Pharmacy Post-Service Claim Edits

The following is a list of drugs that are included in our post-service claim edits program. The fact that a particular drug is not included on this list does not mean that such drug is not reviewed for appropriate billing and reimbursement. See the policy for each medication listed on our website for more information on guidelines and limitations for claims.

Any prior authorization determination from a medical necessity review is specific only to the drug being requested, unless stated otherwise, and is not a guarantee of payment or benefits. For all medications billed under the member’s medical benefit, claims received for a dose, duration, and/or frequency exceeding what is recommended in Food and Drug Administration (FDA) labeling may be subject to review and may result in partial or denied payment. Claims for excessive drug wastage will not be reimbursed.

For certain drugs billed under the medical benefit, pre-payment claim edits are applied based on the policy for that particular drug. These pre-payment claim edits verify that claims are paid in accordance with each policy’s diagnosis, frequency, and maximum billable units allowed.

PLEASE NOTE: Each policy for a particular drug provides specific guidelines which is used to determine pre-payment edits and can subsequently result in a partial or denied payment based on the submitted claim. The guidelines include, but are not limited to, covered and non-covered drugs, preferred/non-preferred drugs, step therapy requirements and exceptions, covered diagnosis code, maximum billable units, dose, frequency, and duration.

Prior authorization is not required for all drugs in scope for pre-payment claim edits. For drugs that do not require prior authorization, the guidelines within their respective policies will still be applied to claims, specifically as it relates to covered/non-covered drugs, preferred/non-preferred drugs, diagnosis, dose, frequency, duration, and maximum billable units. The clinical criteria for approval of a medication will not apply to drugs that do not require prior authorization. A list of drugs that are subject to pre-payment claim edits are noted below.

For drugs that require prior authorization, they will also be noted in our prior authorization list along with their corresponding policies.

A printable version of the PSCE Drug list can be found here.

A printable version of the PSCE Drug list can be found here.

* Indicates Prior Authorization Applies

Post-Service Claim Edits Drug List