS EXCEEDED	4166	THIS CLAIM EXCEEDS THE MONTHLY LIMIT OF 6 PRESCRIPTIONS.
76-PLAN LIMITATIONS EXCEEDED	4167	A CUSTOM RECORD EXISTS FOR THE NDC. THE QUANTITY SUBMITTED ON THE CLAIM EXCEEDS THE MAX TOTAL UNITS FOR A TIME PERIOD. PLEASE REFER TO QUANTITY LIMIT LIST OR SUBMIT MAX UNIT OVERRIDE PA REQUEST.
76-PLAN LIMITATIONS EXCEEDED	4168	F =CUSTOM REC; ALL DOSES - SUBMITTED DAYS > MAX DAYS SUPP FOR SPEC CLAIM
76-PLAN LIMITATIONS EXCEEDED	4169	SUBMITTED QTY OR # OF RXS EXCEEDS THE ALLOWED QTY FOR THIS DRUG. PRESCRIBER MAY SUBMIT 'MAX UNIT OVERRIDE' PA REQUEST IF GREATER QTY NEEDED.
76-PLAN LIMITATIONS EXCEEDED	4170	REFILL LIMIT EXCEEDED FOR PRESCRIPTION NUMBER
76-PLAN LIMITATIONS EXCEEDED	4171	M =CUSTOM REC; ALL DOSES - SUBMITTED UNITS > MAX UNITS FOR SPEC DUR
76-PLAN LIMITATIONS EXCEEDED	4172	N =CUSTOM REC; ACUTE DOSE - SUBMITTED UNITS > MAX UNITS FOR SPEC DUR
76-PLAN LIMITATIONS EXCEEDED	4208	HYOSCYAMINE DROPS LIMITED TO 1-15ML BOTTLE PER MONTH.
76-PLAN LIMITATIONS EXCEEDED	4253	INHALERS/NEBULIZERS QUANTITY LIMITS EXCEEDED. MANUAL PA REQUIRED FOR HIGHER DOSAGE.
76-PLAN LIMITATIONS EXCEEDED	4255	CHANTIX 1 MG CONT MONTH PAK MINIMUM AGE OF 18 AND MAX UNITS OF 56 IN 21 DAYS
76-PLAN LIMITATIONS EXCEEDED	4371	THE TOTAL NUMBER OF BRAND DRUGS FOR THIS RECIPIENT EXCEEDS THE 2 BRAND LIMIT PER CALENDAR MONTH.
76-PLAN LIMITATIONS EXCEEDED	4472	OXYCODONE SHORT ACTING TABS/CAPS LIMITED TO 62 TOTAL CUMULATIVE UNITS OF ALL/ANY STRENGTHS IN THE PAST 31 ROLLING DAYS. MUST SUBMIT MAX UNIT OVERRIDE REQUEST TO DOM PA UNIT.
76-PLAN LIMITATIONS EXCEEDED	4473	OXYCODONE LIQUID LIMITED TO 180 TOTAL CUMULATIVE ML. OF ALL/ANY STRENGTHS IN THE PAST 31 ROLLING DAYS. PRESCRIBER MAY SUBMIT MAX UNIT OVERRIDE PA REQUEST IF HIGHER QTY IS NEEDED.
76-PLAN LIMITATIONS EXCEEDED	4474	SEDATIVE-HYPNOTIC AGENTS ARE LIMITED TO 31 CUMULATIVE UNITS OF ALL/ANY STRENGTHS IN THE PAST 31 ROLLING DAYS. PRESCRIBER MAY SUBMIT MAX UNIT OVERRIDE REQUEST IF HIGHER QTY NEEDED.
76-PLAN LIMITATIONS EXCEEDED	4475	ANXIOLYTIC AGENTS ARE LIMITED TO 62 TOTAL CUMULATIVE UNITS OF ALL/ANY STRENGTHS IN THE PAST 31 ROLLING DAYS. MUST SUBMIT MAX UNIT OVERRIDE REQUEST TO DOM PA UNIT.
76-PLAN LIMITATIONS EXCEEDED	4604	CLIENT SPECIFIC EDIT (MS: CUSTOMER IS ALLOWED ONLY FIVE REFILLS PER PRESCRIPTION NUMBER
76-PLAN LIMITATIONS EXCEEDED	4626	NDC HAS MAXIMUM QUANTITY ASSIGNED BY DOM. ALLOWED QTY CAN BE FOUND UNDER ' REFERENCE', 'DRUG CUSTOMER SPECIFIC'
76-PLAN LIMITATIONS EXCEEDED	4627	SUBMITTED UNITS EXCEED MAX ALLOWED FOR CALENDAR MONTH. PRESCRIBER MAY SUBMIT 'MAX UNIT OVERRIDE' PA REQUEST IF GREATER QTY NEEDED.
76-PLAN LIMITATIONS EXCEEDED	4823	PLAN LIMITATIONS EXCEEDED - PA LIMIT DEFINITIONS INDICATE PRIOR AUTHORIZATION IS REQUIRED FROM DOM.
76-PLAN LIMITATIONS EXCEEDED	4831	"PLAN LIMITS EXCEEDED - SEE BELOW REASON CODES: B =CUSTOM REC; ALL DOSES - MAX $ LIMIT EXCEEDED FOR SPEC DUR"
76-PLAN LIMITATIONS EXCEEDED	4832	C =CUSTOM REC; ACUTE DOSE - MAX $ LIMIT EXCEEDED FOR SPEC DURATION
76-PLAN LIMITATIONS EXCEEDED	4833	P= PATIENT EXCEEDS MONTHLY REFILL LIMIT
76-PLAN LIMITATIONS EXCEEDED	4867	E =CUSTOM REC; ACUTE DOSE - SUBMITTED UNITS > MAX UNITS FOR SPEC CLAIM
76-PLAN LIMITATIONS EXCEEDED	4868	J =CUSTOM REC; ACUTE DOSE - MAX NUM SCRIPTS EXCEEDED FOR SPEC DUR
76-PLAN LIMITATIONS EXCEEDED	4869	K =CUSTOM REC; ALL DOSES - SUBMITTED DAYS > MAX DAYS SUPP FOR SPEC DURATION
76-PLAN LIMITATIONS EXCEEDED	4870	L =CUSTOM REC: ACUTE DOSE - SUBMITTED DAYS > MAX DAYS SUPP FOR SPEC DURATION
76-PLAN LIMITATIONS EXCEEDED	4913	GREATER THAN 31 DAYS SUPPLY FOR NON-MAINT. DRUG PRIOR AUTHORIZATION REQUIRED FROM DOM.
76-PLAN LIMITATIONS EXCEEDED	4923	EXCEEDS MONTHLY QUANTITY LIMIT FOR INSULIN PEN, MUST SUBMIT MAX UNIT OVERRIDE REQUEST TO PA UNIT
77-DISCONTINUED PRODUCT/SVC ID NO	4173	DRUG IS OBSOLETE OR DATE OF SERVICE IS AFTER CMS TERM DATE. CHECK EXPIRATION DATE ON BOTTLE OF NDC DISPENSED
77-DISCONTINUED PRODUCT/SVC ID NO	4503	RESERVED FOR FUTURE USE
78-COST EXCEEDS MAXIMUM	4174	CLAIMS OVER $999.99 REQUIRE PRIOR AUTHORIZATION
78-COST EXCEEDS MAXIMUM	4176	EDIT IGNORED
78-COST EXCEEDS MAXIMUM	4189	CLAIMS OVER $5,000.00 REQUIRE PRIOR AUTHORIZATION
79-REFILL TOO SOON	4177	REFILL TOO SOON. IF DOSAGE HAS CHANGED, SUBMIT 'EARLY REFILL PHARMACY PA' REQUEST.
80-DRUG-DIAGNOSIS MISMATCH	4773	EDIT IGNORED
81-CLAIM TOO OLD	4180	"THE CLAIM IS NOT AN ADJUSTMENT VIA POS AND THE CLAIM OTHER INSURANCE INDICATOR IS SECONDARY INSURANCE CLAIM (2 -3 -4) AND THE CLAIM COB PAYERID DATE IS NUMERIC AND GREATER THAN ZEROS AND THE CLAIM DATE OF ADJUDICATION (CURRENT DATE) IS GREATER THAN THE CLAIM COB PAYERID DATE PLUS 90 DAYS AND LESS THAN
81-CLAIM TOO OLD	4181	"THE CLAIM IS NOT AN ADJUSTMENT VIA POS AND THE CLAIM OTHER COVERAGE CODE IS SECONDARY INSURANCE CLAIM (2 -3 -4) AND THE CLAIM COB PAYERID DATE IS NUMERIC AND GREATER THAN ZEROS AND THE CLAIM DATE OF ADJUDICATION (CURRENT DATE) IS GREATER THAN THE CLAIM COB PAYERID DATE PLUS 548 DAYS."
