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)

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