NDC Rejection and a Partial Package
A prescription for levothyroxine 50 mcg tablets, 1 tablet by mouth daily, 30-day supply, arrives electronically. The pharmacy stocks two generic NDCs: NDC A in a 500-count bottle and NDC B in a 100-count bottle. The claim is submitted with NDC A and rejects: 'NDC not covered-plan requires NDC B.' The pharmacy has 60 tablets of NDC B on hand and 500 tablets of NDC A. The plan's formulary lists NDC B as preferred generic; NDC A requires prior authorization. The patient has been on levothyroxine for years and has no new symptoms. The prescription is due today, and the patient is waiting. The software shows NDC B's package size is 100 tablets, and the plan allows a maximum 30-day supply per fill.
1. What does the rejection mean, and what is the most appropriate first action?
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The rejection is product-specific, not a denial of levothyroxine. It means the plan will not pay for NDC A but covers NDC B. First verify that NDC B is the same drug, strength, dosage form, and generic equivalent, and that the prescriber did not require a specific manufacturer (no DAW). If NDC B is equivalent, change the claim to NDC B. Do not switch to a different strength or dosage form to force payment. Also confirm the quantity and days supply remain 30 and 30. If the prescription is written for brand or has a DAW code, contact the prescriber before substituting.
2. The pharmacy has only 60 tablets of NDC B. Can it dispense a partial fill of 30 tablets from the 60-count stock? What quantity and days supply should be billed?
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Yes. The pharmacy can open the 100-count bottle of NDC B and dispense 30 tablets. Bill quantity 30 and days supply 30, not 60 or 100. Package size does not determine the billed quantity; the amount dispensed does. The remaining 70 tablets stay in inventory. If the plan requires a full package or the pharmacy cannot break the package for some reason, the claim may reject for quantity, but that is not the case here. Confirm the NDC on the claim matches the tablets dispensed, and label the bottle with the correct NDC and beyond-use date.
3. If NDC B later rejects with 'prior authorization required,' what should the technician do, and can the pharmacy substitute NDC A without notifying the prescriber?
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If NDC B rejects for prior authorization, the plan requires clinical review before payment. The technician should not dispense NDC A and bill NDC B, because that is a false claim. NDC A also requires PA, so switching back does not solve the problem. Contact the prescriber to initiate a PA for NDC B or to request a formulary alternative. If the patient needs medication today, ask the prescriber about samples or a short cash supply only with the patient's consent and a valid prescription. Document the PA request and the patient communication. Do not tell the patient the drug is covered until the claim pays.