Breast and Cervical Cancer Diagnosis and Treatment (BCCDT)



Breast and Cervical Cancer Diagnosis and Treatment (BCCDT)

I. Contact Number: 410-767-6787

II. Drug Coverage:

BCCDT-2 – Covered Drugs for All Groups

|Drug Code |Drug Name |Comments |

|H3A |Analgesics, Narcotics | |

|H3D |Analgesics, Salicylates |Oral forms only covered |

|H3E |Analgesics/Antipyretics, Non-Salicylates |Oral forms only covered |

|H6J |Anti-emetics |Exclude HSN 002005 – Scopoloamine |

|S2B |Anti-Inflammatory Agents |Oral forms only covered |

|W1W |Cephalosporins – 1st gen |Oral forms only covered |

|W1X |Cephalosporins – 2nd gen |Oral forms only covered |

|W1Y |Cephalosporins – 3rd gen |Oral forms only covered |

|W1Z |Cephalosporins – 4th gen |Oral forms only covered |

|W1K |Lincosamides |Oral forms only covered |

|W1D |Macrolides |Oral forms only covered |

|W2F |Nitrofuran Derivatives |Oral forms only covered |

|H2E |Non-Barbiturates, Sedative-Hypnotic |Oral forms only covered |

|W1A |Penicillins |Oral forms only covered |

|W1Q |Quinolones |Oral forms only covered |

|H7E |Serot-2 Amtag/Reuptake Inhib (SARIS) |Oral forms only covered |

|H7C |Serot-Norepineph Reup-Inhib (SNRIS) |Oral forms only covered |

|H2S |Serotonin Spec Reuptake Inhib (SSRI) |Oral forms only covered |

|W1C |Tetracyclines |Oral forms only covered |

|W4E |Trichomonacides |Oral forms only covered |

|H2U |Tricy Antidepr & Rel NSRUI |Oral forms only covered |

|HSN 010249 |Anastrozole | |

|HSN 001653 |Bupropion HCL |Exclude GSN 031439 |

|HSN 018385 |Capecitabine | |

|HSN 002860 |Cortisone Acetate | |

|HSN 003893 |Cyclophosphamide | |

|HSN 002889 |Dexamethasone | |

|HSN 001847 |Deflunisal | |

|HSN 020803 |Exemestane | |

|GSN 011832, 001645, 001646, 017378 |Ferrous Sulfate |OTC TO COVER |

|HSN 002867 |Hydrocortisone | |

|HSN 012351 |Letrozole | |

|HSN 001975 |Meclizine HCL | |

|HSN 002877 |Methylprednisolone | |

|HSN 002148 |Metoclopramide HCL | |

|HSN 004129 |Nystatin | |

|HSN 002874 |Prednisolone | |

|HSN 002879 |Prednisone | |

|HSN 012014 |Promethazine HCL |Rectal forms only covered |

|HSN 011632 |Toremifene Citrate | |

|HSN 018801 |Trastuzumab | |

|F1A |Androgenic Agents | |

|TC 48 |Anticonvulsants | |

|D6D |Anti-diarrheal Agents | |

|Z2A |Antihistamines | |

|TC 30 |Antineoplastic Agents | |

|TC 16 |Antitussives – Expectorants | |

|TC 15 |Bronchodilators | |

|TC 76 |Cardiovascular Preparations, Other | |

|P5A |Corticosteroids, Inhaled | |

|TC 58 |Diabetic Therapy | |

|TC 74 |Digitalis Preparations | |

|TC 79 |Diuretics | |

|Q6I |Eye Antibiotic – Coticoid Combination | |

|Q6W |Eye Antibiotics | |

|Q6P |Eye Antiinflammatory Agent | |

|Q6V |Eye Antiviral | |

|Q6S |Eye Sulfonamide | |

|TC 71 |Hypotensive, Others | |

|D6S |Laxatives & Cathartics | |

|H7J |MAOIS – Non-Selective & Irreversible | |

|M9P |Platelet Aggregation Inhibitors | |

|C1D |Potassium Replacement | |

|H6H |Skeletal Muscle Relaxants | |

|TC 55 |Thyroid Preparations | |

|Q5P |Topical Antiinflammatory (corticosteroids) | |

|Q4F |Vaginal Antifungals | |

|TC 72 |Vasodilators, Coronary | |

|TC 73 |Vasodilators, Peripheral | |

|HSN 004047 |Bacitracin | |

|HSN 007708 |Cadexomer Iodine | |

|HSN 009005 |Fosfomycin Tromethamine | |

|HSN 022142 |HC Acetate/Lidocaine HCL | |

|GSN 007062 |HC Acetate/Pramoxine HCL | |

|HSN 015176 |Hydrocortisone/Pramoxine HCL | |

|GSN 040262 |Lidocaine | |

|GSN 043256 |Lidocaine | |

|GSN 003407 |Lidocaine HCL | |

|GSN 003411 |Lidocaine HCL | |

|GSN 003412 |Lidocaine HCL | |

|GSN 007407 |Lidocaine HCL | |

|GSN 007409 |Lidocaine HCL | |

|HSN 016196 |Lidocaine/Prilocaine | |

