Jane Dotson
The rules for prescription refills vary depending on the insurance plan, the state or territory, and the type of medication. In general, insurance companies enforce prescription refill rules to ensure patients are taking their medication as directed and to control healthcare costs. For example, for a 90-day prescription, a refill is typically allowed once a year. Refills for controlled substances are also subject to stricter laws and policies, with some states forbidding refills on Schedule II substances. In addition, insurance companies use percentages to determine when to approve a refill, with the remaining amount of medication typically needing to be below 15% for controlled substances and 25% for non-controlled substances.
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What You'll Learn
Refill rules vary between insurance plans and location
Refill rules for 90-day medication prescriptions vary between insurance plans and location. In the United States, federal law divides medications into five groups, or schedules, based on their medical value and potential for harm or misuse. These schedules outline the prescription refill rules for controlled substances, which vary in their restrictions. For example, Schedule II substances cannot be refilled, but a physician can provide multiple prescriptions that do not exceed a 90-day supply. Schedule III and IV substances have a maximum of five refills, with each refill occurring no later than 6 months after the prescription date.
Insurers set their own rules about when they cover the cost of a prescription refill, and these rules can differ depending on the state or territory. For example, California does not allow refills on Schedule II substances. Additionally, refill rules can depend on the type of medication being filled, with laws and policies regarding controlled substances being stricter than those for non-controlled substances.
Some insurance plans may allow for a 90-day prescription to be refilled as early as 2 weeks before the supply runs out, while others may require patients to wait until they have only 15% of their medication left, which would be 85 days after the initial fill date. This is known as the "refill too soon" denial.
During the COVID-19 pandemic, some US health insurers eased restrictions and allowed patients to order larger emergency supplies of their routine medications for chronic conditions. This flexibility was also extended during natural disasters, such as hurricanes or earthquakes.
To optimize medication costs, patients can ask their healthcare providers to write a 90-day prescription instead of a 30-day one, which can be more economical in the long run.
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Controlled substances have stricter refill rules
Refilling prescriptions for controlled substances is subject to stricter rules than for non-controlled substances. This is because controlled substances have a higher potential for harm and misuse.
In the United States, federal law divides medications into five groups, or schedules, based on their medical value, potential to cause harm, and likelihood of misuse. Schedule I drugs have no medical use, while Schedule II drugs have the highest potential for harm and misuse, and Schedule V drugs have the lowest.
Controlled substances are subject to the 28-day rule, which means that you can only refill a 30-day prescription after 28 days, or 2 days before the prescription runs out. This rule is not a formal regulation, but it is a common standard. The number of days between refills varies, and federal law, state law, and insurance companies have their own regulations that might apply to specific prescriptions.
For Schedule II substances, there are no refills on prescriptions, and they expire after 6 months. A physician can, however, write multiple prescriptions for Schedule II drugs, as long as they do not exceed a 90-day supply. On each prescription, the doctor must write the earliest date that it may be filled. Schedule III, IV, and V substances may be refilled, but there is a maximum of five refills, and each refill can be no later than 6 months after the date of the prescription.
Insurers set their own rules about when they cover the cost of a prescription refill. For non-controlled substances, insurance companies often have a 75% refill allowance, meaning that 25% of the medication must be used before a refill can be approved. For controlled substances, this allowance is often higher, at 85%, meaning that the refill can only be approved when 15% of the medication is left.
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Insurance companies enforce rules to prevent prescription misuse
In the case of controlled substances, restrictions are often stricter and set by state laws or pharmacy policies. Many pharmacies will not fill prescriptions for controlled substances more than 2 days early, with some states implementing a \"28-day rule\" for monthly prescriptions. This longer waiting period for refills aims to reduce the chance of misuse, which can occur when medications are taken in ways other than as prescribed.
During the COVID-19 pandemic, some insurers eased restrictions to allow patients to obtain larger emergency supplies of routine medications for chronic conditions. However, stocking up on medicine can be challenging, especially for those without insurance or who cannot afford the co-pay for larger quantities.