81-CLAIM TOO OLD	4182	"THE CLAIM IS NOT AN ADJUSTMENT VIA POS AND THE CLAIM OTHER INSURANCE INDICATOR IS NOT SECONDARY INSURANCE CLAIM (2 -3 -4) AND THE CLAIM DATE OF ADJUDICATION (CURRENT DATE) IS GREATER THAN THE CLAIM FIRST DATE OF SERVICE PLUS 90 DAYS AND LESS THAN THE CLAIM FIRST DATE OF SERVICE PLUS 366 DAYS. "
81-CLAIM TOO OLD	4183	"THE CLAIM IS NOT AN ADJUSTMENT VIA POS AND THE CLAIM OTHER INSURANCE INDICATOR IS NOT SECONDARY INSURANCE CLAIM (2 -3 -4) AND THE CLAIM DATE OF ADJUDICATION (CURRENT DATE) IS GREATER THAN THE CLAIM FIRST DATE OF SERVICE PLUS 365 DAYS."
81-CLAIM TOO OLD	4184	CLAIM TOO OLD TO PROCESS ELECTRONICALLY. CLAIMS WITH DATE OF SERVICE GREATER THAN ONE YR MAY BE SUBMITTED VIA PAPER OR WEB PORTAL FOR RETRO ELIGIBILITY.
81-CLAIM TOO OLD	4520	RESERVED FOR FUTURE USE
81-CLAIM TOO OLD	4521	RESERVED FOR FUTURE USE
81-CLAIM TOO OLD	4577	CLIENT SPECIFIC EDIT (MS): TIMELY FILING DATE IS LESS THAN THE FIRST DOS
81-CLAIM TOO OLD	4578	ELECTRONIC CLAIMS MUST BE SUBMITTED WITHIN ONE YEAR OF DATE OF SERVICE.
81-CLAIM TOO OLD	4818	CCO DID NOT SUBMIT ENCOUNTER CLAIM WITHIN 30 DAYS OF ORIGINAL RECEIPT FROM PHARMACY
81-CLAIM TOO OLD	4819	CLAIM TOO OLD - CCO MUST SUBMIT ADJUSTMENT/VOID WITHIN 60 DAYS OF RECEIPT OF ORIGINAL PHARMACY CLAIM
82-CLAIM IS POST-DATED	4420	DATE FILLED CANNOT BE IN THE FUTURE.
82-CLAIM IS POST-DATED	4802	DATE BILLED AFTER ADJUDICATION DATE
82-CLAIM IS POST-DATED	4871	CLAIM POST DATED
83-DUPLICATE PAID/CAPTURED CLAIM	4185	EXACT DUPLICATE OF A PAID CLAIM
83-DUPLICATE PAID/CAPTURED CLAIM	4186	DUPLICATE OF PAID CLAIM.
83-DUPLICATE PAID/CAPTURED CLAIM	4854	DUP CHECK: SEARCHES HISTORY. IF A CLAIM WITH THE SAME FDOS AND 1ST 5 CHARACTERS OF THE GCN’S ARE EQUAL; THEN DUP CHECK CONTINUES. IF PRIOR AUTHORIZATION IS REQUIRED; OR THE PRESCRIBING PHYSICIAN DEA NUMBERS ARE EQUAL; OR THE PRIOR AUTH MED CERT CODE INDICATES MEDICAL CERTIFICATION; OR THE DENIAL OVERRIDE IS SET TO M
83-DUPLICATE PAID/CAPTURED CLAIM	4992	EXACT DUP (WAS EDIT 4185) BUT MODIFIED FOR FLAX -- BUG TRACKER REQUEST # 2042 WHEN EXACT DUPLICATE EDIT IS POSTED, USE EOB 718 IF DIFFERENT PRESCRIBER EOB TEXT: EXACT DUPLICATE - DIFFERENT PRESCRIBER
83-DUPLICATE PAID/CAPTURED CLAIM	4993	EXACT DUP (WAS EDIT 4185) BUT MODIFIED FOR FLAX -- BUG TRACKER REQUEST # 2042 WHEN EXACT DUPLICATE EDIT IS POSTED, USE EOB 101 IF SAME PRESCRIBER EOB TEXT: EXACT DUPLICATE - SAME PRESCRIBER
84-CLAIM HAS NOT BEEN PAID/CAPTRD	4192	THE ORIGINAL CLAIM THAT IS ATTEMPTING TO BE ADJUSTED/CREDITED WAS NOT FOUND OR IS A CREDIT.
84-CLAIM HAS NOT BEEN PAID/CAPTRD	4193	EDIT IGNORED
84-CLAIM HAS NOT BEEN PAID/CAPTRD	4374	"A CREDIT CLAIM CANNOT BE ADJUSTED. THE REPLACEMENT CLAIM OF AN ADJUSTMENT CAN BE VOIDED OR REPLACED - BUT THE CREDIT CLAIM OF AN ADJUSTMENT CAN NEVER BE VOIDED OR REPLACED. THIS EDIT CAN POST TO PROVIDER SUBMITTED CREDIT REQUESTS - PROVIDER SUBMITTED REPLACEMENT CLAIMS - ONLINE ENTERED CREDIT REQUESTS - AND ONLINE EN
84-CLAIM HAS NOT BEEN PAID/CAPTRD	4834	EDIT IGNORED
85-CLAIM NOT PROCESSED	4187	"THE MAXIMUM NUMBER OF ENTRIES FOR THE RELATED HISTORY TABLE HAVE BEEN MET OR EXCEEDED. PROGRAM: S780C / S780 ADD-TO-RLTD-HIST"
85-CLAIM NOT PROCESSED	4188	CLAIM NOT PROCESSED – REJECT CODE NOT FOUND ON REJECT CONTROL TABLE OR TOO MANY REJECT CODES ARE POSTED TO CLAIM OR RELATED HISTORY ENTRIES EXCEEDED FOR CLAIM OR PARTICIPANT
85-CLAIM NOT PROCESSED	4363	THIS EDIT WILL POST IF THE HEADER-LEVEL OVERRIDE EXCEPTION LOCATION CODE DOES NOT HAVE A MATCHING CODE ON THE REFERENCE TEXT LOCATION DATABASE
85-CLAIM NOT PROCESSED	4364	THIS EXCEPTION CAN BE POSTED TO THE CLAIM IF A LOGIC ERROR - SUCH AS A MISSING REPLACED TCN NUMBER FOR A CREDIT TRANSACTION, OR A CREDIT WITH A CLAIM STATUS OF TO-BE-DENIED OCCURS. IN SOME INSTANCES, IT CAN BE USED TO DENOTE UNEXPECTED SQL CODES FROM DB2 CALLS.
85-CLAIM NOT PROCESSED	4375	EDIT IGNORED
85-CLAIM NOT PROCESSED	4379	UNABLE TO PROCESS. SYSTEM UPDATE IN PROCESS. RESUBMIT CLAIM LATER.
85-CLAIM NOT PROCESSED	4404	EDIT IGNORED
85-CLAIM NOT PROCESSED	4414	THE PHARMACY’S PHYSICAL ADDRESS INFORMATION COULD NOT BE FOUND.
85-CLAIM NOT PROCESSED	4415	IF THE LOADED EXCEPTION COUNT IS 0.
85-CLAIM NOT PROCESSED	4445	"CLAIMS IS SYSTEM GENERATED AND (TRANSACTION TYPE IS VOID OR TRANSACTION TYPE IS DEBIT OF ADJUSTMENT) AND CYCLE NUMBER EQUAL ZERO AND BATCH NUMBER IS LESS THAT SYSTEM GENERATED BATCH NUMBER "
86-SUBMIT MANUAL REVERSAL	4775	EDIT IGNORED
87-REVERSAL NOT PROCESSED	4191	THE ORIGINAL CLAIM THAT IS ATTEMPTING TO BE ADJUSTED/CREDITED WAS DENIED.