|HSN 003385 |Mupirocin | |

|HSN 007527 |Mupirocin Calcium | |

|HSN 003363 |Neomy Sulf/Bacitra/Polymyxin B | |

|HSN 004107 |Phenazopy HCL/Hyoscy/Butabarb | |

|GSN 009477 |Phenazopyridine HCL | |

|GSN 009478 |Phenazopyridine HCL | |

|HSN 004284 |Sodium CL 0.45PC Irrig. Soln | |

|HSN 004285 |Sodium CL Irrig Soln | |

|HSN 004270 |Sodium Hypochlorite | |

|HSN 020355 |Temozolomide | |

|HSN 004283 |Water for Irrigation, Sterile | |

|W3B |Antifungal Agents | |

|P4B |Bone Form, Stim Agents Parathy | |

|P4L |Bone Ossification Suppression Agent | |

|D4K |Gastric Acid Secretion Reducers | |

|N1B |Hemantinics, Other | |

|M9K |Heparin Preparations | |

|N1C |Leukocyte (Wbc) Stimulants | |

|M9L |Oral Anticoagulants, Coumarin Type | |

|Q5F |Topical Antifungals | |

|Q4W |Vaginal Antibiotics | |

|Q4S |Vaginal Sulfonamides | |

|HSN 003904 |Carboplatin | |

|HSN 010798 |Gemcitabine HCL | |

|HSN 004570 |Ifosfamide | |

|HSN 010778 |Irinotecan HCL | |

|HSN 007845 |Melphalan | |

|HSN 010166 |Paclitaxel, Semi-Synthetic | |

|HSN 025963 |Bevacizumab | |

|HSN 002285 |Biafine Cream | |

|HSN 010280 |Docetaxel | |

|HSN 003916 |Doxorubicin HCL | |

|HSN 006578 |Epirubicin | |

|HSN 023523 |Fulvestrant | |

|HSN 021114 |Goserelin Acetate | |

|HSN 021102 |Leuprolide Acetate | |

|HSN 003923 |Megestrol Acetate | |

|HSN 003905 |Methotrexate Sodium | |

|HSN 003926 |Tamoxifen Citrate | |

|HSN 003912 |Vinblastine | |

|HSN 003913 |Vincristine Sulfate | |

|HSN 009614 |Vinorelbine Tartrate | |

|Q4K |Vaginal Estrogen Preparations | |

|HSN 003902 |Cisplatin | |

|HSN 003907 |Fluorouracil | |

|HSN 004101 |Methanamine Hippurate | |

|HSN 004102 |Methenamine Mandelate | |

|HSN 004094 |MTH/ME BLUE/BA/SALICY/ATP/HYOS | |

|G1A |Estrogenic Agents |Oral forms only |

|HIC3 = C5U |Nutritional Therapy, Med Cond Special Electrolytes & |Includes products for disease-specific |

| |Misc. Nutrients |nutritional therapy |

|HIC3 = C5F |Dietary Supplements |Includes Ensure-type products |

|HIC3 = C1W |Electrolyte Maintenance |Includes electrolyte solutions |

|HIC3 = C5G |Food Oils |Includes corn, safflower oils |

|HIC3 = M4B |IV Fat Emulsions | |

|TC = 68 |Protein Lysates |Includes amino acid products |

|HSN 004182, 004183 |Acyclovir, Zovirax | |

|HSN 009007 |famcyclovir | |

|HSN 010117 |valacyclovir | |

|HSN 013221 |foscarnet | |

BCCDT-3 – OTC exception list

|OTC Exception List – All OTCs to deny w/ NCPDP 70 – Drug Not Covered w/the exception of the products listed below |

|Drug Code |Drug Name |Comments |

|HIC3 = C5U |Nutritional Therapy, Med Cond Special Electrolytes & |Includes products for disease-specific |

| |Misc. Nutrients |nutritional therapy |

|HIC3 = C5F |Dietary Supplements |Includes Ensure-type products |

|HIC3 = C1W |Electrolyte Maintenance |Includes electrolyte solutions |

|HIC3 = C5G |Food Oils |Includes corn, safflower oils |

|HIC3 = M4B |IV Fat Emulsions | |

|GSN 011832, 001645, 001646, 017378 |Ferrous Sulfate |OTC TO COVER |

BCCDT-4 - Medicare Covered Drugs

|Medicare Covered Drugs - NCPDP 70- NDC Not Covered, Bill Medicare. |

|Providers will contact vendor Call center for PA if not covered by Medicare. |

|Drug Code |Oral Chemotherapy | |

|GSN = 008838 |VePesid( (Etoposide) | |

|GSN = 008770, 008771 |Cytoxan( (Cyclophosphamide) | |

|GSN = 008773 |Alkeran( (Melphalan) | |

|GSN = 036872, 045266, 035928, 036874, 047823, |Methotrexate | |

|047824 | | |

|HSN = 018385 |Xeloda( (Capecitabine) | |

BCCDT-5 - Drugs Requiring PA – All Groups

|These drugs will deny with NCPDP 75 – Prior Authorization Required: MD Call 410-767-6787 for PA |

