POS Edit Codes
(This list is updated daily)




  NCPDP Reject Code / Description     DOM Exception
Code #  
Exception Code Long Description
01-INV BIN NUMBER  4001 THE BIN NUMBER IS MISSING OR IS NOT = '610084'.
01-INV BIN NUMBER  4098 DO NOT USE
03-INV TRANSACTION CODE  4004 THE TRANSACTION CODE IS MISSING (ZEROS) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD IN VERSION 3.2.
03-INV TRANSACTION CODE  4005 THE TRANSACTION CODE IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD IN VERSION 5.1.
03-INV TRANSACTION CODE  4006 THE TRANSACTION CODE IS NOT ONE OF THE TRANSACTION CODES IN VERSION 3.2 OR 5.1 THAT THE CUSTOMER ACCEPTS FOR PROCESSING.
04-INV PROCESSOR CONTROL NUMBER  4007 M/I PROCESSOR CONTROL - MUST BE 'DRMSTEST' OR 'DRMSPROD'.
05-INV PHARMACY NUMBER  4008 THE NPI NUMBER WAS NOT SUBMITTED FOR THE PHARMACY.
05-INV PHARMACY NUMBER  4009 THE PHARMACY PROVIDER ID DOES NOT EXIST ON THE PROVIDER MASTER TABLE.
05-INV PHARMACY NUMBER  4018 THE PROVIDER NUMBER SUBMITTED IS NOT A PHARMACY PROVIDER TYPE.
05-INV PHARMACY NUMBER  4080 EDIT IGNORED
05-INV PHARMACY NUMBER  4365 THE PHARMACY PROVIDER IS ENROLLED IN THE NETWORK ON THE DATE OF SERVICE AND IS UNDER REVIEW
05-INV PHARMACY NUMBER  4370 THE PHARMACY ID ON THE REPLACEMENT OR CREDIT REQUEST DOES NOT MATCH THE PHARMACY PROVIDER NUMBER ON THE CLAIM THAT IS BEING REPLACED OR CREDITED.
05-INV PHARMACY NUMBER  4794 IF PHARMACY ID = ZEROES AND THE PAYEE CODE IS NOT EQUAL TO PAY EMPLOYEE; POST THE ERROR.
05-INV PHARMACY NUMBER  4795 BILLING PROVIDER ID INVALID
05-INV PHARMACY NUMBER  4796 PROVIDER LOC. CODE MISSING
05-INV PHARMACY NUMBER  4797 PROVIDER LOC. CODE INVALID
06-INV GROUP NUMBER  4751 EDIT IGNORED
07-INV CARDHOLDER ID  4010 THE MEMBER ID IS MISSING OR EQUAL TO SPACES.
07-INV CARDHOLDER ID  4011 THE MEMBER ID IS MISSING (ZERO).
07-INV CARDHOLDER ID  4434 MEMBER ID DOES NOT MATCH VALID VALUES
07-INV CARDHOLDER ID  4910 MEMBER ID NOT IN VALID FORMAT
07-INV CARDHOLDER ID  4995 INVALID RECIPIENT CHECK DIGIT
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
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 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
22-INV DAW/PROD SELECTION CD  4982 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  4973 EDIT IGNORED
25-INV PRESCRIBER ID  4975 EDIT IGNORED
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"
32-INV LEVEL OF SERVICE  4961 EDIT IGNORED
33-INV PRESCRIPTION ORIGIN CD  4757 EDIT IGNORED
34-INV SUBMISSION CLARIF CODE  4070 EDIT IGNORED
34-INV SUBMISSION CLARIF CODE  4444 EDIT IGNORED
35-INV PRIMARY CARE PROV ID  4071 THE PRIMARY CARE PROVIDER ID IS MISSING (SPACES).
35-INV PRIMARY CARE PROV ID  4072 M/I PRIMARY CARE PROVIDER ID
36  4758 EDIT IGNORED
38-INV BASIS OF COST  4759 EDIT IGNORED
39-INV DIAGNOSIS CODE  4242 INVALID DIAGNOSIS CODE. ONLY VALID ICD-10 CODES ALLOWED FOR DATE OF SERVICE ON OR AFTER 10/01/2015
39-INV DIAGNOSIS CODE  4760 EDIT IGNORED
40-PHARM NT CONT W PLAN ON DT SRV  4075 PHARMACY IS NOT ENROLLED AS A MEDICAID PROVIDER ON DATE OF SERVICE.
40-PHARM NT CONT W PLAN ON DT SRV  4806 EDIT IGNORED
40-PHARM NT CONT W PLAN ON DT SRV  4807 EDIT IGNORED
40-PHARM NT CONT W PLAN ON DT SRV  4861 PROV. INELIG. TO BILL FOR DOS
40-PHARM NT CONT W PLAN ON DT SRV  4862 "PHARMACY NOT CONTRACTED WITH PLAN ON DATE OF SERVICE - CHECKS IF THE PHARMACY IS ON FILE AND IF THE DATE RANGE FOR THE PLAN INCLUDES THE DATE OF SERVICE ON THE CLAIM; IF NOT - THEN POST THE ERROR EDIT WILL POST FOR NON-590 PROVIDERS SUBMITTING 590 CLAIMS NOTE: THIS IS A GENERIC EDIT THAT POSTS FOR NON-INCAID OR NON
41-SUBMIT BILL TO OTHER PROCESSOR  4062 THE PAYER ID DOES NOT MATCH THE CARRIER CODE ON THE CARRIER TABLE.
41-SUBMIT BILL TO OTHER PROCESSOR  4077 PT. HAS OTHER INSURANCE. SUBMIT CLAIMS TO TO OTHER INSURANCE PRIOR TO BILLING MEDICAID. SEE 'BILLING TIPS' @ HTTP://WWW.MEDICAID.MS.GOV/PHARMACY.ASPX
41-SUBMIT BILL TO OTHER PROCESSOR  4268 SERVICE NOT AUTHORIZED FOR CHIP BENEFICIARY
41-SUBMIT BILL TO OTHER PROCESSOR  4307 BENEFICIARY INCLUDED ON MS CHIP ENCOUNTER CLAIM, BUT IS NOT IN COE 099 OR MS CHIP LOCK IN.
41-SUBMIT BILL TO OTHER PROCESSOR  4377 EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR  4378 EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR  4380 EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR  4382 EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR  4383 EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR  4384 EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR  4396 EDIT IGNORED
41-SUBMIT BILL TO OTHER PROCESSOR  4397 THE COVERAGE TYPE IS 17 AND THE OTHER INSURANCE INDICATOR IS 4 AND THE OTHER AMOUNT PAID IS ZERO AND CARRIER FOUND AND NOT DAW AND THE ADJUDICATION DATE IS GREATER THAN FDOS + 3 DAYS.
41-SUBMIT BILL TO OTHER PROCESSOR  4398 THE COVERAGE TYPE IS 17 AND THE OTHER INSURANCE INDICATOR IS 0 AND THE OTHER AMOUNT PAID IS GREATER THAN ZERO.
41-SUBMIT BILL TO OTHER PROCESSOR  4399 THE COVERAGE TYPE IS 17 AND THE OTHER INSURANCE INDICATOR IS 2 AND THE OTHER AMOUNT PAID IS ZERO.
41-SUBMIT BILL TO OTHER PROCESSOR  4418 THE COVERAGE TYPE IS NOT 17 AND THE OTHER INSURANCE INDICATOR IS 2 AND THE OTHER AMOUNT PAID IS ZERO.
41-SUBMIT BILL TO OTHER PROCESSOR  4419 THE COVERAGE TYPE IS 17 EXISTS AND THE CARRIER IS EQUAL '09200 ' - '09201 ' - '09212' AND THE OTHER AMOUNT PAID IS GREATER THAN ZERO AND/OR THE OTHER INSURANCE INDICATOR IS NOT EQUAL ‘2’ AND/OR THE CARRIER NOT FOUND AND/OR THE PAYER-ID DATE EXISTS.
41-SUBMIT BILL TO OTHER PROCESSOR  4427 "IF PARTICIPANT HAS TPL AND TPL AMOUNT LESS THAN 5% OF SUBMITTED INGREDIENT COST AND OTHER INSURANCE INDICATOR = 2 - 3 OR 4"
41-SUBMIT BILL TO OTHER PROCESSOR  4433 THE COVERAGE TYPE IS NOT 17 AND THE OTHER INSURANCE INDICATOR IS 0 -1 -3 -4 AND THE OTHER AMOUNT PAID IS ZERO.
41-SUBMIT BILL TO OTHER PROCESSOR  4601 CLIENT SPECIFIC EDIT (MS): CLAIMS FILED FOR BENEFICIARIES THAT QUALIFY FOR MEDICARE PART B COVERAGE WHERE THE DRUG ON THE CLAIM IS A MEDICARE PART B COVERED DRUG. MEDICAID EOMB ATTACHMENT
41-SUBMIT BILL TO OTHER PROCESSOR  4602 CLIENT SPECIFIC EDIT (MS): CLAIMS FILED FOR BENEFICIARIES THAT QUALIFY FOR MEDICARE PART B COVERAGE WHERE THE DRUG ON THE CLAIM IS A MEDICARE PART B COVERED DRUG
41-SUBMIT BILL TO OTHER PROCESSOR  4630 THIRD PARTY COVERAGE AND NO AMOUNT WAS RECOVERED FOR COVERAGE CODE 01,03,04,06 AND 07
41-SUBMIT BILL TO OTHER PROCESSOR  4815 BENEFICIARY ON ENCOUNTER CLAIM IS NOT LOCKED IN TO THE CORRECT CCO
41-SUBMIT BILL TO OTHER PROCESSOR  4846 SERVICE NOT AUTHORIZED FOR MISSISSIPPI CAN BENEFICIARY
41-SUBMIT BILL TO OTHER PROCESSOR  4863 MEMBER COVERED BY PRIVATE INS
41-SUBMIT BILL TO OTHER PROCESSOR  4880 MUST BILL HOSPICE. IF HOSPICE PAYS THE CLAIM, IT WILL BE CONSIDERED PAID IN FULL. IF HOSPICE REJECTS DUE TO NONCOVERAGE SUBMIT A '03' IN OTHER COVERAGE CODE FIELD 308-C8
41-SUBMIT BILL TO OTHER PROCESSOR  4962 CLAIM INDICATES OTHER COVERAGE BUT MAINFRAME FILES DON'T HAVE COB/TPL INFO ON FILE. PAY THE CLAIM BUT POST THE EXCEPTION. NO EOB REQUIRED.
50-NON-MATCHED PHARMACY NUMBER  4081 THE SERVICE PHARMACY PROVIDER ID DOES NOT EXIST ON THE PROVIDER MASTER TABLE.
50-NON-MATCHED PHARMACY NUMBER  4440 AN ADJUSTMENT REQUEST RECORD HAS A SERVICING PHARMACY (ALT ID) EQUAL TO SPACES.
50-NON-MATCHED PHARMACY NUMBER  4442 AN ADJUSTMENT REQUEST RECORD HAS TARGETED A HISTORY RECORD FOR ADJUSTMENT - BUT THE BILLING PROVIDER NUMBER ON THE ADJUSTMENT REQUEST RECORD DOES NOT MATCH THE BILLING PROVIDER NUMBER ON THE HISTORY RECORD
50-NON-MATCHED PHARMACY NUMBER  4951 PROVIDER NOT ELIGIBLE TO BILL SPECIALTY DRUGS
50-NON-MATCHED PHARMACY NUMBER  4994 EDIT IGNORED
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.
52-NON-MATCHED CARDHOLDER ID  4996 EDIT IGNORED
53-NON-MATCHED PERSON CODE  4088 PERSON CODE IN FIELD 303-C3 MUST BE 001 (CARDHOLDER)
54-NON-MATCHED PRODUCT/SERVICE ID  4089 NON-MATCHED NDC (NOT ON DRUG FILE)
54-NON-MATCHED PRODUCT/SERVICE ID  4981 NOT A SPECIALTY DRUG, AS THIS DRUG HAS A NADAC PRICE
55-NON-MATCHED PRODUCT PKG SIZE  4761 EDIT IGNORED
56-NON-MATCHED PRESCRIBER ID  4090 PHYSICIAN LIC# NOT ON FILE (LOCKIN)
56-NON-MATCHED PRESCRIBER ID  4220 PRESCRIBER IS NOT A MEDICAID PROVIDER. PRESCRIBER HAS 90 DAYS FROM THE DATE OF FIRST CLAIM SUBMITTED TO MEDICAID TO ENROLL AS PROVIDER UNTIL CLAIMS DENY.
56-NON-MATCHED PRESCRIBER ID  4421 EDIT IGNORED
56-NON-MATCHED PRESCRIBER ID  4535 PRESCRIBER IS NOT A MEDICAID PROVIDER
56-NON-MATCHED PRESCRIBER ID  4977 PHARMACY NPIS &/OR DUMMY PRESCRIBER NPIS ARE NOT ALLOWED IN PRESCRIBER FIELD
57-NONMATCHED PA/MED CERT  4762 EDIT IGNORED
58-NON-MATCHED PRIMARY PRESCRIBER  4763 EDIT IGNORED
59  4764 EDIT IGNORED
60-PROD/SVC NOT COVERED-PAT AGE  4092 BENEFICIARY'S AGE IS LESS THAN THE MINIMUM AGE RECOMMENDED BY MFG. PRESCRIBER MAY SUBMIT 'MEDICAL NECESSITY PA FORM FOR EPSDT ELIGIBLE BENE.'
606-BRAND DRUG REQUIRED  4122 GENERIC PRODUCT IS NON-PREFERRED. DISPENSE THE PREFERRED BRAND RATHER THAN THE NON-PREFERRED GENERIC. (SMART PA)
606-BRAND DRUG REQUIRED  4373 NONPREFERRED GENERIC/ NO PA REQUIRED FOR PREFERRED BRAND
61-PROD/SVC NOT COVRD-PAT GENDER  4094 DRUG NOT INDICATED FOR GENDER.
62-PAT/CARD HOLDER NAME MISMATCH  4765 THE NAME ON THE CLAIM DOES NOT MATCH THE NAME ON THE BENEFICIARY'S MEDICAID CARD. CHECK CARD.
63-INSTIT PAT PROD/SVC ID NOT COV  4766 EDIT IGNORED
64-CLM SUB DOES NOT MTCH PRI AUTH  4096 "(THE CLAIM PA NUMBER MISSING OR THE CLAIM PA NUMBER DOES NOT MATCH THE PA NUMBER) AND THE PA REQUIRES A MATCHING PA NUMBER ON THE CLAIM"
65-PATIENT NOT COVERED  4097 PATIENT NOT COVERED – CHECKS THE COVERAGE DATA ON THE ELIGIBILITY FILE TO SEE IF THE CLAIM FDOS IS IN RANGE. ALSO CHECKS THE RELATIONSHIP TO DETERMINE IF THE MEMBER IS COVERED AND CHECKS TO SEE IF IT IS A COVERED MEMBER ID. IF NOT COVERED FOR ANY OF THESE REASONS; THEN POST THE ERROR.
