Claims : Submission

Quantity Limits

Generally, ForwardHealth follows FDA-labeled dose and administration guidelines to establish quantity limits. The quantity limit allowed for a specific drug and drug strength is established to encourage prescribing and dispensing of the most cost-effective strength and quantity of a drug.

The Quantity Limit Drugs and Diabetic Supplies data table contains the most current quantity limits.

When a claim is submitted with a quantity that exceeds the limit, the claim will be denied.

Prior to requesting a quantity limit policy override, the pharmacy provider should contact the prescriber to determine whether or not it is medically appropriate for a member to exceed the quantity limit. If it is medically appropriate for a member to exceed a quantity limit, pharmacy providers may request a quantity limit policy override by calling the DAPO Center.

Note: Pharmacy providers may dispense up to the allowed quantity limit without contacting the DAPO Center.

Pharmacy providers may request a quantity limit policy override for members enrolled in BadgerCare Plus, Medicaid, or SeniorCare.

Examples of when a quantity limit override request for a non-stimulant drug may be approved through the DAPO Center include, but are not limited to, the following:

• If the member has an appropriate medical need (for example, the member's medications were lost or stolen, the member has requested a vacation supply)
• If the member has been taking too much of a medication because they misunderstood the directions for administration by the prescriber
• If the prescriber changed the directions for administration of the drug and did not inform the pharmacy provider

A quantity limit override request for drugs in the stimulants drug class and the stimulants, related agents - wake promoting drug class is limited to a one-month override and may be approved for the following situations:

• Lost or stolen medication
• Vacation supply
• Medication and/or dosage change by the prescriber

Pharmacy providers may dispense up to a 96-hour supply of a drug to a member when the DAPO Center is closed and a policy override to exceed a quantity limit must be obtained. If the DAPO Center grants a policy override to exceed a quantity limit, the policy override will be retroactive and the pharmacy provider may submit a claim for the drug using the POS system or on paper. If the claim for a 96-hour supply is submitted on paper, the pharmacy provider will be required to complete and submit a Pharmacy Special Handling Request form.

If the DAPO Center denies the policy override, ForwardHealth will reimburse the provider for the 96-hour supply. A claim must be submitted on paper with the Pharmacy Special Handling Request form.

Service Limitations

If an override of the service limitation, such as a quantity limit override, is requested and the request does not meet service limitation override criteria, the override will be denied and the service will be noncovered. Members do not have appeal rights for noncovered drugs or services.