New Prescription Refill Guidelines
Important information regarding allowable prescription refill dates.
The State Health Plan for Teachers and State Employees will be following new guidelines for prescription refills beginning on March 2, 2009. The new prescription refill guidelines are being implemented to comply with pharmacy “best practice” standards and regulatory requirements. Most members will not notice a change when they order a prescription refill.
The updated prescription refill guidelines will be used to review member prescription history to calculate when a medication is eligible for refill. In order to determine when a prescription can be refilled, the following criteria will now be used:
- At least 75 percent of the medication must be used, based on the quantity of the previously filled prescription. (This guideline is currently in place.)
- An excess amount of the medication must not have been accumulated over the past 180 days. (This guideline has been changed from reviewing the past 30 days to reviewing the amount of medication accumulated for the past 180 days.)
Note: The prescription refill review will occur whether the refill is ordered at a participating retail pharmacy or via Medco By Mail.
The State Health Plan’s current refill guidelines only looks back 30 days from the date a refill is requested to determine if it can be filled. Currently, once 75 percent of the medication on hand is used, the prescription can be refilled. With the new prescription refill guidelines, the review period, also called the “look-back” period, is changing from 30 days to 180 days. A member can still receive a refill when 75 percent of the medication on hand is used.
However, if the patient regularly refilled prescriptions a little early each month, those early fill quantities will now be considered when determining whether it is eligible for refill.The new guideline states that no more than a 30-day supply of medication can remain on hand for a refill to be approved. These new refill guidelines are designed to minimize the excessive use, waste and stockpiling of prescription medications. The following chart shows examples of when prescriptions would be approved for refill under the new guidelines:
|
Original Prescription (for 30 days) |
Date of Refill Request |
Date of Refill Eligibility |
| July 1 | July 15 | July 22 (the date 75% of medication has been used) |
| January 1 | July 1 | Date will vary, based on how many doses of medication have been accumulated over the past 180 days. If the refills had been requested for the first of each month, the prescription would be eligible for refill on July 1. If the refills had been requested 7 days early each month, an excess of medication would remain on hand, and the refill would not be approved until 75% of the left over doses were used. |
- For a 30-day retail prescription, order a refill when you have no more than a 7-day supply remaining. (For a 30-day mail order prescription, you may order the refill a few days earlier, to ensure you receive the refill before the medication on had is used.)
- For a 90-day retail or mail order prescription, request the refill when you have no more than a 14-day supply remaining.
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 Medco By Mail, the pharmacy may hold the refill until the allowable date.
Exceptions to this new refill policy can be made under certain circumstances. For example, if you are going on vacation, you may request a vacation supply by contacting 1-800-336-5933.
Please remember that Medco’s network of participating retail pharmacies extends nationwide, and Medco By Mail can ship anywhere in the United States. To begin using Medco By Mail, click here or call 1-800-336-5933.
If you have questions about the New Refill Guidelines, please click here or call Medco Member Services at 1-800-336-5933.
