Alabama Administrative Code
Title 560 - ALABAMA MEDICAID AGENCY
Chapter 560-X-16 - PHARMACEUTICAL SERVICES
Section 560-X-16-.20 - Quantity Limitations
Current through Register Vol. 43, No. 02, November 27, 2024
(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.
(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.
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.