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
|
4841
|
CLAIMS SUBMITTED WITH CARDHOLDER ID (NCPDP 302-C2) SUFFIX OF "V" ARE COVID-19 CLAIMS AND RECEIVE ZERO COPAY
|
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
|
4126
|
INVALID SUBMISSION CLARIFICATION CODE FOR COVID VACCINE ADMINISTRATION - USE SCC 2 FOR FIRST ADMINISTRATION AND SCC 6 FOR SECOND ADMINISTRATION
|
34-INV SUBMISSION CLARIF CODE
|
4207
|
SUBMISSION CLARIFICATION CODE VALUES 2 OR 6 REQUIRED FOR COVID DOUBLE DOSE VACCINE ADMINISTRATION
|
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
|
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
|
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.
|
42-INACTIVE OR EXPIRED PRESC ID
|
4136
|
THE PRESCRIBER ON A COVID VACCINE ADMINISTRATION CLAIM IS NOT ENROLLED AS A PRESCRIBER.
|
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
|
PT. IN LOCK-IN PROGRAM. PRESCRIPTION MAY ONLY BE FILLED IF WRITTEN BY CERTAIN PRESCRIBERS. CALL MEDICAID PROGRAM INTEGRITY UNIT AT 1 -800--880-5920 FOR QUESTIONS.
|
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
|
DISPENSE THE PREFERRED BRAND RATHER THAN THE NONPREFERRED GENERIC. SEE PREFERRED DRUG LIST (PDL) AT HTTP://WWW.MEDICAID.MS.GOV
|
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
|
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
|
4629
|
PRENATAL VITAMIN - ONLY COVERED FOR PREGNANT FEMALES
|
70-PRODUCT/SERVICE NOT COVERED
|
4853
|
EDIT IGNORED
|
70-PRODUCT/SERVICE NOT COVERED
|
4927
|
BILL IV DRUGS ON MEDICAL CLAIMS. PHARMACY BILLING REQUIRES PA.
|
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 >/= 1 YEAR. MUST SUBMIT AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. ALSO REQUIRES A DIAGNOSIS OF DRAVET SYNDROME, LENNOX-GASTAUT SYNDROME OR SEIZURES ASSOICIATED WITH TUBEROUS SCLERODID COMPLEX IN THE PAST 2 YEARS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4061
|
EPIDIOLEX REQUIRES A DIAGNOSIS OF DRAVET SYNDROME, LENNOX-GASTAUT SYNDROME OR SEIZURES ASSOICIATED WITH TUBEROUS SCLERODID COMPLEX 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
|
FOR AGES >/= 18 YEARS, 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
|
REQUESTED PRESCRIPTION IS FOR A NONPREFERRED BRONCHODILATOR. REFER TO THE PDL FOR A LIST OF PREFERRED BRONCHODILATORS. (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
|
CANASA IS NON-PREFERRED. DISPENSE PREFERRED GENERIC RECTAL MESALAMINE PRODUCT OR 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 A PREFERRED TOPICAL ANALGESIC 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 & TRIKAFTA REQUIRE A MANUAL PA FOR APPROVAL. OTHER NONPREFERRED AGENTS REQUIRE HISTORY OF 1 CLAIM WITH THE REQUESTED AGENT IN PAST 105 DAYS FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4112
|
KALYDECO, ORKAMBI, SYMDEKO, AND TRIKAFTA REQUIRE A MANUAL PA FOR APPROVAL. (SMART PA)
|
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
|
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
|
4211
|
NOURIANZ REQUIRES A HISTORY OF A PREFERRED ADJUNCTIVE THERAPY IN THE PAST 45 DAYS FOR APPROVAL. PHARMACY HISTORY INDICATES NO CLAIM WITH A PREFERRED ADJUNCTIVE THERAPY IN THE PAST 45 DAYS. (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
|
DISPENSE THE PREFERRED GENERIC RATHER THAN THE NONPREFERRED BRAND. PRESCRIBER MAY SUBMIT BRAND MEDICALLY NECESSARY PA REQUEST. SEE PDL AT HTTP://WWW.MEDICAID.MS.GOV
|
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 CLINICAL 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
|
