Provider Notice issued 04/06/11

To: Participating Medical Assistance Providers

Date: April 6, 2011​

Re: Prior Approval for Narcotics

The department has implemented restrictions to control utilization of narcotic medications in order to prevent abuse. A prior authorization will be required for all clients who fill prescriptions for excessive quantities of narcotics, and for all narcotic prescriptions for a certain subset of clients who are high utilizers of narcotics.

The basis for these new limitations are as follows:

• Illinois law, Public Act 096-1501, signed into law on January 25, 2011, mandates that the department review utilization of narcotic medications in the medical assistance program and impose utilization controls that protect against abuse. In order to be compliant with this new law, the department is closely monitoring client utilization patterns and provider prescribing patterns, and is requiring prior authorization for narcotics doses that are excessive. In addition, the department will soon require prior approval for all narcotics prescriptions for a certain subset of clients who repeatedly fill high quantities of narcotics prescriptions. In cases where the use is clinically justified, the prior authorization will be approved.
  
• Effective March 25, 2011, under the federal health care reform law, commonly called the Affordable Care Act (ACA), a prescriber must be enrolled with the Medicaid program in order for Medicaid to cover a prescription written by that prescriber. While the edits to enforce this requirement in the claims processing system are not yet in place, the department will not approve a prior approval request for a narcotic prescription written by a non-enrolled prescriber.

If a client has a history of drug abuse or dependence, the department's reviewing clinician may, at his/her discretion, deny a prior approval request for a narcotic medication for that client.

If a prior approval request for an excessive dose of a narcotic is submitted with a supporting diagnosis, but that supporting diagnosis cannot be verified using the department's claims data, the department's reviewing clinician may, at his/her discretion, deny a prior approval request for narcotic medications for that client.

If a prior approval request for a narcotic is denied, the client has the right to appeal that denial through the fair hearings process. The hearing will be heard by an Administrative Law Judge (ALJ). The prescriber should be prepared to provide documentation supporting the medical necessity of the narcotics prescription that he/she has prescribed. That documentation will be reviewed by the ALJ and the department's clinicians during the hearing. The client can request a hearing by writing to the Bureau of Administrative Hearings, 401 S. Clinton Street, Chicago, IL 60607; or by calling 1-800-435-0774 (TTY: 1-877-734-7429).

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