Beginning today, Dec. 27, 2016, Amerigroup will change its “Refills Allowed After” (i.e. Refill Too Soon) limits for members enrolled in its Medicaid and CHIP plans.

The changes to the Medicaid Refills Allowed After limits will require members to use 90% of a prescription before a refill can be obtained. Claims submitted before the 90% threshold has been reached will reject with NCPDP Reject 79, “Refill Too Soon.”

 

*Please see attached PDF for more information.

Effective 1/1/2017, the Morphine Equivalent Dose (MED) edit will be upgraded from messaging only to a soft rejection with messaging for all Navitus clients. The MED edit identifies members who have active opioid prescriptions with a cumulative morphine equivalent dose of 120 mg or greater, prescribed by two or more providers, and filled at two or more pharmacies. The purpose of this edit is to alert the dispensing pharmacist of potential overutilization issues. The soft rejection will allow for a pharmacist to review the clinical appropriateness of the claim, perform any prescriber outreach (as applicable), and, when clinically appropriate, override the rejection at the point-of-sale using standard NCPDP DUR codes. In addition to the soft rejection, pharmacies will receive the following message: "High Morphine Eq Dose, Mult Prescriber/Pharmacy."

Beginning today, Dec. 27, 2016, HealthKeepers, Inc. will change its “Refills Allowed After” (i.e. Refill Too Soon) limits for Anthem HealthKeepers Plus members enrolled in its Medicaid plan.

The changes to the Medicaid Refills Allowed After limits will require members to use 90% of a prescription before a refill can be obtained. Claims submitted before the 90% threshold has been reached will reject with NCPDP Reject 79, “Refill Too Soon.”

Please note HealthKeepers, Inc. introduced a similar change for some of its commercial and HCR/Exchange members on July 20, 2016.

 

*Please see attached PDF for more information.

Effective Jan. 1, 2017, Member ID numbers and Group (Grp) codes will change for prescription drug coverage (Part D) for the following Medica HealthCare plans. If you have patients who are Medica HealthCare Plans Medicare Part D members, please update your files with this new information.

You will need to include the new Member ID number along with the following Bin, PCN and Grp codes when you submit pharmacy claims for Medica HealthCare Plans MedicareMax members. This information is also listed on the front of the Medica HealthCare Plans Medicare Max member ID cards.

*Please see attached PDF for more information.