KESPIMTA, MAVENCLAD AND MAYZENT REQUIRE A CLINICAL REVIEW FOR APPROVAL. (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 NARCOLEPSY WITHOUT CATAPLEXY IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF WAKIX. NO DIAGNOSIS FOUND ON FILE. WAKIX ALSO REQUIRES 30 DAYS OF THERAPY WITH PREFERRED MODAFINIL OR ARMODAFINIL IN THE PAST 6 MONTHS OR HISTORY OF 1 CLAIM WITH WAKIX IN THE PAST 105 DAYS FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4313
|
WAKIX REQUIRES A DIAGNOSIS OF SUBSTANCE ABUSE DISORDER IN THE PAST 2 YEARS OR 30 DAYS OF THERAPY WITH PREFERRED MODAFINIL OR ARMODAFINIL IN THE PAST 6 MONTHS OR HISTORY OF 1 CLAIM WITH WAKIX IN THE PAST 105 DAYS FOR APPROVAL. NO RX FOR MODAFANIL, ARMODAFINIL OR PREVIOUS WAKIX RX FOUND IN PHARMACY CLAIMS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4315
|
WAKIX IS LIMITED TO 2 TABLETS PER DAY. QUANTITY ON REQUESTED RX EXCEEDS THIS LIMIT. (SMART PA)
|
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 PREFERRED. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED SHORT-ACTING STIMULANTS. (SMART PA)
|
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. NEW STARTS REQUIRE A CLINICAL REVIEW FOR APPROVAL. (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 >/= 1 YEAR OF AGE. MUST SUBMIT AN AGE WAIVER SIGNED BY THE PRESCRIBER FOR APPROVAL. ALSO REQUIRES A DIAGNOSIS OF HEART FAILURE WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION IN THE PAST 2 YEARS FOR APPROVAL. (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 AND DRIZALMA SPRINKLE REQUIRES A DIAGNOSIS OF GENERALIZED ANXIETY DISORDER FOR AGES 7-11 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 & TRIKAFTA 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. BRAND KITABIS, BETHKIS AND GENERIC TOBI LABELERS 00093, 00781, 17478, 43598, 65162, AND 68180 ARE THE 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
|
APPROVAL OF EUCRISA REQUIRES A HISTORY OF AT LEAST 28 DAYS OF THERAPY WITH BOTH A CALCINEURIN INHIBITOR AND A TOPICAL STEROID IN THE PAST YEAR. NO PREVIOUS CALCINEURIN HINHIBITOR PRESCRIPTION FOUND IN PHARMACY CLAIMS. (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
|
CLAIM IS FOR NON-PREFERRED DRIZALMA SPRINKLE. PLEASE DISPENSE PREFERRED DULOXETINE CAPSULES OR REFER TO THE PDL FOR A LIST OF PREFERRED ANTIDEPRESSANTS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4494
|
CLAIM IS FOR NON-PREFERRED DRIZALMA SPRINKLE. FOR PATIENTS 12 YEARS OF AGE AND OLDER, PLEASE DISPENSE PREFERRED DULOXETINE CAPSULES OR REFER TO THE PDL FOR A LIST OF PREFERRED ANTIDEPRESSANTS. (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. 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 RETACRIT OR EPOGEN IN THE PAST 6 MONTHS OR 1 CLAIM WITH THE REQUESTED AGENT IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. NO RX FOUND IN PHARMACY CLAIMS. (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. NON-PREFERRED AGENTS MUST ALSO MEET PDL CRITERIA (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4522
|
30 DAYS OF THERAPY WITH A PREFERRED INSULIN OR RELATED AGENT IN THE PAST 6 MONTHS OR 1 CLAIM WITH THE REQUESTED NON-PREFERRED AGENT IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. NO PREVIOUS PHARMACY CLAIMS FOUND. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4524
|
A DIAGNOSIS OF ALLERGIC RHINITIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF NON-PREFERRED INTRANASAL CORTICOSTEROIDS. NO DIAGNOSIS FOUND ON FILE. NON-PREFERRED AGENTS ALSO REQUIRE A HISTORY OF 1 CLAIM WITH 1 PREFERRED INTRANASAL CORTICOSTEROIDS IN THE PAST 6 MONTHS FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4525
|
A HISTORY OF 1 CLAIM WITH 1 PREFERRED INTRANASAL CORTICOSTEROID IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. NO RX FOUND IN PHARMACY CLAIMS HISTORY. (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
|
ANXIOLYTIC INJECTIONS COVERED THROUGH POS FOR BENEFICIARIES IN LONG TERM CARE FACILITIES. ALL OTHER PTS REQUIRE A PA.
