Skip to main content
  • Medicaid Provider Alert: Provider revalidation has begun and those not completing the process risk disenrollment.  Check your account now to learn when your revalidation is due. More information here.
Elizabeth M. Whitehorn, Director

Provider Notice issued 02/02/09

​Duration of Therapy Edit

To:​ Participating Medical Assistance Providers​
Date: February 2, 2009​
Re:​ Duration of Therapy Edit ​

Effective March 2, 2009, the Department will implement a Duration of Therapy edit. This edit is intended to target medications that have the potential for inappropriate length of treatment. The optimal duration of treatment will be based on national practice guidelines and published medical literature.

 

The Department will first implement this edit with nicotine replacement patches. According to guidelines published by the American Psychiatric Association, the recommended duration of therapy for nicotine replacement is six to twelve weeks. Longer durations of nicotine replacement therapy have not been found to be more effective. Therefore, the duration of therapy for nicotine replacement patches will be limited to 90 days within a 365-day period.

 

Claims extending the therapy more than 90 days after the first fill of nicotine replacement patches will reject with an NCPDP error message #76, "Plan Limitations Exceeded." The Department"s rejection message will be B97, "Duration of Therapy Exceeded."

 

If the prescriber believes that it is appropriate to extend the therapy for the patient beyond the initial 90 days, the pharmacy can request a Refill-Too-Soon override using the Refill-Too-Soon Prior Approval Request Worksheet at:

http://www.illinois.gov/hfs/SiteCollectionDocuments/hfs3082a.pdf

 

The pharmacy will need to note on the worksheet that the prescriber has requested that the patient's treatment extend beyond the Department’s established duration limit.

 

If you have any questions concerning this notice, please contact your pharmacy billing consultant in the Bureau of Pharmacy Services toll-free at 1-877-782-5565, Option 7.

 

Theresa A. Eagleson, Administrator

Division of Medical Programs