Prescription Drug List and Refill Guidelines for Medicare Retirees Base PPO Plan (70/30)
The State Health Plan provides a preferred drug list to promote clinically appropriate utilization of pharmaceuticals in a cost-effective manner. The list is developed by the Plan's Pharmacy and Therapeutics Committee, is based on safety, effectiveness and clinical outcomes and is updated quarterly.
Prescription Refill Guidelines
To comply with pharmacy "best practice" standards and regulatory requirements the following criteria is used to determine when a prescription can be refilled:
-
At least 75 percent of the medication must be used, based on the quantity of the previously filled prescription.
-
An excess amount of the medication must not have been accumulated over the past 180 days.
Note: The prescription refill review will occur whether the refill is ordered at a participating retail pharmacy or via the CVS Caremark 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:
| 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 leftover doses were used. |
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:
-
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 hand 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 the CVS Mail Order 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 traveling outside of the United States 90 days or more, you may request an extended day supply of medication by completing the Medication Extended Day Supply Request Form, and emailing it to SHPEDSR@nctreasurer.com 30 days prior to the scheduled departure date. Please notify your provider of your plans. The policy is available by clicking here.