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CO HCPF Pharmacy Billing Manual — Dispensing Requirements

DispensingRequirements

activein force · 2026-07-26 – presentas-observed

ForDEASchedule2through5drugs,85percentofthedays'supplyofthelastfillmustlapsebeforeadrugcanbefilledagain.Fornon-scheduleddrugs,75percentofthedays'supplyofthelastfillmustlapsebeforeadrugcanbefilledagain.Iftheappropriatenumbersofdayshavenotlapsed,theclaimwillbedeniedasarefill-too-soonunlesstherehasbeenachangeinthedosing.Fornon-mailordertransactions,thereisamaximum20-dayaccumulationallowedeveryrolling180days.IfaMedicaidmemberentersorleavesanursingfacility,themembermayrequirearefill-too-soonoverrideinordertoreceivehisorherdrugs.APARmustbesubmittedbycontactingthePharmacyBenefitManagerSupportCenter.

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AllHealthFirstColoradoprovidersarerequiredtousetamper-resistantprescriptionpadsforwrittenprescriptions.ThisrequirementstemsfromtheSocialSecurityAct,42U.S.C.1396b(i)(23),whichliststhree(3)differentcharacteristicstobeintegratedintothemanufactureofprescriptionpads.Prescriptionsmustbewrittenontamper-resistantprescriptionpadsthatmeetallthree(3)ofthestatedcharacteristics.

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Acompoundedprescription(aprescriptionwheretwo[2]ormoreingredientsarecombinedtoachieveadesiredtherapeuticeffect)mustbesubmittedonthesameclaim.APARisonlynecessaryifaningredientinthecompoundissubjecttopriorauthorization.Pharmaciesmayusethenumber8inField#420-DKinsteadofobtainingaPAfornon-coveredingredientstoallowtheclaimtopayfortheingredientsthatareconsideredacoveredbenefit.TheHealthFirstColoradoprogramdoesnotpayacompoundingfee.

SNO-MEDisarequiredfieldforcompounds-therouteofadministrationisrequired-NCPDP#ROUTEOFADMINISTRATION(Field#995-E2).

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UnlessotherwisecommunicatedinthePDLorAppendixP,maintenancemedicationsmaybefilledforuptoa100-daysupply,andnon-maintenancemedicationsmaybefilledforuptoa30-daysupply.

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Prescriptionsgenerallycannotbedispensedinquantitieslessthanthephysicianorderedunlessthequantityorderedismorethana100-daysupplyformaintenancemedicationsormorethana30-daysupplyfornon-maintenancemedications.

ExceptionforDEAScheduleIImedications:InitialIncrementalfillsareallowedforDEAScheduleIIprescriptiondrugsdispensedtoALLmembers.SubsequentincrementalfillsforDEAScheduleIIprescriptionmedicationsareallowedformembersresidinginaLongTermCarefacilitybasedonNCPDPrequirements.

PleaseNote:Incrementalandsubsequentfillsarenotpermittedforcompoundedprescriptions.Incrementalandsubsequentfillsmaynotbetransferredfromone(1)pharmacytoanother.Thestandarddrugingredientreimbursementmethodologyappliestothequantitydispensedwitheachfill.Incrementalandsubsequentfillsmustbedispensedwithin60daysoftheprescribeddate.

Allclaimsforincrementalandsubsequentfillsrequirevalidvaluesinthefollowingfields:

QuantityPrescribed(Field#460-ET)forALLDEAScheduleIIprescriptiondrugs,regardlessofincrementalorfull-quantityfills

QuantityDispensed(Field#422-E7)

DaysSupply(Field#405-D5)

Note:ifapharmacysubmitsaclaimforanon-ScheduleIImedicationandincludesavalueforquantityprescribed,itmustbeavalidvalue.Submittingaquantitydispensedgreaterthanquantityprescribedwillresultinadeniedclaim.

Refertothepayersheetlinkedbelowformoredetailedrequirementsregardingeachfield.

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Inanemergency,whenaPARcannotbeobtainedintimetofilltheprescription,pharmaciesmaydispensea72-hoursupply(three(3)days)ofcoveredoutpatientprescriptiondrugstoaneligiblememberbycontactingthePharmacySupportCenter.Anemergencyisanyconditionthatislife-threateningorrequiresimmediatemedicalintervention.

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TheDepartmentdoesnotpayforearlyrefillswhenneededforavacationsupply.

TheHealthFirstColoradoprogramwillcoverlost,stolenordamagedmedicationsonceperlifetimeforeachmember.PharmaciesmustcontactthePharmacySupportCenterforoverridesforlost,stolen,ordamagedprescriptions.Ifamembercallsthecallcenter,thememberwillbedirectedtohavethepharmacycallfortheoverride.

Note:Ifthemedicationwaslostordamagedasaresultofanaturaldisaster,thereplacementofthemedicationwillnotcounttowardtheonce-per-lifetimelimit.

