NC Medicaid is receiving reports of pharmacists not utilizing the 72-hour Emergency Supply Override and the 01-No Other Coverage Identified code when applicable. Resistance to use these overrides is preventing Medicaid beneficiaries from being able to access necessary medications. As NC Medicaid providers, pharmacists are asked to please become familiar with these options and utilize them appropriately when administering the Medicaid benefit.  

Pharmacists are asked to utilize the 72-Hour Emergency Supply Override when clinically appropriate for Medications pending Prior Authorization. For Medicaid members, including Medicaid Managed Care, Pharmacy providers are encouraged to use the 72-hour emergency supply allowed for drugs requiring prior approval. Federal law requires that this emergency supply be available to Medicaid beneficiaries for drugs requiring prior approval (Social Security Act, Section 1927, 42 U.S.C. 1396r-8(d)(5)(B)). Use of this emergency supply ensures access to medically necessary medications. With use of the override, the system will bypass the prior approval requirement, if an emergency supply is indicated. The pharmacist should use a "3" in the Level of Service field (418-DI) to indicate the transaction is an emergency fill. *  Copayments apply to emergency fills and drug cost is reimbursed; however, a dispensing fee is not paid. There is no limit to the number of times the emergency supply can be used. *Codes may vary by managed care plan. This is the specific code for Medicaid Direct.  

Pharmacists are asked to utilize the "01-No Other Coverage Identified" when a Medicaid claim rejects due to another payor on record. Medicaid is the payer of last resort, which means after any other insurance pays, Medicaid will pay. The other third-party payer must be billed as the primary payor when third party insurance exists, and then Medicaid can be billed as the secondary payor. When a claim is denied due to another payor on record being expired or terminated, the point-of-sale system will deny the claim, and the pharmacist will be prompted to submit the claim to another payer. In the event a beneficiary cannot produce another insurance or the beneficiary states they no longer have the other insurance, the pharmacy shall use the override code "01 – No Other Coverage Identified" in the Other Coverage Code claim segment 308-C8 for NCPDP D.0 transaction. * NC Medicaid will pay the pharmacy and seek payment from the third party, if appropriate. The pharmacy is not held liable for any payments made in these cases. *Codes may vary by managed care plan. This is the specific code for Medicaid Direct. 

Thank you for your time and attention to this valuable information regarding the NC Medicaid Pharmacy Benefit. If you have any questions or concerns with the utilization of these override codes, please contact Angela Smith, Director NC Medicaid Pharmacy Benefit, or the Managed Care Plans directly.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

The Board's revised centralized pharmacy services rule has cleared final review. The chief change achieved by the amendments is to broaden the availability of remote medication order processing from the health-system practice setting to all pharmacy practice settings.  

Even though the amended rule is effective March 1, 2022, several implementation tasks need to be completed. Chief among them: Board staff need to program a registration system for out-of-state pharmacists who are not licensed in North Carolina, but who intend to provide RMOE services to North Carolina pharmacies by obtaining an NABP (National Association of Boards of Pharmacy) Verify credential. NABP staff are implementing the NABP Verify credential application process. Board staff expect both steps to be completed by April 1, 2022.  

In the meantime, North Carolina pharmacies who have implemented RMOE systems under the Board's emergency services waiver may continue to use them. The Board will ensure that pharmacies that have deployed waiver-based RMOE operations have reasonable time and opportunity to transfer to rule-based operations. The full Board will discuss implementation at its March 8, 2022, meeting.  

In the coming weeks, Board staff will also publish a detailed FAQ document on the revised centralized pharmacy services rule. 

Pharmacists are reminded that the Board is proceeding with additional rulemaking to permanently authorize North Carolina pharmacy personnel to perform remote work (other than physical acts in the dispensing process) for their employing pharmacy. North Carolina pharmacies who have implemented waiver-based remote work systems in North Carolina may continue to use them while this rulemaking proceeds. More information on this proposed rule is found here.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.