Bypass of PA/PDL when Medicaid is billed as Secondary for certain Pharmacy Claims

A change was implemented in NCTracks regarding prior approval requirements for Pharmacy claims when primarily paid by a third party. As of November 2, 2014, when third party insurance has paid 60% or more of the calculated Medicaid allowed amount for a Pharmacy claim - point-of-sale (POS) or paper - then the prior approval (PA) requirement will be bypassed, whether the drug requires clinical PA or the PA is for a non-preferred drug. This change is based on date of processing. Providers may rebill previously denied claims.