65-PATIENT NOT COVERED  4099 EDIT IGNORED
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  4102 "THE CLAIM MEMBER ID IS NOT EQUAL TO THE MEMBER ID ON THE PARTICIPANT’S MEMBER TABLE OR THE CLAIM FIRST DATE OF SERVICE IS LESS THAN THE PARTICIPANT MEMBER TABLE ELIGIBILITY BEGAN DATE OR THE CLAIM FIRST DATE OF SERVICE IS GREATER THAN THE PARTICIPANT MEMBER TABLE ELIGIBILITY END DATE. "
65-PATIENT NOT COVERED  4429 IF THE PARTICIPANT IS PRODUCTION AND THE CLAIM WAS MARKED AS A TEST CLAIM BECAUSE IT CONTAINED A TEST PROVIDER
65-PATIENT NOT COVERED  4501 RESERVED FOR FUTURE USE
65-PATIENT NOT COVERED  4518 RESERVED FOR FUTURE USE
65-PATIENT NOT COVERED  4597 BENEFICIARY (K-BABY'S MOTHER) IS NOT FEMALE OR IS NOT AT LEAST 8 YRS OLD ON DOS OR IS NOT ELIGIBLE FOR MEDICAID ON DOS
65-PATIENT NOT COVERED  4617 EDIT IGNORED
65-PATIENT NOT COVERED  4808 EDIT IGNORED
65-PATIENT NOT COVERED  4810 DATE RX FILLED CANNOT BE AFTER DATE SUBMITTED
65-PATIENT NOT COVERED  4811 NO DRUG COVERAGE FOR SLMBS OR COE=11 OR 14 (NO DRUGS COVERED THRU POS FOR SPECIFIED LOW-INCOME (SLMB) MEDICARE BENEFICIARIES OR THOSE RESIDING IN A LONG TERM HOSPITAL).
65-PATIENT NOT COVERED  4812 EDIT IGNORED
65-PATIENT NOT COVERED  4813 MEMBER HAS OTHER INSURANCE BUT NO OTHER PAYOR AMT OR OTHER PAYOR DATE SUBMITTED ON THE CLAIM
65-PATIENT NOT COVERED  4814 EDIT IGNORED
65-PATIENT NOT COVERED  4864 EDIT IGNORED
65-PATIENT NOT COVERED  4865 FILLED AFTER COVERAGE EXPIRED
65-PATIENT NOT COVERED  4866 FILLED AFTER COVERAGE TERMINATED
65-PATIENT NOT COVERED  4911 FILLED BEFORE COVERAGE EFFECTIVE – IF THE CLAIM’S FDOS FALLS BEFORE THE OLDEST COVERAGE BEGINNING DATE IN THE COVERAGE TABLE (ELIGIBILITY FILE); THEN THE ERROR IS POSTED.
65-PATIENT NOT COVERED  4950 BENEFICIARY NOT COVERED FOR OUTPATIENT PHARMACY BENEFITS FOR DATE OF SERVICE. (HPE SERVICE MODIFIER).
65-PATIENT NOT COVERED  4956 BENEFICIARY NOT COVERED FOR PHARMACY BENEFITS. (INMATE SERVICE MODIFIER).
65-PATIENT NOT COVERED  4958 PATIENT NO LONGER COVERED BECAUSE DECEASED
65-PATIENT NOT COVERED  4963 EDIT IGNORED
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
67-FILLED BEFORE COV EFFECTIVE  4997 EDIT IGNORED
68-FILLED AFTER COVERAGE EXPIRED  4998 EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED  4041 MEDICAL DEVICES NOT COVERED
70-PRODUCT/SERVICE NOT COVERED  4111 EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED  4113 "A =DESI DRUG (LESS THAN EFFECTIVE DRUG) - NON-REIMBURSABLE"
70-PRODUCT/SERVICE NOT COVERED  4114 PRODUCT NOT COVERED. (IF MEDICAL SUPPLY SUBMIT DME CLAIM)
70-PRODUCT/SERVICE NOT COVERED  4115 I= DEFAULT CODE – NOT COVERED ON PLAN
70-PRODUCT/SERVICE NOT COVERED  4116 PRODUCT NOT COVERED. IF AGE < 21 PRESCRIBER MAY SUBMIT PA REQUEST =  MEDICAL NECESSITY PA FORM FOR EPSDT ELIGIBLE BENE. (IF MEDICAL SUPPLY SUBMIT DME CLAIM)
70-PRODUCT/SERVICE NOT COVERED  4117 NON-REBATED NDC IS NOT COVERED. EXCEPTIONS MAY BE MADE FOR CHILDREN < 21. PRESCRIBER MAY SUBMIT 'MEDICAL NECESSITY PA FORM FOR EPSDT ELIGIBLE BENE.'
70-PRODUCT/SERVICE NOT COVERED  4118 EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED  4119 EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED  4121 "IF THE PRODUCT/SERVICE ID QUALIFIER INDICATES THAT THE PRODUCT/SERVICE ID FIELD CONTAINS A NDC AND THE CLAIM ALLOWED CHARGE EQUALS $0.00 AND THE GROUP PRICING DAW CODE ON THE GROUP PRICING TABLE EQUALS SPACES."
70-PRODUCT/SERVICE NOT COVERED  4124 EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED  4629 PRENATAL VITAMIN - ONLY COVERED FOR PREGNANT FEMALES
70-PRODUCT/SERVICE NOT COVERED  4853 EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED  4947 BILL VIA MEDICAL CLAIM. PA REQUIRED FOR POS BILLING
70-PRODUCT/SERVICE NOT COVERED  4966 EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED  4967 EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED  4976 EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED  4978 EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED  4980 EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED  4988 EDIT IGNORED
70-PRODUCT/SERVICE NOT COVERED  4989 EDIT IGNORED
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  4067 A DIAGNOSIS OF SCHIZOPHRENIA, SCHIZOEFFECTIVE DISORDER OR BIPOLAR DISORDER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF INJECTABLE RISPERDAL CONSTA. (SMART PA)
75-PRIOR AUTH REQUIRED  4069 A DIAGNOSIS OF SCHIZOPHRENIA OR SCHIZOEFFECTIVE DISORDER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF INJECTABLE INVEGA SUSTENNA OR INVEGA TRINZA. (SMART PA)
75-PRIOR AUTH REQUIRED  4073 A DIAGNOSIS OF BREAST CANCER IN THE PAST 2 YEARS WITH HISTORY INDICATING FULVESTRANT IN THE PAST 60 DAYS AND ENDOCRINE THERAPY IN THE PAST 720 DAYS IS REQUIRED FOR APPROVAL OF IBRANCE. NO HISTORY OF ENDOCRINE THERAPY FOUND. (SMART PA)
75-PRIOR AUTH REQUIRED  4076 A DIAGNOSIS OF SCHIZOPHRENIA OR SCHIZOEFFECTIVE DISORDER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF INJECTABLE ZYPREXA RELPREVV.
75-PRIOR AUTH REQUIRED  4079 MUST CONTINUE ORAL OLANZAPINE WHEN PRESCRIPTION HISTORY INDICATES THE PATIENT HAS BEEN COMPLIANT ON ORAL THERAPY OR HAVE AT LEAST 3 CLAIMS WITH ZYPREXA RELPREVV IN THE PAST 90 DAYS FOR APPROVAL. (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 IS INDICATED FOR AGE >/= 2 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (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  4108 A DIAGNOSIS OF CYSTIC FIBROSIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. BETHKIS AND KITABIS ARE THE PREFERRED CYSTIC FIBROSIS AGENTS. MUST ALSO MEET FDA MINIMUM AGE REQUIREMENTS. (SMART PA)
75-PRIOR AUTH REQUIRED  4112 KALYDECO AND ORKAMBI REQUIRE A MANUAL REVIEW FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4125 EDIT IGNORED
75-PRIOR AUTH REQUIRED  4127 RX EXCEEDS 8 RX/MONTH FOR B2I/B2R BENE. IF AGE < 21, ADDITIONAL RXS ALLOWED WITH PRIOR AUTHORIZATION.
75-PRIOR AUTH REQUIRED  4132 PRIOR AUTHORIZATION REQUIRED
75-PRIOR AUTH REQUIRED  4133 "IF THE DUR AMOUNT LIMIT ACCUMULATOR EQUALS ‘ALL’ AND THE DUR AMOUNT LIMIT TOTAL (A CALCULATED FIELD) IS GREATER THAN THE DUR AMOUNT LIMIT FROM THE PLAN BENEFITS LIMIT TABLE AND THE DUR AMOUNT LIMIT STATUS ON THE PLAN’S BENEFITS LIMIT TABLE EQUALS ‘P’ AND THERE IS NO PRIOR AUTHORIZATION INDICATED ON THE CLAIM."
75-PRIOR AUTH REQUIRED  4134 BILLED QTY IS GREATER THAN APPROVED QTY ON PA.
75-PRIOR AUTH REQUIRED  4135 IF THE PRIOR AUTHORIZATION USED DAYS PLUS THE CLAIM PAID DAYS IS GREATER THAN THE PRIOR AUTHORIZATION APPROVED DAYS.
75-PRIOR AUTH REQUIRED  4136 "A DISPENSE AS WRITTEN CODE 1 OVERRIDE IS NOT FOUND AND THE CLAIM PRESCRIBED DATE IS GREATER THAN OR EQUAL TO NOVEMBER 28 - 2001 (13847 IN MILLENNIUM DATE FORMAT) AND THE CLAIM DISPENSE AS WRITTEN CODE IS EQUAL TO 1 (PHYSICIAN DAW)"
75-PRIOR AUTH REQUIRED  4137 RANITIDINE CAPSULES REQUIRE PRIOR AUTHORIZATION. USE RANITIDINE TABLETS.
75-PRIOR AUTH REQUIRED  4138 EDIT IGNORED
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 MUST CONTINUE ORAL PALIPERIDONE WHEN PRESCRIPTION HISTORY INDICATES THE PATIENT HAS BEEN COMPLIANT ON ORAL THERAPY OR HAVE AT LEAST 3 CLAIMS WITH INVEGA SUSTENNA IN THE PAST 90 DAYS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4175 THE MAXIMUM DOSE ALLOWED IS 1 TABLET PER DAY. THE QUANTITY ON THE CLAIM EXCEEDS THIS AMOUNT. (SMART PA)
75-PRIOR AUTH REQUIRED  4179 30 DAYS THERAPY WITH 2 DIFFERENT PREFERRED LONG ACTING STIMULANTS OR A HISTORY OF 1 CLAIM FOR A 30 DAY SUPPLY WITH THE SAME AGENT AS THE INCOMING CLAIM IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4189 THE MAXIMUM DOSE ALLOWED FOR ABILIFY 20 MG AND ABILIFY 30 MG IS 1 TABLET PER DAY. THE QUANTITY ON THE CLAIM EXCEEDS THIS AMOUNT. (SMART PA)
75-PRIOR AUTH REQUIRED  4190 ALL ALZHEIMER'S AGENTS REQUIRE A HISTORY OF AN APPROVABLE DIAGNOSIS IN THE PAST 2 YEARS FOR APPROVAL. NON-PREFERRED ALZHEIMER'S AGENTS MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED  4216 A DIAGNOSIS OF SUBARACHNOID HEMORRHAGE IN THE PAST 45 DAYS IS REQUIRED FOR APPROVAL OF NIMODIPINE. (SMART PA)
75-PRIOR AUTH REQUIRED  4217 NIMODIPINE IS LIMITED TO 252 CAPSULES OR 2520 ML PER MAXIMUM 21 DAYS OF THERAPY. QUANTITY ON THE INCOMING CLAIM PLUS HISTORY IN THE PAST 21 DAYS EXCEEDS QUANTITY ALLOWED. (SMART PA)
75-PRIOR AUTH REQUIRED  4221 PA REQUIRED FOR NONPREFERRED BRAND/ NO PA REQUIRED FOR PREFERRED GENERIC
75-PRIOR AUTH REQUIRED  4223 ADEMPAS REQUIRES A WHO GROUP 1 DIAGNOSIS OF PULMONARY HYPERTENSION OR A WHO GROUP 4 DIAGNOSIS OF PULMONARY HYPERTENSION DUE TO CHRONIC THROMBOTIC AND/OR EMBOLIC DISEASE FOR APPROVAL. (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 XARELTO 15 MG, XARELTO 20 MG, PRADAXA AND SAVAYSA REQUIRE A DIAGNOSIS OF DEEP VEIN THROMBOSIS OR PULMONARY EMBOLISM IN THE PAST 2 YEARS FOR APPROVAL. THEY ARE NOT INDICATED FOR PROHYLAXIS FOLLOWING SURGERY. (SMART PA)
75-PRIOR AUTH REQUIRED  4240 TOBI PODHALER REQUIRES A MANUAL REVIEW. REQUIRES A DIAGNOSIS OF CYSTIC FIBROSIS, 30 DAYS THERAPY WITH PREFERRED BETHKIS OR KITABIS IN THE PAST 90 DAYS AND A CLINICAL REASON WHY THE PREFERRED AGENT CANNOT BE USED. (SMART PA)
75-PRIOR AUTH REQUIRED  4251 CIPRO HC REQ PA FOR PATIENTS 9YRS & UP. PREFERRED MEDS FOR TX OF ACUTE OTITIS EXTERNA ARE COLY-MYCIN S, CORTISPORIN-TC OR NEOMYCIN/POLYMYXIN/HYDROCORTISONE.
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. PREFERRED MEDS FOR TX OF ACUTE OTITIS EXTERNA ARE COLY-MYCIN S, CORTISPORIN-TC OR NEOMYCIN/POLYMYXIN/HYDROCORTISONE.
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 NON-PREFERRED IBS/SHORT BOWEL SYNDROME AGENTS REQUIRE A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4279 A HISTORY OF 1 CLAIM WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4280 ALPRAZOLAM ER REQUIRES A HISTORY OF 1 CLAIM IN THE PAST 90 DAYS WITH THE SAME AGENT AS ON THE INCOMING CLAIM FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4281 ALPRAZOLAM ER HAS A CUMULATIVE QUANTITY LIMIT OF 31 TABLETS/25 DAYS WHEN THE DAILY DOSE ON THE MOST RECENT APRAZOLAM ER RX FILLED WAS </= 1 TABLET/DAY. (SMART PA)
75-PRIOR AUTH REQUIRED  4282 ALPRAZOLAM ER HAS A CUMULATIVE QUANTITY LIMIT OF 62 TABLETS/25 DAYS WHEN THE DAILY DOSE ON THE MOST RECENT APRAZOLAM ER RX FILLED WAS > 1 TABLET/DAY. (SMART PA)
75-PRIOR AUTH REQUIRED  4292 AMPYRA REQUIRES CLINICAL REVIEW. (SMART PA)
75-PRIOR AUTH REQUIRED  4295 USE BRAND TERAZOL 3, IT IS THE PREFERRED DRUG.
