IL HFS Limits Initial Fill of Opioids & Benzodiazepine for Medicaid & Medicaid Managed Care Plans

Thumbnail Updated Illinois Medicaid Medicaid Managed Care Program Quantity Limits
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Responsibly prescribing and administering commonly abused drugs such as opioids, depressants, and stimulants continues to be a challenging responsibility.  In response, the Illinois Department of Healthcare and Family Services (HFS) has updated its  quantity limits for new opioid and benzodiazepine prescriptions with changes that take effect February 1, 2023. 

When adjudicating Medicaid and Medicaid managed care plan claims for opioids, HFS has limited initial fill quantities, a maximum of a five-day supply. For benzodiazepines, the initial fill limit will be a maximum of a 14-day supply. After the initial fill, prescriptions for these drugs may be filled for a 30-day supply. It’s important to note that the initial fill limit applies to participants who have not had another opioid or benzodiazepine claim within the past 60 days.

While benzodiazepines and opioids are often prescribed together, it should be noted that benzodiazepines have no recognized role in pain control and could be hazardous (due to risk of respiratory depression and death) if prescribed for concurrent use with opioids.

Providers can request prior authorization for chronic opioid therapy for residents diagnosed with chronic painful conditions such as cancer or sickle cell disease. Once approved, the five-day initial fill limit will be bypassed. Continued 30-day refills will then be available to those patients with a prescription and will not require additional prior authorization.  

For long-term care, these changes only affect residents on Medicaid, including Medicaid fee-for-service (FFS) and HealthChoice Illinois (HCI) managed care organization (MCO) plans. Understanding that any new procedures create additional burdens for nursing staff, facilities should share this information with their residents’ physicians to prevent confusion and delays that may arise because of these changes.

Click here to read more and to download a free tip sheet on understanding the new changes.