Ala. Admin. Code r. 560-X-16-.20

Current through Register Vol. 43, No. 02, November 27, 2024

Section 560-X-16-.20 - Quantity Limitations

(1) Prescriptions should be written to provide a sufficient amount of medication necessary for the duration of the illness or an amount sufficient to cover the interval between physician's visits. A prescription shall not be split into small units and submitted as separate claims in order to obtain additional dispensing fees.

(2) The quantity for which a prescription is written should not exceed a maximum of eleven refills for non controlled prescriptions or five refills for Control III-V prescriptions. Claims for prescription refills beyond eleven refills for non controlled prescriptions or five refills for Control III-V prescriptions shall be denied.

(3) Quantities (units) of drugs prescribed by a physician shall not be arbitrarily changed by a pharmacist except by authorization of the physician.

(a) The pharmacist must contact the prescribing physician for authorization to reduce the quantity of any Medicaid prescription.

(b) Authorization to reduce the units of a prescription must be noted on the prescription form by the pharmacist.

(4) If the full quantity prescribed is not available at the time of dispensing, the pharmacist may dispense the quantity available. In this case the pharmacist is required to note on the prescription the number of units dispensed and retain the claim until the balance of medication is dispensed. The claim is then submitted with one dispensing fee. If more than one dispensing fee is received, recoupments may be initiated if the dispensing pharmacy cannot provide documentation to support why multiple dispensing fees were received within the same month.

(5) Maintenance medications are those generally used to treat chronic conditions or illnesses and are ordered/ prescribed and taken regularly and continuously. Medicaid recipients can obtain a three month supply of maintenance medications as designated by the Agency. The patient must first have demonstrated stability for at least 60 days (same strength and dose) on a given maintenance medication. Only one co-pay is collected and only one dispensing fee is paid for the three month supply. A list of maintenance medications is available on the Medicaid website

(6) Effective October 1, 2013, the number of outpatient pharmacy prescriptions for all recipients except as specified below is limited to four brand name and five total drugs per month per recipient. In no case can total prescriptions exceed ten per month per recipient. Prescriptions for Medicaid eligible recipients under age 21 in the Child Health Services/Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program and prescriptions for Medicaid eligible nursing facility residents are excluded from these limitations.

(a) Anti-psychotic, anti-retroviral, and anti-epileptic agents may be paid up to ten prescriptions per month but in no case can total prescriptions exceed ten per month per recipient.

(b) Effective November 22, 2004, coverage of up to ten brand name prescriptions per month may be allowed through overrides for drugs classified by American Hospital Formulary Services (AHFS) or First DataBank (FDB) Therapeutic Class as Antineoplastic Agents, Antiarrhythmic Agents, Cardiotonic Agents, Miscellaneous Vasodilating Agents, Miscellaneous Cardiac Agents, Nitrates and Nitrites, Alpha Adrenergic Blocking Agents, Beta Adrenergic Blocking Agents, Dihydropyridines, Miscellaneous Calcium Channel Blocking Agents, Diuretics, Angiotensin-Converting Enzyme Inhibitors, Angiotensin II Receptor Antagonists, Mineralocorticoid (Aldosterone) Receptor Antagonists, Central Alpha Agonists, Direct Vasodilators, Peripheral Adrenergic Inhibitors, Miscellaneous Hypotensive Agents, Hemostatics, Calcium Replacements, Electrolyte Depleters, Immunosuppresives, Alpha Glucosidase Inhibitors, Amylinomimetics, Biguanides, Dipeptidyl Peptidase-4 Inhibitors, Incretin Mimetics, Insulins, Meglitinides, Sulfonylureas, Thiazolidinediones, and Miscellaneous Diabetic Agents. Overrides will be granted only in cases in which the prescribing physician documents medical necessity for the recipient to be switched from a product in one of the above named classes to a brand name product within the same therapeutic class in the same calendar month. The first product must have been covered by Medicaid.

Ala. Admin. Code r. 560-X-16-.20

Rule effective October 1, 1982. AAmended: Effective December 6, 1984; November 10, 1987. AAmended: Filed January 6, 1998; effective February 10, 1998. Amended: Filed May 14, 2004; effective June 18, 2004. Amended: Filed October 18, 2004; effective November 22, 2004. Amended: Filed October 12, 2005; effective November 16, 2005. Amended: Filed October 12, 2007; effective November 16, 2007. Amended: Filed January 25, 2011; effective March 1, 2011. Amended: Filed August 17, 2011; effective September 21, 2011. Amended: Filed August 13, 2013; effective September 17, 2013.

Author: Bakeba R. Thomas, Associate Director, Pharmacy Clinical Support

Statutory Authority: State Plan, Attachment 3.1A; Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.