EDIT - Benefit Maximums

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Divya Sree

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20.1.202520.1.2025

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There are 5 different Benefit Maximum edits available in the system. All the benefit maximums are accumulated at the member level. There are no maximums established at the Family level.

Benefit Maximum Type	Description
Plan Pay Max Accumulation	Plan Pay accumulation maximums are used when the benefit for a drug/group of drugs is limited. An example is a $300.00 limit per year for Fertility medications. This is NOT Plan Stop Loss accumulation.
Quantity Max Accumulation	Quantity Max accumulation edits are used to accumulate the quantity dispensed to a set maximum. For instance, a member may be allowed a quantity of 7 tablets of migraine medication every 30 days.
Units Max Accumulation	Accumulates total units. Submitted Quantity divided by the package size. For instance, inhaler is 7.2gm for 1 pkg as well as 14.4gm for 1 pkg. Max Units for an edit maybe 5. In this case, 5 inhalers without regard to package size. This rule is ignored for multi-ingredient compounds drug.
Fills Max Accumulation	This edit accumulates the number of Rx Fills to a maximum. An example of this, Opioids have a benefit maximum of 1 fill every 7 days.
Day Supply Max Accumulation	This edit Accumulates the total maximum days supply. For eg., Plan will cover 180 days of smoking cessation medications. Smoking cessation medications would be defined in the Criteria.

Plan Pay Max Accumulation

Quantity Max Accumulation

Units Max Accumulation

Fills Max Accumulation

Days Supply Max Accumulation

Fields

Almost all the fields are the same in all max accumulation edits.

Benefit Amount is the field where the appropriate value should be provided based on the Max Accumulation type.
Drug Level is applicable only for Fills max. This is the Drug Hierarchy level to which the accumulation maximum refers. From NDC11 to ALL (by GPI, ie., GPI14, GPI12, …GPI2, All)

Benefit Maximums	Plan Pay	Quantity Max	Units Max	Fills Max	Day Supply Max
Claim Type	All, POS, DMR	All, POS, DMR	All, POS, DMR	All, POS, DMR	All, POS, DMR
Network Classification	All, In Network, Out of Network	All, In Network, Out of Network	All, In Network, Out of Network	All, In Network, Out of Network	All, In Network, Out of Network
Network Type	All, Retail, Retail 90, Mail, Specialty, Other	All, Retail, Retail 90, Mail, Specialty, Other	All, Retail, Retail 90, Mail, Specialty, Other	All, Retail, Retail 90, Mail, Specialty, Other	All, Retail, Retail 90, Mail, Specialty, Other
Period Type	Lifetime, Term, Rolling, Every X Days	Lifetime, Term, Rolling, Every X Days	Lifetime, Term, Rolling, Every X Days	Lifetime, Term, Rolling, Every X Days	Lifetime, Term, Rolling, Every X Days
Start Date	Term & Lifetime Only	Term & Lifetime Only	Term & Lifetime Only	Term & Lifetime Only	Term & Lifetime Only
Duration, Period	Day, Month	Day, Month	Day, Month	Day, Month	Day, Month
Duration Length	Duration Period	Duration Period	Duration Period	Duration Period	Duration Period
Benefit Amount	Max. Plan Pay Amount	Maximum Quantity	Maximum Units	Maximum # of fill	Maximum Days supply
Drug Level	Not Applicable	Not Applicable	Not Applicable	All, NDC 11, NDC 9, GPI 2 - GPI 14	Not Applicable
Age, Min	No decimals allowed	No decimals allowed	No decimals allowed	No decimals allowed	No decimals allowed
Age, Max	Less than 151, No decimals allowed.	Less than 151, No decimals allowed.	Less than 151, No decimals allowed.	Less than 151, No decimals allowed.	Less than 151, No decimals allowed.
Refill Margin, TYPE (for every X days only)	Days, Percent	Days, Percent	Days, Percent	Days, Percent	Days, Percent
Refill Margin, % or # Days	% or Days	% or Days	% or Days	% or Days	% or Days
DMR Processing	Process as Submitted Reduce to maximum	Process as Submitted Reduce to maximum	Process as Submitted Reduce to maximum	Process as Submitted Reduce to maximum	Process as Submitted Reduce to maximum
Maximums Limitation	Apply to all Maximums Apply Maximums Then Ignore Ignore all Accumulation Maximums	Apply to all Maximums Apply Maximums Then Ignore Ignore all Accumulation Maximums	Apply to all Maximums Apply Maximums Then Ignore Ignore all Accumulation Maximums	Apply to all Maximums Apply Maximums Then Ignore Ignore all Accumulation Maximums	Apply to all Maximums Apply Maximums Then Ignore Ignore all Accumulation Maximums
Reject Message	Prior Auth Required Limits Exceeded	Prior Auth Required Limits Exceeded	Prior Auth Required Limits Exceeded	Prior Auth Required Limits Exceeded	Prior Auth Required Limits Exceeded
Compounds	Bypass, Process	Bypass, Process	Bypass, Process	Bypass, Process	Bypass, Process