75-PRIOR AUTH REQUIRED  4296 A HISTORY OF THERAPY WITH A COMBINATION CARIDOPA AGENT IN PAST 45 DAYS IS REQUIRED IS FOR APPROVAL OF LODOSYN. (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  4302 BYDUREON IS THE PREFERRED AGENT. MEDICAID BENEFICIARIES ARE REQUIRED TO USE PREFERRED BYDUREON EFFECTIVE 10.1.15.(SMART PA)
75-PRIOR AUTH REQUIRED  4306 A DIAGNOSIS OF HUNTINGTON'S CHOREA IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF XENAZINE. (SMART PA)
75-PRIOR AUTH REQUIRED  4310 ZONTIVITY REQUIRES A CLINICAL REVIEW FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4312 A DIAGNOSIS OF A MYOCARDIAL INFARCTION (MI) OR PERIPHERAL ARTERY DISEASE IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF ZONTIVITY. (SMART PA)
75-PRIOR AUTH REQUIRED  4313 A DIAGNOSIS OF A MYOCARDIAL INFARCTION (MI) OR PERIPHERAL ARTERY DISEASE WITH NO HISTORY OF A STROKE, TIA OR INTRACRANIAL HEMORRHAGE (ICH) IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF ZONTIVITY. (SMART PA)
75-PRIOR AUTH REQUIRED  4315 A DIAGNOSIS OF MYOCARDIAL INFARCTION (MI) OR PERIPHERAL ARTERY DISEASE AND A DIAGNOSIS OF A STROKE, TIA OR INTRACRANIAL HEMORRHAGE (ICH) IN THE PAST 2 YEARS AND CONCURRENT THERAPY WITH ASA &/OR CLOPIDOGREL IS REQUIRED FOR APPROVAL OF ZONTIVITY.
75-PRIOR AUTH REQUIRED  4366 A DIAGNOSIS OF SCHIZOPHRENIA OR SCHIZOEFFECTIVE DISORDER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF INJECTABLE ABILIFY MAINTENA. (SMART PA)
75-PRIOR AUTH REQUIRED  4367 MUST CONTINUE ON ORAL ARIPIPRAZOLE WHEN PRESCRIPTION HISTORY INDICATES THE PATIENT HAS BEEN COMPLIANT ON ORAL THERAPY OR HAVE AT LEAST 3 CLAIMS WITH ABILIFY MAINTENA IN THE PAST 90 DAYS FOR APPROVAL. (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 VICTRELIS, INCIVEK, OLYSIO, SOVALDI, HARVONI, VIEKIRA PAK, TECHNIVIE, DAKLINZA, ZEPATIER, VOSEVI AND MAVYRET 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 DAYS SUPPLY IN PAST 30 DAYS AND REMAIN ON A BUPRENORPHINE PRODUCT. (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 PAST 30 DAYS AND REMAIN ON A BUPRENORPHINE PRODUCT. (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 PREFERRED ANDROGEL 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 THERAPYL WITH EITHER A PREF COX-2 OR A PREF NSAID IN THE PAST 6 MONTHS, 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 DOES NOT MEET THE FDA RECOMMENDED AGE REQUIREMENT. 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  4462 CLAIM IS FOR NON-PREFERRED METHYLPHENIDATE ER BY GENERIC LABLER 00406. GENERIC METHYLPHENIDATE ER WITH AUTHORIZED GENERIC LABELER CODES 00591, 62175, AND 68084 ARE PREFERRED. (SMARTPA)
75-PRIOR AUTH REQUIRED  4463 A DIAGNOSIS OF ADD/ADHD IN THE PAST 2 YEARS FOR AGES >/=21 YEARS IS REQUIRED FOR APPROVAL OF ALL STIMULANTS AND NON-STIMULANTS. NONPREFERRED AGENTS MUST ALSO MEET PDL CRITIERIA. (SMART PA)
75-PRIOR AUTH REQUIRED  4464 CLAIM IS FOR NON-PREFERRED GENERIC DEXTROAMPHETAMINE IR. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED SHORT-ACTING STIMULANTS. (SMARTPA)
75-PRIOR AUTH REQUIRED  4465 30 DAYS THERAPY WITH 2 DIFFERENT PREFERRED SHORT ACTING STIMULANTS OR A HISTORY OF 1 CLAIM FOR A 30 DAY SUPPLY WITH THE SAME AGENT AS THE INCOMING CLAIM IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4466 A DIAGNOSIS OF NARCOLEPSY, OBSTRUCTIVE SLEEP APNEA, OR SHIFT WORK SLEEP DISORDER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. NONPREFERRED NUVIGIL MUST ALSO MEET PDL CRITIERIA. (SMART PA)
75-PRIOR AUTH REQUIRED  4467 CLAIM IS FOR A NON-PREFERRED GENERIC METHYLPHENDIDATE CAPSULE OR TABLET. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED LONG-ACTING STIMULANTS. (SMARTPA)
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 REQUIRES A MANUAL CLINICAL REVIEW. (SMART PA)
75-PRIOR AUTH REQUIRED  4470 PATIENT IS FEMALE. REQUESTED ANDROGENIC AGENT IS RECOMMENDED FOR USE IN MALES ONLY. HAVE MD SUBMIT PA REQUEST WITH MEDICAL JUSTIFICATION. (SMART PA)
75-PRIOR AUTH REQUIRED  4471 A DIAGNOSIS ON FILE FOR OSTEOARTHRITIS, RHEUMATOID ARTHRITIS, FAMILIAL ADENOMATOUS POLYPOSIS OR ANKYLOSING SPONDYLITIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4476 AGE IS LESS THAN THE RECOMMENDED MINIMUM AGE AND ALL NONPREFERRED AGENTS MUST ALSO MEET PDL CRITERIA. PREFERRED AGENTS REQUIRE AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4477 AGE IS LESS THAN THE RECOMMENDED MINIMUM AGE OF 7 YEARS FOR TREATMENT OF GENERALIZED ANXIETY DISORDER. APPROVAL REQUIRES AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4478 DULOXETINE REQUIRES A DIAGNOSIS OF GENERALIZED ANXIETY DISORDER IN THE PAST 2 YEARS FOR AGES 7 - 17 YEARS. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED  4479 1 CLAIM WITH 2 DIFFERENT PREFERRED CEPHALOSPORINS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4480 AGE IS LESS THAN THE RECOMMENDED MINIMUM AGE AND ALL NONPREFERRED AGENTS MUST ALSO MEET PDL CRITERIA. PREFERRED AGENTS REQUIRE AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4481 AGE IS LESS THAN THE RECOMMENDED MINIMUM AGE AND REQUIRE AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. ALL NONPREFERRED AGENTS MUST ALSO MEET PDL CRITERIA. NEW STARTS,TOBI PODHALER, KALYDECO & ORKAMBI REQUIRE A MANUAL REVIEW. (SMART PA)
75-PRIOR AUTH REQUIRED  4482 INCOMING CLAIM IS FOR A NON-PREFERRED TOBRAMYCIN PRODUCT. BETHKIS AND KITABIS ARE THE PREFERRED CYSTIC FIBROSIS AGENT. (SMART PA)
75-PRIOR AUTH REQUIRED  4483 REQUESTED NON-PREFERRED BPH AGENT IS NOT INDICATED FOR USE IN FEMALES. (SMART PA)
75-PRIOR AUTH REQUIRED  4484 30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED BPH AGENTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4485 30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED ANTICONVULSANTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AND A DIAGNOSIS OF A SEIZURE DISORDER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4486 A DIAGNOSIS OF KIDNEY TRANSPLANT, RHEUMATOID ARTHRITIS OR OTHER APPROVABLE DIAGNOSIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF AZATHIOPRINE. (SMART PA)
75-PRIOR AUTH REQUIRED  4487 EUCRISA REQUIRES A MANUAL REVIEW FOR APPROVAL. (SMARTPA)
75-PRIOR AUTH REQUIRED  4488 A DIAGNOSIS OF PARKINSON'S DISEASE IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (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 REVIEW 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 A HISTORY OF 1 CLAIM FOR RELISTOR INJECTABLE IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL OF RELISTOR INJECTABLE. (SMART PA)
75-PRIOR AUTH REQUIRED  4494 A HISTORY OF 1 CLAIM FOR RELISTOR TABLETS IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL OF RELISTOR TABLETS. (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 A HISTORY OF 90 DAYS STABLE THERAPY IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL OF KOMBIGLYZE XR, ONGLYZA, OR TANZEUM. (SMART PA)
75-PRIOR AUTH REQUIRED  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  4502 CLAIM IS FOR NON-PREFERRED LAMOTRIGINE ODT. PLEASE DISPENSE PREFERRED LAMOTRIGINE TABLETS OR 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 AND A HISTORY WITH PROCRIT, EPOGEN, OR ARANESP IN THE PAST 6 MONTHS OR 1 CLAIM WITH MIRCERA IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL OF MIRCERA. (SMART PA)
75-PRIOR AUTH REQUIRED  4506 A DIAGNOSIS OF ULCERATIVE COLITIS IN THE PAST 2 YEARS AND A TRIAL WITH 2 PREFERRED INFLAMMATORY BOWEL AGENTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4507 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS ON THE INCOMING CLAIM OR A DIAGNOSIS OF ULCERATIVE COLITIS IN THE PAST 2 YEARS AND 30 DAYS THERAPY WITH 2 DIFFERENT PREFERRED INFLAMMATORY BOWEL AGENTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMARTPA)
75-PRIOR AUTH REQUIRED  4508 BRAND QUDEXY XR IS NONPREFERRED. GENERIC TOPIRAMATE ER IS PREFERRED WITH A DX OF SEIZURE DISORDER IN THE PAST 2 YEARS AND 90 DAYS STABLE THERAPY. 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 BANZEL OR ONFI 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. (SMART PA)
75-PRIOR AUTH REQUIRED  4514 A HISTORY WITH PREFERRED PROCRIT, EPOGEN OR ARANESP IN THE PAST 6 MONTHS OR 1 CLAIM WITH THE SAME AGENT IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4515 KAPVAY AND CLONIDINE ER REQUIRE A DIAGNOSIS OF ADD/ADHD IN THE PAST 2 YEARS. NON-PREFERRED KAPVAY AND CLONIDINE ER MUST ALSO MEET PDL CRITERIA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4516 REQUIRES A DIAGNOSIS OF GLAUCOMA IN THE PAST 2 YEARS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4517 30 DAYS OF THERAPY WITH 2 PREFERRED GLAUCOMA AGENTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4519 A DIAGNOSIS OF DIABETES MELLITUS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4522 A DIAGNOSIS OF DIABETES AND 30 DAYS OF THERAPY WITH A PREFERRED INSULIN OR RELATED AGENT IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4524 A DIAGNOSIS OF ALLERGIC RHINITIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL.(SMART PA)
75-PRIOR AUTH REQUIRED  4525 1 CLAIM WITH 2 DIFFERENT PREFERRED INTRANASAL CORTICOSTEROIDS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4526 AN APPROPRIATE DIAGNOSIS ON FILE IN THE PAST 2 YEARS, 30 DAYS THERAPY WITH A STATIN OR COMBO PRODUCT IN THE PAST YEAR, OR 90 DAYS STABLE THERAPY WITH SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4527 A DIAGNOSIS OF PREGNANCY IN THE PAST 280 DAYS, 30 DAYS THERAPY WITH 2 DIFFERENT PREFERRED BILE ACID SEQUESTRANTS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH WELCHOL IS REQUIRED FOR APPROVAL. WELCHOL. (SMART PA)
75-PRIOR AUTH REQUIRED  4528 30 DAYS THERAPY WITH 2 DIFFERENT PREFERRED FIBRIC ACID DERIVATIVES IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4529 30 DAYS THERAPY WITH 2 DIFFERENT PREFERRED NON-STATIN LIPOTROPICS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4530 30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED STATIN/STATIN COMBINATIONS IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4531 30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED OPHTHALMIC ALLERGY AGENTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL (SMART PA)
75-PRIOR AUTH REQUIRED  4532 A TRIAL OF 1 CLAIM FOR 2 DIFFERENT PREFERRED OPHTHALMIC ANTI-INFLAMMATORY AGENTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL (SMART PA)
75-PRIOR AUTH REQUIRED  4533 MENTAL HEALTH INJECTABLE DRUGS ONLY COVERED THROUGH POS FOR BENEFICIARIES RESIDING IN LONG TERM CARE FACILITIES. ALL OTHER PTS. BILL ON MEDICAL CLAIM.
75-PRIOR AUTH REQUIRED  4537 A NON-PREFERRED SHORT-ACTING NARCOTIC IS NOT ALLOWED WHILE ON A BUPRENORPHINE PRODUCT. (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 NUTRESTORE REQUIRES A MANUAL PA. PHARMACY CLAIMS MUST INDICATE THE PATIENT IS ALSO RECEIVING ZORBTIVE FOR APPROVAL OF NUTRESTORE BY MANUAL REVIEW. (SMART PA)
75-PRIOR AUTH REQUIRED  4541 APPROVAL FOR AGES > 18 YEARS REQUIRES HISTORY OF CRANIAL IRRADIATION OR A DIAGNOSIS ON FILE IN THE PAST 2 YEARS OF A FDA APPROVED INDICATION FOR USE OF A GROWTH HORMONE. (SMARTPA)
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 3 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 VIAGRA AND REVATIO SUSPENSION ARE NOT APPROVED FOR 12 YEARS OF AGE AND OLDER. (SMART PA)
75-PRIOR AUTH REQUIRED  4555 A DIAGNOSIS OF PULMONARY HYPERTENSION IN THE PAST 2 YEARS IS REQUIRED FOR APPROVALOF ALL PAH AGENTS.