|Drug Code |Drug Name |Comments |

|F1A |Androgenic Agents | |

|TC 48 |Anticonvulsants | |

|D6D |Anti-diarrheal Agents | |

|Z2A |Antihistamines | |

|TC 30 |Antineoplastic Agents |EXCLUDE HSN – 025963, 003904, 003902, |

| | |010280, 003916, 006578, 003907, 023523, |

| | |010798, 021114, 004570, 010778, 021102, |

| | |003923, 007845, 003905, 010166, 003926, |

| | |003912, 003913, 009614, 010249, 018385, |

| | |020803, 012351, 011632, 011801 |

|TC 16 |Antitussives – Expectorants | |

|TC 15 |Bronchodilators | |

|TC 76 |Cardiovascular Preparations, Other | |

|P5A |Corticosteroids, Inhaled | |

|TC 58 |Diabetic Therapy | |

|TC 74 |Digitalis Preparations | |

|TC 79 |Diuretics | |

|Q6I |Eye Antibiotic – Coticoid Combination | |

|Q6W |Eye Antibiotics | |

|Q6P |Eye Antiinflammatory Agent | |

|Q6V |Eye Antiviral | |

|Q6S |Eye Sulfonamide | |

|TC 71 |Hypotensive, Others | |

|D6S |Laxatives & Cathartics | |

|H7J |MAOIS – Non-Selective & Irreversible | |

|M9P |Platelet Aggregation Inhibitors | |

|C1D |Potassium Replacement | |

|H6H |Skeletal Muscle Relaxants | |

|TC 55 |Thyroid Preparations | |

|Q5P |Topical Antiinflammatory (corticosteroids) | |

|Q4F |Vaginal Antifungals | |

|TC 72 |Vasodilators, Coronary | |

|TC 73 |Vasodilators, Peripheral | |

|HSN 004047 |Bacitracin | |

|HSN 007708 |Cadexomer Iodine | |

|HSN 009005 |Fosfomycin Tromethamine | |

|HSN 022142 |HC Acetate/Lidocaine HCL | |

|GSN 007062 |HC Acetate/Pramoxine HCL | |

|HSN 015176 |Hydrocortisone/Pramoxine HCL | |

|GSN 040262 |Lidocaine | |

|GSN 043256 |Lidocaine | |

|GSN 003407 |Lidocaine HCL | |

|GSN 003411 |Lidocaine HCL | |

|GSN 003412 |Lidocaine HCL | |

|GSN 007407 |Lidocaine HCL | |

|GSN 007409 |Lidocaine HCL | |

|HSN 016196 |Lidocaine/Prilocaine | |

|HSN 003385 |Mupirocin | |

|HSN 007527 |Mupirocin Calcium | |

|HSN 003363 |Neomy Sulf/Bacitra/Polymyxin B | |

|HSN 004107 |Phenazopy HCL/Hyoscy/Butabarb | |

|GSN 009477 |Phenazopyridine HCL | |

|GSN 009478 |Phenazopyridine HCL | |

|HSN 004284 |Sodium CL 0.45PC Irrig. Soln | |

|HSN 004285 |Sodium CL Irrig Soln | |

|HSN 004270 |Sodium Hypochlorite | |

|HSN 020355 |Temozolomide | |

|HSN 004283 |Water for Irrigation, Sterile | |

|HIC3 = C5U |Nutritional Therapy, Med Cond Special Electrolytes & |Includes products for disease-specific |

| |Misc. Nutrients |nutritional therapy |

|HIC3 = C5F |Dietary Supplements |Includes Ensure-type products |

|HIC3 = C1W |Electrolyte Maintenance |Includes electrolyte solutions |

|HIC3 = C5G |Food Oils |Includes corn, safflower oils |

|HIC3 = M4B |IV Fat Emulsions | |

|TC = 68 |Protein Lysates |Includes amino acid products |

|D4K |Gastric Acid secretion Reducers |Prerequisite rules still apply |

|HSN 004182, 004183 |Acyclovir, Zovirax | |

|HSN 009007 |Famcyclovir | |

|HSN 010117 |Valacyclovir | |

|HSN 013221 |Foscarnet | |

BCCDT-6 - Drugs Requiring PA for BCCDT1

|Drugs Requiring Prior Authorization for recipients with diagnosis of Breast Cancer – Group ID = BCCDT1. |

|These drugs will deny with NCPDP 75 – Prior Authorization Required: MD Call 410-767-6787 FOR PA |

|Drug Code |Drug Name |Comments |

|Q4K |Vaginal Estrogen Preparations | |

|HSN 003902 |Cisplatin | |

|HSN 003907 |Fluorouracil | |

|HSN 004101 |Methanamine Hippurate | |

|HSN 004102 |Methenamine Mandelate | |

|G1A |Estrogenic Agents |Oral forms only |

|HSN 004094 |MTH/ME BLUE/BA/SALICY/ATP/HYOS | |

BCCDT-7 - Drugs Requiring PA for BCCDT2

|Drugs Requiring Prior Authorization for recipients with diagnosis of Cervical Cancer – Group ID = BCCDT2. |

|These drugs will deny with NCPDP 75 – Prior Authorization Required: MD Call 410-767-6787 FOR PA |

|Drug Code |Drug Name |Comments |

|HSN 025963 |Bevacizumab | |

|HSN 002285 |Biafine Cream | |

|HSN 010280 |Docetaxel | |

|HSN 003916 |Dosorubicin HCL | |

|HSN 006578 |Epirubicin | |

|HSN 023523 |Fulvestrant | |

|HSN 021114 |Goserelin Acetate | |

|HSN 021102 |Leuprolide Acetate | |

|HSN 003905 |Methotrexate Sodium | |

|HSN 003926 |Tamoxifen Citrate | |

|HSN 003912 |Vinblastine | |

|HSN 003913 |Vincristine Sulfate | |

|HSN 009614 |Vinorelbine Tartrate | |

|HSN 003893 |Cyclophosphamide | |

BCCDT-8 - Drugs Requiring PA for BCCDT3

|These drugs will deny with NCPDP 75 – Prior Authorization Required: MD Call 410-767-4787 FOR PA |

