Pharmacy Behavioral Health Clinical Edits

Effective May 1, 2017, new pharmacy point of sale (POS) clinical edits for behavioral health medications were applied for pediatric and adult beneficiaries. These changes were communicated in the April and June 2017 Pharmacy Newsletters and the July 2017 Medicaid Bulletin.

The edits are specifically related to dosage and quantity prescribed which exceeds the Food and Drug Administration (FDA) approved maximum dosage, dosage schedule and in-class therapeutic duplication.

A phased implementation was planned for the POS behavioral health clinical edits:

• July 2017: The first two edits were implemented. These edits applied to the dosage and quantity of atypical antipsychotics prescribed for pediatric and adult beneficiaries.
• March 12, 2018: Edits will be implemented which apply to the therapeutic duplication of atypical antipsychotics in pediatric and adult beneficiaries.
• May 14, 2018: Remaining edits will be implemented. These edits will apply to dosage and quantity prescribed and therapeutic duplication of Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder (ADD/ADHD) drugs, anxiolytics and antidepressants prescribed to pediatric and adult beneficiaries.

Bypassing any of the POS behavioral health clinical edits requires an override that should be used by the pharmacist when the prescriber provides clinical rationale for the therapy issue identified by the edit. The edit override is “10” entered in a submission clarification code field.

The bulleted description for the pediatric and adult behavioral health edits follow.

Phase One Implemented July 30, 2017

Edit 4110 Adult; Edit 7110 Pediatric

• Quantities more than the daily dosages recommended by the FDA for the atypical antipsychotics
• Pharmacy POS message “Quantity exceeds the adult (pediatric) dosage recommended by the FDA for atypical antipsychotics.”

Phase Two Implementation March 12, 2018

Edit 58610 Adult; Edit 58650 Pediatric

• Concomitant use of three or more atypical antipsychotics (concomitant use is 60 or more days of overlapping therapy.)
• Pharmacy POS message “Concomitant use of three or more atypical antipsychotics will be denied.”

Phase Three Implementation May 14, 2018

Edit 4125 Adult; Edit 7125 Pediatric

• Quantities more than the daily dosages recommended by the FDA for the antidepressants
• Pharmacy POS message “Quantity exceeds the adult (pediatric) dosage recommended by the FDA for antidepressants.”

Edit 4140 Adult; Edit 7140 Pediatric

• Quantities more than the daily dosages recommended by the FDA for ADD/ADHD medications
• Pharmacy POS message “Quantity exceeds the adult (pediatric) dosage recommended by the FDA for ADD/ADHD medications.”

Edit 4610 Adult; Edit 7610 Pediatric

• Quantities more than the daily dosages recommended by the FDA for the behavioral health medications (does not include antidepressants, atypical antipsychotics, stimulants and ADD/ADHD medications)
• Pharmacy POS message “Quantity exceeds the adult (pediatric) dosage recommended by the FDA for behavioral health meds.”

Note: For the following edits, concomitant use is 60 or more days of overlapping therapy.

Edit 58620 Adult; Edit 58660 Pediatric

• Concomitant use of two or more antidepressants (Selective serotonin reuptake inhibitor -SSRIs includes combination products)
• Pharmacy POS message “Concomitant use of two or more antidepressants will be denied.

Edit 58630 Adult; Edit 58670 Pediatric

• Concomitant use of two or more antidepressants (Serotonin–norepinephrine reuptake inhibitor - SNRIs)
• Pharmacy POS message “Concomitant use of two or more antidepressants will be denied.”

Edit 58640 Adult; Edit 58680 Pediatric

• Concomitant use of two or more anxiolytics
• Pharmacy POS message “Concomitant use of two or more anxiolytics will be denied.”

The edits, with appendices of the drugs included in the edit, are posted on the NCTracks Prior Approval Drugs and Criteria web page.

Outpatient Pharmacy Services
DMA, 919-855-4300