Prescription coverage limits for some Medicaid recipients

On January 3, 2012, the state reduced pharmacy coverage to 6 prescriptions per month for adults in fee-for-service Medical Assistance (ACCESS).

If you are in a Medical Assistance managed care plan and your plan adopts the 6 prescription limit, it must notify you by letter, 30 days before the change.

As of this writing (3/1/12), United Healthcare implemented prescription limits on 3/1/12 and UPMC for You has a target implementation on 5/1/12. Keystone, Amerihealth, and Gateway will implement the limits but do not yet have target dates.  Aetna, Coventry Cares, and Health Partners still don’t have plans to implement the limit.

Drugs to treat HIV/AIDS are not subject to this 6 prescription limit because they are covered by an “automatic exception.”  Many other types of drugs are also covered by automatic exceptions. (Please see the Pennsylvania Health Law Project’s Fact Sheet for the complete list). This means that, if possible, you should try to have prescriptions that are not covered by automatic exceptions filled early in the month and prescriptions that are covered by automatic exceptions filled later in the month.

If you are unable to fill a prescription because of this limit, you can ask your doctor to request an exception for that prescription.  Your pharmacist can also provide a 5 day emergency supply.

For more information, click here for the Pennsylvania Health Law Project’s Fact Sheet or here for the Department of Public Welfare’s Bulletin on the Pharmacy Benefit Package Change.