96-hour Emergency Supply Of Medication
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Policy governing when contracted pharmacies may dispense a temporary emergency supply (typically 96 hours) of medications pending prior authorization or medical necessity determinations for Ambetter Nevada Medicaid members and how Envolve Pharmacy Solutions/People Care should process and document such requests.
No material clinical or coverage changes in this revision.
Coverage / Authorization Criteria
Emergency supply authorization criteria
Covered when ALL of the following are met
Emergency supply override is not available if the rejection is due to refill-too-soon logic when the new fill is due to lost, stolen, broken or damaged supply.
The policy excludes certain medications from emergency supply eligibility. Specifically, medications with a DESI classification other than “Safe and Effective” are not eligible. In addition, medications that belong to non-covered therapeutic categories—examples include appetite suppressants and infertility treatments—are excluded per applicable state plan regulations. The policy also excludes drugs when use is contraindicated because of the member’s medical condition or potential adverse drug interaction, and new prescriptions where short-term use followed by abrupt discontinuation would be medically contraindicated (for example, certain agents used to treat infectious diseases).
Pharmacy and Prescriber Actions
Dispense 96‑hour emergency supply pending PA/MN
A 96-hour supply (or more when state/holiday rules apply) may be dispensed while awaiting prior authorization or medical necessity determination. The dispensing pharmacist must contact Envolve Pharmacy Solutions Customer Service to request an emergency supply override, which will be entered in the PBM and documented on the member record.
- Pharmacy contacts Envolve Pharmacy Solutions Customer Service and requests emergency supply
- Envolve documents the request and enters a PBM override allowing a 96-hour (or longer per state/holiday) supply
Notify prescriber of non‑PDL status / request alternative or PA/MN
If the member’s prescribed product is non‑PDL, the dispensing pharmacy must notify the prescriber and request that a PDL alternative be prescribed or that a PA or MN request be submitted to Envolve Pharmacy Solutions for consideration of continued supply.
- Pharmacy to notify prescriber of non‑PDL status after PBM override is entered or as part of the emergency request
Provide required patient and prescription data to Envolve
When requesting the emergency supply override, the dispensing pharmacy must provide the patient’s name, social security or identification number, medication name, strength, quantity, days’ supply, prescriber name, and prescriber phone number to Envolve Pharmacy Solutions Customer Service.
- Patient name
- Social security number or member identification number
- Medication name and strength
- Quantity and days supply
- Prescriber name and prescriber phone number
No emergency override for certain refill‑too‑soon situations
An emergency supply override is not available for claims rejected due to refill‑too‑soon logic when the new fill is the result of a lost, stolen, broken, or damaged supply.
- Do not request emergency override for refill‑too‑soon rejections tied to lost/stolen/broken/damaged medication
Where Dispensing Occurs
Use contracted pharmacies; Envolve processes PBM overrides
Dispensing must occur at contracted community pharmacies; Envolve Pharmacy Solutions or Envolve People Care will process PBM overrides (entering and documenting the 96‑hour allowance) to permit the emergency supply.
- Envolve Pharmacy Solutions Customer Service enters PBM override and documents request
- Envolve People Care may enter overrides outside normal business hours
Quantity and Days' Supply Limits
Background and Purpose
This policy is intended to prevent interruption or delay of therapy by permitting a short, temporary supply of medication while a prior authorization or medical necessity determination is pending or while the prescriber is unavailable. To accomplish this, contracted pharmacies may dispense an emergency supply (typically a 96-hour supply) after contacting Envolve Pharmacy Solutions/People Care Customer Service to request an override and have the event documented on the member record. The pharmacy must also notify the prescriber to either provide a Preferred Drug List alternative or submit the necessary PA/MN request for continued therapy.
Key Definitions
Policy Revision History
Q1 2020 annual review completed; no clinical policy changes documented.
Q1 2019 annual review completed; no clinical policy changes documented.
Q2 2018 annual review completed; no clinical policy changes documented.
Policy effective date established for NV.PHAR.02 (96 Hour Emergency Supply Of Medication).
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