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Question of the Month ~ January 2013


Q. Do any states place per-beneficiary restrictions on the number of prescriptions covered under their Medicaid programs?

In a 2012 survey done by the Kaiser Family Foundation, 16 states, including Illinois and Kansas, reported having some type of “script limits” in place for Medicaid recipients.
Illinois is one of the latest U.S. states to adopt such a cap, having done so as part of a legislative overhaul of its Medicaid program (HB 5420) in 2012. Initial estimates indicated that a script limit would save the state’s public health-insurance program approximately $140 million in fiscal year 2013.
That savings estimate in Illinois was based on a monthly limit of five prescriptions. Lawmakers ultimately chose to place the cap at four prescriptions per month.
Above this limit, prior approval is now required by the state: A prescriber must enter the request into a state database and have it approved by a physician or pharmacist. These prior-approval requests are typically reviewed within two hours of being entered into the database.
According to the Illinois Department of Healthcare and Family Services, the goal of the new limit is to reduce duplication and unnecessary medications, as well as to curb health problems associated with negative drug interactions.
There are exemptions to Illinois’ new cap, and they are similar to many of those in place in the other 15 states with script limits.
For example, Illinois does not limit the number of prescriptions for children (18 and under) or for individuals living in long-term-care facilities. In addition, contraception does not count toward the four-prescription limit, and certain drugs needed in organ transplants or to fight cancer and HIV/AIDS are exempt.
Kansas has a limit of four prescriptions as well. However, any drug on the state’s “preferred drug list” (lower-cost drugs determined not to compromise safety, effectiveness or clinical outcomes) do not count toward the cap.
Among the 16 U.S. states that report having some type of script limit in place, the cap falls somewhere between three and eight prescriptions per month.
In addition to exemptions for birth control and cancer- and HIV/AIDS-fighting drugs, several states exclude from the cap medications used to treat certain mental health conditions.
These states, too, generally have a process in place for a Medicaid recipient to exceed the limit and receive coverage if he or she can prove the drug is a medical necessity.

Details on state Medicaid prescription drug limits »


Question of the Month response written by Tim Anderson, publications manager at CSG Midwest.