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Elizabeth M. Whitehorn, Director

Provider Notice issued 05/03/2023

 

Date: May 3, 2023
​To: All Participating Pharmacies; Physicians; Physician Assistants; and Advanced Practice Registered Nurses
​Re: Pharmacy – Resumption of Billing Policies at COVID-19 Public Health Emergency End

This notice provides information regarding pharmacy billing policies that will resume at the end of the COVID-19 public health emergency (PHE). The PHE is scheduled to end on May 11, 2023. The requirements discussed in this notice apply to the Department of Healthcare and Family Services' (HFS) fee-for-service (FFS) program. The Medicaid managed care organizations (MCOs) do not have prescription limits as in the FFS program. The MCOs follow the Preferred Drug List (PDL) but set their own coverage policies and may have later implementation dates for the requirements below. Pharmacies may contact the applicable MCO with questions.

Effective with dates of service on and after May 12, 2023, the following pharmacy requirements that were in place prior to the PHE will resume:

Refill Too Soon

Pharmacies will no longer be able to override Refill Too Soon (RTS) claims by entering a Submission Clarification Code (420-DK) of 13, Payer, Recognized Emergency/Disaster Assistance Request.  When a claim rejects for RTS, the pharmacy will need to request an override through pre-COVID processes. The RTS percentages will also be set back to the same tolerances in place prior to the PHE.

Preferred Drug List (PDL) 

Changes made to the preferred drug list (PDL) as a result of potential drug shortages will be removed from the PDL. During the PHE, all albuterol HFA inhalers,  levalbuterol inhalers, and generic levalbuterol nebulizer solutions were changed to preferred status. These will revert to the pre-PHE classification.   

Updates/changes will be maintained on the Department’s website on the PDL webpage. 

Quantity for supplies

Blood glucose/reagent test strips quantity will be decreased to a maximum of 200 per month. Lancet quantity will be decreased to a maximum of 200 per month. Providers are reminded to bill an accurate day supply even if it exceeds one month.

Quantity limits will be reinstated for Tamiflu, insulin, and suboxone.

OTC Coverage

The temporary coverage granted during the PHE for acetaminophen and cough suppressants containing guaifenesin, dextromethorphan or their combinations will revert to the same status in place prior to the PHE.   

3 Brand Limit

Edits that were removed to allow a customer to receive three brand name drugs during a 30-day period will be put back in place.           

4 Prescription Policy

Edits that were removed to allow a customer to receive more than four prescriptions during a 30-day period will be put back in place.

Third Party Liability

Drugs will again be subject to prior approval in situations where the primary insurance did not pay due to a rejection or customer deductible requirement. These edits will resume, and claims will require an override in accordance with pre-PHE billing policy.

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565.

 

Kelly Cunningham, Administrator

Division of Medical Programs