HFS explanation of new four prescription policy

The Illinois Department of Healthcare and Family Services (HFS) will impose a four-prescription per month limit for adults and children as a result of the SMART Act legislation.

This limitation will not be in place on July 1, but will be soon thereafter. An updated provider notice with further details will be released prior to implementation.

HFS will require prior approval for brand and generic prescriptions, with some exceptions, after a client has filed four prescriptions in a 30-day period. Drugs in the following classes are not subject to the four-per month limit: immunosupressive drugs, oncolytic drugs, anti-retroviral drugs, antibiotics, contraceptives, products used in Total Parenteral Nutrition Combinations (TPNs), compound drugs, partial fills, and some drugs that are not typically filled as maintenance medications.

The pharmacy or the provider may submit prior approval requests for a fifth or subsequent prescription. Requests can be made via telephone by calling 1-800-252-8942 or by fax at 1-217-524-0404 and will be approved on a case-by-case basis.

In an emergency situation during non-business hours or state holidays, the pharmacy may dispense, and HFS will pay for, a 72-hour supply. The pharmacy is responsible for following up with a prior approval request for the emergency supply.

HFS has also issued a provider notice that details changes to the prior approval process for specialty drugs, oncolytic drugs, drugs for treatment of HIV or AIDS, immunosupressive drugs, and biological products. These changes are a result of the SMART Act legislation.

Visit these links to learn about changes to your HFS benefits

Beginning July 1, 2012, a new state law has made important changes to your medical benfits. Talk to your primary care provider at your medical home about these changes to understand more about how they will affect you. The Illinois Department of Healthcare and Family Services (HFS) will send notices in the mail to those who are affected.

• Adults must pay $3.65 for most medical services, including doctor and clinic visits.
• Children covered on All Kids Share now have a $3.65 co-payment for office visits.
• Adults and children must pay $3.65 for using the emergency room when they do not have an emergency.
• Adults must pay $2 for each generic prescription and $3.65 for each name-brand prescription.
• If you need more than four prescriptions in a month, your doctor or pharmacist must get special approval to get them covered. This applies to adults and children. Some medications do not have a limit.
• Chiropractic care for adults is not covered.
• Adults are covered for dental care only in an emergency.
• Podiatry care from any foot doctor is covered for adults only if they have diabetes.
• Payment for eyeglasses for adults is limited to one pair of glasses every two years.
• Some adults will lose FamilyCare eligibility due to this state law. The FamilyCare Share, Premium and Rebate programs for parents and caretaker relatives will end June 30, 2012.
• Illinois Cares Rx program ends on June 30, 2012.

For more information about these changes, visit the following program Web sites:

http://www.allkids.com/

http://www.familycareillinois.com/

http://www2.illinois.gov/hfs/agency/Pages/Budget.aspx

http://www.illinoiscaresrx.com/

Learn more about HFS program changes online, via HFS e-mail notices

Due to the recent Saving Medicaid Access and Resources Together (SMART) Act legislation, there will be many changes to Illinois Department of Healthcare and Family Services (HFS) policies and requirements. HFS will be issuing dozens of HFS Provider Releases to explain these changes during the coming weeks.

Illinois Health Connect (IHC) encourages all IHC enrolled medical homes to sign up to receive these HFS Provider Releases through e-mail notification. IHC recommends that medical homes select “All Medical Assistance Providers” in addition to specific categories of service as appropriate. While these HFS Provider Releases are no longer available through the mail, you can view them online.

Information about the SMART Act and the three accompanying bills passed to address the HFS budget is available online.  Provider fact sheets, client fact sheets and copies of the notices sent to affected clients are posted there. HFS will continue to update the budget page of its Web site.

Providers should be aware that the legislation includes these changes, effective July 1, 2012:

• The standard for timely filing is now 180 days or six months from the date of service. The current standard is 12 months.
• Adult clients are now limited to emergency services for dental care.
• The income standard for adults in FamilyCare changes to 133 percent of federal poverty. The current limit is 185 percent of federal poverty. Approximately 26,000 adults will lose coverage on July 1.
• Children and adults will be limited to four perscriptions per month. Additional prescriptions will be possible with Prior Approval.
• Adults co-payments are now $3.65 for office visits, up from $2.
• Children with All Kids Share now have co-payments of $3.65 for office visits.
• Podiatry care for adults is now limited to diabetic patients.
• Payment for eyeglasses for adults is now limited to one pair every two years.