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Specialty Pharmacy Override

Training Team

Created on February 17, 2025

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Transcript

Specialty Pharmacy Override

SP Override Guide

What is an SP Override?

  • When a claim rejection is due to DirectRx not being the preferred/in-network specialty pharmacy --> call insurance for an override!
  • This is often needed for Ohtuvayre since it is a limited distribution drug
Limited Distribution drug: a prescription medication that is restricted to a limited number of specialty pharmacies due to its complex handling, safety concerns, or limited availability

Rejection Examples

Calling Insurance

  • Call phone number in rejection claim, on back of insurance card, or in the insurance payor information in CPR
  • Choose "Claims" option
  • Make sure to have NPI, TIN, Patient ID/Name/DOB available
- Example Statement -

'Hello! My name is _ and I'm calling from DirectRx Specialty Pharmacy in regards to a claim rejection. The rejection states that this drug needs to be filled at a specialty pharmacy. However, this is a limited distribution drug and we are one of the only pharmacies that is authorized to dispense this drug at this time. May I speak to someone about a potential override or is there a specialty pharmacy in network for this patient?'

Pharmacies Authorized for Distrubution

  1. Centerwell Specialty Pharmacy
  2. CVS Specialty Pharmacy
  3. DirectRx Specialty Pharmacy

Notes:

  • If a PA is required, it must be completed BEFORE attempting the SP Override
  • If an ins rep advises to transfer to a pharmacy not authorized for distribution, ask to speak to a supervisor
  • If a call back is needed to check status, give DirectRx's phone number, your name & extension, and confirm best call back number. Call back in 2-3 days to check the status
  • Obtain a case number if available! Create a detailed progress note using the PBM/Provider Override note.

It is the reponsibility of the team member who encounters the SP Override rejection to call and complete the override/transfer. These rejections should not be left in the queues! This will help us service our patients effectively and efficiently.

Q&A

Thank you very much!