87-REVERSAL NOT PROCESSED	4376	THE ADUSTMENT REASON CODE ENTERED ON THE REQUEST IS MISSING OR INVALID (NOT NUMERIC OR NOT ON VALID VALUES TABLE). SEE THE DATA DICTIONARY FOR A LIST OF VALID VALUES.
87-REVERSAL NOT PROCESSED	4439	AN ADJUSTMENT REQUEST RECORD HAS TARGETED A HISTORY RECORD FOR ADJUSTMENT - BUT THE HISTORY RECORD HAS BEEN SUSPENDED
87-REVERSAL NOT PROCESSED	4441	AN ADJUSTMENT REQUEST RECORD HAS TARGETED A HISTORY RECORD FOR ADJUSTMENT - BUT THE HISTORY RECORD HAS BEEN VOIDED
87-REVERSAL NOT PROCESSED	4443	AN ADJUSTMENT REQUEST RECORD HAS TARGETED A HISTORY RECORD FOR ADJUSTMENT - BUT THE KEYED REPLACED NUMBER (TCN) ON THE ADJUSTMENT REQUEST RECORD THAT IDENTIFIES THE HISTORY RECORD IS EQUAL TO ZEROS.
87-REVERSAL NOT PROCESSED	4835	REVERSAL NOT PROCESSED - IF THE MATCHING HISTORY CLAIM WAS FOUND AND WAS ALREADY CREDITED; OR WAS TO-BE-CREDITED; OR THE ORIGINAL CLAIM WAS DENIED; THEN THE ERROR IS POSTED.
87-REVERSAL NOT PROCESSED	4836	EDIT IGNORED
87-REVERSAL NOT PROCESSED	4837	NO POS REVERSAL IN FIN. CYCLE
88-DUR REJECT ERROR	4194	ACCOMPANIED BY DUR CONFLICT CODE: TD
88-DUR REJECT ERROR	4195	"PRENATAL EXCEPTION (HISTORY FDOS IS GREATER THAN IP FDOS OR AFTER PROCESSING THROUGH ALL OF HISTORY CLAIMS) AND IP PARTICIPANT SEX CODE EQUALS FEMALE AND IP THERAPEUTIC CLASS CODE SPECIFIC EQUALS PRE-NATAL VITAMINS AND IP PARTICIPANT AGE IS GREATER THAN 11 AND IP PARTICIPANT AGE IS LESS THAN 60"
88-DUR REJECT ERROR	4196	"EXCESSIVE DURATION EXCEPTION THIS EDIT IS POSTED AFTER ACCUMULATING THE TOTAL NUMBER OF DAYS SUPPLIED FOR ALL HISTORY CLAIMS AND ADDING THE IP DAYS SUPPLY TO THE TOTAL WHEN: THE IP PARTICIPANT IS YOUNGER THAN 13 AND THE PEDIATRIC DURATION OF THERAPY MAXIMUM NUMBER OF DAYS ON THE DRUG RECORD USING THE IP NDC IS LESS
88-DUR REJECT ERROR	4197	ACCOMPANIED BY DUR CONFLICT CODE: DD DRUG/DRUG INTERACTIONS WITH A SEVERITY LEVEL OF 1; REQUIRE PRIOR AUTHORIZATION.
88-DUR REJECT ERROR	4198	"INGREDIENT DUPLICATION FIRST DATE OF SERVICE ON THE CURRENT CLAIM MUST BE AFTER THE FIRST DATE OF SERVICE ON THE HISTORY CLAIM. AND FIRST DATE OF SERVICE ON THE CURRENT CLAIM MUST BE BEFORE THE DATE CALCULATED TO BE THE HISTORY CLAIM’S FIRST DATE OF SERVICE PLUS DAYS SUPPLIED LESS THE GRACE PERIOD. AND THE CLAIM DATE
88-DUR REJECT ERROR	4199	AGE EXCEPTION: THE BENEFICIARY IS YOUNGER THAN THE MINIMUM AGE ON THE DRUG RECORD.
88-DUR REJECT ERROR	4200	DRUG AND/OR DOSAGE NOT INDICATED FOR THIS GENDER
88-DUR REJECT ERROR	4201	"LOW DOSE EXCEPTION (HISTORY FDOS IS GREATER THAN IP FDOS OR AFTER PROCESSING THROUGH ALL OF HISTORY CLAIMS) AND THE DOSE FORM ON THE DRUG RECORD FROM THE IP NDC MUST EQUAL ‘EACH’ OR ‘MILLILITER’ AND IP PARTICIPANT MUST BE AT LEAST 18 YEARS OLD AND NOT OLDER THAN 60 YEARS AND CALCULATED DAILY DOSE MUST BE LESS THAN
88-DUR REJECT ERROR	4202	ACCOMPANIED BY DUR CONFLICT CODE: HD.QUANTITY DIVIDED BY DAYS SUPPLY EXCEEDS RECOMMENDED MAX DAILY DOSE. SUBMIT MAX UNIT OVERRIDE PA IF HIGH DOSE IS REQUIRED
88-DUR REJECT ERROR	4203	"ALLERGY EXCEPTION (HISTORY FDOS IS GREATER THAN IP FDOS OR AFTER PROCESSING THROUGH ALL OF HISTORY CLAIMS) AND THE IP PARTICIPANT MUST HAVE A PRIOR AUTHORIZATION AND THE CONDITION TYPE ON THE PRIOR AUTHORIZATION TABLE MUST BE SET TO ‘AC‘ AND ONE OF THE CONDITION RANGE FIELDS ON THE PRIOR AUTHORIZATION TABLE MUST MA
88-DUR REJECT ERROR	4204	DRUG SHOULD BE USED WITH CAUTION IN PREGNANCY. IF PRESCRIBER HAS BEEN CONTACTED TO VERIFY USE IN PREGNANCY, MAY BE OVERIDDEN BY SUBMITTING APPROPRIATE DUR INTERVENTION VALUES IN REASON FOR SERVICE, INTERVENTION CD.& OUTCOME CD. FIELDS
88-DUR REJECT ERROR	4205	ACCOMPANIED BY DUR CONFLICT CODE: ER EARLY REFILLS REQUIRED PRIOR AUTHORIZATION FROM DOM.
88-DUR REJECT ERROR	4431	DUR REJECT WITH CONFLICT CODE FOR THERAPEUTIC DUPLICATION.
88-DUR REJECT ERROR	4432	CLAIM FAILED A PRO-DUR ALERT
88-DUR REJECT ERROR	4587	AGE EXCEPTION: THE BENEFICIARY IS OLDER THAN THE MAXIMUM AGE ON THE DRUG RECORD.
88-DUR REJECT ERROR	4610	TO ALLOW FOR TREATMENT OF SHORT-TERM ANXIETY, A BENZODIAZEPINE PRESCRIPTION FOR UP TO 2 UNITS USED IN COMBINATION WITH AN OPIOID CAN BE OVERRIDDEN AT THE POINT-OF-SALE BY THE DISPENSING PHARMACIST BASED ON THEIR CLINICAL JUDGEMENT. DUR SERVICE CODES: M0, 1G, AT. (SMART PA)
88-DUR REJECT ERROR	4839	ACCOMPANIED BY DUR CONFLICT CODE FOR DC (DISEASE PRECAUTION) SENT IN DUR SEGMENT
88-DUR REJECT ERROR	4944	TO ALLOW FOR TREATMENT OF ACUTE PAIN, A SHORT ACTING OPIOID PRESCRIPTION FOR UP TO A 3-DAY SUPPLY USED IN COMBINATION WITH A BENZODIAZEPINE CAN BE OVERRIDDEN AT POINT-OF-SALE BY THE DISPENSING PHARMACIST BASED ON THEIR CLINICAL JUDGEMENT. DUR SERVICE CODES: M0, 1G, AT. (SMART PA)
88-DUR REJECT ERROR	4974	CURRENT REFILL IS FILLED LATER THAN (PREVIOUS FILL'S DATE OF SERVICE + 1.25 * ITS DAYS SUPPLY).
89-REJECTED CLAIM FEES PAID	4776	EDIT IGNORED
90-HOST HUNG UP	4777	EDIT IGNORED
91-HOST RESPONSE ERROR	4677	COMMUNICATION ERROR. CONNECTION TO SMART PA PORTAL FAILED. PLEASE RESUBMIT CLAIM LATER.
