North carolina medicaid pharmacy newsletter

An Information Service of the Division of Medical Assistance
North Carolina
Medicaid Pharmacy
Newsletter
Number 156
March 2008
In This Issue.
Additional OTCs Added to the Over-the-Counter Medications Coverage List
Deleted NDCs from CMS
New Pharmacy Prior Authorization Program for Second Generation Antihistamines
FORM Quarterly Letter Update
Program of All-Inclusive Care for the Elderly (PACE) Recipient Eligibility Program
New SmartPA Pharmacy Prior Authorization Program
National Provider Identifiers for End-Dated Providers
National Provider Identifier and Address Information Database
Tax Identification Information
Changes in Drug Rebate Manufacturers
Published by EDS, fiscal agent for the North Carolina Medicaid Program Additional OTCs Added to the Over-the-Counter Medications Coverage List

The following OTC products became available for reimbursement by NC Medicaid in
conjunction with a prescription order by the physician.
Drug Label Name
Effective Date
00781528364 CETIRIZINE HCL 5 MG CHEW TAB 00781528464 CETIRIZINE HCL 10 MG CHEW TAB 57664054088 CETIRIZINE HCL 5 MG CHEW TAB
The list of covered OTC drug codes is available on the NC Division of Medical Assistance Web
site in General Medical Policy A-2 and can be found at
http://www.ncdhhs.gov/dma/mp/mpindex.htm.

Deleted NDCs from CMS

The following products have been deleted from the CMS Master Data Record (MDR) file of
covered outpatient drugs effective as of March 17, 2008. The products do not meet the definition
of a covered outpatient drug.
Drug Name
Drug Name
Carbetapentane Citrate/Phenylephrine HCI /Guafinesin
New Pharmacy Prior Authorization Program for Second Generation Antihistamines
– Updated Implementation Date
The N.C. Medicaid Outpatient Pharmacy Program will implement a new prior authorization (PA)
program for second generation antihistamines on May 5, 2008. Medications that will require
prior authorization include Clarinex, Allegra, fexofenadine, Xyzal and Zyrtec (prescription
versions only). All over-the-counter (OTC) versions of loratadine, Claritin, cetirizine and Zyrtec
will not require prior authorization. After this date, pharmacists will begin receiving a point-of-
sale message that PA is required for these medications. An additional message will indicate that
override at point-of-sale is allowed for these medications. If the prescriber has indicated that the
PA criteria have been met, by writing one of the following phrases on the face of the prescription
in his or her own handwriting, the pharmacist will be able to override the PA edit:
• For generic fexofenadine
1. “Failed loratadine and failed cetirizine for 30 days” 2. “Allergy to loratadine and cetirizine” • For liquid formulations other than loratadine syrup and cetirizine syrup
1. “Failed loratadine and failed cetirizine syrup for 30 days” 2. “Allergy to loratadine and cetirizine syrup” • For all other second generation antihistamines
1. “Failed loratadine for 30 days, failed cetirizine for 30 days and failed 2. “Allergy to fexofenadine, loratadine, and cetirizine” If the second generation antihistamine has a generic version available, “medically necessary”
must also be written on the face of the prescription in the prescriber’s own handwriting in order to
dispense the brand name drug. A “1” in the PA field (461-EU) or a “2” in the submission
clarification field (420-DK) will override the PA edit. These overrides will be monitored by
Program Integrity.
Providers may also contact ACS at 866-246-8505 (telephone) or 866-246-8507 (fax) to request
PA for these medications. The PA criteria and request form for the second generation
antihistamines are available on the N.C. Medicaid Enhanced Pharmacy Program Web site at
http://www.ncmedicaidpbm.com. If the PA is approved by ACS, the POS override codes will not
be needed.

FORM Quarterly Letter Update
Beginning in May 2008, the FORM quarterly letters that pharmacists receive indicating their
patients that participate in the FORM program will include the following new features:
• The quarterly letter will include a list of recipients deleted from the program since the • If more than one page, the quarterly letter will be combined in one envelope instead of These changes are in addition to the new feature added to the February 2008 FORM letters which
included the addition of the dates FORM recipients are entered into the FORM program. These
letters will be mailed out at the end of February, May, August and November during the year.