|
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 FOR ALL MS AGENTS. MAVENCLAD AND MAYZENT 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 THE PAST 6 MONTHS OR A HISTORY OF 3 CLAIMS WITH THE SAME REQUESTED NONPREFERRED MS AGENT 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
|
NEXLETOL, NEXLIZET, PRALUENT AND REPATHA REQUIRE A CLINICAL REVIEW FOR APPROVAL. (SMART PA)
|
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 AND NOURIANZ ARE INDICATED AS ADJUNCTIVE TREATMENT TO A LEVODOPA/CARBIDOPA PRODUCT FOR TREATMENT OF PARKINSONS DISEASE. APPROVAL OF XADAGO & NOURIANZ REQUIRE ONE CLAIM WITH A PREFERRED LEVODOPA/CARBIDOPA IN THE PAST 30 DAYS. PHARMACY HISTORY INDICATES NO RX FOR LEVODOPA/CARBIDOPA IN THE PAST 30 DAYS. (SMART PA)
|
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
|
BRAND PROTOPIC IS NONPREFERRED: PLEASE DISPENSE PREFERRED GENERIC TACROLIMUS. (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
|
CLAIM IS FOR NON-PREFERRED CETIRIZINE CHEWABLE TABLETS. CETIRIZINE SOLUTION IS PREFERRED. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED ANTIHISTAMINES. (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 AIRDUO PRODUCTS AND ARMONAIR DIGIHALERS ARE NON-PREFERRED AND REQUIRE A CLINICAL REVIEW FOR APPROVAL. REFER TO THE PDL FOR A LIST OF PREFERRED INHALED GLUCOCORTICOIDS. (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 TACROLIMUS 0.03% ARE INDICATED FOR AGE >/= 2 YEARS. AN AGE WAIVER SIGNED BY PRESCRIBER MUST BE SUBMITTED FOR APPROVAL FOR < 2 YEARS OF AGE. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4646
|
ELIDEL AND TACROLIMUS 0.1% ARE INDICATED FOR AGE >/= 6 YEARS. AN AGE WAIVER SIGNED BY PRESCRIBER MUST BE SUBMITTED FOR APPROVAL FOR < 6 YEARS OF AGE. (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 CLINICAL REVIEW FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4668
|
A HISTORY OF 1 CLAIM WITH THE REQUESTED AGENT IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL OF LOTRONEX, GATTEX OR ZORBTIVE. BENEFICIARIES WITH NO RX FOUND WILL REQUIRE A CLINICAL REVIEW FOR APPROVAL. (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. NON-PREFERRED VIBERZI ALSO REQUIRES 30 DAYS THERAPY WITH 2 PREFERRED IBS-D AGENTS IN THE PAST 6 MONTHS OR A HISTORY OF 1 CLAIM WITH VIBERZI IN THE PAST 105 DAYS FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4671
|
A HISTORY OF 30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED IBS-D AGENTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. NO 30 DAYS OF THERAPY WITH 2 PREFERRED IBS-D AGENTS FOUND IN PHARMACY CLAIMS HISTORY. (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 2 PREFERRED AGENTS IN THE PAST 6 MONTHS OR 1 CLAIM WITH THE SAME REQUESTED NONPREFERRED AGENT IN THE PAST 105 DAYS 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 CLINICAL REVIEW 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
|
AIMOVIG, AJOVY, AND EMGALITY REQUIRE A MANUAL PA FOR APPROVAL. (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
|
REQUESTED AGENT IS NON-PREFERRED. BUPRENORPHINE/NALOXONE FILM LABELER 52427, BRAND SUBOXONE FILM AND BUPRENORPHINE/NALOXONE TABLETS ARE THE PREFERRED BUPRENORPHINE AGENTS. (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 CLINICAL REVIEW 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 CLINICAL REVIEW 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. NO DIAGNOSIS TOTAL BLINDNESS FOUND. (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
