PACE

Provider Bulletin

October 31, 2008

Program Updates

 

 

AVANDIA®-- Effective January 1, 2009, all new prescriptions for rosiglitazone (Avandia®) will be denied at the point of sale for cardholders not enrolled in a Part D plan.  NO provider requested medical exceptions will be granted. Following this denial, a letter will be sent to the prescriber identified on the claim requesting documentation supporting the prescribing of Avandia. Upon receipt of this documentation, consideration of a medical exception will be made.

 

ACTOS®--  Effective January 1, 2009, all new prescriptions for  pioglitazone (Actos®) will be denied at the point of sale unless the cardholder’s PACE claim’s history contains claims for metformin, a sulfonylurea or insulin within the last 60 days.  As with Avandia®, NO provider requested medical exceptions will be granted.  Following this denial, a letter will be sent to the prescriber identified on the claim requesting documentation supporting the prescribing of Actos®. Upon receipt of this documentation, consideration of a medical exception will be made.

 

Date Prescription Written: Currently the date a prescription is dispensed cannot exceed six (6) months from the Date the Prescription is Written. Claims exceeding this limit are currently identified on remittance advices with an EOB “M/I Date Prescription Written” (PACE 742; NCPDP 28).  Effective Tuesday November 4, 2008, claims dispensed more than 12 months from the date the prescription is written will deny with PACE Error 742; NCPDP Error 28.

 

 

Questions may be directed to Provider Services at:

1-800-835-4080