75-PRIOR AUTH REQUIRED  4556 A DIAGNOSIS OF PULMONARY HYPERTENSION IN THE PAST 2 YEARS IS REQUIRED FOR APPROVALOF 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 ON FILE FOR MULTIPLE SCLEROSIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4561 1 CLAIM WITH 2 DIFFERENT PREFERRED MS AGENTS IN PAST 6 MONTHS OR A HISTORY OF 3 CLAIMS WITH THE SAME AGENT AS ON THE IMCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4562 TRIAZOLAM IS LIMITED TO A CUMMULATIVE DAYS SUPPLY OF </= 60 UNITS PER 365 DAYS. QUANTITY ON CLAIM PLUS PRESCRIPTION HISTORY EXCEEDS THIS AMOUNT. (SMART PA)
75-PRIOR AUTH REQUIRED  4563 30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED ANTIHYPERURICEMICS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4564 A NON-PREFERRED LONG-ACTING NARCOTIC IS NOT ALLOWED WHILE ON A BUPRENORPHINE PRODUCT. (SMART PA)
75-PRIOR AUTH REQUIRED  4565 XOPENEX IS INDICATED FOR AGE >/= 6 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED  4566 A HISTORY OF 1 CLAIM FOR ALBUTEROL INHALATION SOLUTION IN THE PAST 30 DAYS IS REQUIRED FOR APPROVAL OF LEVALBUTEROL INHALATION SOLUTION. (SMART PA)
75-PRIOR AUTH REQUIRED  4567 BROVANA AND PERFOROMIST ARE INDICATED FOR AGE >/= 18 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED  4568 A HISTORY OF 1 CLAIM WITH A DIFFERENT PREFERRED BETA AGONIST SOLUTION IN THE PAST 6 MONTHS OR 3 CLAIMS WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4569 ZYFLO AND ZYFLO CR ARE INDICATED FOR AGE >/= 12 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED  4570 30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED LEUKOTRIENE MODIFIERS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4571 REPATHA AND PRALUENT REQUIRE A MANUAL REVIEW FOR APPROVAL. (SMARTPA)
75-PRIOR AUTH REQUIRED  4572 SEREVENT IS INDICATED FOR AGE >/= 4 YEARS. MUST SUBMIT AN AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4573 EFFIENT REQUIRES A DIAGNOSIS OF ACUTE CORONARY SYNDROME OR PERCUTANEOUS CORNARY INTERVENTION IN THE PAST 2 YEARS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4574 FDA RECOMMENDS REVATIO SHOULD NOT BE PRESCRIBED FOR AGES 1-17 YEARS FOR PULMONARY HYPERTENSION. MUST SUBMIT MANUAL PA WITH AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL.(SMART PA)
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 XIIDRA REQUIRES A MANUAL REVIEW FOR APPROVAL. (SMARTPA)
75-PRIOR AUTH REQUIRED  4582 A TRIAL OF AT LEAST 1 CLAIM FOR 2 DIFFERENT PREFERRED TOPICAL ANTIFUNGALS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4583 A DIAGNOSIS OF A SEIZURE DISORDER IN THE PAST 2 YEARS AND A HISTORY OF 90 DAYS STABLE THERAPY WITH GENERIC TOPIRAMATE ER IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL. NO DIAGNOSIS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED  4584 A HISTORY OF 1 CLAIM WITH PREFERRED ELIDEL IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4585 30 DAYS OF THERAPY WITH TOPIRAMATE IR IN THE PAST 6 MONTHS OR 90 DAYS OF STABLE THERAPY IN THE PAST 105 DAYS IS REQUIRED FOR APPROVAL OF GENERIC TOPIRAMATE ER. NO THERAPY WITH TOPIRAMATE IR FOUND IN CLAIMS HISTORY. (SMART PA)
75-PRIOR AUTH REQUIRED  4586 30 DAYS OF THERAPY WITH 2 PREFERRED GLAUCOMA AGENTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL OF TIMOLOL GEL, COSOPT PF, XALATAN & ALPHAGAN P 0.1%. (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 NO HISTORY OF A PREGNANCY CODE IN PAST 280 DAYS. BUREPNORPHINE 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  4610 BENEFICIARIES CAN BE COVERED FOR A MAXIMUM CUMULATIVE DURATION OF 24 MONTHS OF THERAPY WITH A BUPRENORPHINE PRODUCT. CURRENT CLAIM EXCEEDS 24 MONTHS OF THERAPY. (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 SUBOXONE 8 MG AND BUNAVAIL 4.2 MG ARE LIMITED TO 2/DAY DURING MONTHS 2-4 OF TREATMENT OR FOR 2 MONTHS AFTER RESTART THERAPY WITH A BUPRENORPHINE PRODUCT. SUBOXONE 4 MG & 12 MG, BUNAVAIL 2.1 MG & 6.3 MG ARE LIMITED TO 1/DAY. (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 ONLY ONE RESTART FOLLOWING A 90 DAY GAP IN THERAPY ALLOWED DURING TREATMENT WITH A BUPRENORPHINE PRODUCT. CLAIMS HISTORY INDICATES A PREVIOUS GAP IN THERAPY. (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, IF RX IS NOT FOR PASS MEDS.
75-PRIOR AUTH REQUIRED  4620 CANNOT HAVE AN OPIOID PRESCRIPTION FOR MORE THAN 5 DAYS IN THE PAST 30 DAYS WHILE ON BUPRENORPHINE THERAPY. RX HISTORY INDICATES > 5 DAYS SUPPLY WITH AN OPIOID IN PAST 30 DAYS. (SMART PA)
75-PRIOR AUTH REQUIRED  4621 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  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 SUBOXONE 12 MG AND BUNAVAIL 6.3 MG ARE NOT ALLOWED DURING THE REMAINING MONTHS OF MAINTENANCE THERAPY WITH A BUPRENORPHINE PRODUCT. REFER TO PDL FOR DETAILED BUPRENORPHINE CRITERIA. (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 1 PREFERRED TOPICAL ANALGESIC IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. LIDODERM ALSO APPROVES WITH A DIAGNOSIS OF POST HERPETIC NEURALGIA OR DIABETIC NEUROPATHY IN THE PAST YEAR. VOLTAREN GEL IS PREFERRED. (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 40 MG. PLEASE REFER TO THE PDL FOR A LIST OF PREFERRED ANTIDEPRESSANTS. (SMART PA)
75-PRIOR AUTH REQUIRED  4641 A HISTORY OF 30 DAYS THERAPY WITH A XANTHINE OXIDASE INHIBITOR IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL OF ZURAMPIC. PHARMACY CLAIMS INDICATE NO PREVIOUS THERAPY WITH A XANTHINE OXIDASE INHIBITOR. (SMART PA)
75-PRIOR AUTH REQUIRED  4642 ZURAMPIC IS USED IN COMBINATION WITH A XANTHINE OXIDASE INHIBITOR. APPROVAL OF ZURAMPIC REQUIRES 30 DAYS OF THERAPY WITH A XANTHINE OXIDASE INHIBITOR IN THE PAST 30 DAYS. PHARMACY HISTORY INDICATES NO PAID CLAIM FOR A XANTHINE OXIDASE INHIBITOR IN THE PAST 30 DAYS. (SMARTPA)
75-PRIOR AUTH REQUIRED  4643 BRAND AND GENERIC AIRDUO AND ARMONAIR INHALERS REQUIRE A MANUAL PA FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4644 THE QUANTITY ON THE CLAIM PLUS PRESCRIPTION HISTORY IN THE PAST 25 DAYS EXCEEDS THE QUANTITY LIMIT FOR THIS DRUG. (SMART PA)
75-PRIOR AUTH REQUIRED  4645 ELIDEL AND PROTOPIC 0.03% ARE INDICATED FOR AGE >/= 2 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED  4646 PROTOPIC 0.1% 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  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 2 DIFFERENT PREFERRED SINGLE-ENTITY 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 (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 WITH PREFERRED BRAND SUBOXONE IN THE PAST 6 MONTHS OR 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 HISTORY OF CARISOPRODOL USE IN THE PAST 6 MONTHS. (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 NO SUPPORTING DRUG USE
75-PRIOR AUTH REQUIRED  4668 NO SUPPORTING DIAGNOSIS
75-PRIOR AUTH REQUIRED  4669 CO-MORBIDITY (WITH DIAGNOSIS)
75-PRIOR AUTH REQUIRED  4676 CO-MORBIDITY(INFERRED FROM DRUG)
75-PRIOR AUTH REQUIRED  4678 THE EXISTING PA IS OVERRIDDEN BY THE AUTOMATED PA FROM SMART PA.
75-PRIOR AUTH REQUIRED  4679 ZOFRAM PLAN LIMITS
75-PRIOR AUTH REQUIRED  4680 PATIENT NOT FAILED ALTERNATE THERAPY.
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  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 BRAND PAXIL CR MOVED TO NON-PREFERRED 1-1-14. GENERIC IS PREFERRED. (SMART PA)
75-PRIOR AUTH REQUIRED  4695 CLAIMS FOR > 17 DAYS THERAPY WITH NO HISTORY OF A LMWH RX IN THE PAST 3 MONTHS REQUIRE A DIAGNOSIS OF CANCER IN THE PAST 2 YRS, OR A HIP OR KNEE REPLACEMENT IN THE PAST 60 DAYS FOR APPROVAL. CLAIMS WILL APPROVE FOR FEMALES 8-50 YEARS OLD OF CHILDBEARING AGE. (SMART PA)
75-PRIOR AUTH REQUIRED  4696 A HISTORY OF 1 CLAIM WITH 2 DIFFERENT PREFERRED TRIPTANS IN THE PAST 90 DAYS IS REQUIRED FOR APPROVAL OF NON-PREFFERED ZECUITY. (SMART PA)
75-PRIOR AUTH REQUIRED  4697 A DIAGNOSIS OF ANGINA IN THE PAST TWO YEARS IS REQUIRED FOR APPROVAL OF RANEXA ER. (SMART PA)
75-PRIOR AUTH REQUIRED  4698 A TRIAL OF ONE CLAIM FOR A CALCIUM CHANNEL BLOCKER, BETA-BLOCKER, NITRATE OR COMBINATION AGENT IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT IS REQUIRED FOR APPROVAL OF RANEXA ER. (SMART PA)
75-PRIOR AUTH REQUIRED  4699 BRAND SUBOXONE IS THE PREFERRED AGENT. BUNAVAIL REQUIRES A HISTORY WITH SUBOXONE IN THE PAST 6 MONTHS OR THERAPY WITH BUNAVAIL IN THE PAST 3 MONTHS FOR APPROVAL. GENERIC BUPRENORPHINE/NALOXONE AND ZUBSOLV ARE NONPREFERRED. (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 NUVIGIL REQUIRES 30 DAYS THERAPY WITH BOTH PROVIGIL & A PREFFERED STIMULANT WITH APPROPRIATE INDICATION IN THE PAST 6 MONTHS OR 1 CLAIM FOR NUVIGIL IN THE PAST 105 DAYS FOR APPROVAL. PHARMACY CLAIMS INDICATE NO TRIAL WITH APPROPRIATE STIMULANT OR STABLE THERAPY. (SMART PA)
75-PRIOR AUTH REQUIRED  4705 PHARMACY CLAIMS INDICATE NO TRIAL WITH PREFERRED STIMULANT WITH AN APPROPRIATE INDICATION. NONPREFERRED NUVIGIL REQUIRES 30 DAYS THERAPY WITH BOTH PROVIGIL & A PREFFERED STIMULANT WITH APPROPRIATE INDICATION IN THE PAST 6 MONTHS FOR APPROVAL. (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 MUST CONTINUE ORAL RISPERIDONE WHEN PRESCRIPTION HISTORY INDICATES THE PATIENT HAS BEEN COMPLIANT ON ORAL THERAPY OR HAVE AT LEAST 6 CLAIMS WITH RISPERDAL CONSTA IN THE PAST 90 DAYS FOR APPROVAL. (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 BREAST CANCER OR WELL-DIFFERENTIATED/DEDIFFERENTIATED LIPOSARCOMA IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF IBRANCE. NO DIAGNOSIS FOUND. (SMART PA)
75-PRIOR AUTH REQUIRED  4716 A DIAGNOSIS OF BREAST CANCER IN THE PAST 2 YEARS AND EITHER HISTORY OF A PAID CLAIM WITH LETROZOLE IN THE PAST 30 DAYS OR HISTORY WITH FULVESTRANT IN THE PAST 60 DAYS IS REQUIRED FOR APPROVAL OF IBRANCE. NO HISTORY WITH LETROZOLE OR FULVESTRANT FOUND. (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 CANCER OR RENAL CELL CANCER IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF LENVIMA. NO DIAGNOSIS OF THYROID OR RENAL CELL CANCER FOUND. (SMART PA)
75-PRIOR AUTH REQUIRED  4719 A DIAGNOSIS OF OVARIAN CANCER AND CLAIMS HISTORY OF 3 PRIOR CHEMOTHERAPY AGENTS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF LYNPARZA. NO DIAGNOSIS OF OVARIAN CANCER FOUND. (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 DX OF OVARIAN CANCER & CLAIMS HISTORY OF 3 CLAIMS CHEMOTHERAPY AGENTS IN THE PAST 2 YRS IS REQUIRED FOR APPROVAL OF LYNPARZA. NO CLAIMS HISTORY WITH 3 CHEMO AGENTS. (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 SIROLIMUS IS INDICATED FOR AGE >/= 18 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO HAVE A DIAGNOSIS OF KIDNEY TRANSPLANT IN THE PAST 2 YEARS. (SMART PA)
75-PRIOR AUTH REQUIRED  4735 EVEROLIMUS IS INDICATED FOR AGE >/= 13 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO HAVE A DIAGNOSIS OF KIDNEY TRANSPLANT IN THE PAST 2 YEARS. (SMART PA)
75-PRIOR AUTH REQUIRED  4736 A DIAGNOSIS OF KIDNEY TRANSPLANT IN THE PAST 2 YEARS IF REQUIRED FOR APPROVAL. (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 30 DAYS OF THERAPY WITH 1 DIFFERENT PREFERRED ANTICONVUSANT INDICATED FOR LENNOX-GASTAUT IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT IS REQUIRED FOR APPROVAL OF BANZEL AND ONFI. ALSO REQUIRES A DIAGNOSIS ON FILE FOR LENNOX-GASTAUT IN THE PAST 2 YEARS .(SMART PA)
75-PRIOR AUTH REQUIRED  4747 A DIAGNOSIS ON FILE FOR LENNOX-GASTAUT IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF BANZEL OR ONFI. ALSO REQUIRES 30 DAYS OF THERAPY WITH 1 DIFFERENT PREFERRED ANTICONVUSANT 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 HISTORY OF 4 CLAIMS WITH INVEGA SUSTENNA IN THE PAST 180 DAYS IS REQUIRED FOR APPROVAL OF INVEGA TRINZA. PHARMACY CLAIMS HISTORY INDICATES NO HISTORY OF 4 CLAIMS WITH INVEGA SUSTENNA. (SMART PA)
75-PRIOR AUTH REQUIRED  4750 RX EXCEEDS MONTHLY LIMIT. ADDITIONAL PRESCRIPTIONS ALLOWED FOR BENEFICIARIES UNDER AGE 21 WITH PRIOR AUTHORIZATION.