91-HOST RESPONSE ERROR	4778	EDIT IGNORED
92-SYSTEM/HOST UNAVAILABLE	4779	EDIT IGNORED
93	4780	EDIT IGNORED
94	4781	EDIT IGNORED
95-TIME OUT	4782	EDIT IGNORED
96-SCHEDULED DOWNTIME	4783	EDIT IGNORED
97-PAYER UNAVAILABLE	4784	EDIT IGNORED
98-CONNECTION TO PAYER DOWN	4785	EDIT IGNORED
99-HOST PROCESSING ERROR	4786	EDIT IGNORED
99-HOST PROCESSING ERROR	4995	THE ERROR CODE FROM SMART PA IS NOT ZERO. SEE SPA LOG FOR SPA ERROR CODE. CONTACT POS TEAM.
AA-PATIENT SPENDDOWN NOT MET	4881	BENEFICIARY IS ELIGIBLE FOR LONG TERM CARE FOR DATE OF SERVICE AND CLAIM WILL PAY UNDER LTC PLAN. THIS EDIT WILL POST TO CLAIMS FOR BENEFICIARIES IN PLANS 200 AND 901.
AA-PATIENT SPENDDOWN NOT MET	4882	BENEFICIARY IS ELIGIBLE FOR LONG TERM CARE BUT HAS SERVICE MODIFICATION OF 'STOP PAYMENT' FOR DATE OF SERVICE. THIS EDIT WILL POST TO CLAIMS FOR BENEFICIARIES IN PLANS 200 AND 901, THAT ALSO HAVE A CORRESPONDING STOP PAYMENT INDICATOR(SPI) WHERE THE CLAIMS DATE OF SERVICE FALLS WITHIN DATE SPAN FOR THE SPI.
AB-DATE WRITTEN IS GT DATE FILLED	4206	THE DATE PRESCRIPTION WRITTEN IS GREATER THAN THE DATE OF SERVICE.
AC-PROD NOT COV-NON-PART MANUFCTR	4207	"THE PRODUCT/SERVICE ID QUALIFIER INDICATES THAT THE PRODUCT/SERVICE ID FIELD CONTAINS A NDC AND ((DRUG REBATE DATA IS FOUND FOR THE CLAIM’S NDC AND DATE OF SERVICE ON THE DRUG REBATE TABLE AND THE DRUG REBATE CODE FOR THE NDC = NO REBATE (‘0’) AND THE NDC IS NOT A REBATE EXEMPT NDC (HARD-CODED TABLE – MAS
AE-QMB BILL MEDICARE	4877	DRUG NOT COVERED-BILL MEDICARE PART D
AE-QMB BILL MEDICARE	4931	BILL MEDICARE.
AG-DAYS SUPPLY LIMIT FOR PROD/SVC	4209	"EXCEEDS CUSTOM DAYS SUPPLIED LIMITS – 5.1 ONLY THE CUSTOM PLAN DAYS SUPPLIED ACCUM EQUALS A (ALL DOSES) AND THE CLAIM SUBMITTED DAYS GREATER THAN CUSTOM PLAN DAYS SUPPLIED AND THE CUSTOM PLAN DAYS SUPPLIED STATUS EQUALS D (DENY) AND THE PRIOR AUTHORIZATION INDICATOR IS NOT EQUAL TO ( PRIOR AUTHORIZED OR COVERED
AG-DAYS SUPPLY LIMIT FOR PROD/SVC	4449	THE QUANTITY SUBMITTED ON THE CLAIM EXCEEDS THE MAX DAILY UNITS ALLOWED BY MEDICAID. FOR HIGHER DOSE/DOSE CHANGE, SUBMIT MAX UNIT OVERRIDE REQUEST.
AG-DAYS SUPPLY LIMIT FOR PROD/SVC	4618	THE QUANTITY ON THE CLAIM IS GREATER THAN THE PRIOR AUTHORIZATION QUANTITY DIVIDED BY NUMBER OF REFILLS
AG-DAYS SUPPLY LIMIT FOR PROD/SVC	4656	DAILY DOSE CALCULATED FROM SUBMITTED CLAIM VALUES IS GREATER THAN THE MAXIMUM ALLOWED DAILY DOSE.
AJ-GENERIC DRUG REQUIRED	4035	GENERIC DRUG REQUIRED. IF BRAND IS MEDICALLY NECESSARY PRESCRIBER MUST SUBMIT PA REQUEST
AJ-GENERIC DRUG REQUIRED	4210	CLAIM IS FOR A NON-PREFERRED EPINEPHRINE AUTO-INJECTION. USE GENERIC LABELER 49502 FOR PREFERRED EPINEPHRINE AUTO INJECTION.
AK-INV SOFTWARE VENDR/CERT ID	4211	THE SOFTWARE VENDOR/CERTIFICATION ID IS MISSING (SPACES).
AM-INV SEGMENT IDENTIFICATION	4212	THE SEGMENT IS A MANDATORY SEGMENT AND THE SEGMENT IDENTIFIER IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD
A9-INV TRANSACTION COUNT	4213	THE TRANSACTION COUNT IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
BE-INV PROF SVC FEE SUBMITTED	4214	THE PRODUCT/SERVICE ID QUALIFIER IS NOT NDC AND THE PROFESSIONAL SERVICE FEE SUBMITTED IS MISSING (ZEROS).
B2-INV SERVICE PROV ID QUALIFIER	4215	THE SERVICE PROVIDER ID QUALIFIER IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
CA-INV PATIENT FIRST NAME	4787	FIRST NAME NOT EDITED SEPARATELY. IF THE FIRST NAME IS MISSING ON THE CLAIM; SYSTEM RETURNS COB 0238. THIS EDIT HAS BEEN MAPPED TO CB; M/I PATIENT’S LAST NAME.
CB-INV PATIENT LAST NAME	4789	MEMBER NAME MISSING
CF-INV EMPLOYER NAME	4891	EDIT IGNORED
CG-INV EMPLOYER STREET ADDR	4892	EDIT IGNORED
CH-INV EMPLOYER CITY	4893	EDIT IGNORED
CI-INV EMPLOYER STATE/PROVINCE	4894	EDIT IGNORED
CJ-INV EMPLOYER ZIP/POSTAL CD	4895	EDIT IGNORED
CK-INV EMPLOYER PHONE NUMBER	4896	EDIT IGNORED
CL-INV EMPLOYER CONTACT NAME	4897	EDIT IGNORED
CM-INV PATIENT STREET ADDRESS	4898	EDIT IGNORED
CN-INV PATIENT CITY	4912	EDIT IGNORED
CO-INV PATIENT STATE/PROVINCE	4900	EDIT IGNORED
CP-INV PATIENT ZIP/POSTAL CD	4901	EDIT IGNORED
CQ-INV PATIENT PHONE NUMBER	4902	EDIT IGNORED
CR-INV CARRIER ID	4903	EDIT IGNORED
DC-INV DISPENSING FEE SUBMTED	4222	DISPENSING FEE SUBMITTED IS MISSING OR IS = ZEROS AND THE DISPENSING STATUS="PARTIAL FILL" OR 'NOT SPECIFIED
DQ-INV USUAL AND CUSTOMARY CHG	4790	USUAL AND CUSTOMARY CHARGE (TOTAL CHG AMT) IS MISSING OR ZERO.
DQ-INV USUAL AND CUSTOMARY CHG	4841	EDIT IGNORED
DQ-INV USUAL AND CUSTOMARY CHG	4842	SUSPEND A CLAIM IF BILLED AMOUNT IS > THAN OR EQUAL TO 500% OF ALLOWED AMOUNT OR IF BILLED AMOUNT IS < LESS THAN OR EQUAL TO 20% OF ALLOWED AMOUNT. SUSPEND TO LOCATION CODE 40.
