Emergency Fills for Medications Requiring Preapproval

  • If you urgently need a prescription that requires preapproval filled during our nonbusiness hours, the pharmacy can do a one-time override, or fill, for up to a 7-day supply.

    Note: Emergency fills are only available to members who are enrolled in a Washington fully insured group or individual or family health plan. If you are on a group plan and do not know whether it is fully insured, ask your group benefits administrator.

    Medication list for emergency fills

    The list to address immediate therapeutic needs is as follows (medications in addition to those listed may be covered for emergency fills on a plan-by-plan basis):

    • Antibiotics and antivirals for acute infections
    • Anticoagulant/Antiplatelet medication
    • Antiemetics (for imminent nausea and vomiting)
    • Antirejection/Immunosuppression medication for post-transplant patients
    • Antiretrovirals (continuing current therapy, not new starts except for emergency use)
    • Cardiovascular medications for acute treatment only (for example, antiarrhythmics, antihypertensives)
    • Epinephrine injections
    • Generically available, immediate-release pain medication (does not include transmucosal immediate-release fentanyl)
    • Gout flare (acute) medications
    • Insulin (continuing current therapy, not new starts)
    • Medications for mental health conditions
    • Naloxone
    • Non-OTC pediculocides-lice and scabies treatments
    • Rescue inhalants and delivery support devices
    • Seizure/epilepsy medications
    • Triptans

    High-dollar medications for chronic conditions—such as oral oncology, hepatitis C, biologics, multiple sclerosis treatments, enzyme replacements—do not meet the definition of immediate therapeutic needs and so would not be covered for emergency fills.

    Also, an emergency fill will not be paid in the following situations:

    • The pharmacy is not in network
    • The refill is too soon
    • The quantity limitation is exceeded
    • The yearly maximum of the medication has been met

    When is an emergency fill appropriate?

    Emergency fills are appropriate in those circumstances where a patient comes to a pharmacy with an immediate therapeutic need for a prescribed medication that requires preapproval. The medication may be in this category because of the plan’s drug list or utilization management restrictions.

    What is an immediate therapeutic need?

    Immediate therapeutic needs are those where waiting for medication (such as the time required for an urgent review) without treatment would result in imminent emergency care, hospital admission OR might seriously jeopardize the life or health of the patient or others in contact with the patient. Emergency fill is a short-term dispensed amount of medication that provides time to process a preapproval request.

    How much of the medication can you get?

    The dosage of the emergency fill must either be the minimum packaging size that cannot be broken (for example, injectable), or the lesser of a 7-day supply of the amount as prescribed. Only the emergency fill dosage of the medication will be approved and paid.

    If the medication is to be continued for treatment beyond the emergency fill authorization, we will review the request, following our standard preapproval procedure, where we check it against our drug list or utilization management restrictions.

    What is the process for approval and payment?

    When an eligible member goes to a contracted pharmacy with an immediate therapeutic need and a prescription from the provider for a medication requiring a preapproval (that is specified on the list), the pharmacy will be given a code. This code can be submitted with the claim, which authorizes payment, designating the medication as an emergency fill.

    If you get an emergency fill, you may have to pay your cost share, which is the portion of health care costs you are responsible for, as determined by your plan. This may include deductibles, coinsurance, copayments, and similar charges.