75-PRIOR AUTH REQUIRED  4767 BANZEL IS INDICATED FOR AGE >/= 1 YEAR. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED  4768 HISTORY OF THERAPY WITH PREFERRED PERMETHRIN 5% CREAM IN THE PAST 90 DAYS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4769 A DIAGNOSIS OF PARKINSON'S DISEASE IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL OF NUPLAZID. NO DIAGNOSIS OF PARKINSON'S DISEASE IS FOUND ON FILE. (SMART PA)
75-PRIOR AUTH REQUIRED  4774 PHARMACY HISTORY INDICATES AT LEAST 90 DAYS CONCURRENT THERAPY WITH >/= 2 ANTIPSYCHOTICS. MUST SUBMIT CLINICAL JUSTIFICATION FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4788 PATIENTS WITH A DIAGNOSIS OF CIRCADIAN RHYTHM SLEEP DISORDER MUST ALSO HAVE A DIAGNOSIS OF TOTAL BLINDNESS IN THE PAST 2 YEARS FOR APPROVAL OF HETLIOZ. (SMART PA)
75-PRIOR AUTH REQUIRED  4791 BENEFICIARY MUST HAVE A DIAGNOSIS OF HIV IN THE PAST 2 YEARS OR 1 CLAIM FOR 2 DIFFERENT PREFERRED ORAL ANTIFUNGALS IN PAST 6 MONTHS FOR APPROVAL OF AN ORAL ANTIFUNGAL WITH LEVEL IIB RECOMMENDATION OR HIGHER FOR HIV OPPORTUNISTIC INFECTIONS. (SMART PA)
75-PRIOR AUTH REQUIRED  4792 BENEFICIARY MUST HAVE A DIAGNOSIS OF HIV OR HISTORY OF A TRANSPLANT IN THE PAST 2 YEARS OR A HISTORY OF AN IMMUNOSUPPRESSANT OR ONE CLAIM FOR 2 DIFFERENT PREFERRED AGENTS IN PAST 6 MONTHS FOR APPROVAL OF ITRACONAZOLE. (SMART PA)
75-PRIOR AUTH REQUIRED  4809 CLAIM IS FOR NONPREFERRED ARIPIPRAZOLE ODT OR CLOZAPINE ODT. REFER TO PDL FOR A LIST OF PREFERRED ATYPICAL ANTIPSYCHOTICS. (SMART PA)
75-PRIOR AUTH REQUIRED  4820 INSULIN PENS/CARTRIDGES ARE NONPREFERRED FOR LTC BENES (PLAN 200). DISPENSE INSULIN VIALS. (SEE SYSTEM LIST 5800)
75-PRIOR AUTH REQUIRED  4821 EDIT IGNORED
75-PRIOR AUTH REQUIRED  4822 EDIT IGNORED
75-PRIOR AUTH REQUIRED  4824 30 DAYS OF THERAPY WITH 2 DIFFERENT PREFERRED ALZHEIMER'S AGENTS IN THE PAST 6 MONTHS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4825 30 DAYS OF THERAPY WITH EITHER 2 PREFERRED ANTIDEPRESSANT-OTHERS CLASS OR 30 DAYS WITH BOTH A PREFERRED ANTIDEPRESSANT-OTHER CLASS & A SSRI IN THE PAST 6 MONTHS, OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IN REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4826 A TRIAL OF 30 DAYS WITH A PREFERRED LONG ACTING BETA AGONIST INHALER IN THE PAST 6 MONTHS OR 90 DAYS STABLE THERAPY WITH THE SAME AGENT AS THE INCOMING CLAIM IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4827 LENVIMA IS USED IN COMBINATION WITH EVEROLIMUS FOR TREATMENT OF RENAL CELL CANCER. APPROVAL OF LENVIMA FOR RENAL CELL CARCINOMA REQUIRES ONE CLAIM WITH EVEROLIMUS IN THE PAST 30 DAYS. PHARMACY HISTORY INDICATES NO PAID CLAIM FOR EVEROLIMUS IN THE PAST 30 DAYS. (SMARTPA)
75-PRIOR AUTH REQUIRED  4829 XOPENEX HFA INHALER IS INDICATED FOR AGE >/= 4 YEARS. MUST SUBMIT AGE WAIVER SIGNED BY PRESCRIBER FOR APPROVAL. MUST ALSO MEET PDL CRITERIA. (SMART PA)
75-PRIOR AUTH REQUIRED  4830 RHINOCORT AQ REQUIRES 1 CLAIM WITH 2 DIFFERENT PREFERRED INTRANASAL CORTICOSTEROIDS IN THE PAST 6 MONTHS OR A DIAGNOSIS OF PREGNANCY FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4838 AGE IS LIMITED TO 6-17 YEARS. NONPREFERRED KAPVAY ER AND INTUNIV MUST ALSO MEET PDL CRITERIA. AN AGE WAIVER SIGNED BY PRESCRIBER IS REQUIRED FOR APPROVAL WHEN PDL CRITERIA IS MET. (SMART PA)
75-PRIOR AUTH REQUIRED  4840 BOTH BRAND AND GENERIC AMLODIPINE/ATORVASTATIN COMBINATIONS ARE NON-PREFERRED. DISPENSE PREFERRED INDIVIDUAL COMPONENTS. (SMART PA)
75-PRIOR AUTH REQUIRED  4851 NEULASTA REQUIRES A MANUAL CLINICAL REVIEW. (SMART PA)
75-PRIOR AUTH REQUIRED  4858 APPROVAL OF LENVIMA FOR TREATMENT OF RENAL CELL CARCINOMA REQUIRES COMBINATION THERAPY WITH EVEROLIMUS AND HISTORY OF ONE CLAIM WITH AN ANTI-ANGIOGENIC AGENT IN THE PAST 2 YEARS. NO RX WITH AN ANTI-ANGIOGENIC AGENT FOUND IN PHARMACY CLAIMS. (SMARTPA)
75-PRIOR AUTH REQUIRED  4874 A DIAGNOSIS OF ALZHEIMER'S DISEASE IN THE PAST 2 YEARS AND 30 DAYS CONCURRENT THERAPY WITH BOTH DONEPEZIL AND NAMENDA IN THE PAST 6 MONTHS IS REQUIREED FOR APPROVAL OF NAMZARIC. (SMART PA)
75-PRIOR AUTH REQUIRED  4878 UROXATRAL FOR FEMALE PATIENTS REQUIRES AN APPROVABLE DIAGNOSIS ON FILE IN THE PAST 2 YEARS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4879 DOXAZOSIN FOR FEMALE PATIENTS REQUIRES AN APPROVABLE DIAGNOSIS ON FILE IN THE PAST 2 YEARS FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4883 XIIDRA REQUIRES A HISTORY OF 4 CLAIMS WITH PREFERRED RESTASIS DROPPERETTES IN THE PAST 6 MONTHS FOR APPROVAL. (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  4914 EDIT IGNORED
75-PRIOR AUTH REQUIRED  4915 A DIAGNOSIS OF PSEUDOBULBAR AFFECT, MULTIPLE SCLEROSIS OR AMYOTROPHIC LATERAL SCLEROSIS IN THE PAST 2 YEARS IS REQUIRED FOR APPROVAL. (SMART PA)
75-PRIOR AUTH REQUIRED  4916 EDIT IGNORED
75-PRIOR AUTH REQUIRED  4946 FLUMIST IS NOT RECOMMENDED FOR THE 2016-2017 FLU SEASON BY CDC. PA REQUIRED IF INJECTION CANNOT BE USED BY BENEFICIARY
75-PRIOR AUTH REQUIRED  4948 ONZETRA LIMITED TO 1 BOX/PACKAGE PER MONTH- 16 UNITS (PACKAGE SIZE) PER 22 DAYS.
75-PRIOR AUTH REQUIRED  4959 PRADAXA 110 MG IS NOT INDICATED FOR KNEE REPLACEMENT SURGERY. (SMART PA)
75-PRIOR AUTH REQUIRED  4965 EDIT IGNORED
75-PRIOR AUTH REQUIRED  4969 EDIT IGNORED
75-PRIOR AUTH REQUIRED  4971 EDIT IGNORED
75-PRIOR AUTH REQUIRED  4983 EDIT IGNORED
75-PRIOR AUTH REQUIRED  4984 EDIT IGNORED
75-PRIOR AUTH REQUIRED  4986 EDIT IGNORED
75-PRIOR AUTH REQUIRED  4990 EDIT IGNORED
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. MUST SUBMIT MAX UNIT OVERRIDE REQUEST TO DOM PA UNIT.
76-PLAN LIMITATIONS EXCEEDED  4107 B2I/B2R BENEFICIARIES, AGE 21 & OLDER-CLAIM EXCEEDS MONTHLY PRESCRIPTION LIMIT OF 8
76-PLAN LIMITATIONS EXCEEDED  4109 B2I/B2R BENEFICIARIES, AGE 21 & OLDER- CLAIM EXCEEDS MONTHLY BRAND LIMIT OF 5
76-PLAN LIMITATIONS EXCEEDED  4126 EDIT IGNORED
76-PLAN LIMITATIONS EXCEEDED  4160 H =CUSTOM REC; DAILY DOSE > MAINTENANCE CLAIM DOSE
76-PLAN LIMITATIONS EXCEEDED  4162 "(THE CUSTOM PLAN DAYS SUPPLIED ACCUM IS NOT EQUAL TO N (NONE) OR THE CUSTOM PLAN DAYS SUPPLIED IS NOT EQUAL TO WORK DEFAULT DAYS (999)) AND THE CUSTOM PLAN DAYS SUPPLIED ACCUM EQUALS C (ACUTE DOSE ONLY) AND THE CUSTOM PLAN MAINTENANCE CLAIM DOSE LESS THAN WORK DEFAULT DOSE (9999.999) AND THE DAILY DOSE IS GREATE
76-PLAN LIMITATIONS EXCEEDED  4163 G =CUSTOM REC; ACUTE DOSE - SUBMITTED DAYS > MAX DAYS SUP FOR SPEC CLAIM
76-PLAN LIMITATIONS EXCEEDED  4164 "(THE CUSTOM PLAN MAX UNITS ACCUM IS NOT EQUAL TO N (NONE) AND THE CUSTOM PLAN MAX UNITS IS NOT EQUAL TO WORK DEFAULT MAX UNITS (99999.999)) AND THE CUSTOM PLAN MAX UNITS ACCUM EQUALS C (ACUTE DOSE ONLY) AND THE CUSTOM PLAN MAINTENANCE CLAIM DOSE LESS THAN WORK DEFAULT DOSE (9999.999) AND THE DAILY DOSE IS GREATE
76-PLAN LIMITATIONS EXCEEDED  4165 D =CUSTOM REC; ALL DOSES - SUBMITTED UNITS > MAX UNITS FOR SPEC CLAIM
76-PLAN LIMITATIONS EXCEEDED  4166 THIS CLAIM EXCEEDS THE MONTHLY LIMIT OF 5 PRESCRIPTIONS.
76-PLAN LIMITATIONS EXCEEDED  4167 A CUSTOM RECORD EXISTS FOR THE NDC. THE QUANTITY SUBMITTED ON THE CLAIM EXCEEDS THE MAX TOTAL UNITS FOR A TIME PERIOD. PLEASE REFER TO QUANTITY LIMIT LIST OR SUBMIT MAX UNIT OVERRIDE PA REQUEST.
76-PLAN LIMITATIONS EXCEEDED  4168 F =CUSTOM REC; ALL DOSES - SUBMITTED DAYS > MAX DAYS SUPP FOR SPEC CLAIM
76-PLAN LIMITATIONS EXCEEDED  4169 SUBMITTED QTY OR # OF RXS EXCEEDS THE ALLOWED QTY FOR THIS DRUG. PRESCRIBER MAY SUBMIT 'MAX UNIT OVERRIDE' PA REQUEST IF GREATER QTY NEEDED.
76-PLAN LIMITATIONS EXCEEDED  4170 REFILL LIMIT EXCEEDED FOR PRESCRIPTION NUMBER
76-PLAN LIMITATIONS EXCEEDED  4171 M =CUSTOM REC; ALL DOSES - SUBMITTED UNITS > MAX UNITS FOR SPEC DUR
76-PLAN LIMITATIONS EXCEEDED  4172 N =CUSTOM REC; ACUTE DOSE - SUBMITTED UNITS > MAX UNITS FOR SPEC DUR
76-PLAN LIMITATIONS EXCEEDED  4208 HYOSCYAMINE DROPS LIMITED TO 1-15ML BOTTLE PER MONTH.
76-PLAN LIMITATIONS EXCEEDED  4253 SYMBICORT 80-4.5 MCG INHALER MINIMUM AGE OF 12 AND MAX UNIT OF 10.2 IN 23 DAYS
76-PLAN LIMITATIONS EXCEEDED  4255 CHANTIX 1 MG CONT MONTH PAK MINIMUM AGE OF 18 AND MAX UNITS OF 56 IN 21 DAYS
76-PLAN LIMITATIONS EXCEEDED  4371 THE TOTAL NUMBER OF BRAND DRUGS FOR THIS RECIPIENT EXCEEDS THE 2 BRAND LIMIT PER CALENDAR MONTH.
76-PLAN LIMITATIONS EXCEEDED  4472 OXYCODONE SHORT ACTING TABS/CAPS LIMITED TO 62 TOTAL CUMULATIVE UNITS OF ALL/ANY STRENGTHS IN THE PAST 31 ROLLING DAYS. MUST SUBMIT MAX UNIT OVERRIDE REQUEST TO DOM PA UNIT.
76-PLAN LIMITATIONS EXCEEDED  4473 OXYCODONE LIQUID LIMITED TO 180 TOTAL CUMULATIVE ML. OF ALL/ANY STRENGTHS IN THE PAST 31 ROLLING DAYS. PRESCRIBER MAY SUBMIT MAX UNIT OVERRIDE PA REQUEST IF HIGHER QTY IS NEEDED.
76-PLAN LIMITATIONS EXCEEDED  4474 SEDATIVE-HYPNOTIC AGENTS ARE LIMITED TO 31 CUMULATIVE UNITS OF ALL/ANY STRENGTHS IN THE PAST 31 ROLLING DAYS. PRESCRIBER MAY SUBMIT MAX UNIT OVERRIDE REQUEST IF HIGHER QTY NEEDED.
76-PLAN LIMITATIONS EXCEEDED  4475 ANXIOLYTIC AGENTS ARE LIMITED TO 62 TOTAL CUMULATIVE UNITS OF ALL/ANY STRENGTHS IN THE PAST 31 ROLLING DAYS. MUST SUBMIT MAX UNIT OVERRIDE REQUEST TO DOM PA UNIT.
76-PLAN LIMITATIONS EXCEEDED  4604 CLIENT SPECIFIC EDIT (MS: CUSTOMER IS ALLOWED ONLY FIVE REFILLS PER PRESCRIPTION NUMBER
76-PLAN LIMITATIONS EXCEEDED  4626 NDC HAS MAXIMUM QUANTITY ASSIGNED BY DOM. ALLOWED QTY CAN BE FOUND UNDER ' REFERENCE', 'DRUG CUSTOMER SPECIFIC'
76-PLAN LIMITATIONS EXCEEDED  4627 SUBMITTED UNITS EXCEED MAX ALLOWED FOR CALENDAR MONTH. PRESCRIBER MAY SUBMIT 'MAX UNIT OVERRIDE' PA REQUEST IF GREATER QTY NEEDED.
