On January 3, 2012, the state reduced pharmacy coverage to 6 prescriptions per calendar month for adults 21 years of age and older enrolled in fee-for-service Medical Assistance (ACCESS). This pharmacy benefit change does not apply to ACCESS recipients who are under 21 years of age, are pregnant (including throughout the postpartum period), or reside in a skilled nursing facility or an intermediate care facility. Please note, this pharmacy benefit change does apply to adult recipients 21 years of age and 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 Department of Public Welfare (DPW) will count toward the recipient’s six prescriptions per month pharmacy benefit limit, outpatient legend and non-legend drugs that are dispensed by a pharmacy or by a medical practitioner, and submitted for payment with the appropriate National Drug Code (NDC).  The state will be looking at the first 6 prescriptions billed to medical assistance per month.

Since January, five of the eight Medicaid managed care organizations have opted to adopt the six prescription limit. Please refer to the chart below that has detailed information on which plans are implementing this limit, when, and in what counties they are located.

Medicaid Plan	Prescription Limit	Counties
Fee-for-service (ACCESS)	January 3, 2012	All
Aetna Better Health	Not Adopting	Lehigh, Northampton
AmeriHealth Mercy	June 2012	Lehigh, Northampton, Monroe, Carbon, Pike
Keystone Mercy	May 2012	Does not service our area
Coventry Cares	Not Adopting	Does not service our area
HealthPartners	Not Adopting	Does not service our area
Gateway Health Plan	May 2012	Lehigh, Northampton, Monroe, Carbon, Pike
United Healthcare Community Plan	March 2012	Lehigh, Northampton, Monroe, Carbon, Pike
UMPC For You	May 2012	Lehigh, Northampton, Monroe, Carbon, Pike
*Information accurate as of May 12, 2012 - Plans in bold could possibly effect beneficiaries in our area

There are a couple of noteworthy items to keep in mind about this new prescription limit. Probably most important is that this limit will only effect those consumers utilizing ACCESS or one of the Medicaid manage care plans that have opted to adopt this limit. It has no bearing on Medicare Part D plans. If ACCESS is secondary for a patient and the majority of their prescriptions are covered by their primary insurance, most likely a Medicare Part D plan, this limit should have a minimal impact on the patient.

Another key point is that the limit only looks at the first 6 prescriptions filled for a beneficiary that calendar month, cost and class of medication are not considered at all in this limit. Because they are looking only at chronological order and not cost or class, it is plausible to have a patient that gets 6 low cost drugs billed in the beginning of the month and then have to pay out of pocket for their more expensive medications.

DPW has put in place an exemption process to assist beneficiaries that have a chronic systemic illness or other serious health conditions that would potentially jeopardize their health or life. Each Managed Care plan also has their own exception process.

More information can be found through the Pennsylvania Health Law Project:  http://www.aidslawpa.org/wp-content/uploads/2012/02/PA-Health-Law-fact-sheet-on-RX-limits.pdf

For plan specific information, please see:

• Medical Assistance Bulletin: http://services.dpw.state.pa.us/olddpw/bulletinsearch.aspx?BulletinId=4768 
• Gateway Bulletin: http://www.gatewayhealthplan.com/documents/Rx_Limit_BLE_Request_Form.pdf
• United Healthcare Community Plan: http://www.uhccommunityplan.com/assets/PA-MonthlyPrescriptionLimits.pdf