Microsoft word - medicaid pharmacy changes for pharmacies and prescribers.docx

Information for Medicaid Pharmacy Providers and Prescribers
Pharmacy Program Changes Effective October 1, 2011
Changes to the Ohio Medicaid Pharmacy program that will be effective on October 1, 2011: 1. Change in pharmacy billing and coverage for members of Medicaid-contracting managed 2. Change to fee-for-service Medicaid Preferred Drug List (PDL) Policy Guidance
1. Change in pharmacy billing and coverage for members of Medicaid-contracting MCPs Beginning October 1, 2011, the Medicaid MCPs will resume responsibility for pharmacy coverage and payment for their members. Claims for pharmacy services for consumers enrolled in Medicaid-contracting MCPs should be billed to the appropriate MCP. Claims for managed care consumers submitted by pharmacy providers through ACS, the Medicaid fee-for-service claims processor, will deny with NCPDP edit 41: "submit bill to other processor." Additional messaging will instruct the pharmacy to bill the MCP, and identify the plan by name. The pharmacy should ask the consumer for the MCP identification card to identify the claims processing information and cardholder ID. Please be reminded that although MCPs that serve Ohio Medicaid consumers cover prescription drugs listed on the Ohio Medicaid list of covered drugs, MCPs may have preferred drug lists and prior authorization requirements that are different from the fee-for-service policy described in this MAL. Please see http://jfs.ohio.gov/OHP/bmhc/index.stm for information about Medicaid MCPs. ODJFS and the MCPs are working closely to align prior authorization policies as much as possible to lessen confusion for prescribers and pharmacies. Questions from pharmacies about contracting with and billing the MCPs should be directed to each plan. Links to each MCP's website are available at http://jfs.ohio.gov/OHP/bmhc/index.stm. Links to each MCP’s pharmacy coverage information and a common prior authorization form that can be used with all MCPs are available at http://jfs.ohio.gov/ohp/bhpp/meddrug.stm. Pharmacy Billing and
Pharmacy Billing and
Plan Name
Contracting Phone
Contracting Website
Community Plan of Ohio (Prescription Solutions) WellCare of Ohio 2. Change to fee-for-service Medicaid Preferred Drug List (PDL) The newest phase of the Ohio Medicaid Preferred Drug List (PDL) will be effective on October 1, 2011. The drug classes were reviewed to determine those products that the Department considers "preferred" for Ohio Medicaid fee-for-service consumers. A "preferred" status in these classes indicates that the product does not require prior authorization (PA) in most situations. Products in these classes that are "non-preferred" are subject to prior authorization. A "quick list" of preferred drugs is available at http://jfs.ohio.gov/ohp/bhpp/meddrug.stm. This site also includes other information about the Ohio Medicaid pharmacy program, including the approved drug list, Pharmacy Provider Manual, PA request fax form, and Pharmacy & Therapeutics Committee information. As previously mentioned, MCPs may have preferred drug lists and/or prior authorization requirements that are different from the fee-for-service policy described in this MAL. Beginning in September, messages are sent back to pharmacies when a drug that will change to prior authorization status is dispensed. This gives the pharmacy an opportunity to suggest to prescribers that they consider the use of an alternative "preferred" medication in the future, if appropriate. All prior authorization requests must be initiated by the prescriber or prescriber’s staff. Prior authorization may be requested prior to October. Ohio Medicaid Preferred Drug List changes effective October 1, 2011 Drugs that will require Prior Authorization beginning with date of service 10/1/2011
Drug class
Drug Name
Antihypertensives Cardiovascular: Angiotensin Receptor Blockers All ARBs and ARB combinations will require step therapy: prior treatment with an ACE inhibitor. Patients currently on an ARB/ARB combination will Cardiovascular: Calcium Channel Blockers Cardiovascular: Lipotropic-Calcium Channel Blocker Combination Central Nervous System: Antidepressants Central Nervous System: Medication Assisted Symlin, Byetta, and Victoza will require step therapy: prior treatment with a non-DPP-4 oral hypoglycemic or insulin. Patients currently on a Symlin, Byetta, or Endocrine: Dipeptidyl Peptidase-4 (DPP-4) All DPP-4 and DPP-4 combinations will require step therapy: prior treatment with a non-DPP-4 oral hypoglycemic or insulin. Patients currently on a DPP- 4 or DPP-4 combination will not need to change. Gastrointestinal: Helicobacter Pylori Packages Genitourinary: Benign Prostatic Hyperplasia Drugs that will no longer require a Prior Authorization beginning with date of service 10/1/2011.
Drug class
Drug Name
Cardiovascular: Beta Blocker combinations Cardiovascular: Calcium Channel Blockers Cardiovascular: Lipotropics – Bile Acid Risperidone orally disintegrating tablet Central Nervous System: Sedative-Hypnotics Sodium Sulfacetamide-Sulfur 10%/5% lotion,

Source: http://www.epilepsy-ohio.org/documents/Medicaid_Pharmacy_Changes_for_Pharmacies_and_Prescribers.pdf