76-PLAN LIMITATIONS EXCEEDED  4670 UNDER APPROVAL AGE
76-PLAN LIMITATIONS EXCEEDED  4671 LENGTH OF THERAPY
76-PLAN LIMITATIONS EXCEEDED  4672 WRONG DOSE
76-PLAN LIMITATIONS EXCEEDED  4673 EXCEEDS LIMITS
76-PLAN LIMITATIONS EXCEEDED  4674 DOSE OPTIMIZATION - WRONG DOSE
76-PLAN LIMITATIONS EXCEEDED  4675 THERAPUTIC DUPLICATION
76-PLAN LIMITATIONS EXCEEDED  4823 PLAN LIMITATIONS EXCEEDED - PA LIMIT DEFINITIONS INDICATE PRIOR AUTHORIZATION IS REQUIRED FROM DOM.
76-PLAN LIMITATIONS EXCEEDED  4831 "PLAN LIMITS EXCEEDED - SEE BELOW REASON CODES: B =CUSTOM REC; ALL DOSES - MAX $ LIMIT EXCEEDED FOR SPEC DUR"
76-PLAN LIMITATIONS EXCEEDED  4832 C =CUSTOM REC; ACUTE DOSE - MAX $ LIMIT EXCEEDED FOR SPEC DURATION
76-PLAN LIMITATIONS EXCEEDED  4833 P= PATIENT EXCEEDS MONTHLY REFILL LIMIT
76-PLAN LIMITATIONS EXCEEDED  4867 E =CUSTOM REC; ACUTE DOSE - SUBMITTED UNITS > MAX UNITS FOR SPEC CLAIM
76-PLAN LIMITATIONS EXCEEDED  4868 J =CUSTOM REC; ACUTE DOSE - MAX NUM SCRIPTS EXCEEDED FOR SPEC DUR
76-PLAN LIMITATIONS EXCEEDED  4869 K =CUSTOM REC; ALL DOSES - SUBMITTED DAYS > MAX DAYS SUPP FOR SPEC DURATION
76-PLAN LIMITATIONS EXCEEDED  4870 L =CUSTOM REC: ACUTE DOSE - SUBMITTED DAYS > MAX DAYS SUPP FOR SPEC DURATION
76-PLAN LIMITATIONS EXCEEDED  4913 GREATER THAN 31 DAYS SUPPLY FOR NON-MAINT. DRUG PRIOR AUTHORIZATION REQUIRED FROM DOM.
76-PLAN LIMITATIONS EXCEEDED  4968 EDIT IGNORED
76-PLAN LIMITATIONS EXCEEDED  4970 EDIT IGNORED
76-PLAN LIMITATIONS EXCEEDED  4991 TOTAL DAYS SUPPLIED FOR THIS PARTICIPANT FOR ALL GENERIC EQUIVALENTS OF THIS DRUG EXCEEDS PLAN MAXIMUM
77-DISCONTINUED PRODUCT/SVC ID NO  4173 DRUG IS OBSOLETE OR DATE OF SERVICE IS AFTER CMS TERM DATE. CHECK EXPIRATION DATE ON BOTTLE OF NDC DISPENSED
77-DISCONTINUED PRODUCT/SVC ID NO  4503 RESERVED FOR FUTURE USE
78-COST EXCEEDS MAXIMUM  4174 CLAIMS OVER $999.99 REQUIRE PRIOR AUTHORIZATION
78-COST EXCEEDS MAXIMUM  4176 EDIT IGNORED
79-REFILL TOO SOON  4177 REFILL TOO SOON. IF DOSAGE HAS CHANGED, SUBMIT 'EARLY REFILL PHARMACY PA' REQUEST.
80-DRUG-DIAGNOSIS MISMATCH  4773 EDIT IGNORED
81-CLAIM TOO OLD  4180 "THE CLAIM IS NOT AN ADJUSTMENT VIA POS AND THE CLAIM OTHER INSURANCE INDICATOR IS SECONDARY INSURANCE CLAIM (2 -3 -4) AND THE CLAIM COB PAYERID DATE IS NUMERIC AND GREATER THAN ZEROS AND THE CLAIM DATE OF ADJUDICATION (CURRENT DATE) IS GREATER THAN THE CLAIM COB PAYERID DATE PLUS 90 DAYS AND LESS THAN
81-CLAIM TOO OLD  4181 "THE CLAIM IS NOT AN ADJUSTMENT VIA POS AND THE CLAIM OTHER COVERAGE CODE IS SECONDARY INSURANCE CLAIM (2 -3 -4) AND THE CLAIM COB PAYERID DATE IS NUMERIC AND GREATER THAN ZEROS AND THE CLAIM DATE OF ADJUDICATION (CURRENT DATE) IS GREATER THAN THE CLAIM COB PAYERID DATE PLUS 548 DAYS."
81-CLAIM TOO OLD  4182 "THE CLAIM IS NOT AN ADJUSTMENT VIA POS AND THE CLAIM OTHER INSURANCE INDICATOR IS NOT SECONDARY INSURANCE CLAIM (2 -3 -4) AND THE CLAIM DATE OF ADJUDICATION (CURRENT DATE) IS GREATER THAN THE CLAIM FIRST DATE OF SERVICE PLUS 90 DAYS AND LESS THAN THE CLAIM FIRST DATE OF SERVICE PLUS 366 DAYS. "
81-CLAIM TOO OLD  4183 "THE CLAIM IS NOT AN ADJUSTMENT VIA POS AND THE CLAIM OTHER INSURANCE INDICATOR IS NOT SECONDARY INSURANCE CLAIM (2 -3 -4) AND THE CLAIM DATE OF ADJUDICATION (CURRENT DATE) IS GREATER THAN THE CLAIM FIRST DATE OF SERVICE PLUS 365 DAYS."
81-CLAIM TOO OLD  4184 CLAIM TOO OLD TO PROCESS ELECTRONICALLY. CLAIMS WITH DATE OF SERVICE GREATER THAN ONE YR MAY BE SUBMITTED VIA PAPER OR WEB PORTAL FOR RETRO ELIGIBILITY.
81-CLAIM TOO OLD  4520 RESERVED FOR FUTURE USE
81-CLAIM TOO OLD  4521 RESERVED FOR FUTURE USE
81-CLAIM TOO OLD  4577 CLIENT SPECIFIC EDIT (MS): TIMELY FILING DATE IS LESS THAN THE FIRST DOS
81-CLAIM TOO OLD  4578 ELECTRONIC CLAIMS MUST BE SUBMITTED WITHIN ONE YEAR OF DATE OF SERVICE.
81-CLAIM TOO OLD  4818 CCO DID NOT SUBMIT ENCOUNTER CLAIM WITHIN 30 DAYS OF ORIGINAL RECEIPT FROM PHARMACY
81-CLAIM TOO OLD  4819 CLAIM TOO OLD - CCO MUST SUBMIT ADJUSTMENT/VOID WITHIN 60 DAYS OF RECEIPT OF ORIGINAL PHARMACY CLAIM
82-CLAIM IS POST-DATED  4420 DATE FILLED CANNOT BE IN THE FUTURE.
82-CLAIM IS POST-DATED  4802 DATE BILLED AFTER ADJUDICATION DATE
82-CLAIM IS POST-DATED  4871 CLAIM POST DATED
83-DUPLICATE PAID/CAPTURED CLAIM  4185 EXACT DUPLICATE OF A PAID CLAIM
83-DUPLICATE PAID/CAPTURED CLAIM  4186 DUPLICATE OF PAID CLAIM.
83-DUPLICATE PAID/CAPTURED CLAIM  4854 DUP CHECK: SEARCHES HISTORY. IF A CLAIM WITH THE SAME FDOS AND 1ST 5 CHARACTERS OF THE GCN’S ARE EQUAL; THEN DUP CHECK CONTINUES. IF PRIOR AUTHORIZATION IS REQUIRED; OR THE PRESCRIBING PHYSICIAN DEA NUMBERS ARE EQUAL; OR THE PRIOR AUTH MED CERT CODE INDICATES MEDICAL CERTIFICATION; OR THE DENIAL OVERRIDE IS SET TO M
83-DUPLICATE PAID/CAPTURED CLAIM  4992 EXACT DUP (WAS EDIT 4185) BUT MODIFIED FOR FLAX -- BUG TRACKER REQUEST # 2042 WHEN EXACT DUPLICATE EDIT IS POSTED, USE EOB 718 IF DIFFERENT PRESCRIBER EOB TEXT: EXACT DUPLICATE - DIFFERENT PRESCRIBER
83-DUPLICATE PAID/CAPTURED CLAIM  4993 EXACT DUP (WAS EDIT 4185) BUT MODIFIED FOR FLAX -- BUG TRACKER REQUEST # 2042 WHEN EXACT DUPLICATE EDIT IS POSTED, USE EOB 101 IF SAME PRESCRIBER EOB TEXT: EXACT DUPLICATE - SAME PRESCRIBER
84-CLAIM HAS NOT BEEN PAID/CAPTRD  4192 THE ORIGINAL CLAIM THAT IS ATTEMPTING TO BE ADJUSTED/CREDITED WAS NOT FOUND OR IS A CREDIT.
84-CLAIM HAS NOT BEEN PAID/CAPTRD  4193 EDIT IGNORED
84-CLAIM HAS NOT BEEN PAID/CAPTRD  4374 "A CREDIT CLAIM CANNOT BE ADJUSTED. THE REPLACEMENT CLAIM OF AN ADJUSTMENT CAN BE VOIDED OR REPLACED - BUT THE CREDIT CLAIM OF AN ADJUSTMENT CAN NEVER BE VOIDED OR REPLACED. THIS EDIT CAN POST TO PROVIDER SUBMITTED CREDIT REQUESTS - PROVIDER SUBMITTED REPLACEMENT CLAIMS - ONLINE ENTERED CREDIT REQUESTS - AND ONLINE EN
84-CLAIM HAS NOT BEEN PAID/CAPTRD  4834 EDIT IGNORED
85-CLAIM NOT PROCESSED  4187 "THE MAXIMUM NUMBER OF ENTRIES FOR THE RELATED HISTORY TABLE HAVE BEEN MET OR EXCEEDED. PROGRAM: S780C / S780 ADD-TO-RLTD-HIST"
85-CLAIM NOT PROCESSED  4188 CLAIM NOT PROCESSED – REJECT CODE NOT FOUND ON REJECT CONTROL TABLE OR TOO MANY REJECT CODES ARE POSTED TO CLAIM OR RELATED HISTORY ENTRIES EXCEEDED FOR CLAIM OR PARTICIPANT
85-CLAIM NOT PROCESSED  4363 THIS EDIT WILL POST IF THE HEADER-LEVEL OVERRIDE EXCEPTION LOCATION CODE DOES NOT HAVE A MATCHING CODE ON THE REFERENCE TEXT LOCATION DATABASE
85-CLAIM NOT PROCESSED  4364 THIS EXCEPTION CAN BE POSTED TO THE CLAIM IF A LOGIC ERROR - SUCH AS A MISSING REPLACED TCN NUMBER FOR A CREDIT TRANSACTION, OR A CREDIT WITH A CLAIM STATUS OF TO-BE-DENIED OCCURS. IN SOME INSTANCES, IT CAN BE USED TO DENOTE UNEXPECTED SQL CODES FROM DB2 CALLS.
85-CLAIM NOT PROCESSED  4375 EDIT IGNORED
85-CLAIM NOT PROCESSED  4379 UNABLE TO PROCESS. SYSTEM UPDATE IN PROCESS. RESUBMIT CLAIM LATER.
85-CLAIM NOT PROCESSED  4404 EDIT IGNORED
85-CLAIM NOT PROCESSED  4414 THE PHARMACY’S PHYSICAL ADDRESS INFORMATION COULD NOT BE FOUND.
85-CLAIM NOT PROCESSED  4415 IF THE LOADED EXCEPTION COUNT IS 0.
85-CLAIM NOT PROCESSED  4445 "CLAIMS IS SYSTEM GENERATED AND (TRANSACTION TYPE IS VOID OR TRANSACTION TYPE IS DEBIT OF ADJUSTMENT) AND CYCLE NUMBER EQUAL ZERO AND BATCH NUMBER IS LESS THAT SYSTEM GENERATED BATCH NUMBER "
85-CLAIM NOT PROCESSED  4960 EDIT IGNORED
86-SUBMIT MANUAL REVERSAL  4775 EDIT IGNORED
87-REVERSAL NOT PROCESSED  4191 THE ORIGINAL CLAIM THAT IS ATTEMPTING TO BE ADJUSTED/CREDITED WAS DENIED.
87-REVERSAL NOT PROCESSED  4376 THE ADUSTMENT REASON CODE ENTERED ON THE REQUEST IS MISSING OR INVALID (NOT NUMERIC OR NOT ON VALID VALUES TABLE). SEE THE DATA DICTIONARY FOR A LIST OF VALID VALUES.
87-REVERSAL NOT PROCESSED  4439 AN ADJUSTMENT REQUEST RECORD HAS TARGETED A HISTORY RECORD FOR ADJUSTMENT - BUT THE HISTORY RECORD HAS BEEN SUSPENDED
87-REVERSAL NOT PROCESSED  4441 AN ADJUSTMENT REQUEST RECORD HAS TARGETED A HISTORY RECORD FOR ADJUSTMENT - BUT THE HISTORY RECORD HAS BEEN VOIDED
87-REVERSAL NOT PROCESSED  4443 AN ADJUSTMENT REQUEST RECORD HAS TARGETED A HISTORY RECORD FOR ADJUSTMENT - BUT THE KEYED REPLACED NUMBER (TCN) ON THE ADJUSTMENT REQUEST RECORD THAT IDENTIFIES THE HISTORY RECORD IS EQUAL TO ZEROS.
87-REVERSAL NOT PROCESSED  4835 REVERSAL NOT PROCESSED - IF THE MATCHING HISTORY CLAIM WAS FOUND AND WAS ALREADY CREDITED; OR WAS TO-BE-CREDITED; OR THE ORIGINAL CLAIM WAS DENIED; THEN THE ERROR IS POSTED.
87-REVERSAL NOT PROCESSED  4836 EDIT IGNORED
87-REVERSAL NOT PROCESSED  4837 NO POS REVERSAL IN FIN. CYCLE
88-DUR REJECT ERROR  4194 ACCOMPANIED BY DUR CONFLICT CODE: TD
88-DUR REJECT ERROR  4195 "PRENATAL EXCEPTION (HISTORY FDOS IS GREATER THAN IP FDOS OR AFTER PROCESSING THROUGH ALL OF HISTORY CLAIMS) AND IP PARTICIPANT SEX CODE EQUALS FEMALE AND IP THERAPEUTIC CLASS CODE SPECIFIC EQUALS PRE-NATAL VITAMINS AND IP PARTICIPANT AGE IS GREATER THAN 11 AND IP PARTICIPANT AGE IS LESS THAN 60"
88-DUR REJECT ERROR  4196 "EXCESSIVE DURATION EXCEPTION THIS EDIT IS POSTED AFTER ACCUMULATING THE TOTAL NUMBER OF DAYS SUPPLIED FOR ALL HISTORY CLAIMS AND ADDING THE IP DAYS SUPPLY TO THE TOTAL WHEN: THE IP PARTICIPANT IS YOUNGER THAN 13 AND THE PEDIATRIC DURATION OF THERAPY MAXIMUM NUMBER OF DAYS ON THE DRUG RECORD USING THE IP NDC IS LESS
88-DUR REJECT ERROR  4197 ACCOMPANIED BY DUR CONFLICT CODE: DD DRUG/DRUG INTERACTIONS WITH A SEVERITY LEVEL OF 1; REQUIRE PRIOR AUTHORIZATION.
