Emergency Supply of Medications
All Maryland Medical Assistance
fee-for-service and HealthChoice recipients are entitled to
receive a 72-hour supply of medicine while awaiting prior
authorization or approval to dispense a non-formulary,
non-preferred or brand name medication (for which there is a
generic equivalent drug is available). A 30-day supply is
allowed for atypical antipsychotic agents subject to step
therapy, this includes Zyprexa®.
If the prescriber is unavailable to either
change the medication or obtain preauthorization, or if the
prior authorization process is not completed, all Maryland
Medicaid HealthChoice Managed Care Organizations (MCOs) and the
Maryland Medicaid fee-for-service Pharmacy Program will cover a
minimum 72-hour supply of drugs.
Pharmacists should use their professional
judgment in determining whether the prescription is needed on an
emergency basis. The recipient may present mobility or
access issues that make returning to the pharmacy very difficult
or expensive. The pharmacist should take this factor into
consideration when deciding whether or not it is critical to
dispense an emergency supply.
It will be necessary for the pharmacist to
request authorization to dispense an emergency supply of a
prescription by calling a 24/7 telephone number. In the case of
sprays, inhalers, eye or ear drops, creams, ointments,
antibiotics etc., it may be necessary to dispense the entire
prescription as an emergency supply due to the way the drug is
packaged or administered.
For HealthChoice MCO
and PAC members requiring an emergency supply of non-mental
health and non-antiretroviral drugs, the pharmacist must contact
the appropriate MCO Pharmacy Benefit Manager and follow their
procedures before dispensing an emergency supply. Click here for
detailed information regarding emergency supplies.
In the case of fee-for-service recipients or
for mental health and antiretroviral drugs covered by the State,
the number to call to obtain authorization to dispense an
emergency supply is 800-932-3918. During the 72-hour window,
the pharmacist is to contact the prescriber who must obtain
prior authorization before the remainder of the prescription can
be dispensed. After prior authorization has been
established, the pharmacist can dispense the remainder of the
prescription.

HIV/AIDS Drugs to be carved out of
HealthChoice effective January 1, 2008
Beginning January 1, 2008 all antiretroviral
medications will be carved-out of the HealthChoice managed care
benefit and must be billed fee-for-service (BIN 610084, PCN
DRMDPROD, Group ID MDMEDICAID).
After that date, do not bill any
antiretroviral medications to the HealthChoice Managed Care
Organizations (MCOs) or their Pharmacy Benefit Managers (PBMs).
Claims should be processed fee-for-service,
just as claims for other carved-out drugs, such as mental health
drugs, are currently billed.
Claims for other medications, except those
already carved-out, should continue to be billed to the MCOs or
their pharmacy PBMs. This includes antibiotics associated with
treatment of secondary infections in HIV/AIDS patients. Only the
antiretroviral medications should be billed fee-for-service.
A $1.00 co-pay will be associated with all
claims for antiretroviral therapy except for the exceptions
below. Please note that some of the recipients receiving
antiretrovirals did not previously have a co-payment. No
co-payment is required if the patient is:
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