Guidance Regarding Nationwide Drug Shortage
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This bulletin provides guidance to insurance carriers and pharmacy benefits managers authorized in Delaware about managing drug shortages (pediatric antibiotics and ADHD medications), including prior authorization flexibility and expedited reviews. It affects carriers and PBMs operating in Delaware.
No material clinical or coverage changes in this revision.
Coverage Flexibility During Drug Shortages
Coverage Flexibility Guidance
Recommended actions while shortages endure:
Coding and Administrative Notes
| No codes listed |
Required Provider and PBM Actions
Waive prior authorization and allow brand substitution when generics unavailable
Carriers and PBMs are encouraged to waive prior authorization requirements for brand‑name equivalents when generics are unavailable, and to allow pharmacies to substitute brand‑name drugs if the generic is not available at the pharmacy where the prescription is being filled.
- Waive prior authorization for brand‑name equivalent when a generic is not available.
- Permit pharmacy substitution to the brand‑name product at the point of dispensing if the generic is out of stock.
72‑hour emergency prior authorization prohibition (18 Del. C. § 3336A)
Pharmacy benefits managers are prohibited from requiring prior authorization for coverage of a 72‑hour supply of a noncontrolled medication provided in an emergency, per 18 Del. C. § 3336A.
- Applies to noncontrolled substances supplied for up to 72 hours in an emergency.
- Statutory prohibition: 18 Del. C. § 3336A.
Expedite utilization review and appeals for shortage‑impacted insureds
Carriers should expedite utilization review and appeal processes for insureds affected by the drug shortages and must meet the decision timeframes set forth in Chapter 33 Subchapter II and Chapter 35, Subchapter V of the Insurance Code.
- Prepare to expedite utilization review and appeals for insureds impacted by the shortages.
- Utilization review decisions must comply with the timeframes in Chapter 33 Subchapter II and Chapter 35 Subchapter V of the Insurance Code.
Key Definitions
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