06/29/12 http://www.hfs.illinois.gov/html/062912n3.html Informational NoticeTo: Participating Advanced Practice Nurses, Dentists, Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Encounter Rate Clinics (ERCs), Hospitals, Local Health Departments, Pharmacies, Physicians, Podiatrists and School Based/Linked Health Centers
Re: Four Prescription Limit
As a result of Public Act 097-0689 (pdf), referred to as the Save Medicaid Access and Resources Together (SMART) Act, effective July 1, 2012, the Department will impose a four prescription limit on both adults and children. In the near future, with some exceptions, the Department will require prior approval for brand or generic prescriptions for a client after that client has filled four prescriptions in a 30 day period. This notice provides information on implementation timing, drugs not subject to the policy, and the process for requesting exceptions to the policy.
Purpose of the Policy
The purpose of the four prescription limit is to have providers review their patients’ maintenance medications and, where possible and clinically appropriate, reduce duplication, unnecessary medications, polypharmacy, etc. There will be exceptions to the limit for drugs for which a prescription limit isn’t logical. Examples are drugs such as antibiotics, which are typically not dispensed as maintenance medications, and products used in total parenteral nutrition combinations (TPN), which require multiple prescriptions to be filled for a single patient each month.
This limitation applies to both brand and generic prescription drugs. Over-the-counter drugs and non-drug items such as blood glucose test strips are not subject to the four prescription limit.
This limitation will not be in place on July 1, 2012, but will be in place soon thereafter. An updated provider notice with further details will be released prior to the implementation date.
Exclusions Drugs in the following therapeutic classes will not be subject to prior approval as a result of the four prescription limit: · Immunosuppressive Drugs; · Oncolytic Drugs; · Anti-retroviral Drugs; · Antibiotics; · Contraceptives; · Products used in Total Parenteral Nutrition Combinations (TPNs); · Compound Drugs; · Partial Fills; and · Some drugs that are not typically filled as maintenance medications.
Process for Requesting Approval of a Fifth or Subsequent Drug
A prior approval request may be submitted by either the pharmacy or the prescriber if a provider determines that a patient needs a prescription that rejects as a result of the prescription limit. Drug prior approval requests can be submitted by telephone by calling 1-800-252-8942, or by fax to 217-524-7264 or 217-524-0404. Requests will be reviewed on a case-by-case basis.
Please do not submit prior approval requests related to the prescription limit at this time. The Department does not yet have the programming complete to process requests for prescription limit overrides. Further information on the process for requesting prior approval will be released in the near future.
During non-business hours such as evenings, weekends, and state holidays when department staff are not available to accept a prior approval request, in an emergency situation, the pharmacy can dispense, and the department will pay for, a 72-hour emergency supply. The pharmacy is responsible for following up with a prior approval request for the emergency supply.
The four prescription limit will not be implemented on July 1, 2012, but will be implemented in the near future. The department will implement the four prescription limit in phases, such that not all patients who receive more than four prescriptions per month will have prescriptions reject due to the four prescription limit upon initial implementation.
When a fifth prescription is billed for a patient who has already received four drugs in the preceding 30 day period, the pharmacy will receive the following error message: Exceeds HFS Maximum Scripts Per 30 Day.” Any questions regarding this notice should be directed to the Bureau of Pharmacy services at 1-877-782-5565, option 7.
Theresa A. Eagleson, Administrator
Division of Medical Programs
Tony Paulauski Executive Director
The Arc of Illinois
20901 S. LaGrange Rd. Suite 209
Frankfort, IL 60423