|Drug Code |Drug Name |Comments |

|W3B |Antifungal Agents | |

|P4B |Bone Form, Stim Agents Parathy | |

|P4L |Bone Ossification Suppression Agent | |

|D4K |Gastric Acid Secretion Reducers | |

|N1B |Hemantinics, Other | |

|M9K |Heparin Preparations | |

|N1C |Leukocyte (Wbc) Stimulants | |

|M9L |Oral Anticoagulants, Coumarin Type | |

|Q5F |Topical Antifungals | |

|Q4W |Vaginal Antibiotics | |

|Q4S |Vaginal Sulfonamides | |

|HSN 003904 |Carboplatin | |

|HSN 010798 |Gemcitabine HCL | |

|HSN 004570 |Ifosfamide | |

|HSN 010778 |Irinotecan HCL | |

|HSN 007845 |Melphalan | |

|HSN 010166 |Paclitaxel, Semi-Synthetic | |

|HSN 025963 |Bevacizumab | |

|HSN 002285 |Biafine Cream | |

|HSN 010280 |Docetaxel | |

|HSN 003916 |Dosorubicin HCL | |

|HSN 006578 |Epirubicin | |

|HSN 023523 |Fulvestrant | |

|HSN 021114 |Goserelin Acetate | |

|HSN 021102 |Leuprolide Acetate | |

|HSN 003923 |Megestrol Acetate | |

|HSN 003905 |Methotrexate Sodium | |

|HSN 003926 |Tamoxifen Citrate | |

|HSN 003912 |Vinblastine | |

|HSN 003913 |Vincristine Sulfate | |

|HSN 009614 |Vinorelbine Tartrate | |

|Q4K |Vaginal Estrogen Preparations | |

|HSN 003902 |Cisplatin | |

|HSN 003907 |Fluorouracil | |

|HSN 004101 |Methanamine Hippurate | |

|HSN 004102 |Methenamine Mandelate | |

|HSN 004094 |MTH/ME BLUE/BA/SALICY/ATP/HYOS | |

|HSN 003893 |Cyclophosphamide | |

|HSN 003923 |Megestrol | |

|G1A |Estrogenic Agents |Oral forms only |

|All extended release narcotics (such as | | |

|Oxycontin, Duragesic, Kadian, Actiq, etc.) | | |

BCCDT-9 - Rebate Exclusion List

|Rebate Exclusion List – Rebate is not required for the following products: |

|HSN = 008966 |Pen Needles | |

|DCC = M |Needles & Syringes | |

|DCC = N |Needles & Syringes | |

|DCC = O |Needles & Syringes | |

|DCC = P |Needles & Syringes | |

|DCC = Q |Needles & Syringes | |

|DCC = R |Needles & Syringes | |

|HIC3 = C5U |Nutritional Therapy, Med Cond Special Electrolytes & |Includes products for disease-specific |

| |Misc. Nutrients |nutritional therapy |

|HIC3 = C5F |Dietary Supplements |Includes Ensure-type products |

|HIC3 = C1W |Electrolyte Maintenance |Includes electrolyte solutions |

|HIC3 = C5G |Food Oils |Includes corn, safflower oils |

|HIC3 = M4B |IV Fat Emulsions | |

|TC = 68 |Protein Lysates |Includes amino acid products |

BCCDT-10 - Inj Products /Needles and Syringes last 34 days.

|Injectable Products that will allow Needles and Syringes to pay as long as the RX has been filled within the last 34 days. |

|Drug Code |Drug Name |Comments |

|H3A |Analgesics, Narcotics | |

|F1A |Androgenic Agents | |

|W3B |Antifungal Agents | |

|H6J |Anti-emetics Agents | |

|TC 30 |Antineoplastic Agents | |

|P4B |Bone Formation Stimulants | |

|P4L |Bone Ossification Suppression Agents | |

|G1A |Estrogrenic Agents | |

|N1B |Hemantinics, Other | |

|M9K |Heparin Preparations | |

|C4G |Insulin | |

|N1C |Leukocyte Stimulants | |

BCCDT-11 - Brand Medically Necessary Exclusions

|Brand Medically Necessary Exclusions (all other brands deny with NCPDP 22) |

|GSN = 004558, 016773, 016774, 038014, 043880 |Carbamazepine 200mg tab |Except: Ciba Geigy may be substituted |

| | |w/Lemon Co. Epitol |

|GSN = 004521 |Phenytoin Sodium Extended 100mg cap | |

|GSN = 004543 |Primidone 250mg tab | |

|GSN = 004536 |Valproic Acid 250mg cap | |

|GSN = 000090, 000091, 000093, 036890, 039837, |Theophylline Extended Release 100mg, 200mg & 300mg tabs | |

|043541 | | |

|GSN = 006561, 006560, 006562 |Warfarin 2mg, 2 ½ mg & 5mg tabs | |

BCCDT-12 - Unit Dose Drugs Exceptions

|Unit Dose Drugs Exceptions for Retail Claims (all other U/D will deny with NCPDP 70 – NDC not covered)/ “Unit Dose Package Size” |

|HSN = 000739; and UD |Ferrous Sulfate (single ingredient products only) | |

|GSN = 040910, 040911, 047126; and UD |Micardis 20mg, 40mg & 80mg | |

|GSN = 047326 |Micardis HCT 40/12.5mg | |

|HSN = 001578; and UD |Chloral Hydrate | |

|GSN = 031055, 031056; and UD |Pepcid RPD | |

|GSN = 049296, 040887; and UD |Prevacid Liquid | |

|GSN = 001171; and UD |Water for Inhalation | |

|GSN = 000591, 000592; and UD |Mucomyst | |

|GSN = 000586; and UD |Sodium Chloride | |

|GSN = 045215, 045216; and UD |Androgel | |

|GSN = 009326, 009327; and UD |Vancocin HCL | |

|GSN = 048463; and UD |Zomig ZMT | |

|GSN = 045266; and UD |Methotrexate Dose Pak | |

|GSN = 041562, 041563; and UD |Zofran ODT | |

|GSN = 046565; and UD |Pulmicort | |

|HSN = 000057; and UD |Ipratropium Bromide | |

|Route = ophthalmic; and UD |Eye Drops | |

III. Payer Specific Information

Payer Sheet:

NCPDP VERSION 5.1 PAYER SHEET – B1/B3 Transactions

**GENERAL INFORMATION**

|Payer Name: Maryland Medical Assistance Program |Date: January 1, 2007 |

|Plan Name/Group Name: Breast and Cervical Cancer Diagnosis and Treatment |

|Processor: ACS |Help Desk: TBD |

|Effective as of: January 1, 2007 |Version/Release #: 5.1 |

|Contact/Information Source: Help Desk, Payer Sheet |

|Certification Testing Window: |

|Provider Relations Help Desk Info: |

|Other versions supported: None |

** OTHER TRANSACTIONS SUPPORTED **

|Transaction Code |Transaction Name |

|B1 |Billing |

|B3 |ReBill |

BILLING TRANSACTION:

