Prescription Limit Frequently Asked Questions

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Prescription Limit Frequently Asked Questions

Transcript Of Prescription Limit Frequently Asked Questions

Prescription Limit Frequently Asked Questions
Q: What is the current prescription limit? A: The number of outpatient pharmacy prescriptions is limited to five total drugs (including
up to four brands) per month per adult recipient.
Q: Are any recipients excluded from this prescription limit? A: Children under age 21 and nursing home residents are exempt from this limit. “Group
homes” are not nursing homes and are not exempt from the limit.
Q: Are there any drugs that are exempt from the prescription limit? A: Prescriptions for medications in the three month maintenance supply program will not
count toward the monthly prescription limit, regardless of whether the prescription was dispensed for a maintenance supply or not. Allowances will also be made for up to 10 prescriptions (brand and/or generic) per month for antipsychotics, antiretrovirals, and antiepileptic agents.
Q: Will the Three-Month Mandatory Maintenance Supply Program affect the prescription limit?
A: No. These drugs will be excluded from the prescription limit.
Q: Is there an override for the monthly prescription limit? A: Overrides will be granted in cases in which the prescribing physician documents medical
necessity (such as cases of failure to respond or adverse allergic reaction) for the recipient to be switched from one product to another product within the same therapeutic class in the same calendar month. The first product must have been covered by Medicaid. This is applicable to specific drug classes listed on the Agency website.
Q: What can a recipient do if they have reached their limit for the month but need another prescription?
A: The pharmacy can “back out” a previous, less expensive claim in that same month to allow an open “slot” for that month, and allow the patient to pay for the less expensive drug. Another alternative is the recipient may pay cash for their prescription. Another alternative is the recipient may also check various prescription assistance programs and pharmacy discount or free programs for help with their medications. A guide to patient assistance programs can be found at http://www.medicaid.alabama.gov/documents/4.0_Programs/4.3_PharmacyDME/4.3.13_Contacts_Links/4.3.13_Patient_Assistance_Programs_Revised_9-25-17.pdf
Q: If I have received approval on a prior authorization request for a non-preferred prescription, will Medicaid cover it even if the prescription limit has been met for that month?
A: No, a prior authorization does not allow a recipient to receive more than the allowed number of prescriptions per month.
Q: Will prior authorization still be required for non-preferred drugs that are under the prescription limit for the month?
A: Yes, prior authorization, max unit limitations, therapeutic duplication and early refill edits will still be in place.

Effective 11/13/18

Alabama Medicaid Agency Division of Pharmacy Services

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Q: Are the prescription limits for a thirty day period? A: The prescription limits are based on a calendar month.
Q: When an antipsychotic, antiretroviral, or anti-epileptic drug is involved, does it matter the order in which the medications are dispensed and billed to Medicaid?
A: No, the claim system will recognize that the medication is classified as an antipsychotic, antiretroviral, or anti-epileptic medication in the calculation of the limit.
Q: If a child will turn 21 on January 15th does the prescription limit apply to them for January?
A: No. The system recognizes a person’s age the first day of the month. The limit would begin in February for this recipient.
Q: What if a recipient is taking two strengths of the same medication? A: It will count as two (2) prescriptions toward the limit.
Q: If prescriptions are from different doctors can a recipient receive more than the allowed number of prescriptions per month?
A: No, the claim system will count the individual prescriptions regardless of the prescribing physician.
Q: If prescriptions are dispensed from different pharmacies can a recipient receive more than the allowed number of prescriptions per month?
A: No, the claim system will count the individual prescriptions regardless of the dispensing pharmacy.

Effective 11/13/18

Alabama Medicaid Agency Division of Pharmacy Services

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