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Medical Assistance (Medicaid) Request for Nonformulary Drug Coverage
If changing to a formulary medication is not medically advisable for a patient, a physician must initiate a Request for Nonformulary Drug Coverage by faxing the request form to 1-888-245-2049 during normal business hours, or call 1-800-392-1147 during off-hours and weekends, with all of the information requested on the form.
All requests for exception will receive a response within 24 hours. In the event a decision has not been made in 24 hours, Gateway HealthSM will authorize a temporary supply of the nonformulary medication. For new therapies, a 72-hour supply must be dispensed and for ongoing therapies, a 15-day supply of the nonformulary medication must be dispensed, pending the final determination of the request. Gateway HealthSM members have the right to appeal any decision regarding prescription drug coverage.
Physician National Provider Identifier (NPI number)
When processing a prescription claim for a Gateway HealthSM member, a valid physician’s NPI number is required. Claims submitted without a valid physician’s NPI number will be rejected at the point of sale pharmacy.
Days Supply Dispensing Limitations
Gateway HealthSM members may receive up to a 34-day supply of a pharmaceutical product per prescription order or refill. A 34-day supply shall be interpreted to mean consecutive 34-day supply, i.e., if a physician prescribes a medication b.i.d. (two times a day), a 34-day supply corresponds to a quantity of 68. The prescriber is urged to prescribe in amounts that adhere to FDA guideline and accepted standards of care. The dispensing pharmacist must accurately compute the days supply.