Emergency Prescriptions

One-time overrides are available for urgently needed medications that require prior authorization.

When are emergency fills appropriate?

Emergency Fills are appropriate in those circumstances where a patient presents at a pharmacy with an 'immediate therapeutic need' for a prescribed medication that requires a pre-authorization due to formulary or other utilization management restrictions.

• Immediate therapeutic needs are those where passage of time (i.e. the timeframe required for an Urgent Review) without treatment would result in imminent emergency care, hospital admission OR might seriously jeopardize the life or health of the patient or others in contact with the patient
• Emergency Fill is a short term dispensed amount of medication that allows time for the processing of a pre-authorization request. Only the emergency fill dosage of the medication will be approved and paid.

The dosage of the Emergency Fill must either be the minimum packaging size that cannot be broken (e.g. injectable), or the lesser of a 7-day supply or the amount as prescribed. (Depending upon their policies, Health Plans may exceed this baseline dispensing amount.) In the event the medication is to be continued for treatment beyond the emergency fill authorization, health plans may apply formulary or utilization management restrictions that will be reviewed following the health plans' standard procedure.

What is the process for getting approval and payment of an emergency fill?

When a currently eligible member of the health presents at a contracted dispensing pharmacy with an immediate therapeutic need and a corresponding prescription from their provider for a medication requiring a pre-authorization that is specified on the list.

• If the health plan has 7 day x 24 hours availability to respond to phone calls from a dispensing pharmacy but the health plan cannot reach the prescriber for full consultation, an emergency fill will be authorized for dispensing.

-OR-

• If the dispensing pharmacy cannot reach the health plan's pre-authorization department by phone as it is outside of that department's business hours, an Emergency Fill can be dispensed by the pharmacy and will be approved and paid.

The health plan's Emergency Fill policy (which must be on their web site) will outline their process by which the dispensing pharmacy can secure payment for emergency fill. Two typical processes are:

• The dispensing pharmacy will be given a code that can be submitted with the claim that designates the dispensed medication as an emergency fill and will authorize payment.
• The dispensing pharmacy will contact the health plan's pre-authorization department within 2 business days to inform them of the Emergency Fill so that a claim for the dispensed medication can be retrospectively submitted and paid.