Reminder: Instructions for Dispensing An Emergency Override For Drugs Requiring Prior Authorization
Pharmacies should provide a 72-hour emergency supply of the prescribed drug when a client needs medication without delay, and prior authorization is unavailable. This applies to drugs that are non-preferred on the Preferred Drug List and or drugs subject to clinical prior authorization. The emergency override protocol applies to clients enrolled in traditional Medicaid and Medicaid managed care.
Before dispensing a 72-hour emergency supply, the pharmacist should use professional judgment to determine if taking the prescribed medication jeopardizes the client's health or safety and make good faith efforts to contact the prescribing provider.
A 72-hour emergency prescription will be paid in full, and it does not count toward the three-prescription limit for adults who have not already received their maximum prescriptions for the month. Pharmacies should not use this procedure for routine and continuous overrides.
Pharmacies should submit the information below for emergency override claims. Refer to the Claims Billing (B1) Transaction requirements in the VDP Pharmacy Payer Specifications for specific transaction, segment, and field information.
You can also download the Dispensing 72-hour Emergency Prescriptions Instructions to display in your pharmacy.
| Field Number | Field Name | Value |
|---|---|---|
| 461-EU | Prior Authorization Type Code | 8 |
| 462-EV | Prior Authorization Number Submitted | 801 |
| 405-D5 | Days Supply | 3 |
| 442-E7 | Quantity Dispensed | The submitted amount 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), it is still permissible to indicate that the emergency prescription is a three-day supply, and enter the full quantity dispensed. |
For more information, call the Texas Medicaid Pharmacy and Technical Call Center at 800-435-4165, Monday through Friday from 7 a.m. to 7 p.m. (central time).