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Pharmacy Controlled Substance Overrides

March 14, 2011

Override/authorization is granted in the following circumstances

Circumstance

Action

Prescriber increased the dose of the medication

Verify with the prescriber and document the dose was increased and the date of the increase.

Pharmacy entered the wrong days supply on the first fill

Reverse the claim and rebill

Change in living arrangement such as the recipient was admitted to or discharged from a nursing home

Verify and document the change in living arrangement

The facility kept the medications taken from the recipient and the recipient was discharged/released from a:

• Hospital

• Correctional facility

• Detoxification center

Verify and document the discharge/release from the facility

Recipient enters detoxification facility for detoxification purpose only

Authorization will be granted for only the exact amount needed for the detoxification stay. The detoxification facility must order, pick up, and maintain control of the medication.

Override/authorization is not granted in the following circumstances

Circumstance

Action

Recipient resides in a LTC facility such as a nursing home or ICF/DD and medication was:

• Lost

• Stolen

• Damaged

• Destroyed

The facility must replace the medication at its own cost

Recipient does not reside in a LTC facility such as a nursing home or ICF/DD and medication was:

• Lost

• Stolen

• Damaged

• Destroyed

Additional authorization will not be granted

Pharmacy is trying to be reimbursed for:

• Pass meds

• School supplies

• Work supplies

• Etc

Authorization will not be granted

Recipient must travel and will not return before the supply of a medication runs out

Authorization will not be granted

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