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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyMedStar Family Choice Refill Policy Update | OpenP…
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    CurrentMedStar Family Choice MarylandPolicy 204

    Early Refill, Lost Medication, & Travel Supply Policy

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    This policy governs how MedStar Family Choice Maryland processes requests for early prescription refills, replacement of lost or stolen medication, and medication supplies for travel. Requests may be initiated by members, prescribers, or dispensing pharmacies and are reviewed under the plan's pharmacy authorization procedures.

    Policy Summary
    PayerMedStar Family Choice Maryland
    PolicyEarly Refill, Lost Medication, & Travel Supply Policy
    Policy CodePolicy 204
    Change TypeMaterial policy revision
    Effective DateJul 1, 2026
    Last ReviewJul 1, 2024
    Next Review DateN/A
    Key ActionEnsure that early prescription refill requests are reviewed and approved only by a Medical Reviewer based on individual medical necessity.
    SourceLink
    POLICY UPDATE CHANGES

    The policy clarified the types of early refill requests covered and simplified the medical-necessity language.

    The policy added an exception allowing consideration of an early refill when a dose change depletes the existing supply before the allowable refill date.

    The policy added a potential exception for replacement of stolen medication when the plan may require confirmation of a completed police report.

    The policy clarified that travel within the United States must be redirected to another network pharmacy once the utilization threshold is met.

    The policy clarified that early-fill authorization is limited to no more than a 30-day total supply during a rolling six-month period and must be entered as a one-time override.

    The policy updated regulatory and accreditation references to the current versions identified in the document.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    30 daysMaximum early-fill supply in a rolling six-month period
    1-time overrideEarly-fill authorization entry
    3 exceptionsControlled-medication exception scenarios
    U.S. travelDomestic travel processing
    Active enrollmentInternational travel enrollment requirement

    Early Refill and Travel Supply Criteria

    Controlled-Medication Restrictions and Exceptions

    Controlled medications are generally not authorized for early refills, replacement of lost or stolen medication, or travel supplies. Exceptions may be approved only under the circumstances below.

    ONE of the following exceptions applies

    • The member is receiving controlled medication(s) for cancer treatment, sickle cell disease, hospice care, or palliative care.
    • The request is for a stolen supply of medication and MedStar Family Choice Maryland may require confirmation of a completed police report before approval.
    • A dose change depleted the previous supply before the allowable refill date.

    General Early-Refill Medical Necessity

    Any other prescription early-refill request, including a non-controlled medication request, may be approved only when the Medical Reviewer determines that it is medically necessary for the individual member.

    ALL of the following apply

    • A Medical Reviewer approves the request.
    • The determination is based on the individual member's medical necessity, which may include confirmation from the prescriber of the medical need for an early or additional medication.
    • The request is not based solely on the member's enrollment span ending; this is not considered medical necessity.
    MedStar Family Choice may deny an early medication refill request or reimbursement for a previous early refill paid by the member in cash when sufficient medical necessity is not present.

    The request follows the procedures and timelines in Pharmacy Policy 218: Pharmacy Authorization Process.

    Travel Supply Authorization

    Travel-related early-refill requests must satisfy the applicable documentation, processing, supply-limit, and enrollment requirements.

    Travel request submission

    • The request includes the requested travel dates, location, and purpose.
    • The request includes confirmed proof of travel with dates, such as paid plane, train, or lodging documentation, and any relevant supporting documentation before referral to the Medical Reviewer.
    • The preauthorization staff may contact the prescribing practitioner for clinical information supporting the clinical justification when needed to determine medical necessity.

      Requests for replacement of lost supply or travel supplies may not require clinical documentation.

    ONE applicable travel-processing pathway

    • Travel within the United States

    Authorization Entry and Supply Limits

    Early-Fill Travel Supply
    Travel supply limitNo more than 30 days of total supply in a rolling six-month period
    Early-Fill Authorization
    Authorization entryEnter the early-fill authorization in the PBM clinical software as a one-time override to prevent unintended extension of approval

    Request Submission and Processing Requirements

    Documentation Required

    Submit the Request and Member Information

    Initiate an early refill, lost-medication, or travel-supply request by phone, fax, or website. Provide the member's name and telephone number, prescribing practitioner's name and contact information, and the medication name, dose, and directions.

