FLASH: Important Health Alliance Medicaid Pharmacy Preauthorization News

Please take note of these pharmacy preauthorization changes. If you have questions, contact our Pharmacy Department at 1-800-851-3379, option 4.

Insulin Pens – Effective 11/1/15

• Health Alliance will no longer cover insulin pens without preauthorization.
• Coverage of pens will require documentation of a medical condition that prevents the member from injecting insulin using syringes and vials.
• All existing pen users will be required to transition to vials unless a preauthorization approval has been granted.

Test Strip Limits – Effective 11/1/15

• Health Alliance will cover no more than 50 test strips in 30 days for patients who are not on insulin therapy.
• Preauthorization will be required for coverage of more than 50 test strips in 30 days for these patients.

Controlled Substance Prescription Limits

• Health Alliance will now cover only 3 controlled substance prescriptions in a rolling 30-day period without preauthorization. This policy is being enacted to curb the overuse of controlled substances.
• Coverage for more than three controlled substances within 30 days will require documentation of all the following:
  • The provider was aware of all controlled substances filled within the last 30 days.
  • The provider has reviewed the member’s utilization on the Illinois Prescription Monitoring Website.
  • The member has not gone to more than three different pharmacies within the last 30 days.
• Select members will have preauthorization placed on all controlled substances if the member meets any one of the following:
  • The member has come up on a quarterly fraud, waste and abuse report.
  • The member has reported identity theft involving controlled substance fills.
  • A provider reports a patient is filling prescriptions for controlled substances under the provider that the provider did not write.

Electronic Step Edits and Preauthorizations with Prerequisite Drug – Effective 10/15/15

• Health Alliance will look back for 90 days of a prerequisite medication in the past 120 days without requiring a preauthorization.
• Current electronic step logic looks for a 30-day supply of medication in the past 180 or 365 days.
• The change will ensure that only those members who have been compliant with a prerequisite medication will be able to bypass preauthorization.