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.
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):
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:
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.
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.
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.
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.