DQ-INV USUAL AND CUSTOMARY CHG	4843	EDIT IGNORED
DQ-INV USUAL AND CUSTOMARY CHG	4844	CLAIM PRICED AT ZERO
DQ-INV USUAL AND CUSTOMARY CHG	4845	EDIT IGNORED
DQ-INV USUAL AND CUSTOMARY CHG	4848	EDIT IGNORED
DQ-INV USUAL AND CUSTOMARY CHG	4849	EDIT IGNORED
DQ-INV USUAL AND CUSTOMARY CHG	4872	"EDIT WILL CHECK FOR BOTH MISSING AND INVALID CONDITIONS WILL ALSO POST FOR 590 CLAIMS IN EXCESS OF $500 THAT REQUIRE A PA IN CONJUNCTION WITH EDIT 75; EXCEPTION CODE 4965 (PATTY LYNN)"
DQ-INV USUAL AND CUSTOMARY CHG	4917	EDIT IGNORED
DR-INV PRESCRIBER LAST NAME	4225	EDIT IGNORED
DT-INV UNIT DOSE INDICATOR	4226	M/I UNIT DOSE INDICATOR
DU-INV GROSS AMOUNT DUE	4227	EDIT IGNORED
DV-INV OTHER PAYER AMOUNT PD	4229	OTHER PAYER AMOUNT PAID CANNOT BE A NEGATIVE AMOUNT.
DV-INV OTHER PAYER AMOUNT PD	4231	"CLAIM REQUIRES TPL REVIEW (MASSACHUSETTS SPECIFIC) IF THE OTHER COVERAGE CODE IS 2 (OTHER COVERAGE EXISTS – PAYMENT COLLECTED) AND THE PAYERID PAID AMOUNT IS MISSING (ZERO). OR IF THE OTHER COVERAGE CODE IS ‘0’ (NOT SPECIFIED) OR ‘1’ (NO OTHER COVERAGE IDENTIFIED) ‘3’ (OTHER COVERAGE EXISTS - THIS CLAM NOT COVERED)
DV-INV OTHER PAYER AMOUNT PD	4816	MISSING/INVALID COB PAID AMOUNT - CCO DID NOT SUBMIT A COB PAID AMOUNT ON A PAID ENCOUNTER CLAIM
DV-INV OTHER PAYER AMOUNT PD	4817	CCO DID NOT SUBMIT THEIR ALLOWED AMOUNT - CCO MUST SUBMIT A COB PAID AMOUNT >0 WITH A COB PAID CODE OF '99 - OTHER'
DV-INV OTHER PAYER AMOUNT PD	4855	IF THE OTHER INSURANCE INDICATOR = 3 OR 4; AND THE PRIMARY PAYER DATE NOT NUMERIC OR NOT > ZEROES OR THE OTHER AMOUNT IS NOT EQUAL TO ZEROES; THEN THE ERROR IS POSTED.
DW	4232	EDIT IGNORED
DX-INV PATIENT PAID AMT SUBM	4233	EDIT IGNORED
DY-INV DATE OF INJURY	4234	EDIT IGNORED
DZ-INV CLAIM/REFERENCE ID	4235	EDIT IGNORED
EC-INV COMPND INGRED COMP COUNT	4236	A COMPOUND SEGMENT IS PRESENT AND THE COMPOUND INGREDIENT COMPONENT COUNT IS ZEROS.
ED-INV COMPOUND INGREDIENT QTY	4237	THE COMPOUND INGREDIENT QUANTITY IS MISSING (ZEROS).
EE-INV COMPND INGRED DRUG COST	4238	THE INGREDIENT DRUG COST IS MISSING (ZEROS).
EF-INV COMP DOSAGE FORM DESC CODE	4935	THE DOSAGE FORM DESCRIPTION CODE (NCPDP FIELD # 450-EF) DOES NOT CONTAIN A VALID VALUE FOR A COMPOUND DRUG
EG-INV COMP DISP UNIT FORM IND	4936	COMPOUND CLAIM AND MISSING OR INVALID DOSAGE FORM CODE
EH-INV COMP RTE OF ADMINISTRATION	4937	COMPOUND CLAIM AND MISSING OR INVALID ROUTE OF ADMINISTRATION
EM-INV RX/SVC REF NUM QUALIFIER	4239	'RX/SERVICE REFERENCE CODE IS MISSING OR NOT =1(RX BILLING) OR 2 (SERVICE BILLING)
ET-INV QUANTITY PRESCRIBED	4243	THE QUANTITY PRESCRIBED IS MISSING (ZEROS).
ET-INV QUANTITY PRESCRIBED	4262	TOPICALS ARE LIMITED TO TWO TIMES THE PACKAGE SIZE PER CLAIM
ET-INV QUANTITY PRESCRIBED	4615	ZELNORM IS LIMITED TO 360 TOTAL CUMULATIVE UNITS PER YEAR.
EU-INV PRIOR AUTH TYPE CODE	4244	"THE PRIOR AUTHORIZATION TYPE CODE DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD OR THE PRIOR AUTHORIZATION TYPE CODE IS MISSING AND THE PRIOR AUTHORIZATION NUMBER IS PRESENT."
EU-INV PRIOR AUTH TYPE CODE	4600	EDIT IGNORED
EV-INV PRIOR AUTH NUM SUBMITTED	4245	THE PRIOR AUTHORIZATION NUMBER SUBMITTED IS MISSING AND THE PRIOR AUTHORIZATION TYPE CODE EQUALS ‘PA’.
EY-INV PROVIDER ID QUALIFIER	4246	"THE PHARMACY PROVIDER ID QUALIFIER IS MISSING OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD OR THE PHARMACY PROVIDER ID QUALIFIER IS MISSING AND THE PHARMACY PROVIDER ID IS PRESENT."
EZ-INV PRESCRIBER ID QUALIFIER	4247	"THE PRESCRIBER ID QUALIFIER IS MISSING AND A PRESCRIBER ID EXISTS OR OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD"
E1-INV PRODUCT/SVC QUALIFIER	4248	M/I PRODUCT/SERVICE ID QUALIFIER
E2	4907	EDIT IGNORED
E3-INV INCENTIVE AMOUNT SUBMITTED	4249	M/I INCENTIVE AMOUNT SUBMITTED
E4-INV REASON FOR SERVICE CODE	4250	EDIT IGNORED
E4-INV REASON FOR SERVICE CODE	4430	"DUR OVERRIDE CONFLICT THE REASON FOR SERVICE IS MISSING AND THE DUR INTERVENE CODE OR DUR OUTCOME CODE IS PRESENT."
E5-INV PROFESSIONAL SERVICE CODE	4252	EDIT IGNORED
E6-INV RESULT OF SERVICE CODE	4254	EDIT IGNORED
E7-INV QUANTITY DISPENSED	4150	EXCEEDS MAXIMUM ALLOWABLE QUANTITY
E7-INV QUANTITY DISPENSED	4256	EDIT IGNORED
E7-INV QUANTITY DISPENSED	4847	QUANT > ESTIMD PRICE BY 800%
E7-INV QUANTITY DISPENSED	4873	QUANTITY DISPENSED MUST BE A MULTIPLE OF THE PACKAGE SIZE.
E8-INV OTHER PAYER DATE	4257	EDIT IGNORED
E8-INV OTHER PAYER DATE	4258	OTHER PAYER DATE CANNOT BE GREATER THAN DATE RX FILLED
E8-INV OTHER PAYER DATE	4259	OTHER PAYER DATE – IF OTHER INSURANCE INDICATOR = 0 OR 1 AND PRIMARY PAYER DENY DATE IS NUMERIC AND > ZERO; OR OTHER AMOUNT IS NOT EQUAL TO ZERO; ERROR IS POSTED.
E8-INV OTHER PAYER DATE	4261	"INVALID OTHER INSURANCE 2 – 5.1 ONLY IF THE OTHER COVERAGE CODE IS 2 (OTHER COVERAGE EXISTS - PAYMENT COLLECTED) AND THE OTHER PAYER AMOUNT PAID EQUALS ZEROS OR THE OTHER PAYERID DATE = 0001-01-01"
E9-INV PROVIDER ID	4263	THE PHARMACY PROVIDER ID IS MISSING AND THE PHARMACY PROVIDER ID QUALIFIER IS PRESENT.
GE-INV PCNT SALES TAX AMT SUBM	4265	"THE PERCENTAGE SALES TAX AMOUNT SUBMITTED IS MISSING (ZEROS) AND THE FLAT TAX AMOUNT IS MISSING OR ZEROES."
HA-INV FLAT SALES TAX AMT SUBM	4266	"THE FLAT SALES TAX AMOUNT SUBMITTED IS MISSING (ZEROS) AND THE PERCENTAGE SALES TAX AMOUNT IS MISSING OR ZEROES."
HB-INV OTHER PAYER AMT PAID COUNT	4267	A COB SEGMENT IS PRESENT AND THE OTHER PAYER AMOUNT PAID COUNT IS MISSING (ZEROS).