88-DUR REJECT ERROR  4198 "INGREDIENT DUPLICATION FIRST DATE OF SERVICE ON THE CURRENT CLAIM MUST BE AFTER THE FIRST DATE OF SERVICE ON THE HISTORY CLAIM. AND FIRST DATE OF SERVICE ON THE CURRENT CLAIM MUST BE BEFORE THE DATE CALCULATED TO BE THE HISTORY CLAIM’S FIRST DATE OF SERVICE PLUS DAYS SUPPLIED LESS THE GRACE PERIOD. AND THE CLAIM DATE
88-DUR REJECT ERROR  4199 AGE EXCEPTION: THE BENEFICIARY IS YOUNGER THAN THE MINIMUM AGE ON THE DRUG RECORD.
88-DUR REJECT ERROR  4200 DRUG AND/OR DOSAGE NOT INDICATED FOR THIS GENDER
88-DUR REJECT ERROR  4201 "LOW DOSE EXCEPTION (HISTORY FDOS IS GREATER THAN IP FDOS OR AFTER PROCESSING THROUGH ALL OF HISTORY CLAIMS) AND THE DOSE FORM ON THE DRUG RECORD FROM THE IP NDC MUST EQUAL ‘EACH’ OR ‘MILLILITER’ AND IP PARTICIPANT MUST BE AT LEAST 18 YEARS OLD AND NOT OLDER THAN 60 YEARS AND CALCULATED DAILY DOSE MUST BE LESS THAN
88-DUR REJECT ERROR  4202 ACCOMPANIED BY DUR CONFLICT CODE: HD.QUANTITY DIVIDED BY DAYS SUPPLY EXCEEDS RECOMMENDED MAX DAILY DOSE. SUBMIT MAX UNIT OVERRIDE PA IF HIGH DOSE IS REQUIRED
88-DUR REJECT ERROR  4203 "ALLERGY EXCEPTION (HISTORY FDOS IS GREATER THAN IP FDOS OR AFTER PROCESSING THROUGH ALL OF HISTORY CLAIMS) AND THE IP PARTICIPANT MUST HAVE A PRIOR AUTHORIZATION AND THE CONDITION TYPE ON THE PRIOR AUTHORIZATION TABLE MUST BE SET TO ‘AC‘ AND ONE OF THE CONDITION RANGE FIELDS ON THE PRIOR AUTHORIZATION TABLE MUST MA
88-DUR REJECT ERROR  4204 DRUG SHOULD BE USED WITH CAUTION IN PREGNANCY. IF PRESCRIBER HAS BEEN CONTACTED TO VERIFY USE IN PREGNANCY, MAY BE OVERIDDEN BY SUBMITTING APPROPRIATE DUR INTERVENTION VALUES IN REASON FOR SERVICE, INTERVENTION CD.& OUTCOME CD. FIELDS
88-DUR REJECT ERROR  4205 ACCOMPANIED BY DUR CONFLICT CODE: ER EARLY REFILLS REQUIRED PRIOR AUTHORIZATION FROM DOM.
88-DUR REJECT ERROR  4431 DUR REJECT WITH CONFLICT CODE FOR THERAPEUTIC DUPLICATION.
88-DUR REJECT ERROR  4432 CLAIM FAILED A PRO-DUR ALERT
88-DUR REJECT ERROR  4587 AGE EXCEPTION: THE BENEFICIARY IS OLDER THAN THE MAXIMUM AGE ON THE DRUG RECORD.
88-DUR REJECT ERROR  4839 ACCOMPANIED BY DUR CONFLICT CODE FOR DC (DISEASE PRECAUTION) SENT IN DUR SEGMENT
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
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.
AA-PATIENT SPENDDOWN NOT MET  4929 EDIT IGNORED
AB-DATE WRITTEN IS GT DATE FILLED  4206 THE DATE PRESCRIPTION WRITTEN IS GREATER THAN THE DATE OF SERVICE.
AC-PROD NOT COV-NON-PART MANUFCTR  4207 "THE PRODUCT/SERVICE ID QUALIFIER INDICATES THAT THE PRODUCT/SERVICE ID FIELD CONTAINS A NDC AND ((DRUG REBATE DATA IS FOUND FOR THE CLAIM’S NDC AND DATE OF SERVICE ON THE DRUG REBATE TABLE AND THE DRUG REBATE CODE FOR THE NDC = NO REBATE (‘0’) AND THE NDC IS NOT A REBATE EXEMPT NDC (HARD-CODED TABLE – MAS
AD-BILLING PROV INELGIBLE TO BILL  4930 EDIT IGNORED
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.
AH-UNIT DOSE PKG FOR NURSING HOME  4932 EDIT IGNORED
AJ-GENERIC DRUG REQUIRED  4035 GENERIC DRUG REQUIRED. IF BRAND IS MEDICALLY NECESSARY PRESCRIBER MUST SUBMIT PA REQUEST
AJ-GENERIC DRUG REQUIRED  4210 EDIT IGNORED
AK-INV SOFTWARE VENDR/CERT ID  4211 THE SOFTWARE VENDOR/CERTIFICATION ID IS MISSING (SPACES).
AM-INV SEGMENT IDENTIFICATION  4212 THE SEGMENT IS A MANDATORY SEGMENT AND THE SEGMENT IDENTIFIER IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD
A9-INV TRANSACTION COUNT  4213 THE TRANSACTION COUNT IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
BE-INV PROF SVC FEE SUBMITTED  4214 THE PRODUCT/SERVICE ID QUALIFIER IS NOT NDC AND THE PROFESSIONAL SERVICE FEE SUBMITTED IS MISSING (ZEROS).
B2-INV SERVICE PROV ID QUALIFIER  4215 THE SERVICE PROVIDER ID QUALIFIER IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
CA-INV PATIENT FIRST NAME  4787 FIRST NAME NOT EDITED SEPARATELY. IF THE FIRST NAME IS MISSING ON THE CLAIM; SYSTEM RETURNS COB 0238. THIS EDIT HAS BEEN MAPPED TO CB; M/I PATIENT’S LAST NAME.
CB-INV PATIENT LAST NAME  4789 MEMBER NAME MISSING
CF-INV EMPLOYER NAME  4891 EDIT IGNORED
CG-INV EMPLOYER STREET ADDR  4892 EDIT IGNORED
CH-INV EMPLOYER CITY  4893 EDIT IGNORED
CI-INV EMPLOYER STATE/PROVINCE  4894 EDIT IGNORED
CJ-INV EMPLOYER ZIP/POSTAL CD  4895 EDIT IGNORED
CK-INV EMPLOYER PHONE NUMBER  4896 EDIT IGNORED
CL-INV EMPLOYER CONTACT NAME  4897 EDIT IGNORED
CM-INV PATIENT STREET ADDRESS  4898 EDIT IGNORED
CN-INV PATIENT CITY  4912 EDIT IGNORED
CO-INV PATIENT STATE/PROVINCE  4900 EDIT IGNORED
CP-INV PATIENT ZIP/POSTAL CD  4901 EDIT IGNORED
CQ-INV PATIENT PHONE NUMBER  4902 EDIT IGNORED
CR-INV CARRIER ID  4903 EDIT IGNORED
CT  4904 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
DP  4905 EDIT IGNORED
DQ-INV USUAL AND CUSTOMARY CHG  4790 USUAL AND CUSTOMARY CHARGE (TOTAL CHG AMT) IS MISSING OR ZERO.
DQ-INV USUAL AND CUSTOMARY CHG  4841 EDIT IGNORED
DQ-INV USUAL AND CUSTOMARY CHG  4842 SUSPEND A CLAIM IF BILLED AMOUNT IS > THAN OR EQUAL TO 500% OF ALLOWED AMOUNT OR IF BILLED AMOUNT IS < LESS THAN OR EQUAL TO 20% OF ALLOWED AMOUNT. SUSPEND TO LOCATION CODE 40.
DQ-INV USUAL AND CUSTOMARY CHG  4843 EDIT IGNORED
DQ-INV USUAL AND CUSTOMARY CHG  4844 CLAIM PRICED AT ZERO
DQ-INV USUAL AND CUSTOMARY CHG  4845 EDIT IGNORED
DQ-INV USUAL AND CUSTOMARY CHG  4848 EDIT IGNORED
DQ-INV USUAL AND CUSTOMARY CHG  4849 EDIT IGNORED
DQ-INV USUAL AND CUSTOMARY CHG  4872 "EDIT WILL CHECK FOR BOTH MISSING AND INVALID CONDITIONS WILL ALSO POST FOR 590 CLAIMS IN EXCESS OF $500 THAT REQUIRE A PA IN CONJUNCTION WITH EDIT 75; EXCEPTION CODE 4965 (PATTY LYNN)"
DQ-INV USUAL AND CUSTOMARY CHG  4917 EDIT IGNORED
DR-INV PRESCRIBER LAST NAME  4225 EDIT IGNORED
DS  4906 EDIT IGNORED
DT-INV UNIT DOSE INDICATOR  4226 M/I UNIT DOSE INDICATOR
DU-INV GROSS AMOUNT DUE  4227 EDIT IGNORED
DV-INV OTHER PAYER AMOUNT PD  4229 OTHER PAYER AMOUNT PAID CANNOT BE A NEGATIVE AMOUNT.
DV-INV OTHER PAYER AMOUNT PD  4231 "CLAIM REQUIRES TPL REVIEW (MASSACHUSETTS SPECIFIC) IF THE OTHER COVERAGE CODE IS 2 (OTHER COVERAGE EXISTS – PAYMENT COLLECTED) AND THE PAYERID PAID AMOUNT IS MISSING (ZERO). OR IF THE OTHER COVERAGE CODE IS ‘0’ (NOT SPECIFIED) OR ‘1’ (NO OTHER COVERAGE IDENTIFIED) ‘3’ (OTHER COVERAGE EXISTS - THIS CLAM NOT COVERED)
DV-INV OTHER PAYER AMOUNT PD  4816 MISSING/INVALID COB PAID AMOUNT - CCO DID NOT SUBMIT A COB PAID AMOUNT ON A PAID ENCOUNTER CLAIM
DV-INV OTHER PAYER AMOUNT PD  4817 CCO DID NOT SUBMIT THEIR ALLOWED AMOUNT - CCO MUST SUBMIT A COB PAID AMOUNT >0 WITH A COB PAID CODE OF '99 - OTHER'
DV-INV OTHER PAYER AMOUNT PD  4855 IF THE OTHER INSURANCE INDICATOR = 3 OR 4; AND THE PRIMARY PAYER DATE NOT NUMERIC OR NOT > ZEROES OR THE OTHER AMOUNT IS NOT EQUAL TO ZEROES; THEN THE ERROR IS POSTED.
DW  4232 EDIT IGNORED
DX-INV PATIENT PAID AMT SUBM  4233 EDIT IGNORED
DY-INV DATE OF INJURY  4234 EDIT IGNORED
DZ-INV CLAIM/REFERENCE ID  4235 EDIT IGNORED
EA-INV ORIG PRESC PROD/SVC CD  4933 M/I ORIGINALLY PRESCRIBED PRODUCT/SERVICE CODE
EB-INV ORIG PRESCRIBED QTY  4934 M/I ORIGINALLY PRESCRIBED QUANTITY
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
EJ-INV ORIG PRESCRIBED PRD/SVC ID  4938 EDIT IGNORED
EK-INV SCHEDULED RX ID NUMBER  4939 EDIT IGNORED
EM-INV RX/SVC REF NUM QUALIFIER  4239 'RX/SERVICE REFERENCE CODE IS MISSING OR NOT =1(RX BILLING) OR 2 (SERVICE BILLING)
ET-INV QUANTITY PRESCRIBED  4243 THE QUANTITY PRESCRIBED IS MISSING (ZEROS).
ET-INV QUANTITY PRESCRIBED  4262 TOPICALS ARE LIMITED TO TWO TIMES THE PACKAGE SIZE PER CLAIM
ET-INV QUANTITY PRESCRIBED  4615 ZELNORM IS LIMITED TO 360 TOTAL CUMULATIVE UNITS PER YEAR.
EU-INV PRIOR AUTH TYPE CODE  4244 "THE PRIOR AUTHORIZATION TYPE CODE DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD OR THE PRIOR AUTHORIZATION TYPE CODE IS MISSING AND THE PRIOR AUTHORIZATION NUMBER IS PRESENT."
EU-INV PRIOR AUTH TYPE CODE  4600 EDIT IGNORED
EV-INV PRIOR AUTH NUM SUBMITTED  4245 THE PRIOR AUTHORIZATION NUMBER SUBMITTED IS MISSING AND THE PRIOR AUTHORIZATION TYPE CODE EQUALS ‘PA’.
EW-INV INTERMEDIARY AUTH TYPE ID  4940 EDIT IGNORED
EX-INV INTERMEDIARY AUTH ID  4941 M/I INTERMEDIARY AUTHORIZATION ID
EY-INV PROVIDER ID QUALIFIER  4246 "THE PHARMACY PROVIDER ID QUALIFIER IS MISSING OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD OR THE PHARMACY PROVIDER ID QUALIFIER IS MISSING AND THE PHARMACY PROVIDER ID IS PRESENT."
EZ-INV PRESCRIBER ID QUALIFIER  4247 "THE PRESCRIBER ID QUALIFIER IS MISSING AND A PRESCRIBER ID EXISTS OR OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD"
E1-INV PRODUCT/SVC QUALIFIER  4248 M/I PRODUCT/SERVICE ID QUALIFIER
E2  4907 EDIT IGNORED
E3-INV INCENTIVE AMOUNT SUBMITTED  4249 M/I INCENTIVE AMOUNT SUBMITTED
E4-INV REASON FOR SERVICE CODE  4250 EDIT IGNORED
E4-INV REASON FOR SERVICE CODE  4430 "DUR OVERRIDE CONFLICT THE REASON FOR SERVICE IS MISSING AND THE DUR INTERVENE CODE OR DUR OUTCOME CODE IS PRESENT."
E5-INV PROFESSIONAL SERVICE CODE  4252 EDIT IGNORED
E6-INV RESULT OF SERVICE CODE  4254 EDIT IGNORED
E7-INV QUANTITY DISPENSED  4150 EXCEEDS MAXIMUM ALLOWABLE QUANTITY
E7-INV QUANTITY DISPENSED  4256 EDIT IGNORED
E7-INV QUANTITY DISPENSED  4847 QUANT > ESTIMD PRICE BY 800%
E7-INV QUANTITY DISPENSED  4873 QUANTITY DISPENSED MUST BE A MULTIPLE OF THE PACKAGE SIZE.
