Provider Notice issued 09/04/12

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:

• Oncolytics

• Anti-Retroviral Agents

• Contraceptives

• Immunosuppressives

• Antibiotics

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.

Exceptions

The department will allow clients to exceed four prescriptions per month in certain situations, with prior approval. A list of drugs that can be approved beyond four prescriptions can be found on the Four Prescription Limit Web page. If the drug is not on the approvable drug list, the drug will not be allowed as an exception to the four prescription limit.

Prior Approval Process

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