Definitions
This is an override that is performed when a person is travelling and will run out of medication due to refill too soon.
Vacation Override
What is the QL for Topiramate ER cap 150mg?
QL = 2 caps/day
PA 0000202198
What is the date span of the approval for this request?
06/13/2025 - 06/13/2026
Which three section need to be completed to run a test claim?
Pharmacy
Drug (Including Quantity & Day Supply)
Prescriber
What is denial code 75?
Prior Authorization Required
This indicates the maximum amount of medication allowed without a prior authorization.
Quantity Limit
What category does Entresto fall under?
Cardiovascular Agents
PA 0000208392
What is the external ID for this request?
BJBBNCRF
How far in advance can a Vacation Override be requested?
2 Weeks
What is denial code 70?
Product/Service Not Covered Plan/Benefit Exclusion
This is a drug sold under a trademark and is a protected name. These products are considered exclusive and can only be produced and sold by the manufacturer.
Brand Name Drug
What is the generic equivalent for Avapro & is it covered on this plan?
Irbesartan tab - Yes, it is covered.
PA 0000107818
How was this authorization initiated?
The prescribing provider called in and initiated it with one of our CSRs.
After placing and override - what should you do?
Run a new Test Claim to verify the claim will pay.
What is denial code 608?
608 – Step Therapy, Alternate Drug Therapy Required Prior To Use Of Submitted Product Service ID
This is an exclusive listing of all medications covered on the plan.
Formulary or Preferred Drug List
Which medication needs to be trialed before the plan will cover Brinzolamide Ophthalmic Suspension.?
Step Therapy requires trial of Dorzolamide 2% Ophthalmic Suspension.
PA 0000201846
Why was this PA cancelled?
A prior authorization is not required.
What is the difference between a hard reject and a soft reject?
Hard reject: Pharmacy must call to get a claim overridden in order to pay.
Soft reject: Claim can be overridden by pharmacy entering acceptable codes.
What is denial code 79
Fill Too Soon
This identifies brand and generic drugs with the greatest specificity. It is an 11-digit number, with the first five digits identifying the manufacturer, the next four identifying the drug and the last two identifying the package size.
NDC (National Drug Code)
Which pharmacy needs to be used to fill Bosulif?
Only available through Walgreens
PA 0000135534
Why was this request denied?
Mental health medications are not covered under pharmacy benefits through EOCCO. This drug is covered directly by OHP open card.
What is DUR Reject code DD?
Drug-Drug Interaction: 2 or more drugs that the member is prescribed can cause unpredictable or undesirable effects.
What is denial code 889?
Prescriber Not Enrolled in State Medicaid Program