|
ORTIKOS ER REQUIRES A CLINICAL REVIEW FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4831
|
REQUESTED RX IS FOR NONPREFERRED ELIDEL OR PIMECROLIMUS. PLEASE DISPENSE PREFERRED GENERIC PIMECROLIMUS LABELER CODE 68682. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4832
|
SPIRIVA RESPIMAT IS INDICATED FOR AGE >/= 6 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. ALSO REQUIRES A DIAGNOSIS OF ASTHMA IN THE PAST 2 YEARS FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4833
|
SPIRIVA RESPIMAT REQUIRES A DIAGNOSIS OF ASTHMA IN THE PAST 2 YEARS FOR APPROVAL. NO DIAGNOSIS FOUND. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4834
|
A HISTORY OF 1 CLAIM FOR HEMLIBRA IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. NO PREVIOUS RX FOR HEMLIBRA FOUND IN PHARMACY CLAIMS HISTORY. NEW STARTS REQUIRE MANUAL A PA FOR APPROVAL (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4835
|
VIBERZI REQUIRES 30 DAYS THERAPY WITH 2 PREFERRED IBS-D AGENTS IN THE PAST 6 MONTHS OR A HISTORY OF 1 CLAIM WITH VIBERZI IN THE PAST 105 DAYS FOR APPROVAL. NO VIBERZI RX FOUND IN PHARMACY CLAIMS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4836
|
APPROVAL OF EUCRISA REQUIRES A HISTORY OF AT LEAST 28 DAYS OF THERAPY WITH BOTH A CALCINEURIN INHIBITOR AND A TOPICAL STEROID IN THE PAST YEAR. NO PREVIOUS TOPICAL STEROID PRESCRIPTION FOUND IN PHARMACY CLAIMS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4837
|
FOR AGES 1 - 17 YEARS, ENTRESTO REQUIRES A DIAGNOSIS OF HEART FAILURE WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION IN THE PAST 2 YEARS FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4838
|
CLAIM IS FOR NON-PREFERRED PULMICORT RESPULES OR BUDESONIDE 1 MG AMPUL. 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
|
4842
|
ALL TRICYCLIC ANTIDEPRESSANT PRESCRIPTIONS FOR BENEFICIARIES < 25 YEARS OF AGE REQUIRE A CLINICAL REVIEW FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4843
|
REYVOW REQUIRES A DIAGNOSIS OF MIGRAINE IN THE PAST 2 YEARS FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. MUST ALSO MEET PDL CRITERIA FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4844
|
REYVOW REQUIRES A HISTORY OF 2 DIFFERENT TRIPTANS IN THE PAST 90 DAYS FOR APPROVAL. PHARMACY CLAIMS INDICATE NO RX FILLED FOR 2 DIFFERENT TRIPTANS IN THE PAST 90 DAYS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4845
|
NON-PREFERRED REYVOW REQUIRES A TRIAL OF PREFERRED NURTEC ODT IN THE PAST 90 DAYS FOR APPROVAL. PHARMACY CLAIMS INDICATE NO RX FOR NURTEC ODT IN THE PAST 90 DAYS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4847
|
THE REQUESTED QUANTITY EXCEEDS THE QUANTITY LIMIT ALLOWED FOR REYVOW. REYVOW 50 MG ALLOWED 4 TABLETS PER MONTH AND REYVOW 100 MG ALLOWED 8 TABLETS PER MONTH. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4848
|
FINTEPLA REQUIRES A CLINICAL REVIEW FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4849
|
XYREM AND XYWAV REQUIRE A CLINICAL REVIEW FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4851
|
LYNPARZA CAPSULES REQUIRE A CLINICAL REVIEW 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
|
4861
|
NURTEC ODT AND UBRELVY REQUIRE A DIAGNOSIS OF MIGRAINE IN THE PAST 2 YEARS FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. MUST ALSO MEET PDL CRITERIA FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4862
