TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 140 MEDICAL PAYMENT
SECTION 140.443 FILLING OF PRESCRIPTIONS
Section 140.443 Filling of Prescriptions
a) The prescription must contain the information required under Section 3(e) of the Pharmacy Practice Act of 1987 [225 ILCS 85/3(e)], 68 Ill. Adm. Code 1330 and 42 USC 1936(i)(23) and also contain the prescriber's:
1) Drug Enforcement Administration (DEA) Number; or
2) National Provider Identifier (NPI); or
3) Medical Assistance Program Provider Number; or
4) Illinois State License Number.
b) To the extent required by federal law, effective with new prescriptions executed on or after April 1, 2008, for clients covered under Title XIX of the Social Security Act, a non-electronic prescription must be written on a tamper-resistant prescription pad to be eligible for reimbursement. This requirement applies to all prescriptions regardless of whether the Department is the primary payor.
1) Non-electronic prescriptions are prescriptions that are not transmitted from the prescriber to the pharmacy via telephone, telefax, electronic prescribing (e-prescribing) mechanism, or other means of electronic transmission.
2) Effective April 1, 2008, a prescription form is considered tamper-resistant when it contains any of the following characteristics and, effective October 1, 2008, to be considered tamper-resistant, a prescription form must contain all of the following characteristics:
A) one or more industry-recognized features designed to prevent unauthorized copying of a completed or blank form;
B) one or more industry-recognized features to prevent the erasure or modification of information written on the prescription by the prescriber;
C) one or more industry-recognized features designed to prevent the use of counterfeit prescription forms.
3) If a patient presents at a pharmacy with a prescription written on a prescription pad that is not tamper-resistant, and the pharmacist contacts the prescriber via telephone, telefax, or other electronic communication device, and the prescriber or the prescriber's agent verifies the validity of the prescription, the prescription is then considered "electronic" and, therefore, exempt from the requirement that the prescription be written on a tamper-resistant pad. In such cases, the pharmacist shall note on the original prescription that the prescriber was contacted and the prescriber or the prescriber's agent verified the validity of the prescription.
4) If a patient presents at a pharmacy with a non-electronic prescription written on a pad that is not tamper-resistant, and the pharmacist is unable to contact the prescriber or the prescriber's agent to verify the validity of the prescription, and the pharmacist, in using his or her professional judgment, determines that not filling the prescription poses a health risk to the patient, the pharmacist may fill the prescription and the Department will reimburse for the prescription, provided that the patient is eligible for coverage of the drug and provided that the drug is covered by the Department. The pharmacist must obtain from the prescriber or the prescriber's agent a verbal, faxed, electronic or compliant written prescription within 72 hours after the date on which the prescription was filled.
c) Pharmacies shall not accept blank, presigned prescription forms.
d) If a drug is available by generic name and the identical drug is prescribed by trade name, payment will be based on cost of the generic product unless prior authorization has been obtained for reimbursement based upon the innovator product, or unless the Department determines that the innovator product, reimbursed at the brand name pricing methodology, is more cost-effective than the generic equivalent.
e) The Department shall not pay for dispensed items in excess of the maximum quantity established by the Department, unless prior approval has been granted to dispense an amount in excess of the maximum. The Department shall pay for no more than one month's supply of the item dispensed.
f) The Department shall pay for refills only if the prescribing practitioner authorized refills on the original prescription in accordance with State law.
g) Pharmacies may use a unit dose system in the dispensing of drugs when such a system is in compliance with all applicable State and federal laws. The total quantity dispensed on one prescription cannot exceed the quantity prescribed or the maximum allowable quantity.
h) Effective January 1, 2013, brand-name, solid, oral drugs dispensed to clients residing in any facility that provides medical group care services as defined in Section 140.500, except Intermediate Care Facilities for the Developmentally Disabled (ICF/DD), must be dispensed in 14-day supplies. Exceptions: Solid oral doses of antibiotics and drugs that are dispensed in their original container as indicated in the Food and Drug Administration Prescribing Information or are customarily dispensed in their original packaging to assist patients with compliance (for example, oral contraceptives), may be dispensed in supplies for greater than 14 days.
(Source: Amended at 37 Ill. Reg. 10282, effective June 27, 2013)