Temporary COVID-19 Coverage Criteria — Pharmacy temporary dispensing and supply allowances
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Policies for medication supply limits, emergency dispensing, and temporary additions to covered hand sanitizer products for Kern Family Health Care members during the COVID-19 response; applies to KFHC providers, pharmacies, and members.
Allow up to a 60 day supply for maintenance medications and permit prescriptions to be filled up to 90 days for maintenance medications.
KFHC covers isopropyl alcohol and is adding other hand sanitizers and wipes billable through the PBM as benefits.
Emergency supply policy: up to a 72-hour supply may be dispensed in emergency situations with a TAR documenting the event.
Temporary COVID-19 Coverage Criteria
Temporary COVID-19 Coverage Criteria
Covered with temporary allowances during COVID-19 response when conditions apply.
Temporary measure during COVID-19 response
Coverage dependent on PBM billing eligibility
Verbal authorizations from a KHS nurse will be honored but may require next-business-day clearing
There are no explicit exclusions called out in this communication beyond the standard formulary preference. Coverage additions described are limited to products that can be billed through the PBM; the notice specifically identifies isopropyl alcohol as covered and indicates other hand sanitizers and wipes will be added when they are billable through the PBM.
This communication does not specify any items or services as not medically necessary. No NMN conditions are listed in the document.
Coding and Supply Limits
| No codes listed |
Provider Responsibilities and Authorization Rules
Authorize up to 72‑hour emergency supply with TAR
In true emergent situations a pharmacy may dispense up to a 72‑hour emergency supply; this dispensing is authorized when a truly emergent situation exists (including weekends/holidays when immediate prior authorization cannot be obtained). A TAR documenting the emergency event is required.
- Efforts should be made to provide formulary medications.
- If a KHS nurse gives a verbal authorization it will be honored but may require next-business-day clearance.
Document emergency supply with TAR and record verbal nurse authorizations
When dispensing a 72‑hour emergency supply the pharmacy must create and retain a TAR that documents the emergency event; verbal authorizations from a KHS nurse must be recorded and may require next-business-day follow-up to clear.
- TAR must document the facts of the emergent situation.
- Document any verbal KHS nurse authorization and complete clearing the authorization the next working business day if required.
Risk of denial or recoupment for undocumented or out‑of‑limits dispensing
Dispensing beyond the temporary allowances (60‑day maintenance allowance/90‑day fills) or providing more than a 72‑hour emergency supply without the required TAR or documented authorization may trigger denial or require recoupment.
- Unapproved dispensing beyond stated limits risks claim denial or retrospective review.
- Verbal authorizations must be documented to avoid denial risk.
Policy Background
This is a temporary operational policy enacted by Kern Family Health Care in response to the evolving COVID-19 pandemic to reduce member exposure and maintain medication access and supply. It permits up to a 60‑day supply for maintenance medications (with prescriptions allowed to be filled up to 90 days), identifies coverage for isopropyl alcohol and adds other sanitizers/wipes billable through the PBM, and establishes emergency dispensing procedures that allow up to a 72‑hour supply in true emergent situations with a TAR documenting the event. The policy also encourages pharmacies to use delivery, mailing, and drive‑thru services to minimize member exposure.
Definitions
Quantity Limits and Allowances
Site of Care and Dispensing Options
Encourage delivery, mailing, and drive‑thru to reduce exposure
Pharmacies should use delivery, mailing, and drive‑thru services and inform members of these options to reduce member exposure and support social distancing.
- Share delivery, mailing, and drive-thru availability with members who are anxious or practicing social distancing.
- Encourage use of these services to help avoid in-person pickup and limit exposure.
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