In the article Patient GPI Counts we covered how to set up a GPI counter to track and set fill limits for individual patients. Now, we are excited to share a way to set fill limits directly in authorizations using Fill Total ‘Up To’ and ‘Over’ selector fields. This feature is expected to provide added flexibility in setting limits for specific classes of drugs, such as narcotics, and limiting the number of fills allowed at the Group level. 

In this article:

• the difference between Fill Total ‘Up To’ and ‘Over’ selector fields
• when to use ‘Up To’ and ‘Over’
• how to use the Checker tool to verify authorization behavior
• scenarios describing use cases for fill total limit authorizations

Article Contents

Fill Total Selector Fields Explained

Fille total limits can be set on Patient or Group authorizations via the ‘Up To‘ and ‘Over‘ selection fields. Both fields can be combined with drug, pharmacy, or doctor selectors, but they function differently.

Fill Total ‘Up To:’ Tracks the number of fills until they reach the specified limit. Once the limit is reached, tracking stops, and the authorization disables automatically.

Fill Total ‘Over:’ Can be used to cause a rejection to go to the pharmacy if a fill limit is exceeded. Authorizations with this selector will stay enabled unless manually disabled. 

When to Use ‘Up To’

Use ‘Up To’ when you want to allow a specific number of fills, then let the plan default take over. Common scenarios:

• Prior authorization overrides
• Refill-too-soon overrides
• Duplicate therapy overrides

Example: A patient needs 5 fills of a non-formulary drug. Set Fill Total ‘Up To’ to 5. After the 5th fill, the authorization disables and the closed formulary rule applies again.

When to Use ‘Over’

Use ‘Over’ when you want to reject claims that exceed a limit. Pair it with an NCPDP rejection code.

Example: A plan limits opioid fills to 3 per year. Set Fill Total ‘Over’ to 3 with rejection code 76 (Plan Limitations Exceeded). The 4th fill attempt is rejected.

Important Limitations

• The selectors do not cause rejections on their own. You have to set a rejection code on the authorization to enforce a limit.
• GPI counters track fills. Even with a fill limit authorization in place, add a GPI counter to the patient’s profile so the system can track fill counts.
• Don’t set a limit in the GPI counter when using fill total authorizations. The authorization manages the limit. The counter just tracks. Setting both could cause conflicts.

Testing Fill Total Authorization Behavior

Use the “Checker” tool to verify your authorizations are behaving as expected. The tool does not retrieve data from patient profiles but you can enter hypothetical claim details to test various scenarios.

To confirm an authorization with fill limits is behaving as expected:

• Fill in the check form with the necessary details, such as a GPI code and the number of existing fills on file.
• Scroll down and click check. The check result and a list of matching authorizations will display on the screen.
• To simulate a processed claim, select“Increment Matched Counters.” This will increase the count for each check submitted.
• To simulate a reverse claim, select “Decrease Matched Counters.” This will decrease the count for each check submitted.

Scenarios

In this section, we will explore two scenarios for using the fill total selectors in authorizations: overriding a plan default and setting a drug-specific fill limit.

Override a Plan Default

You may come across situations where a patient needs more than one fill of a medication that is not covered according to one of the plan’s default rules. The Fill Total ‘Up To’ selector field can be used to handle such scenarios. It allows you to specify the approved number of fills for a medication in one authorization and eliminates the need for separate overrides for multiple fills.

In order for the authorization to do what we need:

• the authorization number has to be smaller than the number assigned to the plan default.
• the action needs to match the action on the authorization being overridden.
• the number of fills authorized needs to be entered in the Fill Total ‘Up To’ field.
• a 10-digit GPI code for the approved medication has to be entered if the authorization is for a specific drug.
• a GPI counter for the approved drug needs to be set up on the patient’s profile to track the number of fills.

Let’s take a look at an example. The table below shows a Global authorization that sends a rejection for any drug that has not been pre-approved.