HC-INV OTHER PAYER AMT PAID QUAL	4269	THE OTHER PAYER AMOUNT PAID QUALIFIER IS MISSING (SPACES) AND THE OTHER PAYER AMOUNT PAID IS GREATER THAN ZEROS.
HC-INV OTHER PAYER AMT PAID QUAL	4270	THE OTHER PAYER AMOUNT PAID QUALIFIER DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD
HD-INV DISPENSING STATUS	4271	MISSING OR INVALID DISPENSING STATUS.
HD-INV DISPENSING STATUS	4272	THE DISPENSING STATUS DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
HD-INV DISPENSING STATUS	4416	COMPOUND CODE IS EQUAL TO ‘2’ AND THE DISPENSING STATUS IS GREATER THAN SPACES.
HF-INV QTY INTENDED TO BE DISP	4274	THE QUANTITY INTENDED TO BE DISPENSED IS MISSING (ZEROS) AND THE DISPENSING STATUS INDICATES A PARTIAL FILL (‘P’) OR ‘C’.
HF-INV QTY INTENDED TO BE DISP	4275	THE QUANTITY INTENDED TO BE DISPENSED IS GREATER THAN ZEROS BUT THE DISPENSING STATUS DOES NOT INDICATE A PARTIAL FILL (‘P’).
HG-INV DAYS SUP INTEND TO BE DISP	4276	THE DAYS SUPPLY INTENDED TO BE DISPENSED IS MISSING (ZEROS) AND THE DISPENSING STATUS INDICATES A PARTIAL FILL (‘P’).
HG-INV DAYS SUP INTEND TO BE DISP	4277	THE DAYS SUPPLY INTENDED TO BE DISPENSED IS GREATER THAN ZEROS BUT THE DISPENSING STATUS DOES NOT INDICATE A PARTIAL FILL (‘P’).
H6-INV DUR CO-AGENT ID	4283	THE DUR CO-AGENT ID IS MISSING (SPACES).
H7-INV OTH AMT CLAIMED SUBM COUNT	4284	THE OTHER AMOUNT CLAIMED SUBMITTED COUNT IS MISSING (ZEROS) AND THE OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER OR AMOUNT IS PRESENT.
H8-INV OTH AMT CLAIMED SUBM QUAL	4285	THE OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD AND THE OTHER AMOUNT CLAIMED SUBMITTED AMOUNT IS GREATER THAN ZERO.
H9-INV OTH AMT CLAIMED SUBMITTED	4286	THE OTHER AMOUNT CLAIMED SUBMITTED IS MISSING (ZEROS) AND THE OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER IS PRESENT
JE-INV PCNT SALES TAX BASIS SUBM	4287	THE PERCENTAGE SALES TAX BASIS SUBMITTED IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
J9-INV DUR CO-AGENT ID QUALIFIER	4288	THE DUR CO-AGENT ID QUALIFIER IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
MZ-ERROR OVERFLOW	4899	NUMBER OF ERRORS ON THE CLAIM EXCEED THE MAXIMUM NUMBER OF ERRORS ALLOWED BY THE SYSTEM.
M1-NOT COVERED IN THIS AID CATEG	4289	EDIT IGNORED
M1-NOT COVERED IN THIS AID CATEG	4290	EDIT IGNORED
M1-NOT COVERED IN THIS AID CATEG	4291	EDIT IGNORED
M1-NOT COVERED IN THIS AID CATEG	4428	EDIT IGNORED
M1-NOT COVERED IN THIS AID CATEG	4856	EDIT IGNORED
M2-RECIPIENT LOCKED IN	4293	"PARTICIPANT/PROVIDER LOCKIN MISMATCH THE CLAIM FIRST DATE OF SERVICE FELL WITHIN THE DATE RANGE OF ONE OF THE PROVIDERS IN THE LOCKIN TABLE BUT THE CLAIM PROVIDER NUMBER IS NOT EQUAL TO THE PROVIDER NUMBER IN THE LOCKIN TABLE. "
M2-RECIPIENT LOCKED IN	4857	EDIT IGNORED
M3-HOST PA/MC ERROR	4908	EDIT IGNORED
M4-RX NUM TIME LIMIT EXCEEDED	4294	EDIT IGNORED
M5-REQUIRES MANUAL CLAIM	4793	EDIT POSTED FOR COMPOUNDS IN 3.2 WHICH REQUIRE A MANUAL / PAPER CLAIM
M5-REQUIRES MANUAL CLAIM	4972	COMPOUND CLAIMS EXCEEDING $200 REQUIRE PAPER CLAIM
M6-HOST ELIGIBILITY ERROR	4594	LAST NAME: 1. REQUIRED. ACTUALLY CHECK 1ST POSITION FOR CHARACTERS "A" THRU "Z". FIRST NAME: 1. REQUIRED. ACTUALLY CHECK 1ST POSITION FOR CHARACTERS "A" THRU "Z". 2. INVALID-FIRST-NAME VALUES 'BABY ' 'BAB ' 'BBY ' SPACES 'NEWBORN' 'INFANT ' 'GIR
M6-HOST ELIGIBILITY ERROR	4595	K-BABY EDIT - BILLING UNDER MOTHER'S MEDICAID ID LIMITED TO ONE YEAR. REBILL UNDER BABY'S ID. IF THE DOB ON THE CLAIM IS WITHIN 365 DAYS, THEN THE EDIT ISN'T POSTED. OTHERWISE, 4014 IS POSTED.
M6-HOST ELIGIBILITY ERROR	4909	EDIT IGNORED
M8-HOST PROVIDER FILE ERROR	4850	HOST PROVIDER FILE ERROR
PB-INV TRANS CNT FOR TRANS CODE	4297	THE TRANSACTION COUNT IS GREATER THAN 4 FOR A BILLING - REVERSAL - OR REBILL REQUEST.
PC-INV CLAIM SEGMENT	4218	340B CLAIM WITH NO 20 IN SUBMISSION CLARIFICATION CODE OR NO 08 IN BASIS OF COST DETERMINATION
PC-INV CLAIM SEGMENT	4298	A CLAIM SEGMENT WAS NOT RECEIVED WITH A BILLING REQUEST.
PC-INV CLAIM SEGMENT	4299	A CLAIM SEGMENT WAS RECEIVED WITH AN ELIGIBILITY REQUEST.
PD-INV CLINICAL SEGMENT	4300	M/I CLINICAL SEGMENT
PE-INV COB/OTHER PAYMENTS SEGMENT	4303	A COB/OTHER PAYMENTS SEGMENT WAS RECEIVED WITH AN ELIGIBILITY - A REVERSAL - OR A PRIOR AUTHORIZATION REVERSAL REQUEST.
PF-INV COMPOUND SEGMENT	4304	M/I COMPOUND SEGMENT
PF-INV COMPOUND SEGMENT	4305	A COMPOUND SEGMENT WAS RECEIVED WITH AN ELIGIBILITY OR A REVERSAL REQUEST.
PH-INV DUR/PPS SEGMENT	4308	"DUR/PPS SEGMENT INVALID WITH ELIGIBILITY REQUEST – 5.1 ONLY A DUR/PPS SEGMENT WAS RECEIVED WITH AN ELIGIBILITY REQUEST."
PJ-INV INSURANCE SEGMENT	4309	M/I INSURANCE SEGMENT
PK-INV PATIENT SEGMENT	4311	M/I PATIENT SEGMENT
PM-INV PHARMACY PROVIDER SEGMENT	4314	"PHARMACY PROVIDER SEGMENT INVALID WITH REVERSAL REQUEST – 5.1 ONLY A PHARMACY PROVIDER SEGMENT WAS RECEIVED WITH A REVERSAL REQUEST."
PN-INV PRESCRIBER SEGMENT	4316	"PRESCRIBER SEGMENT INVALID WITH REQUEST TYPE - 5.1 ONLY A PRESCRIBER SEGMENT WAS RECEIVED WITH AN ELIGIBILITY OR A REVERSAL REQUEST."
PP-INV PRICING SEGMENT	4120	NO PRICE EXISTS FOR PRICING POLICY.
PP-INV PRICING SEGMENT	4123	NO PRICING ON FILE. IF NEW DRUG, BILL NEXT MONDAY.
