Behavioral Health Clinical Edits

The final implementation phase of behavioral health clinical edits was completed on May 14, 2018.  The edits target dose optimization, dosages exceeding Food and Drug Administration (FDA) recommendations and concomitant use within same chemical class beyond 60 days.  Atypical antipsychotics, antidepressants, Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit Disorder (ADD), and stimulants, anxiolytics and other behavioral health drugs, including suboxone, are in the edit logic.

Examples of Point of Sale (POS) edit messages returned to the pharmacy are:

• Quantity exceeds the adult (pediatric) dosage recommended by the FDA for atypical antipsychotics.
• Concomitant use of two or more antidepressants will be denied.
• Quantity exceeds the adult (pediatric) dosage recommended by the FDA for behavioral health meds.

Bypassing the edit will require an override (submission clarification code 10) that should be used by the pharmacist when the prescriber provides clinical rationale for the therapy issue alerted by the edit.

Questions can be directed to the CSRA call center at 866-246-8505. CSRA cannot override the claim on behalf of the pharmacy or the prescriber. Additionally, clinical rationale should be provided to the beneficiary’s dispensing pharmacy and not CSRA.

A prescriber may proactively document the clinical rationale with issuance of the prescription.  The concise documentation may provide information about the patient's situation, history, therapy goals and outcome.  Documentation solely of a diagnosis code is not legitimate justification.  The adequacy of proactive documentation is the professional judgment of the pharmacist.

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

[The original version of this article appeared in the June 2018 Pharmacy Newsletter]