Transaction Header Segment: Mandatory in all cases

|Field # |NCPDP Field Name/length |Value |M/R/RW |Comment |

|1Ø1-A1 |BIN Number |61ØØ84 |M | |

|1Ø2-A2 |Version/Release Number |51 |M | |

|1Ø3-A3 |Transaction Code |B1 = Billing |M | |

| | |B2 = Reversals | | |

| | |B3 = Rebill | | |

|1Ø4-A4 |Processor Control Number |DRBCPROD = Production |M | |

| | |DRBCACCP = Test | | |

|1Ø9-A9 |Transaction Count |1 = One Occurrence |M | |

| | |2 = Two Occurrences | | |

| | |3 = Three Occurrences | | |

| | |4 = Four Occurrences | | |

|2Ø2-B2 |Service Provider ID Qualifier |07 – NCPDP ID Number |M | |

|2Ø1-B1 |Service Provider ID |NABP / NCPDP Provider number |M | |

|4Ø1-D1 |Date of Service |CCYYMMDD |M | |

|11Ø-AK |Software Vendor/Certification ID |ØØØØØØØØØØ (zeros) |M |Zero fill or use current |

| | | | |Certification number |

Patient Segment: Required

|Field |NCPDP Field Name |Value |M/R/RW |Comment |

|111-AM |Segment Identification |Ø1 |M |Patient Segment |

|331-CX |Patient ID Qualifier |Blank = Not Specified |NA |Not used by MD BCCDT |

| | |Ø1=Social Security Number | | |

| | |Ø2=Driver’s License Number | | |

| | |Ø3=U.S. Military ID | | |

| | |99=Other | | |

|332-CY |Patient ID | |NA |Not used by MD BCCDT |

|304-C4 |Date of Birth |CCYYMMDD |R | |

|305-C5 |Patient Gender Code |Ø =Not specified |R | |

| | |1=Male | | |

| | |2=Female | | |

|310 –CA |Patient First Name | |R |First 5 characters |

|311 – CB |Patient Last Name | |R |First 5 characters |

|322-CM |Patient Street Address | |NA |Not used by MD BCCDT |

|323-CN |Patient City Address | |NA |Not used by MD BCCDT |

|324-CO |Patient State/Province Address | |NA |Not used by MD BCCDT |

|325-CP |Patient Zip/POSTAL Zone | |NA |Not used by MD BCCDT |

|326-CQ |Patient Phone Number | |NA |Not Used by MD BCCDT |

|307-C7 |Patient Location |0=Not specified |NA | |

| | |1=Home | | |

| | |2=Inter-Care | | |

| | |3=Nursing Home | | |

| | |4=Long Term/Extended Care | | |

| | |5=Rest Home | | |

| | |6=Boarding Home | | |

| | |7=Skilled Care Facility | | |

| | |8=Sub-Acute care Facility | | |

| | |9=Acute Care Facility | | |

| | |10=Outpatient | | |

| | |11=Hospice | | |

|333-CZ |Employer ID | |NS |Not Supported |

|334-1C |Smoker/Non-Smoker Code | |NS |Not Supported |

|335-2C |Pregnancy Indicator |Blank=Not Specified |NA |Not used by MD BCCDT |

| | |1=Not pregnant | | |

| | |2=Pregnant | | |

Insurance Segment: Mandatory

|Field # |NCPDP Field Name |Value |M/R/RW |Comment |

|111-AM |Segment Identification |Ø4 |M |Insurance Segment |

|3Ø2-C2 |Cardholder ID |Member’s MDBCCT ID Number |M |9 characters |

|312-CC |Cardholder First Name | |NA |Not used by MD BCCDT |

|313-CD |Cardholder Last Name | |NA |Not used by MD BCCDT |

|314-CE |Home Plan | |NS |Not Supported |

|524-FO |Plan ID | |NA |Not used by MD BCCDT |

|309-C9 |Eligibility Clarification Code |Ø =Not specified |NA |Not used by MD BCCDT |

| | |1=No Override | | |

| | |2=Override | | |

| | |3=Full Time Student | | |

| | |4=Disabled Dependent | | |

| | |5=Dependent Parent | | |

| | |6=Significant Other | | |

|336-8C |Facility ID | |NS |Not Supported |

|301-C1 |Group ID |MDBCCDT |R | |

|306-C6 |Patient Relationship Code |1 = Cardholder |R |1 = Cardholder |

| | |2 = Spouse | | |

| | |3=Child | | |

| | |4=Other | | |

Claim Segment: Mandatory

|Field # |NCPDP Field Name |Value |M/R/RW |Comment |

|111-AM |Segment Identification |Ø7 |M |Claim Segment |

|455-EM |Prescription/Service Reference Number Qualifier |1 = Rx Billing |M | |

|4Ø2-D2 |Prescription/Service Reference Number |Rx Number assigned by the pharmacy |M | |

|436-E1 |Product/Service ID Qualifier |Ø3 = National Drug Code |M | |

|4Ø7-D7 |Product/Service ID |NDC Number |M | |

|456-EN |Associated Prescription/Service Reference # |New to MDBCCT |RW |Required when submitting a |

| | | | |claim for a completion fill |

|457-EP |Associated Prescription/Service Date |New to MDBCCDT |RW |Required when submitting a |

| | | | |claim for a completion fill |

|458-SE |Procedure Modifier Count | |NA |Not Used by MD BCCDT |

|459-ER |Procedure Modifier Code Count | |NA |Not Used by MD BCCDT |

|442-E7 |Quantity Dispensed |Metric Decimal Quantity |R | |

|403-D3 |Fill Number |Ø = Original Dispensing |R |The system will edit on the |

| | |1-99 = Number of refills | |12th refill |

|405-D5 |Days Supply | |R | |

|406-D6 |Compound Code | Ø = Not specified |R | |

| | |1= Not a compound | | |

| | |2 = Compound | | |

|408-D8 |Dispense as Written (DAW) |Ø =Default, no product selection |RW |Allow 0,1 or 5 |

| | |indicated | | |

| | |1=Physician request | | |

| | |2=patient request | | |

| | |3=pharmacist request | | |

| | |4=generic out of stock (temp) | | |

| | |5=brand used as generic | | |

| | |6=override | | |

| | |7=brand mandated by law | | |

| | |8=generic not available in | | |

| | |marketplace | | |

| | |9=not used | | |

|414-DE |Date Prescription Written |CCYYMMDD |R | |

|415-DF |Number of Refills Authorized |Ø =Not Specified |R | |

| | |1-99=number of refill | | |

|419-DJ |Prescription Origin Code |0=Not specified |NA |Not used by MD BCCDT |

| | |1=Written | | |

| | |2=Telephone | | |

| | |3=Electronic | | |

| | |4=Facsimile | | |

|420-DK |Submission Clarification Code |Ø =Not specified, default |RW |Can be submitted when |

