The Illinois Department of Healthcare and Family Services (HFS) issued a Provider Release to update providers about the implementation of the prior approval policy for medications.
The purpose of this policy is to have providers review their patients' entire profile of maintenance medications, and where possible and clinically appropriate, reduce duplication, eliminate unnecessary medications and poly-pharmacy, and avoid other problems. Antibiotics, immunosuppressives, oncology agents, anti-retroviral agents and contraceptives are excluded from needing prior approval. PA is required for name brand and generic drugs.
This statutory requirement was signed into law on June 30 as part of the SMART Act legislation and will eventually apply to all adults and children who have coverage through HFS medical programs.
The implementation of the policy is being phased in gradually as HFS determines its capacity to process the Prior Approval (PA) requests.
At this time, HFS clients less than 19 years old will not be affected. Until further notice from HFS, PA requests are not necessary for All Kids clients. HFS is currently requiring prior approval requests for adult clients who fill more than nine prescriptions in the previous 30-day period.
Pharmacies are able to dispense a 72-hour supply of medications in an emergency situation when HFS is closed and not able to process PA requests.
PA requests will generally be granted for a period of one year.
Providers are highly encouraged to use the new Drug Prior Approval/Refill Too Soon application on the MEDI System to submit PA requests. While PA requests can be submitted through fax or phone, these requests require HFS to do data entry which is adding an average of four hours to the review process.
Providers can check the status of a PA request using MEDI if the request was submitted via MEDI. If the PA request was sent via fax or phone, providers are encouraged to use the HFS online status inquiry system. Providers should not call the HFS Pharmacy Hotline to check on the status of a PA request.
If you need assistance with MEDI registration, please contact your IHC Provider Services Representative or the IHC Provider Services Help Desk at 877-912-1999, extension 3. A step-by-step guide to MEDI registration is available on the IHC Web site.
The HFS Pharmacy page contains the PA request form, a link to the online status inquiry system as well as the phone and fax numbers for HFS Pharmacy.
IHC also posted information on the Bulletin Board about this policy on October 11, September 25 and September 11. Check back to the Bulletin Board for more updates on this policy is implemented.