|
NURTEC ODT AND UBRELVY ARE INDICATED FOR AGES >/= 18 YEARS. MUST SUBMIT AN AGE WAIVER SIGNED BY THE PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4863
|
NURTEC ODT AND UBRELVY REQUIRE A HISTORY OF 2 DIFFERENT TRIPTANS IN THE PAST 180 DAYS FOR APPROVAL. PHARMACY CLAIMS INDICATE NO RX FILLED FOR 2 DIFFERENT TRIPTANS IN THE PAST 180 DAYS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4864
|
NURTEC ODT SHOULD NOT BE PRESCRIBED CONCURRENTLY WITH OTHER CGRP AGENTS. PHARMACY CLAIMS HISTORY INDICATES A RX FOR A DIFFERENT GGRP AGENT FILLED IN THE PAST 30 DAYS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4865
|
THE REQUESTED QUANTITY EXCEEDS THE 8 TABLETS PER MONTH QUANTITY LIMIT ALLOWED FOR NURTEC ODT. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4866
|
NON-PREFERRED UBRELVY REQUIRES A TRIAL OF PREFERRED NURTEC ODT IN THE PAST 180 DAYS FOR APPROVAL. PHARMACY CLAIMS INDICATE NO RX FOR NURTEC ODT IN THE PAST 180 DAYS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4867
|
UBRELVY SHOULD NOT BE PRESCRIBED CONCURRENTLY WITH OTHER CGRP AGENTS. PHARMACY CLAIMS HISTORY INDICATES A RX FOR A DIFFERENT GGRP AGENT WAS FILLED IN THE LAST 30 DAYS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4868
|
THE REQUESTED QUANTITY EXCEEDS THE 16 TABLETS PER MONTH QUANTITY LIMIT ALLOWED FOR UBRELVY. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4869
|
UBRELVY IS CONTRAINDICATED WITH CONCOMITANT USE OF A STRONG CYP3A4 INHIBITORS. PHARMACY HISTORY INDICATES A RX FOR A STRONG CYP3A4 INHIBITOR FILLED IN THE PAST 30 DAYS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4870
|
A DIAGNOSIS OF CYSTIC FIBROSIS IN THE PAST 2 YRS IS REQUIRED FOR APPROVAL OF COLISTIMETHATE. ALL OTHER DIAGNOSES REQUIRE A CLINICAL REVIEW FOR APPROVAL. (SMART PA)
|
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
|
4891
|
BAQSIMI REQUIRES AT LEAST 1 CLAIM WITH A PREFERRED GLUCAGON OR 1 CLAIM FOR BAQSIMI IN THE PAST 365 DAYS FOR APPROVAL. PHARMACY CLAIMS INDICATE NO PREFERRED GLUCAGON OR PREVIOUS BAQSIMI RX FILLED IN THE PAST 365 DAYS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4892
|
NONPREFERRED GLUCAGONS REQUIRE AT LEAST 1 CLAIM WITH A PREFERRED GLUCAGON IN THE PAST 30 DAYS FOR APPROVAL. PHARMACY CLAIMS INDICATE NO PREFERRED GLUCAGON RX FILLED IN THE PAST 30 DAYS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4893
|
NONPREFERRED GVOKE REQUIRES AT LEAST 1 CLAIM WITH PREFERRED BAQSIMI IN THE PAST 30 DAYS FOR APPROVAL. PHARMACY CLAIMS INDICATE NO RX FILLED FOR BAQSIMI IN THE PAST 30 DAYS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4900
|
FASENRA SYRINGES, NUCALA VIALS, CINQAIR AND XOLAIR ARE NOT SELF-ADMINISTERED AND CANNOT BE BILLED THROUGH POS. PLEASE BILL THROUGH MEDICAL VENUE. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4901
|
AGE IS LESS THAN THE RECOMMENDED MINIMUM AGE FOR THIS DRUG. APPROVAL REQUIRES AN AGE WAIVER SIGNED BY THE PRESCRIBER. ALL AGENTS MUST ALSO MEET DIAGNOSIS AND PDL CRITERIA FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4902
|
A DIAGNOSIS OF SEVERE PERSISTANT ASTHMA IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF REQUESTED AGENT. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4903
|
