Four Prescription Policy

Beginning April 1, 2013, the Illinois Department of Healthcare and Family Services will reduce the number of prescriptions that can be filled in a thirty-day period, without prior authorization, from five to four.

The purpose of the four prescription policy is to have providers review their patients' entire medication regimen and where possible and clinically appropriate, reduce duplication, unnecessary medications, polypharmacy, etc. The four prescription policy was developed as a result of budget negotiations, but best-practices call for an annual review of the full regimen of prescriptions for any patient. The four prescription policy is not a "hard" limit. Medicaid patients can and should have access to medications that are medically necessary, even if they exceed four prescriptions per 30 days. The policy simply requires prior approval for prescriptions above the limit, for the purpose set forth above.

Certain drugs do not require prior approval due to the Four Prescription Policy, and you should not request prior authorization for those drugs. The classes of drugs that do not require prior authorization are listed below:

Currently, prescriptions for children under the age of 19 will not reject as a result of the policy. In addition, currently, prescriptions for clients residing in a Community Integrated Living Arrangement (CILA) or a Supportive Living Facility (SLF) will not reject as long as their residence in the CILA or SLF is properly recorded in the department's eligibility system. The department will continue to phase in the implementation based on capacity.

Requesting a Four Prescription Policy Override Prior Approval:

Prescribers are strongly encouraged to enter prior approval requests using the Medical Electronic Data Interchange (MEDI) System. To simplify the prior authorization request process, the Department has added the Four Prescription Policy Override Request Form to the MEDI system. Requests entered into the MEDI system go directly into the Department's drug prior approval adjudication database for review by a physician or pharmacist. Requests that are faxed to the Department's Prior Approval Hotline must be data entered after receipt. Prior approval requests are typically reviewed within two hours of being entered into the adjudication database, but can take longer.

The MEDI system also allows prescribers to easily check the status of a prior approval request that was entered through the MEDI system, by using the prior authorization number that was assigned when the request was entered. More information about registering for MEDI, and requesting prior approval through the MEDI system, is available on the Department's MEDI Website Getting Started Web page.

In addition, for prescribers that do not have access to the MEDI system, the department has created online applications to both submit and check the status of requests. The links for those applications are listed below.

You can also complete the following form and fax it to 217-524-7264, or call 1-800-252-8942 and provide all information requested on the form below.

Emergency Situations:

During non-business hours such as evenings and weekends, when department staff are not available to make a determination on a four prescription policy override prior authorization request, the pharmacy can dispense, and the department will pay for, an emergency 72-hour supply of a covered prescription drug to an eligible client in an emergency situation. The pharmacy is responsible for following up with a prior approval request for the emergency supply.


Pharmacy

 

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