Prescription Refill Guidelines*
*Applicable to the Traditional 70/30 Plan, Enhanced 80/20 Plan, and Consumer-Directed Health Plan (CDHP).
To comply with pharmacy "best practice" standards and regulatory requirements the following criteria is used to determine when a prescription can be refilled:
Note: The prescription refill review will occur whether the refill is ordered at a participating retail pharmacy or via the Medco Pharmacy.
The Plan's refill guideline "look back" period is 180 days. A member can receive a refill when 75 percent of the medication on hand is used.
However, if the patient regularly refills prescriptions a little early each month, those early fill quantities will be considered when determining whether it is eligible for refill.
These early refill guidelines are designed to minimize the excessive use, waste and stockpiling of prescription medications. No more than a 30-day supply of medication can remain on hand for a refill to be approved. The following chart shows examples of when prescriptions would be approved for refill under these guidelines:
Please remember that if you regularly order a medication when only 75 percent of the quantity has been used, you will accumulate an excess supply and the refill date may be adjusted. To avoid having a refill delayed, please follow these guidelines:
If a prescription reflects a change in dosage, it is treated like a new prescription and the look back period starts over from zero. However, if a new prescription is identical to the previous one, the system will continue to look back 180 days to determine if the refill can be approved.
If you order a refill at a participating retail pharmacy too soon, you will be asked to wait until the allowable refill date. If you order the refill through the Medco Pharmacy, the pharmacy may hold the refill until the allowable date.
Exceptions to this refill policy can be made under certain circumstances. For example, if you are going on vacation, you may request a vacation supply by calling 800-336-5933.
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