In an effort to fully explain the SMART Act mandated prior approval policy for medications, the Illinois Department of Healthcare and Family Services (HFS) has provided the following answers to questions that providers recently asked of Illinois Health Connect. The answers in this post were sent to IHC on October 10. HFS answered a previous set of questions in a IHC Bulletin Board post on September 25.
Q: Has HFS started to enforce the limit of four prescriptions per month?
HFS: The Department is currently rejecting prescriptions billed for patients who exceed eight (8) prescriptions in a 30-day period. Once a script rejects and after reviewing a patient's profile to reduce duplication and unnecessary medications where clinically appropriate, the prescriber should request Prior Approval for any medication contained on the approvable drug list that the patient needs. 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.
Q: How can a provider determine if an additional provider is prescribing drugs for a patient?
HFS: Prescribers can access a patient's Claims History on the IHC Provider Portal via the HFS MEDI System to identify all prescriptions being filled by the patient that are being reimbursed by the HFS Medicaid program.
Q: Does HFS have a schedule for Prior Approval to drop from 10-8-6-4 on specific dates?
HFS: The Department is currently rejecting prescriptions billed for patients that exceed eight (8) prescriptions in a 30 day period. The Department is working toward the four per month limit over time to assess its capability of handling the Prior Approval requests and to respond to situations that arise, which could not have been anticipated prior to implementation.
Q: When a Prior Approval request is submitted via phone or fax, is there a approval confirmation sent to provider by fax or phone?
HFS: No.
Q: How are providers notified when Prior Approval requests are approved?
HFS: The HFS pharmacist reviewing the PA request may contact the prescriber to request additional information necessary to make the determination, but prescribers are not specifically notified of whether or not a request has been approved. The provider can determine approval status using MEDI or the Pharmacy Prior Approval Hotline at 1-800-252-8942. If PA is denied, a denial letter is sent to the patient.
Q: Are PA requests processed at different speeds when submitted by phone, fax or MEDI?
HFS: There is no significant variance in processing time based on how PA request was received. PA requests are reviewed in the order they are received unless the reviewing pharmacist is waiting on additional information from prescriber or pharmacy.
Q: Where can a provider get further information that is not detailed in the HFS Provider Release or the Four Prescription Limit page on HFS Web site?
HFS: Providers should call the HFS Bureau of Pharmacy Services at 877-782-5565, extension 7.