| | |1=No override | |submitting a multi-line |

| | |2=Other override | |compound claim. |

| | |3=Vacation Supply | | |

| | |4=Lost Prescription | | |

| | |5=Therapy Change | | |

| | |6=Starter Dose | | |

| | |7=Medically Necessary | | |

| | |8=Process compound for Approved | | |

| | |Ingredients | | |

| | |9=Encounters | | |

| | |99=Other | | |

|460-ET |Quantity Prescriber | |NS |Not Used, use 442-E7 |

|308-C8 |Other Coverage Code |Ø=Not Specified |R | |

| | |1=No other Coverage Identified | | |

| | |2=Other coverage exists-payment | | |

| | |collected | | |

| | |3=Other coverage exists-this claim | | |

| | |not covered | | |

| | |4=Other coverage exists-payment not| | |

| | |collected | | |

| | |5=Managed care plan denial | | |

| | |6=Other coverage exists, not a | | |

| | |participating provider | | |

| | |7=Other Coverage exists-not in | | |

| | |effect at time of service | | |

| | |8=Claim is a billing for a copay | | |

|429-DT |Unit Dose Indicator |Ø =Not specified | |3 = Pharmacy Unit Dose |

| | |1=Not Unit Dose | | |

| | |2=Manufacturer Unit Dose | | |

| | |3=Pharmacy Unit Dose | | |

|453-EJ |Orig Prescribed Product/Service ID Qual |Ø3=National Drug Code (NDC) |NA |Not used by MD BCCDT |

|445-EA |Originally Prescribed Product/Service Code | |NA |Not used by MD BCCDT |

|446-EB |Originally Prescribed Quantity | |NA |Not used by MD BCCDT |

|330-CW |Alternate ID | |NS |Not supported |

|454-EK |Scheduled prescription ID Number | |NS |Not Supported |

|418-DI |Level of Service |3 = Emergency |RW |Required when submitting a |

| | | | |claim for an emergency fill. |

|461-EU |Prior Authorization Type Code |Ø=Not Specified |RW | |

| | |1=Prior Authorization | | |

| | |2=Medical Certification | | |

| | |3=EPSDT (Early Periodic Screening | | |

| | |Diagnosis Treatment) | | |

| | |4=Exemption from Copay | | |

| | |5=Exemption from RX | | |

| | |6=Family Plan. Indic. | | |

| | |7=AFDC (Aid to Families with | | |

| | |Dependent Children) | | |

| | |8=Payer Defined Exemption | | |

|462-EV |Prior Authorization Number Submitted | |RW | |

|463-EW |Intermediary Authorization Type ID | |NA |Not used by MD BCCDT |

|464-EX |Intermediary Authorization ID | |NA |Not used by MD BCCDT |

|343-HD |Dispensing Status |P = initial Fill |RW |Required when submitting a |

| | |C=Completion Fill | |claim for a partial fill |

| | |New to MDBCCDT | | |

|344-HF |Quantity Intended to be Dispensed |New to MDBCCDT |RW |Required when submitting a |

| | | | |claim for a partial fill |

|345-HG |Days Supply Intended to be Dispensed |New to MDBCCDT |RW |Required when submitting a |

| | | | |claim for a partial fill |

|600-28 |Unit of Measure | |NS |Not Supported |

Pharmacy Provider Segment: Optional - Not used by MDBCCDT

|Field # |NCPDP Field Name |Value |M/R/RW |Comment |

|111-AM |Segment Identification |Ø2 |NA |Pharmacy Provider Segment |

|465-EY |Provider ID Qualifier |Blank=Not specified |NA |Not used by MD BCCDT |

| | |Ø1=Drug Enforcement Administration | | |

| | |(DEA) | | |

| | |Ø2=State License | | |

| | |Ø3=Social Security Number (SSN) | | |

| | |Ø4=Name | | |

| | |Ø5=National Provider Identifier | | |

| | |(NPI) | | |

| | |Ø6=Health Industry Number (HIN) | | |

| | |Ø7=State Issued | | |

| | |99=Other | | |

|444-E9 |Provider ID | |NA |Not used by MD BCCDT |

Prescriber Segment: Required

|Field # |NCPDP Field Name |Value |M/R/RW |Comment |

|111-AM |Segment Identification |Ø3 |M |Prescriber Segment |

|466-EZ |Prescriber ID Qualifier |12 = DEA |R | |

|411-DB |Prescriber ID |DEA Number |R |. |

|467-1E |Prescriber Location Code | |NS |Not Supported |

|427-DR |Prescriber Last Name | |NA |Not used by MD BCCDT |

|498-PM |Prescriber Phone Number | |NA |Not used by MD BCCDT |

|468-2E |Primary Care Provider ID Qualifier |Blank=Not Specified |NA | Not Used by MD BCCDT |

| | |Ø1=National Provider ID (NPI) | | |

| | |Ø2=Blue Cross | | |

| | |Ø3=Blue Shield | | |

| | |Ø4=Medicare | | |

| | |Ø5=Medicaid | | |

| | |Ø6=UPIN | | |

| | |Ø7=NCPDP Provider ID | | |

| | |Ø8=State License | | |

| | |Ø9=Champus | | |

| | |1Ø=Health Industry Number (HIN) | | |

| | |11=Federal Tax ID | | |

| | |12=Drug Enforcement Administration | | |

| | |(DEA) | | |

| | |13=State Issued | | |

| | |14=Plan Specific | | |

| | |99=Other | | |

|421-DL |Primary Care Provider ID | |NA |Not used by MD BCCDT |

|469-H5 |Primary care Provider Location Code | |NS |Not Supported |

|470-4E |Primary Care Provider Last Name | |NS |Not Supported |

COB/Other Payments Segment: Optional

|Field # |NCPDP Field Name |Value |M/R/RW |Comment |

|111-AM |Segment Identification |Ø5 |M |COB/Other Payments Segment |

|337-4C |Coordination of Benefits/Other Payments Count | |M | |

|338-5C |Other Payer Coverage Type | |M | |

| | | |(Repeating) | |

|339-6C |Other Payer Id Qualifier |Blank=Not Specified |R |Required when submitting a |

