Provider Bulletin - April 2020 - COVID-19

P.O. Box 15018
Albany, New York 12212-5018

Attention Pharmacy Providers: COVID-19 and Early Refill requests

The following guidance is effective until the official Declared Disaster Emergency in the State of New York over Novel Coronavirus (COVID-19) has ended. The purpose of this bulletin is to provide updated guidance regarding submission of claims that would normally fall into the "Refill Too Soon" category and therefore reject.

Early Fills: Early refills for members in need of medications due to quarantine or outbreak (controlled substances and non-controlled substances) will be allowed, per the provider's discretion, in accordance with State and federal laws. An early fill response will be returned when a prescription claim is transmitted prior to the date when 75 percent of the previous supply would have been used. During the Declared Disaster Emergency in the State of New York, a pharmacy can override edit payer field 439-E4 Reason for Service code - "Early Refill (ER) Overuse Precaution" denial at the point of sale by using the following combination (where NCPDP stands for National Council for Prescription Drug Programs):

  • NCPDP Field 440-E5 PROFESSIONAL SERVICE CODE = 00 = No Intervention
  • NCPDP Field 441-E6 RESULT OF SERVICE CODE = 1B = Filled prescription as is

In addition to using the above override codes, pharmacists are required to also document the Declared Disaster Emergency in the State of New York within the pharmacy's processing system. The Submission Clarification NCPDP field is 420-DK, and select 13 - Disaster Situation code.

The EPIC program seeks to ensure the maximum drug benefit for all members, therefore, below are some resources that may further assist your pharmacy and the member with Medicare coverage pursuant to this change:

Pharmacies that have questions regarding what Medicare Part D covers, please contact the member's plan directly. Should you have any additional questions or concerns, please contact the EPIC Provider Helpline at 1-800-634-1340.