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Inadditiontoanyotherrequirementsat3CCR719-1Section1.00.18,apharmacistorpharmacistdesigneeshalloffercounselingregardingthedrugtherapytoeachHealthFirstColoradomemberwithaneworrefillprescriptionifthepharmacistorpharmacistdesigneebelievesthatitisinthebestinterestofthemember.Theoffertocounselshallbeface-to-facecommunicationwheneverpracticalorbytelephone.Apharmacistshallnotberequiredtocounselamemberorcaregiverwhenthememberorcaregiverrefusessuchconsultation.Thepharmacistorpharmacistdesigneeshallkeeprecordsindicatingwhencounselingwasnotorcouldnotbeprovided.Theserecordsmustbemaintainedforatleastseven(7)years.

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DAWCode

DAWDescription

Action

Description

DAW0

NoProductSelectionIndicated

Allow

Claimswithgenericproductsorsingle-sourcebrandnameproductswithnogenericsallowed.Claimswithmulti-sourcebrandswithavailablegenericformulations,NCPDPUU:DAW0CANNOTBESUBMITTEDMSDRUGW/AVAILGEN.

DAW1

SubstitutionNotAllowedbyPrescriber

Allow

DAW1maybesubmittedongenericproductsandsingle-sourcebrands.ProductmayrequireaPARforbrandnamecoverage.

DAW2

SubstitutionAllowed-PatientRequestedProductDispensed

NotSupported

NCPDPEC22-M/IDISPENSEASWRITTENCODERESUBMITWITHAPPROPRIATEDAWCODE:1-PRESCRIBERREQUESTSBRAND,8-GENERICNOTAVAILABLEINMARKETPLACE,OR9-PLANPREFERSBRANDPRODUCT.

DAW3

SubstitutionAllowed-PharmacistSelectedProductDispensed

NotSupported

NCPDP22-M/IDISPENSEASWRITTENCODERESUBMITWITHAPPROPRIATEDAWCODE:1-PRESCRIBERREQUESTSBRAND,8-GENERICNOTAVAILABLEINMARKETPLACE,OR9-PLANPREFERSBRANDPRODUCT.

DAW4

SubstitutionAllowed-GenericDrugNotinStock

NotSupported

NCPDPEC22-M/IDISPENSEASWRITTENCODERESUBMITWITHAPPROPRIATEDAWCODE:1-PRESCRIBERREQUESTSBRAND,8-GENERICNOTAVAILABLEINMARKETPLACE,OR9-PLANPREFERSBRANDPRODUCT.

DAW5

SubstitutionAllowed-BrandDrugDispensedasaGeneric

NotSupported

NCPDPEC22-M/IDISPENSEASWRITTENCODERESUBMITWITHAPPROPRIATEDAWCODE:1-PRESCRIBERREQUESTSBRAND,8-GENERICNOTAVAILABLEINMARKETPLACE,OR9-PLANPREFERSBRANDPRODUCT.

DAW6

Override

NotSupported

NCPDPEC22-M/IDISPENSEASWRITTENCODERESUBMITWITHAPPROPRIATEDAWCODE:1-PRESCRIBERREQUESTSBRAND,8-GENERICNOTAVAILABLEINMARKETPLACE,OR9-PLANPREFERSBRANDPRODUCT.

DAW7

SubstitutionNotAllowed-BrandDrugMandatedbyLaw

NotSupported

NCPDPEC22-M/IDISPENSEASWRITTENCODERESUBMITWITHAPPROPRIATEDAWCODE:1-PRESCRIBERREQUESTSBRAND,8-GENERICNOTAVAILABLEINMARKETPLACE,OR9-PLANPREFERSBRANDPRODUCT.

DAW8

SubstitutionAllowed-GenericDrugNotAvailableinMarketplace

AllowBillingID=DAW8

Ifthereisamarketplaceshortageforthegenericversionoftheprescribeddrugandonlythebrand-nameproductisavailable,claimwillpaywithDAW8.Thedruglistwillupdateasoftenasnecessarytoaccommodatefordrugshortages.Ifdrugisonlist,claimwillpay.

NotSupported

AllNon-BillingID=DAW8

NCPDPEC8K-DAWCodeNotSupportedandreturnthesupplementalmessageSUBMITTEDDAWISSUPPORTEDWITHGUIDELINES.PLEASECALL888-672-7203FORASSISTANCE

DAW9

AllowedbyPrescriberbutPlanRequestsBrand

AllowFormularyInd=BNR

Druglistcriteriadesignatesthebrandproductaspreferred,(i.e.,BNR=BrandNameRequired),claimwillpaywithDAW9;HealthFirstColorado’sdruglistdesignatesbothabranddruganditsgenericequivalentasnon-preferredproductsandalsodesignatesthatthenon-preferredbrandproductsisfavoredforcoverageovertheequivalentnon-preferredgeneric.

AllowFormularyInd=NPP

MaybeusedforcaseswhereHealthFirstColorado'sdruglistdesignatesbothabranddruganditsgenericequivalentasnon-preferredproductsandalsodesignatesthatthenon-preferredbrandproductisfavoredforcoverageovertheequivalentnon-preferredgeneric.