Program of All-Inclusive Care for the Elderly (PACE) Recipient Eligibility Program
The Program of All-Inclusive Care for the Elderly (PACE) is a managed care program that
enables elderly individuals who are certified to need nursing facility care to live as independently
as possible. The PACE provider receives monthly Medicare and/or Medicaid capitation
payments for each eligible enrollee. The PACE provider assumes full financial risk for
participants’ care without limits on amount, duration, or scope of services.
Effective February 1, 2008, to enroll in this program, an individual must be Medicaid eligible and
•
Certified by the State to require nursing facility level of care; Able to live safely in the community at the time of enrollment; and Reside in the service area of the PACE organization. Services provided directly by the PACE provider include, but are not limited to: •
New SmartPA Pharmacy Prior Authorization Program
On April 4, 2008, North Carolina Medicaid will be implementing SmartPA to conduct point-of-
sale (POS) clinical editing and pharmacy prior authorizations. SmartPA is a clinical editing and
pharmacy prior authorization program that delivers pharmaceutical cost containment, efficient
pharmacy benefit administration, and continued access to quality medications. Unlike other prior
authorization programs, this program uses a clinical rules system, in conjunction with drug and
medical claims data, to help providers determine the appropriateness of dispensing certain
medications to Medicaid patients.
SmartPA streamlines the prior authorization process for all stakeholders -- physicians,
pharmacists, recipients, and payers. The SmartPA tool adjudicates prior authorization requests
online in real time. Prescriptions that meet a predefined set of criteria are approved in seconds. A
provider whose prescription is rejected by SmartPA may be instructed to contact a call center
representative for prior authorization reconsideration.
National Provider Identifiers for End-Dated Providers

DMA continues to adjudicate claims for providers who have been end-dated when the claims are
for dates of service prior to the provider’s end-date. To date, more than 6,000 providers who
were end-dated during the past 12 months have not reported their National Provider Identifier
(NPI) to DMA. After May 23, 2008, claims will be denied for end-dated providers who have not
reported their NPI to DMA.
To report your NPI or to verify that your NPI has been received, please access the NPI and
Address Information database at http://www.ncdhhs.gov/dma/WebNPI/default.htm.
If all information is correct, no action is necessary. If the NPI column is blank, your NPI has not
been reported. Print the form and submit your NPI with a copy of the National Plan and Provider
Enumeration System (NPPES) certification.
National Provider Identifier and Address Information Database
The Division of Medical Assistance (DMA) has implemented a searchable National Provider
Identifier (NPI) and address database. Providers can access the database by NPI or Medicaid
provider number, at http://www.ncdhhs.gov/dma/NPI.htm.
Please access the database as soon as possible to verify your NPI, site address, and billing
address.
• If all information is correct, no action is necessary. • To correct typographical errors: print the form, make corrections, and fax to the number • To correct more serious (non-typographical) errors, submit a Provider Change Form (http://www.ncdhhs.gov/dma/Forms/changeprovstatus.pdf) and include any other applicable documentation.
If your NPI is not in the database, previously submitted documentation was either not sufficient to
update the database or has not been submitted at all. Providers should print the form and submit
your NPI with a copy of your National Plan and Provider Enumeration System (NPPES)
certification.
Tax Identification Information
The NC Medicaid program must have the correct tax information on file for all providers. This
ensures that 1099 MISC forms are issued correctly each year and that correct tax information is
provided to the IRS. Incorrect information on file with Medicaid can result in the IRS
withholding 28% of a provider’s Medicaid payments. The individual responsible for
maintenance of tax information must receive the information contained in this article.
How to Verify Tax Information
The last page of the Medicaid Remittance and Status Report (RA) indicates the tax name and
number on file with NC Medicaid for the provider number listed. Review the NC Medicaid RA
throughout the year to ensure that the correct tax information is on file for each provider number.
If you do not have access to a Medicaid RA, call EDS Provider Services at 919-851-8888 or 1-
800-688-6696 to verify the tax information on file for each provider.
How to Correct Tax Information
All providers are required to complete a W-9 form for each provider for whom incorrect
information is on file. Please go to the following Web site to obtain a copy of a W-9 form
http://www.irs.gov/pub/irs-pdf/fw9.pdf. Correct information must be received by November 1,
2008.
All providers who identify incorrect tax information must submit a completed and signed W-9
form along with a completed and signed Medicaid Provider Change form
http://www.ncdhhs.gov/dma/formsprov.html to the address listed below:
Division of Medical Assistance - Provider Services
2501 Mail Service Center
Raleigh NC 27699-2501
Changes in Drug Rebate Manufacturers
The following changes are being made in manufacturers with Drug Rebate Agreements. They are
listed by manufacturer code, which are the first five digits of the NDC.

Additions

The following labelers have entered into Drug Rebate Agreements and have joined the rebate
program effective on the dates indicated below:
Code
Manufacturer
Date

Voluntarily Terminated Labeler

The following labelers requested voluntary termination, which was effective January 1, 2008:
Checkwrite Schedule
Electronic Cut-Off Schedule

Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite. Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date. POS claims must be transmitted and completed by 12:00 midnight on the day of the electronic cut-off date to be included in the next checkwrite.

Source: http://www.ncdhhs.gov/dma/pharmnews/0308pharm.pdf