Healthcare Choices Resource Center

HealthCare Choices Resource Center Alert

Medicaid Four Prescription Limit December 17, 2012

As part of the SMART Act effective July 1, 2012, the Department of Healthcare and Family (HFS) Services instituted a four prescription limit for individuals on Medicaid. Individuals affected by this new limit will be able to fill up to four prescription drugs (not counting drugs in the categories listed as exceptions above) each month at the pharmacy. The fifth prescription that an individual tries to fill will be denied until the individual’s doctor obtains prior authorization approval from HFS. A doctor may obtain prior authorization approval by telephone, fax, or electronic submission. Once prior authorization is obtained, the individual will usually have Medicaid coverage for that drug until the end of the year.

The limit applies to both brand name and generic drugs; however, the following drugs are exempt (do not count toward the limit):

 Oncology Agents  Anti-Retroviral Agents  Contraceptives  Immunosuppressives  Over-the-counter medications  Non-drug items (e.g., glucose test strips and monitors)

This limit also does not apply to the following individuals:

 Dual Eligibles (except in the rare case where the individual is prescribed more than 4 medications that are excluded by Medicare Part D but covered by Medicaid);  Anyone enrolled in the Integrated Care Program with Aetna Better Health or Illinicare;  Children under the age of 19, until processing delays are addressed.

The state is implementing this new limit in phases, starting with the people who take the most prescription drugs. The limit is currently in place for anyone who takes more than seven prescription drugs, and it will gradually be applied to individuals with fewer prescriptions (6, then 5, etc). Note: This does not mean that the limit only applies to the seventh prescription, though – it will apply to all prescriptions beyond the first four. The phase-in only determines what groups of people are currently being affected by the limit. (In other words, the people who are already experiencing the new limit will have their fifth prescription, and all prescriptions thereafter, denied at the pharmacy until they receive prior authorization.)

Make Medicare Work Coalition December 17, 2012 Tips for People Affected by the Four Prescription Limit

 Individuals who will be faced with the four prescription limit at the pharmacy should be sure to fill their most important and/or most expensive prescriptions at the pharmacy first, to avoid having these drugs affected by the limit.

 When necessary prescriptions are denied at the pharmacy due to this new limit, the individuals affected should speak with their doctors and ask that their doctors submit a prior authorization request to HFS for the prescription(s).

 Pharmacies are able to provide emergency 72 hour supplies of prescriptions on evenings, weekends, and holidays when the prior authorization hotline is closed and the prescriptions are critical to the individual’s health. The pharmacy can then be reimbursed by HFS for these prescriptions once the prior authorization has been submitted and approved.

 Individuals who are on traditional Medicaid only and who take more than four prescription drugs (excluding ‘exempt’ drugs listed at the beginning of this alert) should begin talking with their doctors and pharmacists about their medications, in order to find out if they are taking any unnecessary drugs or taking brand name drugs that may have cheaper generic forms available. It is better to start planning now than to wait for the limit to take effect and risk not being able to access critical prescriptions.

 If prior authorization requests are being denied and the person’s doctor is unsuccessful in appealing the denials, the person can seek the following alternatives to obtain their prescriptions (Note: these could also be used short-term to obtain prescriptions while waiting for prior authorization approval): o Use $4 generic programs to obtain generic prescriptions at certain chain pharmacies (Target, Wal-Mart, etc.). Meijer pharmacies also offer certain antibiotics for free. o Ask the doctor for samples of necessary prescriptions o Use a prescription discount card to lower the full price of the drug at the pharmacy

Information about $4 generic programs and prescription discount cards is included in our MMW Charities and Co-Pay Relief Programs list here: http://www.ageoptions.org/whatwedo/documents/CharitiesPAPsDiscountCards6-6-12.pdf

HFS is maintaining information and documents regarding the new four prescription limit on their website here: http://www.hfs.illinois.gov/pharmacy/script/

Make Medicare Work Coalition December 17, 2012 Resources to Assist in Prior Authorization Process

As implementation of this new rule is put in place, HFS has been experiencing some delays in processing prior authorization requests. Click on the following link for a notice from HFS issued on October 26, 2012 regarding these delays and how doctors should obtain information about prior authorization: http://www.hfs.illinois.gov/assets/102612n.pdf

HFS strongly encourages doctors to enter prior approval requests using the Medical Electronic Data Interchange (MEDI) System. Requests using this system go directly into the Department’s drug prior approval adjudication database and allows prescribers to easily check the status of a prior approval request. More information about registering for MEDI, and requesting prior approval through the MEDI system, is available on the Department’s MEDI Web site.

HFS has also created website pages that doctors can use to submit prior authorization requests and submit questions regarding the status of prior authorization requests that they have already submitted. Those website links are included below:

 Website where doctors may submit prior authorization requests to HFS: http://www2.illinois.gov/hfs/MedicalProvider/Pharmacy/Pages/Four%20Prescription %20LimitPriorAuthorization.aspx  Website where doctors may check the status of prior authorization requests already submitted: http://www2.illinois.gov/hfs/MedicalProvider/Pharmacy/Pages/ScriptLimitInquiry.aspx

If you have any questions, please contact us: Erin Weir, AgeOptions; [email protected] John Coburn, Health & Disability Advocates; [email protected] Rebecca Thompson, Progress Center for Independent Living; [email protected]

Make Medicare Work Coalition December 17, 2012