Emergency Fills for Medications Requiring a Pre-Authorization

  • If a customer urgently needs medication filled during Premera's non-business hours, the pharmacy can do a one-time override. To see if a medication qualifies for an emergency override, view our list of medication types eligible for up to a 7-day override.

    This emergency override list is only applicable to customers who are enrolled in a Washington fully-insured group or individual health plan.

    Customers who get an emergency fill may have to pay their cost share, which is the portion of healthcare costs the customer is responsible for, as determined by their plan. This may include deductibles, coinsurance, copayments, and similar charges.

    Medication list for emergency fills

    The medication list for emergency fill to address immediate therapeutic needs is as follows: (Medications in addition to those listed may be covered for Emergency Fill on a health plan by health plan basis).

    • Antibiotics & Antivirals for acute infections
    • Medications for mental health conditions
    • Anticoagulant/Antiplatelet medication
    • Antiemetics (for imminent nausea and vomiting)
    • Anti-Rejection/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, anti-hypertensives)
    • 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)
    • 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, and so on are not consistent with the definition of “immediate therapeutic needs” and thus would not be covered for emergency fill.

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

    • Non-contracted pharmacy
    • Refill too soon
    • Quantity limitation exceeded
    • Yearly maximum met

    When are emergency fills appropriate?

    Emergency Fills are appropriate in those circumstances where a patient presents at a pharmacy with an 'immediate therapeutic need' for a prescribed medication that requires a pre-authorization due to formulary or other utilization management restrictions.

    • Immediate therapeutic needs are those where passage of time (i.e., the timeframe 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 allows time for the processing of a pre-authorization request. Only the emergency fill dosage of the medication will be approved and paid.

    The dosage of the Emergency Fill must either be the minimum packaging size that cannot be broken (e.g., injectable), or the lesser of a 7-day supply or the amount as prescribed. (Depending upon their policies, Health Plans may exceed this baseline dispensing amount.) In the event the medication is to be continued for treatment beyond the emergency fill authorization, health plans may apply formulary or utilization management restrictions that will be reviewed following the health plans' standard procedure.

    What is the process for getting approval and payment of an emergency fill?

    When a currently eligible member of the health presents at a contracted dispensing pharmacy with an immediate therapeutic need and a corresponding prescription from their provider for a medication requiring a pre-authorization that is specified on the list, the health plan's Emergency Fill policy (which must be on their web site) will outline their process by which the dispensing pharmacy can secure payment for emergency fill. Two typical processes are:

    • The dispensing pharmacy will be given a code that can be submitted with the claim that designates the dispensed medication as an emergency fill and will authorize payment.
    • The dispensing pharmacy will contact the health plan's pre-authorization department within 2 business days to inform them of the Emergency Fill so that a claim for the dispensed medication can be retrospectively submitted and paid.