Update on HFS “Four Prescription Limit

Posted on: October 30, 2012

On Friday, October 26, the Illinois Department of Healthcare and Family Services (HFS) issued an informational notice regarding the implementation of prior approval for more than four prescriptions, as mandated by the SMART Act (Public Act 097-0689).  This informational notice acknowledges difficulty in handling the volume of prior approval requests, and most importantly for ICAAP members, states that prescriptions for children under the age of 19 will not reject as of this week.  Because the SMART Act requires this prescription limit to include children, we expect it to be phased back in later, however starting immediately prescriptions for children on Medicaid will not fall under this limit and providers should experience fewer hassles. ICAAP members and partner organizations stressed the challenges we were having with this new policy, and we are pleased to see this temporary change implemented.

Please take note of the following from the notice:

 - This program is NOT currently being implemented for children under the age of 19. However, the memo notes that the SMART does require this limit to be applied to both children and adults in the Medicaid program.

- Providers are STRONGLY encouraged to use the Medical Electronic Data Interchange (MEDI) system to process prior approval requests and to check the status of requests. Requests entered into MEDI go directly to the adjudication database for review and reduces the amount of data entry performed by HFS staff.  To use the MEDI system, complete the registration process.

- The policy is not to “limit” prescriptions to four but require prior approval for prescriptions above four. The goal to review the patient’s entire profile of maintenance medications to reduce duplication, unnecessary medications and poly-pharmacy.

- A pharmacy can dispense a 72-hour emergency supply when HFS is not available to process requests

- Approvals are for one year however in certain circumstance short-term approval will be granted.

Currently, HFS is requiring prior approval for adult patients with more than nine prescriptions. The requirement for prior authorization will be begin when patient fills their fifth prescription within 30 days. For more information please review the HFS memo.

ICAAP continues to be in contact with HFS regarding this program to provide guidance and feedback. Please contact Scott Allen via email at sallen@illinoisaap.com or at 312/733-1026 ext 202 or Jennie Pinkwater at jpinkwater@illinoisaap.com at 312/733-1026 ext 213 with any problems or feedback regarding the program.