PR-211: National Drug Codes (NDC) Not Eligible for Rebate, Not Covered

What Does PR-211 Mean?

With PR (Patient Responsibility), the patient is financially responsible for the non-covered drug. If a covered alternative exists, discuss it with the patient and prescriber before collecting.

CARC 211 indicates that the drug identified by the NDC on the claim is not eligible for coverage because the manufacturer has not participated in the required drug rebate program. For Medicaid, this means the drug manufacturer has not signed a Medicaid Drug Rebate Agreement, making the drug ineligible for Medicaid coverage. For other federal programs, the drug may not be listed in the Federal Supply Schedule.

This denial can also occur when the wrong NDC was submitted (a data entry error), when a brand-name NDC was billed instead of a covered generic equivalent, or when the drug product has been removed from the rebate program. The resolution depends on whether the correct NDC was submitted and whether a covered alternative exists.

How to Resolve

1. Check for alternatives Before billing the patient, verify whether a covered generic or alternative drug exists.
2. Discuss with prescriber If an alternative is available, discuss switching with the prescribing physician.
3. Collect from the patient if no alternative If the specific drug is necessary and not covered, communicate the cost and collect.

How to Prevent PR-211

• Verify formulary status before dispensing and inform patients of non-covered drug costs
• Discuss covered alternatives with patients and prescribers proactively

Also Filed As

The same CARC 211 may appear with different Group Codes:

Related Denial Codes