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

https://medicaid.ncdhhs.gov/blog/2022/06/21/pharmacy-behavioral-health-clinical-edits