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The purpose of this bulletin is to alert pharmacy providers that effective September 21, 2020, DMAS must comply with a new federal rule relating to all pharmacy claims for Schedule II drugs.

• All Scheduled II pharmacy claims without the Quantity Prescribed will deny for “NCPDP ET M/I Quantity Prescribed.”
  • DMAS will allow network pharmacies to request an override for sixty (60) days past September 21, 2020 ending November 20, 2020. This is to ensure members are not penalized if the pharmacy’s software is not updated in time to meet the September 21, 2020 deadline. Please contact the appropriate Pharmacy Benefit Manager for an override.
• Once the total quantity dispensed is equal to the total quantity prescribed, all requests past that quantity will deny for “NCPDP ET Quantity.” Overrides are not allowed.  
• All subsequent fills of an incremental fill must be completed within thirty (30) days from the date the prescription was written and if greater than thirty (30) days it will deny for “NCPDP 76 Plan Limitations Exceeded.” Overrides are not allowed.

This rule is applicable to prescriptions dispensed for all members enrolled in the Virginia Medicaid program, including those members enrolled in the Commonwealth Coordinated Care Plus (CCC+) and Medallion 4 managed care programs.

Background Information

On January 24, 2020, CMS released the following message:

The Department of Health & Human Services (HHS) announces the January 24, 2020, Federal Register publication of the Final Rule (FR) CMS-0055-F, which modifies the requirements for use of the National Council for Prescription Drug Programs (NCPDP) Telecommunication Standard Implementation Guide, Version D, Release 0, August 2007, by requiring the use of the Quantity Prescribed (460-ET) field to identify partial fills for Schedule II drugs.

The Comprehensive Addiction and Recovery Act (CARA) of 2016 expanded the circumstances in which a pharmacist may dispense less than the full-prescribed amount of Schedule II drugs. A technical issue with version D.0 necessitated a modification of the requirements for the use of that standard to accurately reflect this provision of CARA. In January 2019 (84 FR 633), the Secretary published a proposed rule titled "Administrative Simplification: Modification of the Requirements for the Use of Health Insurance Portability and Accountability Act of 1996 (HIPAA) National Council for Prescription Drug Programs (NCPDP) D.0 Standard". This final rule adopts this change as proposed.

This modification enables covered entities to clearly distinguish in a HIPAA retail pharmacy transaction if a prescription is a “partial fill” where less than the full amount prescribed is dispensed under the CARA provision. This is a modification to ensure information is available to help prevent impermissible refills of Schedule II drugs and to yield better data for researchers to enhance understanding of prescribing trends.  We believe this modification will assist with addressing the public health concerns associated with prescription drug abuse in the United States.

The official CMS Information Bulletin is located at https://www.cms.gov/files/document/d0-final-rule-information-bulletin.pdf

Important note: The usage of the term “partial fill” in this context does not match the NCPDP definition of “partial fill”. An “NCPDP partial fill” is specific to the situation where the pharmacy cannot completely dispense a fill of the prescription due to an inventory shortage. NCPDP utilizes the term “incremental fill” for Schedule II drugs, for which refills are not allowed, when the member or prescriber requests that the dispensing pharmacy fills only a partial quantity of the prescribed quantity in the pursuit of responsible opioid use. If necessary, the member can obtain the balance of their Schedule II prescription in a subsequent claim(s).

18VAC110-20-310. Partial Dispensing of Schedule II Prescriptions.

This change corresponds with the current Virginia Partial Dispensing of Schedule II Prescriptions allowance

A prescription for a Schedule II drug may be filled in partial quantities if the partial fill is requested by the patient or by the practitioner who wrote the prescription provided:

1. The total quantity dispensed in all partial fillings does not exceed the total quantity prescribed and.
2. The prescription is written and filled in accordance with state and federal law; and
3. The remaining portions are filled not later than thirty (30) days after the date on which the prescription is written.

Statutory Authority

§§ 54.1-2400 and 54.1-3307 of the Code of Virginia.

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