| | |Ø1=National Payer ID | |COB claim |

| | |Ø2=Health Industry Number | |Valid Value = 99 |

| | |Ø3=Bank Information Number (BIN) | | |

| | |Ø4=National Association of | | |

| | |Insurance Commissioners (NAIC) | | |

| | |Ø9=Coupon | | |

| | |99-Other | | |

|340-7C |Other Payer ID | |R |Valid Values = |

| | | | |88888. |

| | | | |77777 for Med D |

|443-E8 |Other Payer Date |CCYYMMDD |R |Required when there is |

| | | | |payment from another source|

|341-HB |Other Payer Amount Paid Count | |R |Required when submitting |

| | | | |this segment |

|342-HC |Other Payer Amount Paid Qualifier |Blank=Not specified |R |Required when the re is |

| | |Ø1=Delivery |(Repeating) |payment from another source|

| | |Ø2=Shipping | | |

| | |Ø3=Postage | | |

| | |Ø4=Administrative | | |

| | |Ø5=Incentive | | |

| | |Ø6=Cognitive Service | | |

| | |Ø7=Drug Benefit | | |

| | |Ø 8=Sum of all Reimbursement | | |

| | |98=Coupon | | |

| | |99=Other | | |

|431-DV |Other Payer Amount Paid | |R |Required when there is |

| | | | |payment from another source|

|471-5E |Other Payer Reject Count | |NA |Not used by MD BCCDT |

|472-6E |Other Payer Reject Code | |NA |Not used by MD BCCDT |

DUR/PPS Segment: Optional

|Field # |NCPDP Field Name |Value |M/R/RW |Comment |

|111-AM |Segment Identification |Ø8 |M |DUR/PPS Segment |

|473-7E |DUR/PPS Code counter | |M |Required when submitting this|

| | | | |segment |

|439-E4 |Reason For Service Code |See Attached list of valid values |R |Required when there is a |

| | | |(Repeating) |conflict to resolve or reason|

| | | | |for service to be explained |

|440-E5 |Professional Service Code |See Attached list of valid values |R |Required when there is a |

| | | | |professional service to be |

| | | | |identified |

|441-E6 |Result of Service Code |See attached list of valid values |R |Required when There is a |

| | | | |result of service to be |

| | | | |submitted |

|478-8E |DUR/PPS Level of Effort | |NA |Not used by MD BCCDT |

|475-J9 |DUR Co-Agent ID Qualifier | |NA |Not used by MD BCCDT |

|476-H6 |DUR Co-Agent ID | |NA |Not Used by MD BCCDT |

Pricing Segment: Mandatory

|Field # |NCPDP Field Name |Value |M/R/RW |Comment |

|111-AM |Segment Identification |11 |M |Pricing Segment |

|409-D9 |Ingredient Cost Submitted | |NA | |

|412-DC |Dispensing Fee Submitted | |NA |Not used by MD BCCDT |

|477-BE |Professional Service Fee Submitted | |NA |Not used by MD BCCDT |

|433-DX |Patient Paid Amount | |NA |Not used by MD BCCDT |

|478-H7 |Other Amount Claimed Submitted Count |Used with Other Coverage code 8 |RW |Required when submitting a |

| | | | |co-pay only claim |

|479-H8 |Other Amount Claimed Submitted Qualifier | |RW |Required when submitting a |

| | | | |claim for a co-pay only |

|480-H9 |Other Amount Claimed Submitted | |RW |Required when submitting a |

| | | | |claim for a copay only. This |

| | | | |amount must equal Field 430-DQ|

|481-HA |Flat Sales Tax Amount Submitted | |NA |Not used by MD BCCDT |

|482-GE |Percentage Sales Tax Amount Submitted | |NA |Not used by MD BCCDT |

|484-JE |Percentage Sales Tax Basis Submitted |Blank=Not specified |NA |Not used by MD BCCDT |

| | |01=Gross Amount Due | | |

| | |02=Ingredient Cost | | |

| | |03=Ingredient Cost + Dispensing Fee| | |

|426-DQ |Usual and Customary Charge | |R | |

|430–DU |Gross Amount Due | |R |For copay only claims – this |

| | | | |amount must equal the amount |

| | | | |in field 480-H9 |

|423-DN |Basis of Cost Determination |Blank=Not specified |NA |Not used by MD BCCDT |