Key: A/N = Authorization Number, N = No

Let’s create an authorization to allow up to five fills for GPI 7510005010 for a patient. Instead of creating an authorization for each approved fill, add one authorization to the patient’s profile with:

• a smaller authorization number relative to the Global authorization
• an action code that matches the Global authorization
• an action value that describes the intended behavior of the authorization
• the number of approved fills in the Fill Total ‘Up To’ field
• the 10-digit GPI code for the approved drug in the Drug GPI code field

Here is an example:

Key: A/N = Authorization Number, Y = Yes

Add a GPI counter to the patient’s profile to track the total number of fills for the approved drug. At a minimum, the counter needs to have the 10-digit GPI code being tracked. Optionally, an end date and the number of existing in-network and out-of-network fills can also be specified. For this use case, there is no need to enter a limit in the GPI counter. Doing so could override limits set in authorizations.

🛈 If you don’t know how to add a GPI counter to a patient, check out the article Patient GPI Counts.

Here is an example of a GPI counter for a patient, Jane Doe:

Notice the limit in the table above is zero. This is because you DO NOT need to enter a value in the limit field on the GPI counter. The limit is being managed in the authorization.

When a claim is submitted for the specified GPI, the value in the In Network column will automatically increase by one. When a claim is reversed, the In Network total will decrease by one. When the value in the Total column reaches five, 35000-505 will be disabled allowing the plan default rule to take priority again.

⚠ The system cannot automatically track out-of-network fills at this time. However, you can manually enter fill counts in the Out of Network column at any time, if needed. Just click edit in the fill count table to add the information. Changes, including edits, are tracked in the history record.

The next table shows the details of the Patient authorization followed by the Global authorization (aka, plan default). The system will match on 35000-505 until the patient reaches five fills for GPI 7510005010. Effectively, overriding the plan default (89000-000). Once the limit is reached, 35000-505 will disable and 89000-000 will take priority again. If a submitted claim puts the patient over the approved limit, the system will send a rejection message to the pharmacy.

Key: A/N = Authorization Number, Y = Yes, N = No

Set a Drug-Specific Fill Limit

The Fill Total ‘Over’ selector field can be used to enforce a maximum number of fills for a specific drug. For example, a health plan may only cover a certain number of fills for opioid analgesics, after which the patient is expected to switch to an alternative treatment. If a submitted claim would cause a patient to go over the allowable limit, a rejection needs to occur.

The table below shows an example of a Group authorization limiting GPI 6510005010 to three fills.

Even though there is an authorization in place, the issue of keeping track of the number of fills for individual patients remains. If you need to do this, add a GPI counter to the patient’s profile. Then, the system will keep track of in-network fill counts for the patient according to the GPI specified as claims are processed. When the patient’s fill total reaches three, additional claims will not be processed and 55000-510 will cause a rejection message to go to the pharmacy. 

⚠ In this scenario, you DO NOT need to set a fill limit in the GPI count screen. The limit has already been set in 55000-510. Entering a limit on the patient GPI counter may override limits set in authorizations.

This table contains an example of GPI counter details for a patient called John Doe: 

When a claim is submitted for the specified GPI, the In Network value will increase by one. When a claim is reversed, the In Network total will decrease by one. The system does not automatically track out-of-network fills at this time. Fill counts can be added manually added in the Out of Network field at any time if needed. Click edit in the fill count table to add the information. 

To learn how to set up a GPI counter on a patient’s profile, check out the article Patient GPI Counts.

Summary

The Fill Total ‘Up To‘ and ‘Over‘ selection fields make setting fill limits directly in authorizations possible.

• Use the ‘Up To‘ field to override plan defaults and approve multiple fills. Authorizations with this selector will disable automatically after the limit is reached, and the plan default will take priority again.
• The ‘Over‘ field can be used to enforce fill limits by sending a rejection message to the pharmacy if a fill limit is exceeded.

Don’t forget to set up a GPI counter to track the number of fills for individual patients. Once set, the system automatically tracks in-network fill counts.

Contact Support

Our team is here to help!

For plan-specific or urgent needs, contact your account manager directly.

For general Authorization System questions, contact EHO360 Operations at ops@ehorx.com