In summary, insurance companies enforce rules to prevent prescription misuse by setting refill restrictions based on the type of medication and the time elapsed since the last refill. These rules aim to ensure patient safety and proper medication usage while managing healthcare costs.
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Insurers may ease restrictions in emergencies
Typically, insurance companies have strict schedules for authorising refills. For instance, if you have a 30-day supply, you may have to wait until the 28th day for a refill, and if you have a 90-day supply, you may have to wait until the 85th or 88th day. These refill rules are in place to ensure that patients are taking their medication as directed and to prevent misuse and abuse.
However, insurers may ease restrictions in emergencies, such as natural disasters or, as was the case during the COVID-19 pandemic, allowing patients to order a larger emergency supply of their routine medications for chronic conditions. In such cases, pharmacists can use their clinical judgment to dispense emergency refills if a healthcare provider cannot be reached in a timely manner to authorise a prescription. This is known as Kevin's Law.
Insurers may also ease restrictions by waiving early medication refill limits on 30-day prescription maintenance medications and encouraging members to use their 90-day mail-order benefit. For example, during the COVID-19 pandemic, some insurers recommended that members talk with their doctors about increasing their regular one-month supply of medication to three months.
It is important to note that even with relaxed policies, stocking up on medication can be challenging, especially for those without insurance or who cannot afford the co-pay for a larger quantity of medicine. Additionally, if you refill a medication early, your insurance may not cover the cost, resulting in a "refill too soon" denial.
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Ask your healthcare provider for a 90-day prescription
Prescription refill rules vary between insurance plans, states or territories, and the type of medication being filled. Insurers set their own rules about when they cover the cost of a prescription refill. If you refill a medication early, your pharmacy may dispense the drug, but your insurance may not cover the cost. This is called a "refill too soon" denial.
Federal law in the United States regulates most drugs and divides them into five groups: Schedule I, II, III, IV, and V. Medications are grouped according to their medical value, their potential to cause harm, and the likelihood of misuse. Schedule I drugs have no medical use, while Schedule II drugs have the highest potential for harm and misuse, and Schedule V drugs have the lowest. For Schedule II substances, there are no refills on prescriptions. However, a physician can write multiple prescriptions for a Schedule II drug as long as the total supply does not exceed 90 days.
If you have a 90-day supply, you typically cannot refill it until the 85th or 88th day. To avoid the hassle of strict prescription refill rules, ask your healthcare provider to write you a 90-day prescription instead of a 30-day one. This can often be cheaper in the long run. If you are in a health emergency, you and your healthcare provider can request an expedited appeal to shorten the review time. Your healthcare provider may also suggest alternative treatments or medications in the same class as the one you need.
In light of the COVID-19 pandemic, some U.S. health insurers have started allowing patients to order larger emergency supplies of their routine medications for chronic conditions. Some insurers have also begun to waive early medication refill limits on 30-day prescription maintenance medications and encourage members to use their 90-day mail-order benefit.
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Frequently asked questions
Prescription refill rules vary between insurance plans, the state or territory you're in, and the type of medication being refilled. For example, federal law in the US regulates most drugs and divides them into five groups, known as Schedule I, II, III, IV, or V. Medications in these groups are known as controlled substances. Schedule II substances, which have the highest potential for harm and misuse, do not allow for refills, but a physician can write multiple prescriptions provided they do not exceed a 90-day supply. For a 90-day prescription, some insurance companies may allow a refill after 60 days, while others may require you to wait until the 85th or 88th day.
The 28-day rule refers to how long you may have to wait before refilling a prescription. For example, if you have a 30-day supply, you can get a refill no earlier than 2 days before the 30 days are up.
An emergency prescription refill is when a pharmacist authorizes a one-time refill of a maintenance medication because a healthcare provider cannot be reached in a timely manner. The amount and type of medication that can be provided varies between states.
