Pharmacy Early-Refill Overrides

Revised: November 16, 2021

· Pharmacy Overrides

· Pharmacy Cash Payment for Controlled Substance

Pharmacy Overrides

The MHCP Provider Resource 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
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	MHCP may grant authorization for one incident every 12 months.
Prescriber increased the dose of the medication	MHCP will 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.	MHCP will 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.	MHCP 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 and there is not an enrolled pharmacy that can fill the prescription(s) before the next prescription fill date.	MHCP may allow a travel override only if the member will not have returned, or will not have access to pharmacy services, before the prescription(s) next refill date. MHCP may grant authorization once every 12 months for prescription(s) the member is unable to refill while the member is traveling. The maximum override allowed by state law is a 34-day supply, unless state law allows MHCP to cover the drug as a 90-day supply (for example, contraceptive or drugs on the 90-day supply list).

The MHCP Provider Call Center will not grant override or authorization 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	MHCP will not grant authorization. The facility must replace the medication at its own cost.
Member increased the dose of the medication without a new prescription.	MHCP will not grant authorization.
Member received authorization once within the last 12 months because one of the following occurred with the medication: · Lost · Stolen · Damaged · Destroyed	MHCP will not grant additional authorization.
Member received authorization once during the last 12 months due to travel.	MHCP will not grant additional authorization.
Pharmacy is trying to get reimbursement for: · School supplies · Work supplies	MHCP will not grant authorization.
Pharmacy entered the wrong days’ supply on the first fill.	MHCP will not grant authorization. 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 Member Notice of Noncovered Prescription (DHS-3641) (PDF)

· The prescription is not for a controlled substance unless it meets guidelines for an exception listed on the Advance Member Notice.

· The prescription is not for gabapentin unless it meets guidelines for an exception listed on the Advance Member Notice.

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 Member Notice of Noncovered Prescription (DHS-3641), and the prescriber also confirms all of the following:

· That covered alternatives are not viable options for the member

· 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 Member Notice of Noncovered Prescription (DHS-3641) (PDF), 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 keep 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 Member Notice of Noncovered Prescription to MHCP, unless requested. The completed Advance Member 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 authorization in addition to following the steps outlined in this exception.