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:

• Younger than 21 years old

• Pregnant

• An inpatient in a long-term care facility