NotSupported

NCPDPEC8K-DAWCodeNotSupportedandreturnthesupplementalmessageSUBMITTEDDAWISSUPPORTEDWITHGUIDELINES.PLEASECALL888-672-7203FORASSISTANCE.

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EffectiveJuly1,2023,HealthFirstColoradomembersdonothaveapharmacyco-pay.

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Pharmaciesusingachronologicallogshallreviewprescriptionsinwill-callstatusatleastweekly.Ifthememberdoesnotpickuptheprescriptionwithin14calendardaysofbilling,theclaimmustbereversedonthe15thcalendarday.Thepharmacymustretainarecordofeachreversalonfileforauditpurposes.

Pharmaciesusinganelectronicprescriptiontrackingsystemshallreviewprescriptionsinwill-callstatusonadailybasis.Ifthememberdoesnotpickuptheprescriptionwithin10calendardaysofbilling,theclaimmustbereversed.Thepharmacymustretainarecordofeachreversalonfileforauditpurposes.

Ifapharmacyneedstoreverseaclaimforanyotherreason,thismustbedonewithin999days.Ifaclaimisreversedafter120daysandthepharmacyattemptstorebill,theclaimwillrejectfortimelyfiling,andaconsiderationformmustbesubmittedwithavalidreasonforrebillingoutsidethe120-daywindow.RefertotheRebillingDeniedClaimssectionbelow.

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Pharmaciesmustkeeparecordshowingwhenaprescriptionwasreceivedbyamemberortheirauthorizedagent.Thiscanbedoneinoneoftwoways:

Awrittenlogthatincludesthemember’sname,their(ortheirauthorizedagent’s)signature,andthedatetheprescriptionwaspickedup;or

Anelectronictrackingsystemthatshowsthestatusoftheprescriptionandrecordsthedateandtimeitwasgiventoapersonwhompharmacystaffconfirmedwasthememberortheirauthorizedagent.

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Sourcedocumentsandsourcerecordsusedtocreatepharmacyclaimsshallbemaintainedinsuchawaythatallelectronicmediaclaimscanbereadilyassociatedandidentified.Thesesourcedocuments,inadditiontoanyworkpapersandrecordsusedtocreateelectronicmediaclaims,shallberetainedbytheproviderforseven(7)yearsandshallbemadereadilyavailableandproduceduponrequestoftheSecretaryoftheDepartmentofHealthandHumanServices,theDepartment,andtheMedicaidFraudControlUnitandtheirauthorizedagents.

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ThefollowingNCPDPfieldsarerequiredon340Bcoveredoutpatientdrugclaims.

NCPDPFieldName&Number

Value

Description

SubmissionClarificationCode(420-DK)

20=340BClaim

Requiredfor340BClaims.Thevalueof'20'submittedintheSubmissionClarificationfield(NCPDPField#420-DK)toindicatea340Btransaction.Indicatesthatthedrugwaspurchasedthroughthe340BDrugPricingProgram.

BasisofCostDetermination(423-DN)

05=AcquisitionCostor08=DisproportionateSharePricing

Requiredfor340BClaims.Thevalueof'05'(Acquisition)or'08'(340BDisproportionateSharePricing/PublicHealthService)intheBasisofCostDeterminationfield(NCPDPField#423-DN).

Refertothe340BPoliciesandProceduresManualformoreinformationrelatedto340Bbilling.

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EffectiveJanuary1,2026,claimsforparenteralnutritionproductsareeligibletoreceiveanenhanceddispensingfeeasrequiredbySenateBill25-084.Toreceivetheenhanceddispensingfee,thefollowingNCPDPfieldsarerequiredonclaimsforparenteralnutritionproducts.

NCPDPFieldName&Number

Value

Description

DrugUtilizationReview/ProfessionalPharmacyService(DUR/PPS)

LevelofEffort(LOE)=21

Requiredfortheenhanceddispensingfee.ClaimssubmittedwithoutLOE21willbereimbursedatthestandarddispensingfeerate.

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EnrolledMedicaidfee-for-service(FFS)membershavetheoptiontoreceivetheiroutpatientmedicationsthroughmaildelivery.

Pharmaciesenrolledasamailorderpharmacyspecialtytype460mayonlybillforoutpatientmaintenancemedicationsforchronicconditions.PharmaciesenrolledspecificallyasMailOrderwillreceivedenialsfornon-maintenancemedications.

Localandout-of-stateretailpharmaciesotherthanmailorderpharmaciesmayprovidemaildeliveryprescriptionsforMedicaidmembersiftheyareenrolledwiththeHealthFirstColoradoprogramandareregisteredandingoodstandingwiththeStateBoardofPharmacy.

HealthFirstColoradodoesnotpaydeliveryfees.

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Provenance

Source: hcpf.colorado.gov
Retrieved: 2026-07-26
Edition: 2026-07-26
Content hash: c9e6b12128b1af0d19e8bdbd7209ee1f6e2c15f3b52e6dc18ee060dbc75386a8

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