Frequently Asked Questions

Pharmacy and Drugs - Prescription and Brand Limits

The Alabama Medicaid Agency limits the number of prescriptions recipients may receive each month.
Below are some questions people often ask about Medicaid prescription drug limits. Click on the questions to see the answers:

Adult Medicaid recipients may get up to five total drugs (including up to four brand name drugs) per month. There are no limits on drugs for children.
Children under age 21 and nursing home residents are exempt from this limit. However, "Group Homes" are not considered nursing homes and group home residents are not exempt from the limit.
Prescriptions for medications in the three-month maintenance supply program will not count toward the monthly prescription limit, regardless of whether or not if the prescription was dispensed for a maintenance supply. Allowances will also be made for up to 10 prescriptions (brand and/or generic) per month for antipsychotics, antiretrovirals and anti-epileptic drugs.
No. These drugs are excluded from the prescription limit.
Overrides will be granted in cases in which the prescribing physician documents medical necessity (such as cases of failure to respond or adverse allergic reaction) for the recipient to be switched from one product to another product within the same therapeutic class in the same calendar month. The first product must have been covered by Medicaid. This is applicable to specific drug classes listed on the Agency's website.
The pharmacy can "back out" a previous, less expensive prescription in that same month to allow an open "slot" for that month, and allow the patient to pay for the less expensive drug. Another alternative is the recipient may also check various prescription assistance programs and pharmacy discount or free programs for help with their medications. A guide to patient assistance programs is available on the Agency's website at http://medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME/4.3.13_Contacts_LInks.aspx.
No. A prior authorization does not allow a recipient to receive more than the allowed number of prescriptions per month.
Yes. Prior authorization, max unit limitations, therapeutic duplication and early refill edits will still be in place.
The prescription limits are based on a calendar month.
No. The claim system will recognize that the medication is classified as an anti-psychotic, antiretroviral or anti-epileptic medication in the calculation of the limit.
No. The system recognizes a person's age on the first day of the month. The limit would begin in February for this recipient.
It will count as two (2) prescriptions toward the limit.
No. The claim system will count the individual prescriptions regardless of the prescribing physician.
No. The claim system will count the each prescription regardless of the dispensing pharmacy.