If a prescription is denied at the pharmacy:

• Make sure you are using an in-network pharmacy provider.
• Make sure the child does not have additional private insurance that needs to be used first.
• Make sure the pharmacy has the correct health plan information (ex. Sunshine uses Express Scripts, Inc: BIN# 003858, PCN code MA, GRP# 2EDA).
• Ask the pharmacy to call your health plan’s pharmacy benefit manager or prior authorization department to determine why the medication was denied.
• If a prior authorization is needed, ask the pharmacy to call the ordering physician to start the prior authorization process or order a different medication that does not require prior authorization. If medication was ordered after an ER visit or hospitalization, you may need to call your child’s Primary Care Physician.
• If the medication is considered a “specialty medication” it may need to go through a different vendor (ex. Sunshine Health uses AcariaHealth).
• If there is an error with the actual prescription, ask the pharmacy to call the ordering physician for clarification.

If the medication is still denied after the above steps, call your SCC Medical Team during business hours or contact your child’s health plan’s after-hours number.

Tips to avoid potential pharmacy issues:

• Before leaving the doctor’s office or hospital, ask the nurse or doctor if the new medication is generally covered by Medicaid health plans. If not, ask them if they can start the prior authorization process or prescribe a similar medication.
• Ask the doctor or pharmacy if they can call the prescription into the pharmacy before you leave.
• If it’s a medication that needs compounding (or considered a “specialty medication”), make sure the pharmacy carries the medication and/or you are using the correct vendor.
• Make sure you have your child’s most current insurance card.
• Start the refill process early to avoid running out of medication. It can be dangerous to miss or delay doses of certain medications.

RESOURCES:

Sunshine Health www.sunshinehealth.com                                            

CWSP Member Services: 855-463-4100