Refills/Renewals of Prescription Drugs

Refills/Renewals of Prescription Drugs A. A written, faxed, e-prescribed, or telephoned prescription may be refilled, in compliance with the prescriber’s order, up to a limit of eleven (11) times per year, if compliant with state and/or federal regulations and guidelines. Additionally, the following are applicable: 1. The absence of an indication to refill by the prescribing provider renders the prescription non-refillable. 2. Refills are reimbursable only if specifically authorized by the prescribing provider. 3. The Division of Medicaid does not reimburse prescription refills: a) Exceeding the specific number authorized by the prescribing provider. b) Dispensed after one (1) year from the date of the original prescription. c) With greater frequency than the approximate interval of time that the dosage regimen of the prescription would indicate, unless extenuating circumstances are documented which would justify the shorter interval of time before the refilling of the prescription. d) With quantities in excess of the prescribing provider’s authorization. e) Without an explicit request from a beneficiary or the beneficiary’s responsible party, such as a caregiver, for each filling event. The possession, by a provider, of a prescription with remaining refills authorized does not in itself constitute a request to refill the prescription. f) Until seventy-five percent (75%) of the day’s supply of the drug has elapsed as indicated on the prescription. g) For any controlled substance (Schedule III, IV, and V) until eighty- five percent (85%) of the day’s supply of the drug has elapsed as indicated on the prescription. Any attempt to refill a prescription through the Point-of-Sale system before the twenty-sixth (26th) day will be automatically denied. h) For any Schedule II narcotics. B. Beneficiaries or providers cannot waive the explicit refill request and enroll beneficiaries in an electronic automatic refill in pharmacies. C. The Division of Medicaid may permit an early refill of an original claim as long as the monthly service limits have not been exhausted under one (1) of the following circumstances: 1. The beneficiary’s life is at risk, 2. When an acute clinical condition is occurring, which would require extra medication to stop or mitigate further morbidity, or 3. The prescribing provider either increases the dosing frequency or the amount per dose. a) The prescribing provider must document the change in dosage or frequency by writing or phoning in a new prescription. b) The prescriber(s) who wrote the original prescription must initiate any request for additional medication. 4. If a beneficiary requires an early refill, the prescribing provider must request an exception override of this requirement by seeking approval from Division of Medicaid’s Pharmacy Prior Authorization (PA) Unit. D. The Division of Medicaid does not reimburse for replacement of prescription medications unless the beneficiary can show good cause, which must include documentation such as a police report or insurance claim, that the prescription medications were lost, stolen or otherwise destroyed beyond the beneficiary’s control. A replacement may be approved only if the monthly service limit, if applicable, has not been reached.