CCRx Daily Update        
January 8, 2006

                                                 Automated Override Codes!
 
 
In response to your calls and in the interest of helping you serve your patients with CCRx, we are immediately implementing the following processes.
 
Reject messages/edits removed for PA, QVT, and Step Edits
 
We have temporarily removed all rejects for Prior Authorization (PA), Quantity Limits (QVT), and Step Edits. You will not need to call the Pharmacy Tech Center to process these claims.
 
Non-Formulary Override Code – (See Very Important Note Below)
 
We have implemented a process to automate the requests for initial non-formulary prescriptions for your patients.
 
  1. During the claim adjudication process, CCRx will issue the CMS required reject for non-formulary medications.
  2. The pharmacy will be able to use a single, dynamic PA number to override all PRODUCT NOT COVERED rejects and automatically implement a Transition Fill.
 
  1. When you receive a non-formulary reject:
Enter PA Type – 1
PA number – 29100441281
 
  1. The procedure replaces the need to call the Pharmacy Tech Center or use the automated fax procedure to file the Transition Fill Request form.
  2. The dynamic PA will remain in place as needed in January.
 
By using the dynamic PA number, the pharmacy will be acknowledging that this claim is for an initial 30 day transitional fill for CMS covered medications not on the Community Care Rx formulary. It is imperative that you communicate to your patient that this is a non-formulary product, and the next refill will reject. Patients need to work with you and their physician to identify an appropriate formulary product or request an exception.
 
All non-formulary products will pay at Tier 3 – Non-Preferred brand through this process. 
 
VERY IMPORTANT: This code should NOT be used for CMS therapeutically excluded medications, such as barbiturates, benzodiazepines, multivitamins, or OTC products. Any claims for these products will be reviewed; pharmacies will be billed back for these claims and will need to charge their patients for them. Information about excluded drug classes and related Medicaid coverage of these drug classes by state is available from CMS at http://new.cms.hhs.gov/States/EDC/list.asp#TopOfPage.
                                                                                  
ELIGIBILITY and COPAY ISSUES
 
CCRx is continuing to work with CMS to address all eligibility and copay issues and will keep you informed.