Beginning Jan. 1, 2017, the South Carolina Department of Health and Human Services (SCDHHS) will require all pharmacies filling prescriptions for Medicaid members to have a valid South Carolina State Medicaid ID.

If a pharmacy without a valid state Medicaid ID number submits a claim for a Medicaid member they will receive reject code 50 "PHARMACY’S STATE MEDICAID ID NOT ON FILE".

Beginning today, Dec. 27, 2016, BlueChoice HealthPlan will change its “Refills Allowed After” (i.e. Refill Too Soon) limits for members enrolled in its Medicaid 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 note BlueChoice HealthPlan introduced a similar change for some of its commercial and HCR/Exchange members on July 20, 2016.

 

*Please see attached PDF for more information.

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.