The Pennsylvania Medical Society (PAMED) has heard from physicians who are concerned about the new Medical Assistance (MA) pharmacy benefit change that limits adult recipients to six prescriptions per month. Physicians say they are worried about their patients who take more than the new monthly limit, which went into effect Jan. 3, 2012.
There is an exception form for physicians to complete on behalf of their MA patients who exceed six prescriptions a month. In order to approve an exception, the Pennsylvania Department of Public Welfare (DPW) must determine that one of the following criteria is being met:
- The recipient has a serious chronic systemic illness or other serious health condition and denial of the exception will jeopardize the life of the recipient or will result in the rapid, serious deterioration of his or her health.
- Granting a specific exception is a cost-effective alternative.
- Granting an exception is necessary in order to comply with federal law.
DPW also has published a list of medications that are automatic benefit limit exceptions, such as cancer and diabetes medications.
Some additional highlights of the pharmacy benefits package change include:
- It only applies to those recipients who: are age 21 or older; are not pregnant or in the 60-day postpartum period; or who do not reside in a nursing home or immediate care facility.
- It does apply to those 21 or older who reside in personal care homes, domiciliary care homes, and assisted living facilities, as well as adult recipients enrolled in home and community-based waiver programs.
- The appropriate managed care organization (MCO) has the ability to impose the same or lesser limits for pharmacy services. Those who choose to make these changes must notify network providers 30 days in advance.
- Pharmacists have the discretion to dispense a five-day emergency supply that will not go against the six-prescription limit.
- Regardless of whether the enrollee’s medication falls under the exception process or not, all current prior authorization requirements still apply.
- MA recipients have the right to appeal the benefit limit exception request within 30 days of denial.
For more information, read DPW’s MA Bulletin published on Dec. 31, 2011.