Prescription Insurance Question from Pharmacy Tech Student

by Patty
(Bakersfield Ca )

What ar the most common problems with claims being rejected in a pharmacy setting?

Answer:

-Filled After Coverage Terminated (Customer no longer has insurance coverage through the information the pharmacy has-Ask customer for new Insurance card.)
-Refilled Too Soon (Customer has already filled a prescription for this drug recently either with your pharmacy, a different pharmacy, or through mail order.)
-Prior Authorization (Insurance company needs to hear from the prescribing doctor and get some clinical information from him/her and insurance company decides whether or not they will approve this drug.)
-DUR Reject (stands for Drug Utilization Review. This prescription may be able to be overridden with some override codes at the pharmacy.)
-Cost Exceeds Maximum Allowed (This rejection is less common. It is usually for very expensive, specialty drugs. This usually means the pharmacy puts a call in to the insurance company to get more information.)

Please also see the following pages:


Prescription Insurance

Refill Too Soon

Prior Authorization