Plan Limitations Exceeded

What is the Plan Limitations Exceeded pharmacy insurance rejection?  And how do I, as a pharmacy technician, override it quickly so that I can move on to more important job duties required before the end of my shift?

Accuracy and speed are very important in the resolution of rejected pharmacy insurance claims.  Some pharmacies call this Point-Of-Sale (POS).  For some pharmacies, each order entry tech is responsible for resolving their own rejected claims.  Other pharmacies designate one person to handle the whole store or locations' Point-Of-Sale issues.

Regardless of how your pharmacy resolves these rejections, it is important to be familiar with the Plan Limitations Exceeded denial, because it comes up more often than you may want to admit.

What is the Plan Limitations Exceeded rejection?  And how is it resolved?

This particular prescription insurance rejection can mean any number of things:

  • First, it could mean that the maximum recommended daily dosage has been exceeded.  In this case, the value entered in the days supply field should be checked for accuracy.  If the value in the days supply field is accurate, most major PBMs or pharmacy insurance carriers suggest that the prescriber should be consulted to verify the dosage instructions.  Remedy: If the prescriber approves and confirms the dosage, the prescription claim may be resubmitted/retransmitted using an 02 in the submission clarification fields.
  • Secondly, a Plan Limitations Exceeded rejection could mean the member's or client's benefit cap has been exceeded.  What does this mean in plain english?  This means that the cumulative amount of covered prescription benefits has been exhausted.  Most PBMs or Prescription Insurers have a monetary cap up to which they cover medication expenses.  After this cap, they no longer cover the patients/members costs.  Remedy:  The pharmacy customer should contact their insurance's member service line to inquire if this coverage limit has been met.
  • Thirdly, this rejection might mean the number of prescription fills which are covered under the members/patients prescription health plan has been exceeded for the claim you are attempting to process.  Remedy: the pharmacy customer should call their insurance's member service number (which should be printed on the back of their insurance card) to find out how many fills are covered for the medication in question.
  • Fourth, the Rx Issue Date (the date the prescription was written by the prescriber) is too far in the past.  For federal legend drugs which are non-schedule (for example, non-controlled substances), "too far in the past" is typically 365 days from the date originally written by the medical provider.  Remedy: the issue date should be checked and if necessary, the provider should be contacted for a new prescription.
  • Fifthly, a Plan Limitations Exceeded rejection possibly means the medication's days supply limit covered by the plan may have been exceeded.  This may mean that a specific drug may have a quantity/days supply ratio, for example, the migraine headache medication Relpax (elitriptan EBr) may only be covered if the pharmacy technician fills 20 pills for a 30 days supply.          Remedy: The pharmacy technician must find out the "key" (specific combination of quantity and days supply values) which "unlock" the reimbursement from the PBM or insurance company.  It is possible that this must be done by trial and error (be aware, however, that some insurance organizations bill your pharmacy for each transmission; both denied and paid claims)

Top of Plan Limitations Exceeded

Back to Pharmacy Insurance Rejections

Back to Home

New! Comments

Have your say about what you just read! Leave me a comment in the box below.
[?]Subscribe To This Site
  • XML RSS
  • follow us in feedly
  • Add to My Yahoo!


Didn't find what you were looking for? Use the box below to search this entire site.

Custom Search



Recent Articles

  1. Plan Limitations Exceeded

    Jun 30, 19 08:44 PM

    Plan Limitations Exceeded - This Prescription Insurance Rejection is explained in simple terms on this informative and enlightening page.

    Read More

  2. 1 cap po tid x10/7 days amoxicillin 500mg

    Mar 17, 19 09:58 AM

    Amoxicillin 500 mg 1cap po tid x 10/7

    Read More

  3. I got thirty pills for Vicodin 7.5 my dr wants me to take half a pill in the morning and whole pill at night how long should that last me

    Mar 15, 19 11:57 PM

    I got 30 Vicodin I have to take a half of pill in the morning and whole pill at night how long should my script last me

    Read More

  4. SILICONE RINGS IN A CLEAN ROOM

    Jan 13, 19 07:44 PM

    The USP797 rules state that no jewelry can be worn in the I.V. clean room setting because it wouldn't be sterile. I was wondering if silicone rings would

    Read More

  5. Did my pharmacist violate hips law today

    Jan 13, 19 05:34 PM

    While approaching my pharmacy counter today my pharmacist very loudly said Nicole I found out what was wrong with your suboxane P.A.Your Dr. Office done

    Read More

  6. When can it be refilled? 35 pills, 3 times a day, so it's not even.

    Jan 13, 19 04:50 PM

    35 pills, 3 times a day, so it’s not even. When do I refill?

    Read More

  7. Day Supply: Take 1 tab TID #100

    Jan 13, 19 04:26 PM

    Take 1 Tablet TID, dispense #100 Refills 2 What is the days supply for insurance?

    Read More

  8. IV vs. Oral Medication Pharmacology - Absorption or Metabolism

    Jan 13, 19 03:57 PM

    When a drug is given IV rather than orally, it eliminates the need for what? Absorption or Metabolism?

    Read More

  9. A question about Synthroid Vs. Sintrocid and drug milligrams?

    Jan 13, 19 03:37 PM

    What is the difference in 0.112mg in Synthroid and 100mcg in Sintrocid from Mexico? Would this be the same dosage?

    Read More

  10. Wondering About How Many Percocet Should be in my Bottle?

    Jan 13, 19 02:17 PM

    I had a prescription filled for my #120 Percocet on February 18th, how many of the pills should be in my bottle on March 16th? The directions are for me

    Read More

  11. How Does Nalexone Nasal Spray Help an Overdose Victim?

    Jan 01, 19 07:07 PM

    This page discusses, "How Does Nalexone Nasal Spray Help an Overdose Victim?"

    Read More

  12. Fioricet Script is for 60 pills take 2 every 8 hours How many days supply is that?

    Jan 01, 19 06:34 PM

    I have a script for Firocet. It says take 2 pills every 8 hours. It was written for 60 pills. How many days of supply is it?

    Read More

  13. Is it still a 20 day supply if “as needed” is written?

    Jan 01, 19 06:28 PM

    Percocet 5/325, qty: #60, take 1 tablet by mouth 3 times a day as needed for severe pain. Is this a 20 day supply, even though it says, “as needed?” Will

    Read More

  14. Suboxone film take 2 and 1/2 per day given quantity of 70.

    Jan 01, 19 06:16 PM

    How many days will #70 Suboxone Film last at a dose of 2 & 1/2 per day?

    Read More

  15. Diphenhydramine 25mg tablets Days Supply 2 tabs po qid #40

    Jan 01, 19 05:53 PM

    BENADRYL (diphenhydramine) 25MG TABLETS TAKE 2 TABLETS PO QID #40 NEED THE PRACTICE METHOD ON THIS BROKEN DOWN

    Read More