    Documentation Required

    Document Travel Authorization

    For travel authorization, submit the requested travel dates, location, purpose, and confirmed proof of travel showing the dates, along with any relevant supporting documentation, before the request is forwarded to a Medical Reviewer.

    • Examples of proof of travel include paid plane or train tickets and lodging documentation.
    Prior Authorization

    Policy Terminology

    Definition
    Medical ReviewerMedical Director or Health Plan Pharmacist
    Policy Summary
    PayerMedStar Family Choice Maryland
    PolicyEarly Refill, Lost Medication, & Travel Supply Policy
    Policy CodePolicy 204
    Change TypeMaterial policy revision
    Effective DateJul 1, 2026
    Last ReviewJul 1, 2024
    Next Review DateN/A
    Key ActionEnsure that early prescription refill requests are reviewed and approved only by a Medical Reviewer based on individual medical necessity.
    SourceLink
    On This Page
    Early Refill and Travel Supply CriteriaAuthorization Entry and Supply LimitsRequest Submission and Processing RequirementsPolicy Terminology
    The request is redirected to another network pharmacy once the utilization threshold is met.
  1. The prior authorization entry is limited to a total supply of no more than 30 days in a running 6-month period.<= 30 days per running 6 months
  2. The early-fill authorization is entered in the PBM clinical software as a one-time override to prevent unintended extension of approval.

  3. Travel outside the United States

    • The request is processed with an override in the PBM clinical software system.
    • The member has an enrollment segment that extends through and covers the entire travel period.

      For example, a June travel fill requested in May requires active enrollment during June; a May 31 disenrollment date does not satisfy this requirement.

  4. An exception is approved at the discretion of the Medical Reviewer for a member with restricted pharmacy access under Policy 217: Corrective Managed Care.

    5. Support Medical Necessity When Requested

    Respond to preauthorization staff requests for clinical information supporting the clinical justification and medical necessity of the request. Replacement of lost medication or travel-supply requests may not require clinical documentation.

    Unsupported block type: prior_auth

    Denial Risk

    Apply Controlled-Medication Restrictions

    Do not authorize early refills, lost or stolen medication replacements, or travel supplies for controlled medications unless a policy exception applies.

    • Exceptions may apply when the medication is used for cancer treatment, sickle cell disease, hospice, or palliative care.
    • An exception may apply when a dose change depletes the prior supply before the allowable refill date.
    • A stolen-supply exception may require confirmation of a completed police report before approval.
    Documentation Required

    Verify the Stolen-Medication Report

    When a controlled medication replacement is requested because the supply was stolen, obtain or request confirmation of a completed police report when required by MedStar Family Choice Maryland before approving the exception.

    • Document or verify the completed police report confirmation as part of the authorization review.
    Prior Authorization

    Medical Reviewer Approval Required

    Any other prescription early-fill request may be approved only by a Medical Reviewer and must be based on the individual member's medical necessity. The determination may include confirmation from the prescriber of the medical need for early or additional medication.

    • Requests made solely because the member's enrollment span is ending are not considered medically necessary.
    • Requests may be denied, including reimbursement for a prior cash-paid early refill, when sufficient medical necessity is not present.
    Prior Authorization

    Process the International Travel Override

    For extended travel outside the United States, confirm that the member has an active enrollment segment covering the entire travel period, then enter a one-time early-fill override in the PBM clinical software system.

    • The prior authorization entry is limited to no more than a 30-day total supply in a running 6-month period.
    • Do not authorize the prescription if the system shows disenrollment before or during the travel period.
    Billing Rule

    Process Domestic Travel Refills

    For travel within the United States, redirect the member to fill the prescription at another network pharmacy once the utilization threshold is met.

    Note

    Handle Restricted Pharmacy Access

    At the Medical Reviewer's discretion, consider exceptions for members with restricted pharmacy access under Policy 217: Corrective Managed Care.