| | |00=Not specified | | |

| | |Ø1=AWP (Average Wholesael Price) | | |

| | |Ø2=Local Wholesaler | | |

| | |Ø3=Direct | | |

| | |Ø4=EAC (Estimated Acquisition Cost)| | |

| | |Ø5=cquisition | | |

| | |Ø6=MAC (Maximum Allowable Cost) | | |

| | |Ø7=Usual & customary | | |

| | |Ø9=Other | | |

Coupon Segment: Segment is not supported

|Field # |NCPDP Field Name |Value |M/R/RW |Comment |

|111-AM |Segment Identification |Ø9 |NS |Coupon Segment |

|485-KE |Coupon Type | |NS | |

|486-ME |Coupon Number | |NS | |

|487-NE |Coupon Value Amount | |NS | |

Compound Segment: Required When Submitting a Multi-Line Compound Claim

|Field # |NCPDP Field Name |Value |M/R/RW |Comment |

|111-AM |Segment Identification |1Ø |M |Compound Segment |

|45Ø-EF |Compound Dosage Form Description Code | |M |Ø1=Capsule |

| | | | |Ø2=Ointment |

| | | | |Ø3=Cream |

| | | | |Ø4=Suppository |

| | | | |Ø5=Powder |

| | | | |Ø6=Emulsion |

| | | | |Ø7=Liquid |

| | | | |1Ø=Tablet |

| | | | |11=Solution |

| | | | |12=Suspension |

| | | | |13=Lotion |

| | | | |14=Shampoo |

| | | | |15=Elixir |

| | | | |16=Syrup |

| | | | |17=Lozenge |

| | | | |18=Enema |

|451-EG |Compound Dispensing Unit Form Indicator | |M |1=Each |

| | | | |2=Grams |

| | | | |3=Milliliters |

|452-EH |Compound Route of Administration | |M |1=Buccal |

| | | | |2=Dental |

| | | | |3=Inhalation |

| | | | |4=Injection |

| | | | |5=Intraperitoneal |

| | | | |6=Irrigation |

| | | | |7=Mouth/Throat |

| | | | |8=Mucous Membrane |

| | | | |9=Nasal |

| | | | |1Ø=Ophthalmic |

| | | | |11=Oral |

| | | | |12=Other/Miscellaneous |

| | | | |13=Otic |

| | | | |14=Perfusion |

| | | | |15=Rectal |

| | | | |16=Sublingual |

| | | | |17=Topical |

| | | | |18=Transdermal |

| | | | |19=Translingual |

| | | | |2Ø=Urethral |

| | | | |21=Vaginal |

| | | | |22=Enteral |

| | | | | |

| | | | | |

| | | | | |

|447-EC |Compound Ingredient Component (Count) | |M | |

| | | |(Repeating) | |

|488-RE |Compound Product ID Qualifier | |M |Ø3=National Drug Code (NDC) |

| | | |(Repeating) | |

|489-TE |Compound Product ID | |M | |

| | | |(Repeating) | |

|448-ED |Compound Ingredient Quantity | |M | |

| | | |(Repeating) | |

|449-EE |Compound Ingredient Drug Cost | |NA |Not used by MD BCCDT |

|490-UE |Compound ingredient basis of Cost Determination |Blank=Not specified |NA |Not used by MD BCCDT |

| | |Ø1=AWP | | |

| | |Ø2=Local Wholesaler | | |

| | |Ø3=Direct | | |

| | |Ø4=EAC | | |

| | |Ø5=Acquisition | | |

| | |Ø6=MAC | | |

| | |Ø7=Usual & customary | | |

| | |Ø9=Other | | |

Prior Authorization Segment: Not Used by MDBCCDT Medicaid

|Field # |NCPDP Field Name |Value |M/R/RW |Comment |

|111-AM |Segment Identification |12 |NA |Prior Authorization Segment |

|498-PA |Request Type | |NA | |

|498-PB |Request Period Date –Begin | |NA | |

|498-PC |Request Period Date- End | |NA | |

|498-PD |Basis of Request | |NA | |

|498-PE |Authorized Representative First Name | |NA | |

|498-PF |Authorized Representative Last Name | |NA | |

|498-PG |Authorized Representative Street Address | |NA | |

|498-PH |Authorized Representative City Address | |NA | |

|498-PJ |Authorized Representative State/Province Address | |NA | |

|498-PK |Authorized Representative Zip/Postal Code | |NA | |

|498-PY |Prior Authorization Number Assigned | |NA | |

|503-F3 |Authorization Number | |NA | |

|498-PP |Prior Authorization Supporting Documentation | |NA | |

Clinical Segment: Optional for MDBCCDT

|Field # |NCPDP Field Name |Value |M/R/RW |Comment |

|111-AM |Segment Identification |13 |NA |Clinical Segment |

|491-VE |Diagnosis Code Count | |RW |Required when a DX is used to |

| | | | |determine coverage |

|492-WE |Diagnosis Code | |RW |Required when a DX is used to |

| | | | |determine coverage |

|424-DO |Diagnosis Code | |RW |Required when a DX is used to |

| | | | |determine coverage |

|493-XE |Clinical Information Counter | |NA | |

|494-ZE |Measurement Date | |NA | |

|495-H1 |Measurement Time | |NA | |

|496-H2 |Measurement Dimension | |NA | |

|497-H3 |Measurement Unit | |NA | |

|499-H4 |Measurement Value | |NA | |

Additional Claim Information

DUR Codes

Reason for Service Codes (DUR Conflict Codes)

|Code |Meaning |Code |Meaning |

|AT |Additive Toxicity |LD |Low Dose alert |

|CH |Call Help Desk |LR |Under Use Precaution |

|DA |Drug Allergy Alert |MC |Drug Disease Precaution |

|DC |Inferred Drug Disease Precaution |MN |Insufficient Duration Alert |

|DD |Drug-Drug Interaction |MX |Excessive Duration Alert |

|DF |Drug Food Interactions |OH |Alcohol Precaution |

|DI |Drug Incompatibility |PA |Drug Age Precaution |

|DL |Drug Lab conflict |PG |Drug Pregnancy alert |

|DS |Tobacco use precaution |PR |Prior Adverse drug reaction |

|ER |Over Use precaution |SE |Side effect alert |

|HD |High Dose alert |SX |Drug gender alert |

|IC |Iatrogenic condition alert |TD |Therapeutic Duplication |

|ID |Ingredient Duplication | | |

Professional Service Codes (Intervention Codes)

|Code |Meaning |Code | Meaning |

|M0 |MD Interface |R0 |Pharmacist reviewed |

|P0 |Patient Interaction | | |

Result of Service Codes (DUR Outcome Codes)

|Code |Meaning |Code |Meaning |

|1A |Filled – False Positive |1F |Filled – Different quantity |

|1B |Filled as is |1G |Filled after prescriber approval |

|1C |Filled with different dose |2A |Not Filled |

|1D |Filled with different directions |2B |Not Filled – Directions Clarified |

IV. Provider Information :

Provider Manual

Provider Cheat Sheet

V. Emergency Procedures:

Not Applicable

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