The Illinois Department of Healthcare and Family Services (HFS) has responded to three questions about the SMART Act mandated prior approval policy for medications that were asked during the most recent Illinois Health Connect Provider Network Subcommittee Meeting.
1. What is the turn-around time for pharmacy prior approvals?
HFS response: Currently, the Bureau of Pharmacy Services processes requests for prior approval within approximately one hour. Prior approval request decisions are not carried over to the next day unless the review staff is waiting on information from the provider.
2. Currently, prior approval requests to exceed the four prescription limit must be made by the prescriber. How is that handled if the prescriber is an ER physician?
HFS response: In the case of a script written by an ER physician, HFS would allow a prior approval request from a pharmacy. HFS is in the process of publishing a clarification on this issue.
3. What is the criteria for denial of a request to exceed the four prescription limit?
HFS response: If the drug is on the Four Prescription Limit Approvable Medications List, the request will be approved unless the reviewing pharmacist identifies the drug is duplicative of other drugs in the profile, or if it is being used inappropriately, in which case, the reviewing pharmacist will notify the prescriber of the denial. Update: HFS reported on November 16 that there is no longer an "approvable drug list." Prior Approval requests can be submitted and will be clinically reviewed for approval for any drug.