APPROVAL OF REQUESTED AGENT REQUIRES ADHERENCE TO CONTROLLER THERAPY AS EVIDENCED BY 90 DAYS OF THERAPY WITH A COMBINATION ICS/LABA PRODUCT OR AN INHALED CORTICOSTEROID IN THE PAST 120 DAYS. NO RX FOR AN ICS/LABA OR ICS PRODUCT FOUND IN PHARMACY CLAIMS. (SMART PA)
|
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 1 CLAIM WITH THE SAME REQUESTED NONPREFERRED AGENT IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4907
|
APPROVAL OF REQUESTED AGENT REQUIRES ADHERENCE TO CONTROLLER THERAPY AS EVIDENCED BY 90 DAYS OF THERAPY WITH AN INHALED CORTICOSTEROID AND EITHER A LABA INHALER OR A LEUKOTREINE MODIFIER IN THE PAST 120 DAYS. NO RX FOR A LABA INHALER OR A LEUKOTRIENE MODIFIER FOUND IN PHARMACY CLAIMS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4908
|
APPROVAL OF REQUESTED AGENT REQUIRES 2 OR MORE EXACERBATIONS PER YEAR AS EVIDENCED BY AT LEAST 2 CLAIMS FOR 3 DAYS EACH WITH AN ORAL CORTICOSTEROID IN THE PAST YEAR. NO 2 RX FOR 3 DAYS EACH WITH AN ORAL CORTICOSTEROID FOUND IN PHARMACY CLAIMS HISTORY. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4909
|
APPROVAL OF REQUESTED AGENT REQUIRES CURRENT CONTROLLER THERAPY AS EVIDENCED BY 1 CLAIM WITH A COMBINATION ICS/LABA PRODUCT OR AN INHALED CORTICOSTEROID IN THE PAST 30 DAYS. NO RX FOR AN ICS/LABA OR ICS PRODUCT FOUND IN PHARMACY CLAIMS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4910
|
APPROVAL OF REQUESTED AGENT REQUIRES CURRENT CONTROLLER THERAPY AS EVIDENCED BY 1 CLAIM WITH AN INHALED CORTICOSTEROID AND EITHER A LABA INHALER OR A LEUKOTREINE MODIFIER IN THE PAST 30 DAYS. NO RX FOR A LABA INHALER OR A LEUKOTREINE MODIFIERFOUND IN PHARMACY CLAIMS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4911
|
REQUESTED AGENT SHOULD NOT BE PRESCRIBED CONCURRENTLY WITH ANY OTHER ASTHMA IMMUNOLOGIC THERAPY. PHARMACY CLAIMS HISTORY INDICATES A RX FOR A DIFFERENT ASTHMA IMMUNOLOGIC THERAPY WAS FILLED IN THE PAST 30 DAYS. (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
|
4917
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A 3-DRUG COMBINATION HYPOGLYCEMIC IN THE PAST 30 DAYS. REQUESTED SINGLE ENTITY HYPOGLYCEMIC RX IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4918
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A 3-DRUG COMBINATION ORAL HYPOGLYCEMIC IN THE PAST 30 DAYS. REQUESTED 2-DRUG COMBINATION ORAL HYPOGLYCEMIC IS > 4 ORAL HYPOGLYCEMIC AGENTS IN THE PAST 30 DAYS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4919
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A SINGLE ENTITY OR A 2-DRUG ORAL HYPOGLYCEMIC IN THE PAST 30 DAYS. REQUESTED 3-DRUG COMBINATION ORAL HYPOGLYCEMIC IS THE 4TH OR > ORAL HYPOGLYCEMIC AGENT. (SMART PA)
|
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 FOR > 7-DAY SUPPLY 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
|
PROAIR DIGIHALER REQUIRES A CLINICAL REVIEW 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 PA FOR APPROVAL. PHARMACY CLAIMS INDICATE THERE IS HISTORY OF A DPP-4 OR A GLP-1 RX FILLED IN THE PAST 30 DAYS. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4952
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF 3 OR MORE ORAL HYPOGLYCEMICS IN THE PAST 30 DAYS. REQUESTED SINGLE ENTITY HYPOGLYCEMIC RX IS THE 4TH OR > ORAL HYPOGLYCEMIC AGENT. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4953
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT WHICH REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF 2 OR MORE COMBINATION HYPOGLYCEMICS IN THE PAST 30 DAYS. REQUESTED SINGLE ENTITY HYPOGLYCEMIC RX IS THE 4TH OR > ORAL HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4954