Period Types

Period Type	Comments
Lifetime	This type of period has a beginning date and no end date associated with it.
Term	The Term period has a defined start date and then a defined number of days or months.
Rolling	This type of period accumulates for a fixed period (days or months) and then restarts for another fixed period of the same length. As an example, a Day Supply Accumulation may be every 3 months. The maximum accumulation period begins on the Date of Service of the first claim for the member that meets the criteria for the EDIT.
Every X Days	This type of period resets accumulations every X days. This period type requires a look back in history of X days from the claim date of service, X days after the claim date of service, AND X days divided by 2 before and after the date of service. The maximum accumulation period begins on the Date of Service of the first claim for the member that meets the criteria for the EDIT.

Reject Message

The selected reject message will be used if the claim exceeds the benefit maximum

Options	Reject Message in Response	Description
Prior Authorization Required	75 - Prior Authorization Required	If this option is selected, the claim will be rejected with reject code 75. There is no option to override this rejection. Member should have a PA in order to process the claim
Limits Exceeded	76 - Plan Limitations Exceeded	If this option is selected, the claim will be rejected with reject code 76. You can allow override by selecting the option

Options

Reject Message in Response

Description

Prior Authorization Required

75 - Prior Authorization Required

If this option is selected, the claim will be rejected with reject code 75. There is no option to override this rejection.

Member should have a PA in order to process the claim

Limits Exceeded

76 - Plan Limitations Exceeded

If this option is selected, the claim will be rejected with reject code 76. You can allow override by selecting the option

Maximums Limitation

Type	Description
Apply to all Maximums	If the EDIT is established with this Maximum Limitation type, the accumulation maximum will be calculated and applied
Apply Maximum Then Ignore	If this Maximum Limitation is selected, the accumulation maximum for this edit will be used but any lower-level accumulation limitation will be ignored.
Ignore all Accumulation Maximums	If this Maximum Limitation is selected, the accumulation maximum for this edit will be ignored and all ensuing accumulation maximum edits will be ignored.
Ignore All Maximums for this Edit type	MEMBER LEVEL ONLY. This means that this EDIT will not be accumulated to any other accumulation of this type. The reason for this option is to allow more than one MAXIMUM EDIT to apply to a claim. This may be needed if an NDC is part of different Maximum EDITs criteria. For instance, Criteria A has a quantity maximum and Criteria D has a quantity maximum. The NDC is reflected in both Criteria. *This option is Not available*

Refill Margin

This is effectively a more specific refill too soon edits for the accumulator. Specifies how early from the end of the prior fill can the prescription be refilled. For instance, a claim on 3/1/2018 with a 30-day supply. The EDIT is Every 30 Days. Without a tolerance, a member would have to use all the prescription before being able to have a refill processed successfully. The Refill Margin provides the ability to refill the Rx before the member runs out. In the example above, if the DAYS was 6, the member could have a refill processed 6 days before the end of the Full Day Supply. If the EDIT has a Percentage set at 70, 70% of the initial prescription (70% x 30 days = 21 days) must be “used” before a refill can be processed.

- Days: a value of ZERO is valid and indicates a DAILY maximum. (allow only full days)
- Percent: the % of the previous fill to be used before a refill can be processed. (allow 2 decimal points)

DMR Processing

- Process claim as submitted
- Reduce submitted values
  - Plan Dollar, Day Supply or Quantity are reduced to the EDIT maximum For instance, if the Quantity accumulation total is 100 and it is currently at 95, only 5 Quantity are left for coverage. The process should reduce for this limitation the submitted quantity to 5, price and process the claim.