E8-INV OTHER PAYER DATE  4257 EDIT IGNORED
E8-INV OTHER PAYER DATE  4258 OTHER PAYER DATE CANNOT BE GREATER THAN DATE RX FILLED
E8-INV OTHER PAYER DATE  4259 OTHER PAYER DATE – IF OTHER INSURANCE INDICATOR = 0 OR 1 AND PRIMARY PAYER DENY DATE IS NUMERIC AND > ZERO; OR OTHER AMOUNT IS NOT EQUAL TO ZERO; ERROR IS POSTED.
E8-INV OTHER PAYER DATE  4261 "INVALID OTHER INSURANCE 2 – 5.1 ONLY IF THE OTHER COVERAGE CODE IS 2 (OTHER COVERAGE EXISTS - PAYMENT COLLECTED) AND THE OTHER PAYER AMOUNT PAID EQUALS ZEROS OR THE OTHER PAYERID DATE = 0001-01-01"
E9-INV PROVIDER ID  4263 THE PHARMACY PROVIDER ID IS MISSING AND THE PHARMACY PROVIDER ID QUALIFIER IS PRESENT.
GE-INV PCNT SALES TAX AMT SUBM  4265 "THE PERCENTAGE SALES TAX AMOUNT SUBMITTED IS MISSING (ZEROS) AND THE FLAT TAX AMOUNT IS MISSING OR ZEROES."
HA-INV FLAT SALES TAX AMT SUBM  4266 "THE FLAT SALES TAX AMOUNT SUBMITTED IS MISSING (ZEROS) AND THE PERCENTAGE SALES TAX AMOUNT IS MISSING OR ZEROES."
HB-INV OTHER PAYER AMT PAID COUNT  4267 A COB SEGMENT IS PRESENT AND THE OTHER PAYER AMOUNT PAID COUNT IS MISSING (ZEROS).
HC-INV OTHER PAYER AMT PAID QUAL  4269 THE OTHER PAYER AMOUNT PAID QUALIFIER IS MISSING (SPACES) AND THE OTHER PAYER AMOUNT PAID IS GREATER THAN ZEROS.
HC-INV OTHER PAYER AMT PAID QUAL  4270 THE OTHER PAYER AMOUNT PAID QUALIFIER DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD
HD-INV DISPENSING STATUS  4271 MISSING OR INVALID DISPENSING STATUS.
HD-INV DISPENSING STATUS  4272 THE DISPENSING STATUS DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
HD-INV DISPENSING STATUS  4416 COMPOUND CODE IS EQUAL TO ‘2’ AND THE DISPENSING STATUS IS GREATER THAN SPACES.
HF-INV QTY INTENDED TO BE DISP  4274 THE QUANTITY INTENDED TO BE DISPENSED IS MISSING (ZEROS) AND THE DISPENSING STATUS INDICATES A PARTIAL FILL (‘P’) OR ‘C’.
HF-INV QTY INTENDED TO BE DISP  4275 THE QUANTITY INTENDED TO BE DISPENSED IS GREATER THAN ZEROS BUT THE DISPENSING STATUS DOES NOT INDICATE A PARTIAL FILL (‘P’).
HG-INV DAYS SUP INTEND TO BE DISP  4276 THE DAYS SUPPLY INTENDED TO BE DISPENSED IS MISSING (ZEROS) AND THE DISPENSING STATUS INDICATES A PARTIAL FILL (‘P’).
HG-INV DAYS SUP INTEND TO BE DISP  4277 THE DAYS SUPPLY INTENDED TO BE DISPENSED IS GREATER THAN ZEROS BUT THE DISPENSING STATUS DOES NOT INDICATE A PARTIAL FILL (‘P’).
H6-INV DUR CO-AGENT ID  4283 THE DUR CO-AGENT ID IS MISSING (SPACES).
H7-INV OTH AMT CLAIMED SUBM COUNT  4284 THE OTHER AMOUNT CLAIMED SUBMITTED COUNT IS MISSING (ZEROS) AND THE OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER OR AMOUNT IS PRESENT.
H8-INV OTH AMT CLAIMED SUBM QUAL  4285 THE OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD AND THE OTHER AMOUNT CLAIMED SUBMITTED AMOUNT IS GREATER THAN ZERO.
H9-INV OTH AMT CLAIMED SUBMITTED  4286 THE OTHER AMOUNT CLAIMED SUBMITTED IS MISSING (ZEROS) AND THE OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER IS PRESENT
JE-INV PCNT SALES TAX BASIS SUBM  4287 THE PERCENTAGE SALES TAX BASIS SUBMITTED IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
J9-INV DUR CO-AGENT ID QUALIFIER  4288 THE DUR CO-AGENT ID QUALIFIER IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
KE-INV COUPON TYPE  4942 EDIT IGNORED
ME-INV COUPON NUMBER  4943 EDIT IGNORED
MZ-ERROR OVERFLOW  4899 NUMBER OF ERRORS ON THE CLAIM EXCEED THE MAXIMUM NUMBER OF ERRORS ALLOWED BY THE SYSTEM.
M1-NOT COVERED IN THIS AID CATEG  4289 EDIT IGNORED
M1-NOT COVERED IN THIS AID CATEG  4290 EDIT IGNORED
M1-NOT COVERED IN THIS AID CATEG  4291 EDIT IGNORED
M1-NOT COVERED IN THIS AID CATEG  4428 EDIT IGNORED
M1-NOT COVERED IN THIS AID CATEG  4856 EDIT IGNORED
M2-RECIPIENT LOCKED IN  4293 "PARTICIPANT/PROVIDER LOCKIN MISMATCH THE CLAIM FIRST DATE OF SERVICE FELL WITHIN THE DATE RANGE OF ONE OF THE PROVIDERS IN THE LOCKIN TABLE BUT THE CLAIM PROVIDER NUMBER IS NOT EQUAL TO THE PROVIDER NUMBER IN THE LOCKIN TABLE. "
M2-RECIPIENT LOCKED IN  4857 EDIT IGNORED
M2-RECIPIENT LOCKED IN  4964 EDIT IGNORED
M2-RECIPIENT LOCKED IN  4987 EDIT IGNORED
M3-HOST PA/MC ERROR  4908 EDIT IGNORED
M4-RX NUM TIME LIMIT EXCEEDED  4294 EDIT IGNORED
M5-REQUIRES MANUAL CLAIM  4793 EDIT POSTED FOR COMPOUNDS IN 3.2 WHICH REQUIRE A MANUAL / PAPER CLAIM
M5-REQUIRES MANUAL CLAIM  4972 COMPOUND CLAIMS EXCEEDING $200 REQUIRE PAPER CLAIM
M6-HOST ELIGIBILITY ERROR  4594 LAST NAME: 1. REQUIRED. ACTUALLY CHECK 1ST POSITION FOR CHARACTERS "A" THRU "Z". FIRST NAME: 1. REQUIRED. ACTUALLY CHECK 1ST POSITION FOR CHARACTERS "A" THRU "Z". 2. INVALID-FIRST-NAME VALUES 'BABY ' 'BAB ' 'BBY ' SPACES 'NEWBORN' 'INFANT ' 'GIR
M6-HOST ELIGIBILITY ERROR  4595 K-BABY EDIT - BILLING UNDER MOTHER'S MEDICAID ID LIMITED TO ONE YEAR. REBILL UNDER BABY'S ID. IF THE DOB ON THE CLAIM IS WITHIN 365 DAYS, THEN THE EDIT ISN'T POSTED. OTHERWISE, 4014 IS POSTED.
M6-HOST ELIGIBILITY ERROR  4909 EDIT IGNORED
M8-HOST PROVIDER FILE ERROR  4850 HOST PROVIDER FILE ERROR
NE-INV COUPON VALUE AMT  4944 EDIT IGNORED
NN-TRANS REJ AT SW/INTERMEDIARY  4945 TRANSACTION REJECTED AT SWITCH OR INTERMEDIARY
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. "
PZ-NON-MATCHED UNIT OF MEA TO PRD  4949 NON-MATCHED UNIT OF MEASURE TO PRODUCT/SERVICE ID
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.
RK-ASOC PART FILL TRANS NOT SUPRT  4952 EDIT IGNORED
RM-COMP TR NP W SAME DOS AS PART  4953 COMPLETION TRANSACTION NOT PERMITTED WITH SAME ‘DATE OF SERVICE’ AS PARTIAL TRANSACTION
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.
R8-SYNTAX ERROR  4954 EDIT IGNORED
R9-VAL IN GR AMT DOES NF PRI FORM  4355 "GROSS AMOUNT DUE FOR RX = INGREDIENT COST SUBMITTED + DISPENSING FEE SUBMITTED + FLAT SALES TAX AMOUNT SUBMITTED + PERCENTAGE SALES TAX SUBMITTED
SE-INV PROCEDURE MODIFIER CODE CT  4356 THE PROCEDURE MODIFIER CODE COUNT IS MISSING (ZEROS) AND A PROCEDURE MODIFIER IS PRESENT.
TE-INV COMPOUND PRODUCT ID  4357 COMPOUND CLAIM SUBMITTED AND NDC IS MISSING.
UE-INV CPD ING BASIS OF CST DET  4358 THE COMPOUND INGREDIENT BASIS OF COST DETERMINATION IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
VE-INV DIAGNOSIS CODE COUNT  4359 THE DIAGNOSIS CODE COUNT IS MISSING (ZEROS) AND A DIAGNOSIS CODE IS PRESENT.
WE-INV DIAGNOSIS CODE QUALIFIER  4241 INVALID DIAGNOSIS CODE QUALIFIER. ONLY ICD-10 (VALUE '02') ACCEPTED FOR DATE OF SERVICE ON OR AFTER 10/01/2015
WE-INV DIAGNOSIS CODE QUALIFIER  4360 THE DIAGNOSIS CODE QUALIFIER IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD.
XE-INV CLINICAL INFO COUNTER  4361 THE CLINICAL INFORMATION COUNTER IS MISSING (ZEROS) OR IT DOES NOT MATCH THE NUMBER OF SETS OF MEASUREMENT FIELDS ON A CLINICAL SEGMENT.
ZE-INV MEASUREMENT DATE  4362 THE MEASUREMENT DATE IS MISSING (ZEROS).
1C-INV SMOKER/NON-SMOKER CODE  4918 M/I SMOKER/NON-SMOKER CODE
1E-INV PRESCRIBER LOCATION CD  4919 M/I PRESCRIBER LOCATION CODE
2C-INV PREGNANCY INDICATOR  4031 "MISSING/INVALID PREGNANCY INDICATOR 5.1 ONLY THE PREGNANCY INDICATOR IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD."
2C-INV PREGNANCY INDICATOR  4628 BENEFICIARY IS PREGNANT (PREGNANCY INDICATOR = 2) BUT THE GENDER OF THE BENEFICIARY IS NOT FEMALE.
2E-INV PCP ID QUALIFIER  4032 "MISSING/INVALID PRIMARY CARE PROVIDER ID QUALIFIER 5.1 ONLY THE PRIMARY CARE PROVIDER ID IS SUBMITTED ON THE PRESCRIBER SEGMENT AND THE PRIMARY CARE PROVIDER ID QUALIFIER IS MISSING OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD."
3A-INV REQUEST TYPE  4048 "MISSING/INVALID REQUEST TYPE – 5.1 ONLY THE 5.1 TRANSACTION CODE EQUAL P1-P4 AND THE REQUEST TYPE ON THE PA TRANSACTION IS MISSING OR NOT EQUAL TO ONE OF THE VALID VALUES SPECIFIED."
3B-INV REQUEST PD DATE-BEGIN  4049 "MISSING REQUEST PERIOD DATE-BEGIN – 5.1 ONLY THE REQUEST PERIOD DATE-BEGIN IS MISSING (ZEROS)."
3C-INV REQUEST PD DATE-END  4050 "MISSING REQUEST PERIOD DATE-END – 5.1 ONLY THE REQUEST PERIOD DATE-END IS MISSING (ZEROS)"
3D-INV BASIS OF REQUEST  4051 "MISSING/INVALID BASIS OF REQUEST – 5.1 ONLY THE BASIS OF REQUEST IS MISSING (SPACES) OR IT DOES NOT MATCH ONE OF THE VALID VALUES SPECIFIED FOR THE FIELD."
3F-INV AUTH REP LAST NAME  4053 M/I AUTHORIZED REPRESENTATIVE LAST NAME
3G-INV AUTH REP STREET  4920 M/I AUTHORIZED REPRESENTATIVE STREET ADDRESS
3H-INV AUTH REP CITY  4921 M/I AUTHORIZED REPRESENTATIVE CITY ADDRESS
3J-INV AUTH REP STATE/PROV  4922 M/I AUTHORIZED REPRESENTATIVE STATE/PROVINCE ADDRESS
3K-INV AUTH REP ZIP/POSTAL CODE  4923 EDIT IGNORED
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)."
3P-INV AUTHORIZATION NUM  4955 EDIT IGNORED
3R-PRIOR AUTH NOT REQUIRED  4924 PRIOR AUTHORIZATION NOT REQUIRED
3S-INV PRI AUTH SUPPORT DOC  4057 M/I PRIOR AUTHORIZATION SUPPORTING DOCUMENTATION
3X-AUTH NUM NOT FOUND  4060 "AUTHORIZATION NUMBER NOT FOUND – 5.1 ONLY AN INQUIRY OR A REVERSAL WAS MADE ON A PRIOR AUTHORIZATION THAT COULD NOT BE FOUND."
3Y-PRIOR AUTHORIZATION DENIED  4061 "PRIOR AUTHORIZATION DENIED – 5.1 ONLY AN INQUIRY WAS MADE ON A PRIOR AUTHORIZATION THAT WAS IN PENDING STATUS."
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)."
4E-INV PRIM CARE PROV LAST NM  4925 M/I PRIMARY CARE PROVIDER LAST NAME.
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
6C-INV OTHER PAYER ID QUALIFIER  4926 EDIT IGNORED
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
7C-INV OTHER PAYER ID  4957 EDIT IGNORED
7E-INV DUR/PPS CODE COUNTER  4110 THE DUR/PPS CODE COUNTER IS MISSING (ZEROS).
8C-INV FACILITY ID  4927 EDIT IGNORED
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
8E-INV DUR/PPS LVL OF EFFORT  4928 EDIT IGNORED
9T-PA TYP CD SUBMITTD NOT COVERED  4068 DOM DOES NOT ALLOW THE SUBMISSION OF NCPDP FIELD 461-EU PRIOR AUTHORIZATION TYPE CODE (PA CERT CD FOUND ON 'MAIN' TAB)
N/A  4413 CLAIM FOR SIMVASTATIN AT DOSE > 80 MG IS GREATER THAN THE FDA RECOMMENDED DOSE.
N/A  4500 RESERVED FOR FUTURE USE
N/A  4534 RESERVED FOR FUTURE USE
N/A  4685 IMMUNOSUPPRESSANTS-CYCLOSPORINE SMART FUSION ONLY
N/A  4999 EDIT IGNORED