Dispensing 72-hour Emergency Prescriptions
Federal and Texas law require that a 72-hour emergency supply of a prescribed drug must be provided when a medication is needed without delay and prior authorization (PA) is not available. This rule applies to all drugs requiring a prior authorization (PA), either because they are non-preferred drugs on the Preferred Drug List or because they are subject to clinical edits. Pharmacies will be paid in full for 72-hour emergency prescription claims.
A 72-hour emergency supply of prescribed medication should be dispensed any time a Medicaid claim rejects with NCPDP error 75 (“Prior authorization required”), the PA is not available and a prescription for a medical condition must be filled for any medication on the Texas Vendor Drug formulary.
Claims that reject with error 75 will include a message instructing the pharmacy to contact the prescriber reminding the pharmacy that the 72-hour emergency supply can be dispensed. If the prescribing provider cannot be reached, or is unable to request a prior authorization, the pharmacy should move forward with submitting an emergency 72-hour prescription claim.
Pharmacies should re-submit the claim with the following information:
- "8" in "Prior Authorization Type Code" (Field 461-EU).
- "8Ø1" in "Prior Authorization Number Submitted" (Field 462-EV).
- "3" in "Days Supply" (in the Claim segment of the billing transaction) (Field 4Ø5-D5).
- The quantity submitted in "Quantity Dispensed" (Field 442-E7) should not exceed the quantity necessary for a three-day supply according to the directions for administration given by the prescriber.
If the medication is a dosage form that prevents a three-day supply from being dispensed (e.g. an inhaler, eye or ear drops, or creams) it is permissible to indicate that the emergency prescription is a three-day supply, and enter the full quantity dispensed.
This procedure should not be used for routine and continuous overrides. A 72-hour emergency prescription will be paid in full to the pharmacy, and it does not count toward the three-prescription limit for adults who have not already received their maximum prescriptions for the month (there is no prescription limit for children under 21).
A 72-hour emergency prescription claim can be used both for Medicaid fee-for-service and Medicaid managed care members.
Pharmacies submitting fee-for-service claims to Vendor Drug should request Prior Authorization from the Texas Prior Authorization Call Center. Pharmacies submitting claims for Medicaid clients enrolled in managed care should refer the prescriber to the client’s health plan’s prior authorization call center.
We encourage pharmacy staff to post these instructions in your pharmacy for reference and to reproduce this information for staff education. It is important that your staff understands the 72-hour emergency supply policy and procedures and uses them appropriately.