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF BOTH A COMBINATION AGENT AND A SINGLE ENTITY HYPOGLYCEMIC IN THE PAST 30 DAYS. REQUESTED SINGLE ENTITY HYPOGLYCEMIC IS THE 4TH OR > 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 OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A SULFONYLUREA PRODUCT, A MEGLITINIDE PRODUCT AND A DIFFERENT HYPOGLYCEMIC IN THE PAST 30 DAYS. REQUESTED SINGLE ENTITY HYPOGLYCEMIC RX IS THE 4TH OR > 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 OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF 2 OR MORE ORAL HYPOGLYCEMICS IN THE PAST 30 DAYS. REQUESTED 2-DRUG COMBINATION HYPOGLYCEMIC RX IS THE 4TH OR > ORAL HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4961
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A 2-DRUG COMBINATION HYPOGLYCEMIC IN THE PAST 30 DAYS. REQUESTED 2 DRUG COMBINATION HYPOGLYCEMIC RX IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4963
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF BOTH A SULFONYLUREA PRODUCT AND A MEGLITINIDE PRODUCT IN THE PAST 30 DAYS. REQUESTED 2-DRUG COMBINATION HYPOGLYCEMIC RX IS THE 4TH OR > ORAL HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4964
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A COMBINATION MEGLITINIDE PRODUCT IN THE PAST 30 DAYS. REQUESTED COMBINATION SULFONYLUREA RX IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4965
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A DIFFERENT HYPOGLYCEMIC AND A COMBINATION MEGLITINIDE PRODUCT IN THE PAST 30 DAYS. REQUESTED SULFONYLUERA RX IS THE 4TH OR > ORAL HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4966
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A MEGLITINIDE PRODUCT AND ANOTHER HYPOGLYCEMIC IN THE PAST 30 DAYS. REQUESTED COMBINATION SULFONYLUERA RX IS THE 4TH OR > ORAL HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4967
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A MEGLITINIDE PRODUCT AND 2 OR MORE OTHER HYPOGLYCEMICS IN THE PAST 30 DAYS. REQUESTED SULFONYLUREA RX IS THE 4TH OR > ORAL HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4968
|
THE ADDITION OF A 4TH CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A MEGLITINIDE PRODUCT AND A COMBINATION HYPOGLYCEMIC IN THE PAST 30 DAYS. REQUESTED SULFONYLUREA IS THE 4TH HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4969
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A COMBINATION SULFONYLUREA PRODUCT IN THE PAST 30 DAYS. REQUESTED COMBINATION MEGLITINIDE RX IS THE 4TH ORAL HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4970
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A HYPOGLYCEMIC AND A COMBINATION SULFONYLUERA PRODUCT IN THE PAST 30 DAYS. REQUESTED MEGLITINIDE RX IS THE 4TH OR > ORAL HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4971
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF ANOTHER HYPOGLYCEMIC AND A SULFONYLUERA PRODUCT IN THE PAST 30 DAYS. REQUESTED COMBINATION MEGLITINIDE IS THE 4TH OR > ORAL HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4973
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A SULFONYLUREA PRODUCT AND 2 OR MORE OTHER HYPOGLYCEMICS IN THE PAST 30 DAYS. REQUESTED MEGLITINIDE RX IS THE 4TH OR > ORAL HYPOGLYCEMIC. (SMART PA)
|
75-PRIOR AUTH REQUIRED
