To be printed in the 2008 Winter Issue of "The Arkansas Pharmacist"

The Third Party Liability (TPL) Unit of Arkansas Medicaid identifies recipients who have other insurance sources that must pay prior to payment by Medicaid. Federal statute dictates claim rejection at the point of sale (POS) for Medicaid recipients with additional prescription drug coverage if the Medicaid claim does not reflect the third party billing as primary. Third party billing is also addressed in section 340.000, sub-sections 341.000 through 343.000 of every provider manual. Pharmacists currently receive a message in the claim detail section under additional information at POS stating that the recipient has other insurance coverage and provide available private party insurance information. Effective February 13, 2008, Medicaid will begin to deny payment at POS when third party sources are not utilized. If it is determined at point of sale (POS) that the insurance information is incorrect, the beneficiary should contact the DHS/DMS TPL Unit at 501-682-6711, 682-8328, or 682-8339. It is imperative that pharmacists bill all other insurers first, utilizing Arkansas Medicaid as the payer of last resort. To process claims for recipients who no longer have other insurance coverage, the pharmacist must enter the Third Party Liability (TPL) denial date into the TPL denial date field (443-E8 Other Payer Date). This TPL denial override process should only be used for claims that cannot be successfully billed to the primary insurance provider. All Medicaid claims are subject to audit so it is important that providers submit correct claims. If you have questions in reference to billing the Arkansas Medicaid program as a secondary payer, please discuss them with your software vendor. If concerns remain after following vendor instructions, the vendor and/or pharmacy may contact a pharmacist at the Arkansas Medicaid Pharmacy Help Desk at (800) 707-3854 (instate) or (501) 374-6609, ext. 500 (Little Rock local calling area and out of state).

As printed in the 2007 Fall Issue of "The Arkansas Pharmacist"

Arkansas Medicaid was required to implement, by October 1, 2007, a rule to require the use of tamper resistant prescription pads.  The receipt of federal guidance from the Centers for Medicare and Medicaid (CMS) in the middle of August left us little time for promulgation of a rule and sending out provider notification.  At the final hour, just as this rule was to be implemented, on Saturday, September 29, 2007, President George W. Bush signed the “Extenders Law,” delaying the implementation date for all paper Medicaid prescriptions to be written on tamper-resistant paper.  Arkansas Medicaid chose to follow federal guidance and delay implementation until April 1, 2008 at which time you will be receiving further information.

In addition, we have been made aware of issues with the NPI dissemination of data from the National Plan and Provider Enumeration System (NPPES).  Although we had determined October 15, 2007 as the date to allow only the NPI, it is in the best interest of the beneficiaries and providers that we delay this implementation to a later date. 

There are still some pharmacies who have not yet reported their NPI number to EDS.  Arkansas Medicaid encourages providers to use our website for easy reporting of your NPI. Go to www.medicaid.state.ar.us and double click on the “Provider” icon to enter your Arkansas Medicaid Provider number and SSN or Tax ID to report your NPI.  If you need assistance with the Web site, you may call our help desk at 1-866-311-5502 (Local 501-301-7611).

The Third Party Liability (TPL) Unit of Arkansas Medicaid identifies recipients who have other insurance sources that must pay prior to payment by Medicaid. Currently, pharmacists receive a message at POS stating, in the claim detail section under additional information, that the recipient has other insurance coverage as well as providing available private party insurance information.  At a point in the future, Medicaid will be required to deny payment at POS when third party sources are not utilized.  It is in your best interest to share this insurance coverage information with your patients to allow for a smooth transition when the edit is set. If it is determined that the insurance information is incorrect, the beneficiary should contact the DHS / DMS TPL Unit at 501-682-6711 to assure the information is corrected.  

It is imperative that pharmacists bill all other insurers first, utilizing Arkansas Medicaid as the payer of last resort.   Pharmacy providers will be notified in advance prior to final implementation of the referenced TPL edit.  

