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Pharmacy Early-Refill Overrides

Posted: September 14, 2018

  • Pharmacy Overrides
  • Pharmacy Cash Payment for Controlled Substance
  • Pharmacy Overrides

    The MHCP Provider Call Center may grant an override or authorization in the circumstances described in this Pharmacy Override Table. See the specific circumstance and the actions MHCP may take.

    Pharmacy Override Table

    Circumstance

    Action of MHCP

    Member does not reside in a long-term care (LTC) facility, such as a nursing home or intermediate care facility for developmental disabilities (ICF-DD) and one of the following occurred with the medication:

  • • Lost
  • • Stolen
  • • Damaged
  • • Destroyed
  • May grant authorization for one incident every 12 months.

    Prescriber increased the dose of the medication

    Verify with the prescriber or pharmacist and document that the dose was increased.

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

    Verify and document the change in living arrangement; may grant authorization once for the change in living arrangement.

    Member enters a detoxification facility for the purpose of detoxification only.

    May grant authorization for only the exact amount needed for the detoxification stay. The detoxification facility must order, pick up and maintain control of the medication.

    Member must travel for a medically necessary reason (that is, he or she is not electing to travel) and there is not an enrolled pharmacy that can fill the prescription before the next anticipated prescription fill date.

    A medically necessary travel override will be allowed only after 50 percent of the last supply’s days have passed.

    May grant authorization once every 12 months.

    The maximum allowed override is a 34-day supply.

    Member requires an early refill override to allow a medication supply at camp.

    May grant authorization once.

    The maximum allowed override is a 34-day supply.

    Override or authorization will not be granted in the following circumstances

    Circumstance

    Action

    Member resides in an LTC facility, such as a nursing home or ICF-DD and medication was:

  • • Lost
  • • Stolen
  • • Damaged
  • • Destroyed
  • Authorization will not be granted. The facility must replace the medication at its own cost.

    Member increased the dose of the medication without a new prescription.

    Authorization will not be granted.

    Member received authorization once within the last 12 months because one of the following occurred with the medication:

  • • Lost
  • • Stolen
  • • Damaged
  • • Destroyed
  • Additional authorization will not be granted.

    Member received authorization once during the last 12 months due to travel.

    Additional authorization will not be granted.

    Pharmacy is trying to get reimbursement for:

  • • School supplies
  • • Work supplies
  • Authorization will not be granted.

    Pharmacy entered the wrong days’ supply on the first fill.

    Authorization will not be granted. Reverse the claim, correct the days’ supply, and rebill

    Pharmacy Cash Payment for Controlled Substance

    Do not accept cash payment from a member or from someone paying on behalf of the member for any MHCP covered prescription drug.

    A pharmacy may accept cash payment for a noncovered prescription drug if all of the following apply:

  • • The patient is not enrolled in the restricted recipient program
  • • All available covered alternatives have been reviewed with the member
  • • The pharmacy obtains an Advance Recipient Notice of Noncovered Prescription (DHS-3641) (PDF)
  • • The prescription is not for a controlled substance (other than weight loss medications that are not part of the MA benefit, such as phentermine) unless it meets guidelines for an exception
  • • The prescription is not for gabapentin unless it meets guidelines for an exception
  • Exception for gabapentin or controlled substance

    MHCP will not authorize a pharmacy to accept cash if the medication requires prior authorization or is subject to a quantity limit and the prescriber has not attempted to obtain the prior authorization or authorization to exceed the quantity limit. The pharmacy may accept cash payment for a noncovered controlled substance or gabapentin after the prescriber and member complete their sections of the Advance Recipient Notice of Noncovered Prescription (DHS-3641), and the prescriber also confirms all of the following:

  • • That covered alternatives are not viable options for the recipient
  • • That the prescriber is aware that they are seeking authorization for the pharmacy to charge the member for the medication
  • • That the prescriber is aware of the last time the medication was filled for the member, if applicable
  • • That the prescriber attests that allowing the member to purchase the medication is medically necessary
  • The prescriber must sign the Advance Recipient Notice of Noncovered Prescription (DHS-3641), send the completed form to the pharmacy and retain a copy of the completed form in the member’s medical record. The pharmacy must also retain a copy of the completed form as documentation of approval from MHCP to accept cash payment on the date of service. You do not need to submit a copy of the completed Advance Recipient Notice of Noncovered Prescription to MHCP, unless requested. The completed Advance Recipient Notice of Noncovered Prescription is authorization from MHCP to accept cash payment on the date of service.

    The prescriber or pharmacy does not need to call MHCP for additional authorization.

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