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.