|
4975
|
THE ADDITION OF A 4TH OR > CONCURRENT ORAL ANTIHYPERGLYCEMIC AGENT REQUIRES A PA FOR APPROVAL. THERE IS A HISTORY OF A SULFONYLUREA PRODUCT AND A COMBINATION HYPOGLYCEMIC IN THE PAST 30 DAYS. REQUESTED MEGLITINIDE RX IS THE 4TH OR > 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. NO RIOMET RX FOUND IN PHARMACY CLAIMS IN THE PAST 90 DAYS. (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. NO PREVOUS RX FOR REQUESTED AGENT FOUND. (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 PREFERRED AMITIZA 8 MCG AND LINZESS 290 MCG IN THE PAST 6 MONTHS OR 1 CLAIM WITH NONPREFERRED TRULANCE IN THE PAST 105 DAYS 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
|
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
|
4227
|
PATIENT HAS HISTORY OF PREVIOUS COVID VACCINE ADMINISTRATION THAT IS IN CONFLICT WITH THE IN PROCESS CLAIM.
|
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
|
4413
|
REBATED KITS REQUIRE A PA. NON- REBATED KITS ARE NOT COVERED. EXCEPTIONS MAY BE MADE FOR CHILDREN <21
|
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
|
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
|
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
|
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.
|
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.
|
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.
|
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
|
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
|
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
|
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)"
|
DR-INV PRESCRIBER LAST NAME
|
4225
|
EDIT IGNORED
|
DT-INV UNIT DOSE INDICATOR
|
4226
|
M/I UNIT DOSE INDICATOR
|
DV-INV OTHER PAYER AMOUNT PD
|
4229
|
OTHER PAYER AMOUNT PAID CANNOT BE A NEGATIVE AMOUNT.
|
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.
|
ET-INV QUANTITY PRESCRIBED
|
4916
|
QUANTITY PRESCRIBED ENTERED INTO NCPDP FIELD # 460-ET REQUIRED WHEN BILLING DEA SCHEDULE II DRUGS
|
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
|
E3-INV INCENTIVE AMOUNT SUBMITTED
|
4124
|
VACCINE ADMINISTRATION FEE PAID - NO DISPENSING FEE PAID - INFORMATIONAL ONLY
|
E3-INV INCENTIVE AMOUNT SUBMITTED
|
4125
|
INCENTIVE AMOUNT SUBMITTED FOR VACCINE ADMINISTRATION DOES NOT MATCH ALLOWED ADMINISTRATION FEE - INFORMATIONAL ONLY.
|
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
|
4176
|
PROFESSIONAL SERVICE CODE NOT MA ON A VACCINE ADMINISTRATION CLAIM
|
E5-INV PROFESSIONAL SERVICE CODE
|
4231
|
THIS EDIT POSTS TO SHOW THAT THE CLAIM IS FOR COVID 19 VACCINE ADMINISTRATION. IT MEANS THAT THE PHARMACY SUBMITTED A PROFESSIONAL SERVICE CODE VALUE MA ON A CLAIM THAT IS FOR A COVID VACCINE. (INFORMATIONAL ONLY)
|
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
|
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.
|
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
|
PT. LOCKED IN TO ONE PHARMACY FOR MEDS. CALL MEDICAID PROGRAM INTEGRITY UNIT AT 1 -800--880-5920 FOR QUESTIONS.
|
M2-RECIPIENT LOCKED IN
|
4857
|
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.
|
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).
|
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).
|
7K-CVRG CD PYR AMT DISCREPANCY
|
4261
|
OTHER PAYER AMOUNT PAID IS REQUIRED IF PAYMENT COLLECTED
|
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)
|