The Arc is very concerned about the changes the Dept of Health Care & Family Services has made regarding individuals on Medicaid who are on more than four prescriptions. We have developed this memo to assist you as we work with other advocates to understand these new procedures.
In the meantime, your relationship with your primary care physician and your pharmacist is critical, and we encourage you to work closely with them.
Here are some recommendations for you to consider, possible resource materials and the HFS Notice on Four Prescription Limit see highlighted areas.
Consider this a work in progress, and we will share more information with you as it becomes available.
Children under age 21 (including all children under age 19 in All Kids, and children ages 19-21 who are SSI recipients and also enrolled in Medicaid):
If any child in this group is denied a prescription/prior authorization, this may be an EPSDT violation (Early Periodic Screening Diagnosis & Treatment Program, the child health component of Medicaid).
Contact: Stephanie Altman at Health and Disability Advocates 312-223-9600.
Adults over age 21 Action steps:
Discuss list of medications with primary care physician and ask for a print out of medications by price per month (this can also be requested from your pharmacy). Explain why you need it.
Ask physician to put the most expensive meds in the “top four” on the list.
Ask physician to prioritize the medications in order of medical necessity and to start the prior authorization process for each of them.
Ask physician if any of your prescriptions can be filled with a substitute from either the “Approvable Drug List” or the “Preferred Drug List.”
If you participate in a Medicaid managed care arrangement, ask the case manager for a written copy of the policy overriding the “4-prescription rule.”
To: 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 – Update and Clarification
This notice provides an update and clarification regarding the four prescription limit. The department has begun reviewing prescriptions billed for patients that exceed the department’s four prescription limit, beginning with those that exceed 10 prescriptions per month. As the department enforces the prescription limit, when a pharmacy bills a prescription that exceeds the department’s prescription limit, the claim will reject, with some exceptions.
As a reminder, 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. The following classes of drugs will not require prior approval as a result of the four prescription limit:
The June 29, 2012 notice regarding the four prescription limit stated that compounds would be excluded from the limit. As a clarification, compounds will count as only one prescription. The individual ingredients within the compound will be exempt from the limit.
A prior approval request for an exception to the four prescription limit may be submitted by the prescriber if the drug is on the approvable drugs list, and the prescriber determines that a patient needs a prescription that rejects as a result of the prescription limit. Initially, only prescribers will be allowed to request prior approval for prescriptions beyond the four prescription limit.
A drug prior approval request for prescriptions beyond the limit may be made by using the Medical Electronic Data Interchange (MEDI) system. More information about the Drug Prior Approval and Refill-Too-Soon application on the MEDI system will be published soon on the Drug Prior Approval Web page. In addition, 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. A specific form will be required for requests beyond the four prescription limit if the request is made by fax. This form is available on the department’s Four Prescription Limit Web page. Requests will be reviewed on a case-by-case basis.
Department staff are not available to process prior approval requests during non-business hours such as evenings, weekends, and state holidays. During these times, in an emergency situation, a pharmacy can dispense a 72-hour supply, and will be reimbursed after the pharmacy follows up with a prior approval request for the emergency supply.
Information for Pharmacies
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.” If a claim rejects because of the prescription limit, the pharmacy should notify the prescriber that they must request a prior approval for a prescription limit override in order for the department to continue to reimburse for the drug. Pharmacies are encouraged to work with prescribers and clients to address prescription limit issues.
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