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Comment on Six Drugs Per Month Pharmacy Limit
December 5, 2011

The Office of Medical Assistance Programs (OMAP) has distributed a draft Medical Assistance (MA) Bulletin, Medical Assistance Pharmacy Benefit Package Change, to provide guidance on the six prescriptions per month limit that will apply to most adult recipients with MA drug coverage, effective January 3, 2012. This bulletin addresses the benefit limit, exceptions criteria and process, and automatic exceptions to the benefit limit. Related draft operational instructions, handbook pages, forms, and desk reference material were also distributed for review and comment. The comment deadline is 5:00 p.m. December 7 in order to finalize the bulletin for issuance before December ends.

The benefit limit applies to individuals age 21 and older who are enrolled in MA as categorically needy. The bulletin applies to pharmacies and prescribers serving individuals who are enrolled in the Fee-for-Service delivery system, including Access Plus. Exceptions to the limit may be approved if the following criteria are met:

  • The department determines 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.
  • The department determines the recipient has a serious chronic systemic illness or other serious health condition and denial of the exception will result in the rapid, serious deterioration of the health of the recipient.
  • The department determines that granting a specific exception is a cost effective alternative for the MA program.
  • The department determines that granting an exception is necessary in order to comply with federal law.

Medications that will qualify for automatic exceptions include anticonvulsants, antidepressants, and antihypertensives with certain conditions, and antipsychotics, antiarrhythmics, diabetes medications, and others. The complete list of automatic exceptions, the draft bulletin, benefit exception request form, handbook pages, and desk reference pages are available from the links.. Members are encouraged to share this information with clinical staff and provide comment to OMAP. Please submit comments to Dan Sorge (dsorge@pa.gov) by 5:00 p.m. December 7 and share a copy with Betty Simmonds (betty@paproviders.org).   

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