PP-INV PRICING SEGMENT	4317	M/I PRICING SEGMENT
PP-INV PRICING SEGMENT	4318	"PRICING SEGMENT INVALID WITH ELIGIBILITY REQUEST - 5.1 ONLY A PRICING SEGMENT WAS RECEIVED WITH AN ELIGIBILITY REQUEST"
PR-INV PRIOR AUTH SEGMENT	4319	M/I PRIOR AUTHORIZATION SEGMENT
PR-INV PRIOR AUTH SEGMENT	4320	"PRIOR AUTHORIZATION SEGMENT INVALID WITH REQUEST TYPE – 5.1 ONLY A PRIOR AUTHORIZATION SEGMENT WAS RECEIVED WITH AN ELIGIBILITY OR A REVERSAL REQUEST."
PS-INV TRANSACTION HEADER SEGMENT	4321	"MISSING MANDATORY TRANSACTION HEADER SEGMENT – 5.1 ONLY AN ELIGIBILITY - BILLING - REVERSAL - OR RE-BILL REQUEST WAS RECEIVED WITHOUT A MANDATORY TRANSACTION HEADER SEGMENT."
PS-INV TRANSACTION HEADER SEGMENT	4322	EDIT IGNORED
PT-INV WORKERS COMP SEGMENT	4323	EDIT IGNORED
PT-INV WORKERS COMP SEGMENT	4324	EDIT IGNORED
PV-NON-MATCHED ASSOC RX/SVC DATE	4325	"ASSOCIATED PRESCRIPTION/SERVICE DATE DOES NOT MATCH DOS - 5.1 ONLY THE ASSOCIATED PRESCRIPTION/SERVICE DATE ON A CLAIM SEGMENT WITH A DISPENSING STATUS OF C (COMPLETION FILL) DID NOT MATCH THE DATE OF SERVICE ON THE MATCHING PARTIAL FILL TRANSACTION. "
P1-ASSOCIATED RX/SVC REF NUM NF	4326	THE ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER ON A CLAIM SEGMENT WITH A DISPENSING STATUS OF C (COMPLETION FILL) DID NOT MATCH THE REFERENCE NUMBER ON THE MATCHING PARTIAL FILL TRANSACTION
P2-CLINICAL INFO CNTR OUT OF SEQ	4327	THE CLINICAL SEGMENTS WERE NOT RECEIVED IN THE CORRECT NUMERICAL SEQUENCE.
P3-CPD INGR COMP CNT NE REPTIONS	4328	THE COMPOUND INGREDIENT COMPONENT COUNT DOES NOT MATCH THE NUMBER OF COMPOUND PRODUCT ID’S RECEIVED ON A COMPOUND SEGMENT.
P4-COB/OTH PY CNT NE REPITITIONS	4329	THE COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT DOES NOT MATCH THE NUMBER OF COB/OTHER PAYMENT SEGMENTS RECEIVED.
P6-DATE OF SERVICE PRIOR TO DOB	4330	DATE OF FILL LESS THAN DATE OF BIRTH
P7-DIAG CD CNT NE NUM REPETITIONS	4331	THE DIAGNOSIS CODE COUNT DOES NOT MATCH THE NUMBER OF DIAGNOSIS CODES ON A CLINICAL SEGMENT.
P8-DUR/PPS CD CNTR OUT OF SEQ	4332	THE SETS OF DUR/PPS INFORMATION WERE RECEIVED OUT OF NUMERICAL SEQUENCE.
P9-FIELD IS NON-REPEATABLE	4333	EDIT IGNORED
RB-MULTIPLE PARTIALS NOT ALLOWED	4334	MORE THAN ONE PARTIAL FILL TRANSACTIONS WERE RECEIVED FOR THE SAME PRESCRIPTION/SERVICE ID.
RC-DIFF DRUG ENTITY-PARTIAL/COMP	4335	THE PRODUCT/SERVICE ID AND/OR QUALIFIER ON THE COMPLETION TRANSACTION (DISPENSING STATUS OF C ) DOES NOT MATCH THE PRODUCT/SERVICE ID AND/OR QUALIFIER ON THE ASSOCIATED PARTIAL FILL TRANSACTION (DISPENSING STATUS OF P ).
RD-DIFF CARDHLDR/GRP ID-PART/COMP	4336	THE MEMBER ID AND THE GROUP ID ON THE INSURANCE SEGMENT OF A COMPLETION TRANSACTION (DISPENSING STATUS OF C ) DOES NOT MATCH THE MEMBER ID AND GROUP ID ON THE INSURANCE SEGMENT OF THE ASSOCIATED PARTIAL FILL TRANSACTION (DISPENSING STATUS OF P ).
RE-INV COMPOUND PROD ID QUALIFIER	4337	PRODUCT QUALIFIER FOR THE NDC FIELD IS MISSING.
RF-IMP ORD-DISP STAT CD PART FL	4338	"COMPLETION WITH NO PARTIAL – 5.1 ONLY A CLAIM SEGMENT WITH A DISPENSING STATUS OF C WAS RECEIVED BUT NO MATCHING PARTIAL FILL TRANSACTION (DISPENSING STATUS OF P ) COULD BE FOUND"
RG-IMV ASOC RX/SVC REF-CMP TRANS	4339	THE ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER ON A CLAIM SEGMENT WITH A DISPENSING STATUS OF C IS MISSING (ZEROS).
RH-INV ASOC RX/SVC REF DT-CMP TRA	4340	"THE ASSOCIATED PRESCRIPTION/SERVICE DATE ON A CLAIM SEGMENT WITH A DISPENSING STATUS OF C IS MISSING (ZEROS) OR IT IS NOT A VALID DATE. "
RH-INV ASOC RX/SVC REF DT-CMP TRA	4417	"PARTIAL AND COMPLETION NOT ALLOWED ON SAME DAY 5.1 ONLY FIRST DATE OF SERVICE EQUAL ASSOCIATED PRESCRIPTION/SERVICE DATE."
RJ-ASOC PART FILL TRANS NOT ON FL	4341	A PAID OR TO BE PAID CLAIM WITH A DISPENSING STATUS OF P AND AN ASSOCIATED PRESCRIPTION/SERVICE REFERENCE NUMBER THAT MATCHES THE IN-PROCESS CLAIM’S PRESCRIPTION/SERVICE REFERENCE NUMBER AND AN ASSOCIATE PRESCRIPTION/SERVICE DATE THAT MATCHES THE IN-PROCESS CLAIM’S DATE PRESCRIPTION WRITTEN COULD NOT BE FOUND.
RN-PLAN LMT EXC ON INT PART FL	4342	"INTENDED QUANTITY EXCEEDS PLAN LIMITS THE QUANTITY INTENDED TO BE DISPENSE RECEIVED ON A CLAIM SEGMENT WITH A P DISPENSING STATUS EXCEEDS THE MAXIMUM DISPENSED QUANTITY LIMITS ON THE PLAN FOR WHICH THE PARTICIPANT IS ELIGIBLE. "
RN-PLAN LMT EXC ON INT PART FL	4343	"INTENDED DAYS SUPPLY EXCEEDS PLAN LIMITS – 5.1 ONLY THE DAYS SUPPLY INTENDED TO BE DISPENSE RECEIVED ON A CLAIM SEGMENT WITH A P DISPENSING STATUS EXCEEDS THE MAXIMUM SUBMITTED DAYS LIMITS ON THE PLAN FOR WHICH THE PARTICIPANT IS ELIGIBLE."
RP-OUT OF SEQ P REV ON PART FL TR	4344	"PARTIAL REVERSED BEFORE COMPLETION REVERSED – 5.1 ONLY A REVERSAL FOR A PARTIAL FILL TRANSACTION WAS SUBMITTED BEFORE THE COMPLETION TRANSACTION WAS REVERSED. THE REPLACEMENT TCN NUMBER ON THE MATCHING COMPLETION TCN IS ZEROS. SEE PAGE 7 OF NM BLUEPRINT. NOTE: 5.1 SAME DAY INSPECT DISPENSING STATUS IN ORDER TO REVE
RS-INV ASOC RX/SVC DT ON PART TR	4345	"THE ASSOCIATED PRESCRIPTION/SERVICE DATE IS MISSING (ZEROS) OR IS AN INVALID DATE WHEN A CLAIM SEGMENT WITH A DISPENSING STATUS OF P WAS RECEIVED. ASSOCIATED FIELDS ARE NOT REQUIRED ON A PARTIAL TRANSACTION."
