The Illinois Department of Healthcare and Family Services (HFS) has started to review prescriptions for HFS clients in accordance with the prior approval policy for medications established by the Save Medicaid Access and Resources Together (SMART) Act. HFS started the review with clients who fill more than 10 prescriptions per month and will gradually expand the review.
HFS will allow clients to exceed four prescriptions per month in certain situations, with prior approval. HFS will review each request on a case-by-case basis. If approved, each prior approval request will be valid for one year.
Prior approval can be done via telephone (1-800-252-8942), fax (217-524-7264 or 217-524-0404) or a new application on the HFS MEDI System.
When a pharmacy bills for prescription that exceeds the limit, the claim will reject with some exceptions. The monthly limitation applies to name brand and generic drugs. Over-the-counter drugs and non-drug items such as blood glucose test strips are not subject to the limit.
The following classes of drugs are exempt from the limit: oncolytics, anti-retroviral agents, contraceptives, immunosuppressives and antibiotics. Compounds will count as one prescription. In an emergency situation, a pharmacy may dispense a 72-hour supply and HFS will pay for that 72-hour supply.
The prior approval form and and an online request application are posted on this HFS Pharmacy page. Providers can also check the status of their requests through and online application. HFS asks that providers do not call to check the status of requests.
