Refill Too Soon Edit

• Refills are available if indicated on the member's original prescription.
• The refill too soon edit is applied to all plans.
• For most commercial plans, refills are covered only after two-thirds of the member's prescription has already been used.
• Criteria may differ based on an employer group's benefit design.
• For Medicare Part D plans, refills are covered only after three-fourths of the member’s prescription has already been used for non-controlled substances. For controlled substances, refills are covered after 80% of the member’s prescription has been used.
• For QUEST Integration plans, refills are covered only after three-fourths of the member’s prescription has already been used.
• The on-line claims processing system will deny the claim if the refill threshold is not met.
• Quantity limits still apply.

Revision History