RT-INV ASOC RX/SVC RF ON PART TR	4346	(EDIT IGNORED) INVALID RX NUMBER FOR A PARTIAL REFILL
RU-MAND DATA ELE MUST BE BEF OPT	4347	"OPTIONAL FIELDS PRECEDE MANDATORY FIELDS A SEGMENT OF ANY TYPE WAS RECEIVED WITH AN OPTIONAL FIELD OR FIELDS PRECEDING THE MANDATORY FIELDS."
R1-OTH AMT CLM SUB CT NE NUM REP	4348	THE OTHER AMOUNT CLAIMED SUBMITTED COUNT DOES NOT MATCH THE NUMBER OF OTHER AMOUNT CLAIMED SUBMITTED FIELDS RECEIVED ON A PRICING SEGMENT.
R2-PYR REJ CT NE NUM REP	4349	THE OTHER PAYER REJECT COUNT DOES MATCH THE NUMBER OF OTHER PAYER REJECT CODES RECEIVED ON A COB/OTHER PAYMENTS SEGMENT
R3-PROC MOD CODE CT NE NUM REP	4350	THE PROCEDURE MODIFIER CODE COUNT DOES NOT MATCH THE NUMBER OF PROCEDURE MODIFIER CODES RECEIVED ON A CLAIM SEGMENT
R4-PROC MOD CODE INV FOR PROD/SVC	4351	EDIT IGNORED
R5-PS ID MUST= 0 IF PS ID QUAL=6	4352	THE PRODUCT/SERVICE ID ON THE CLAIM SEGMENT WAS NOT ZEROS WHEN THE PRODUCT/SERVICE ID QUALIFIER INDICATED THAT THE CLAIM WAS FOR DUR/PROFESSIONAL PHARMACY SERVICE.
R6-PROD/SVC NOT APPROPR FOR LOC	4353	EDIT IGNORED
R7-REP SEG NOT ALLOWED IN SAME TR	4354	AN IDENTICAL SEGMENT WAS SUBMITTED ON A SINGLE TRANSACTION.
R9-VAL IN GR AMT DOES NF PRI FORM	4355	"GROSS AMOUNT DUE FOR RX = INGREDIENT COST SUBMITTED + DISPENSING FEE SUBMITTED + FLAT SALES TAX AMOUNT SUBMITTED + PERCENTAGE SALES TAX SUBMITTED
SE-INV PROCEDURE MODIFIER CODE CT	4356	THE PROCEDURE MODIFIER CODE COUNT IS MISSING (ZEROS) AND A PROCEDURE MODIFIER IS PRESENT.
TE-INV COMPOUND PRODUCT ID	4357	COMPOUND CLAIM SUBMITTED AND NDC IS MISSING.
UE-INV CPD ING BASIS OF CST DET	4358	THE COMPOUND INGREDIENT BASIS OF COST DETERMINATION IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
VE-INV DIAGNOSIS CODE COUNT	4359	THE DIAGNOSIS CODE COUNT IS MISSING (ZEROS) AND A DIAGNOSIS CODE IS PRESENT.
WE-INV DIAGNOSIS CODE QUALIFIER	4241	INVALID DIAGNOSIS CODE QUALIFIER. ONLY ICD-10 (VALUE '02') ACCEPTED FOR DATE OF SERVICE ON OR AFTER 10/01/2015
WE-INV DIAGNOSIS CODE QUALIFIER	4360	THE DIAGNOSIS CODE QUALIFIER IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
XE-INV CLINICAL INFO COUNTER	4361	THE CLINICAL INFORMATION COUNTER IS MISSING (ZEROS) OR IT DOES NOT MATCH THE NUMBER OF SETS OF MEASUREMENT FIELDS ON A CLINICAL SEGMENT.
ZE-INV MEASUREMENT DATE	4362	THE MEASUREMENT DATE IS MISSING (ZEROS).
1C-INV SMOKER/NON-SMOKER CODE	4918	M/I SMOKER/NON-SMOKER CODE
1E-INV PRESCRIBER LOCATION CD	4919	M/I PRESCRIBER LOCATION CODE
2C-INV PREGNANCY INDICATOR	4031	"MISSING/INVALID PREGNANCY INDICATOR 5.1 ONLY THE PREGNANCY INDICATOR IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD."
2C-INV PREGNANCY INDICATOR	4628	BENEFICIARY IS PREGNANT (PREGNANCY INDICATOR = 2) BUT THE GENDER OF THE BENEFICIARY IS NOT FEMALE.
2E-INV PCP ID QUALIFIER	4032	"MISSING/INVALID PRIMARY CARE PROVIDER ID QUALIFIER 5.1 ONLY THE PRIMARY CARE PROVIDER ID IS SUBMITTED ON THE PRESCRIBER SEGMENT AND THE PRIMARY CARE PROVIDER ID QUALIFIER IS MISSING OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD."
3A-INV REQUEST TYPE	4048	"MISSING/INVALID REQUEST TYPE – 5.1 ONLY THE 5.1 TRANSACTION CODE EQUAL P1-P4 AND THE REQUEST TYPE ON THE PA TRANSACTION IS MISSING OR NOT EQUAL TO ONE OF THE VALID VALUES SPECIFIED."
3B-INV REQUEST PD DATE-BEGIN	4049	"MISSING REQUEST PERIOD DATE-BEGIN – 5.1 ONLY THE REQUEST PERIOD DATE-BEGIN IS MISSING (ZEROS)."
3C-INV REQUEST PD DATE-END	4050	"MISSING REQUEST PERIOD DATE-END – 5.1 ONLY THE REQUEST PERIOD DATE-END IS MISSING (ZEROS)"
3D-INV BASIS OF REQUEST	4051	"MISSING/INVALID BASIS OF REQUEST – 5.1 ONLY THE BASIS OF REQUEST IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD."
3F-INV AUTH REP LAST NAME	4053	M/I AUTHORIZED REPRESENTATIVE LAST NAME
3N-INV PRIOR AUTHORIZED NUM	4055	"MISSING PRIOR AUTHORIZATION NUMBER ASSIGNED – 5.1 ONLY THE PRIOR AUTHORIZATION NUMBER ASSIGNED IS MISSING (ZEROS)."
3P-INV AUTHORIZATION NUM	4056	"MISSING AUTHORIZATION NUMBER – 5.1 ONLY THE AUTHORIZATION NUMBER IS MISSING (SPACES)."
3S-INV PRI AUTH SUPPORT DOC	4057	M/I PRIOR AUTHORIZATION SUPPORTING DOCUMENTATION
4C-INV COB/OTHER PAYMENTS CNT	4074	"MISSING/INVALID COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT – 5.1 ONLY A COB SEGMENT IS PRESENT AND THE COORDINATION OF BENEFITS/OTHER PAYMENTS COUNT IS MISSING (ZEROS)."
5C-INV OTHER PAYER COV TYPE	4078	OTHER INSURANCE INDICATOR ENTERED IS NOT ONE OF THE FOLLOWING: 00, 01, 02, 03, 04, 05, 06, 07 OR 08. SEE 'BILLING OTHER INSURANCE' INSTRUCTIONS
6E-INV OTHER PAYER REJECT CODE	4091	THE OTHER PAYER REJECT COUNT IS GREATER THAN ZERO AND THE OTHER PAYER REJECT CODE IS MISSING (SPACES).
6E-INV OTHER PAYER REJECT CODE	4828	ENCOUNTER DENIED BY CCO
7E-INV DUR/PPS CODE COUNTER	4110	THE DUR/PPS CODE COUNTER IS MISSING (ZEROS).
8C-INV FACILITY ID	4927	BILL IV DRUGS ON MEDICAL CLAIMS. PHARMACY BILLING REQUIRES PA.
8E-INV DUR/PPS LVL OF EFFORT	4178	A DUR/PPS SEGMENT IS PRESENT AND THE DUR/PPS LEVEL OF EFFORT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD
9T-PA TYP CD SUBMITTD NOT COVERED	4068	DOM DOES NOT ALLOW THE SUBMISSION OF NCPDP FIELD 461-EU PRIOR AUTHORIZATION TYPE CODE (PA CERT CD FOUND ON 'MAIN' TAB)
N/A	4413	CLAIM FOR SIMVASTATIN AT DOSE > 80 MG IS GREATER THAN THE FDA RECOMMENDED DOSE.