Skip to main content
NC Medicaid logo NC Medicaid

Topical Navigation

  • Home
  • Beneficiaries
  • Meetings & Notices
  • Find a Doctor
  • Providers
  • Counties
  • Reports
  • FAQs and Resources
  • ABOUT US
  • NC.GOV
  • NCDHHS
  • SERVICES
NC Medicaid »   Home »   blog

Pharmacy Behavioral Health Clinical Edits Edits scheduled to resume on July 1, 2022

June 21, 2022

The pharmacy point of sale (POS) clinical edits for behavioral health medications target dosage (based on claim quantity and day supply) exceeding the Food and Drug Administration (FDA) approved maximum dosage and in-class therapeutic duplication. Behavioral health edits were turned off March 2020 as part of the pharmacy COVID-19 flexibilities implemented for the public health emergency (PHE).   

The edits are scheduled to resume on July 1, 2022. 

  • The behavioral health edits alert will cause claims to stop. 
  • Bypassing the edit requires an override that should be used by the pharmacist when the prescriber provides clinical rationale for the therapy issue flagged by the edit.  
  • The override is 10 entered in a submission clarification code field.  

The behavioral health edits are subject to the 72-hour emergency supply override, same as those available for prior authorization medications. Based on the judgment of the pharmacist, this will allow a limited medication supply to be dispensed when communication with the prescriber is delayed. 

The descriptions for the pediatric and adult behavioral health edits follow.

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.”

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 attention-deficit/attention deficit hyperactivity disorder (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.”

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

Edit 58610 Adult; Edit 58650 Pediatric

  • Concomitant use of three or more atypical antipsychotics
  • Pharmacy POS message “Concomitant use of three or more atypical antipsychotics will be denied”

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 Prior Approval Drugs and Criteria page in NCTracks.

Contact

NC Medicaid Contact Center: 888-245-0179

This blog is related to:

  • Bulletins
  • All Providers
  • Behavioral Health Providers
  • Pharmacy Providers

Related Articles

  • SPECIAL BULLETIN COVID-19 #255: Mandatory Coverage of COVID-19-Related Treatment Under the American Rescue Plan Act of 2021
  • Increase in Copay Amounts for Medicaid Services
  • Community Alternatives Program for Disabled Adults Waiver Amendment
  • SPECIAL BULLETIN COVID-19 #254: Pfizer-BioNTech Pediatric Vaccine
  • SPECIAL BULLETIN COVID-19 #253: Nursing Facility Program Updates
  • SPECIAL BULLETIN COVID-19 #252: Updates to Current Temporary COVID-19 Rate Increases
  • Pharmacy Behavioral Health Clinical Edits
  • UPDATE: Prior Authorizations End-dated When a Beneficiary Transitions to Managed Care
  • Additional Healthy Opportunities Services Now Available
  • SPECIAL BULLETIN COVID-19 #251: Sunsetting of Temporary COVID-19 Flexibilities Tied to the NC State of Emergency
  • Tailored Plan 101: Ready, Set, Launch Series
  • SPECIAL BULLETIN COVID-19 #250: Planning for the Transition out of the Appendix K Public Health Emergency for CAP/C and CAP/DA Waivers
  • Prior Approval Requirements Resume for Children’s Developmental Services Agency Providers
  • NC Medicaid Managed Care Provider Update - June 7, 2022
  • Updates to Requirements for the Consent for Sterilization Form

Share this page:

  • Facebook
  • Twitter
  • Email
Back to top

Contact Information

NC Medicaid
Division of Health Benefits

2501 Mail Service Center
Raleigh, NC 27699-2501
 
NC Medicaid Contact Center
Phone: 888-245-0179
Monday-Friday 8 a.m. to 5 p.m.
Closed on State holidays. 
 
Visit RelayNC for information about TTY services. 
 
More
 

Recent Tweets

Tweets by @ncdhhs

Follow Us

  • Facebook
  • Twitter
  • YouTube
  • LinkedIn
  • EMPLOYEE DIRECTORY
  • TRANSLATION DISCLAIMER
  • Accessibility
  • Terms of Use
  • Privacy Policy
  • Open Budget
NC Medicaid
https://medicaid.ncdhhs.gov/blog/2022/06/21/pharmacy-behavioral-health-clinical-edits