If you have questions in reference to billing the Arkansas Medicaid program as a secondary payer, please discuss them with your software vendor.  If concerns remain after following vendor instructions, the vendor and/or pharmacy may contact a pharmacist at the Arkansas Medicaid Pharmacy Help Desk at (800) 707-3854 (in state) or (501) 374-6609, ext. 500 (Little Rock local calling area and out of state

 

As  printed in the 2007 Spring Issue of "The Arkansas Pharmacist"

New Drug Class for PDL:  2nd Generation Antidepressants

Effective April 10, 2007 the following drugs will be the preferred drugs in the 2nd Generation Antidepressant class and will be reimbursed by Arkansas Medicaid without prior authorization (PA):  bupropion regular release tablets, citalopram tablets and solution, fluoxetine 10 mg, 20 mg capsules and solution, Lexapro® (escitalopram) 10 mg and 20 mg tablets, mirtazapine 15 mg, 30 mg and 45 mg tablets, paroxetine HCL regular release tablets, Pexeva® (paroxetine mesylate), sertraline tablets and oral concentrate, venlafaxine regular release tablets, and Wellbutrin XL® (bupropion XL) tablets.  Patients who are stable and compliant on their current medication regimen, defined as at least 90 days of the same medication and dose out of the previous 120 days, will be allowed to continue the medication therapy.  The Arkansas Medicaid Drug Utilization Review (DUR) Board voted to implement clinical edits regarding dose and therapeutic duplication for the 2nd Generation Antidepressant drug class.  The edits may be viewed at www.medicaid.state.ar.us.  If a prescriber believes that a non-preferred product is medically necessary and the patient does not meet the clinical edit criteria, the prescriber may contact the UAMS PA Call Center at 501-526-4200 or 866-250-2518 to speak directly with a clinical pharmacist or physician regarding the request for a non-preferred drug.

 Revised Clinical Edits regarding C-II Stimulants

As of March 12, 2007, revised clinical edits regarding C-II stimulants were implemented.  In addition to the existing therapeutic duplication edit which allows concurrent therapy of one long-acting C-II stimulant and one short-acting C-II stimulant, the new therapeutic duplication edits allow for (1) an inferred change in therapy from the same prescriber and (2) creation of commercially unavailable strengths from the same prescriber. That is, a therapeutic duplication with a different date of service for two prescriptions with overlapping day’s supply will pay at the point-of-sale (POS) once per 93 days for either two different long or short-acting stimulants (inferred change).  Or, when it is necessary to combine two agents to make a dose that is not commercially available, a therapeutic duplication with the same date of service and prescriber for both prescriptions will pay at the POS for either two different long or short-acting stimulants.

Also effective March 12, 2007, the DUR board implemented revised dose optimization and maximum dose edits.  Certain C-II stimulant maximum doses have been revised from the previous edits posted to either bring the dose up to 2X the FDA maximum recommended dose or to reduce the maximum dose allowed for that strength.  Dose optimization limits the number of tablets/capsules per day based on the FDA recommended administration schedule.  Since long-acting C-II stimulants are indicated for once daily dosing, a patient taking #2 Metadate CD 10 mg capsules daily should instead dose optimize to #1 Metadate CD 20 mg capsule daily.  A complete listing of C-II stimulants and the maximum daily dose allowed with dose optimization may be viewed at www.medicaid.state.ar.us .  

As printed in the 2006 Fall Issue of "The Arkansas Pharmacist:
Reminder: Drug-Drug Interactions Severity Level 1 - What does this really mean?

At the July 2006 Medicaid Pharmacy Drug Utilization Review (DUR) board meeting, concern was voiced by the members regarding the drug-drug interaction of QT prolonging medications. Interactions pertaining to QT prolongation are just one subset of drug-drug interactions classified as a Level 1 severity. The alerts designated as severity level 1 are contraindicated drug combinations that are clearly contraindicated in all cases and should not be dispensed or administered to the patient. Level 1 Severity interactions are alerted to the pharmacist at the point of sale, and require an override by the pharmacist. By overriding this interaction, the pharmacist is taking the responsibility for the outcome related to the interaction. According to the data from the Prospective DUR report presented at the July DUR board meeting, the above mentioned drug-drug interaction alert was overridden 73% of the time.

Arkansas Medicaid Third Party Liability (TPL) Update

As many of you know, federal statute requires that prescription claims submitted to the Medicaid program be rejected at the Point of Sale (POS) if the patient has another source of insurance. The Arkansas Medicaid Program has been notifying pharmacies of the potential presence of other insurance coverage with a message at the POS, but has not been rejecting claims.
The Centers for Medicare and Medicaid Services (CMS) will be requiring the state to enforce this edit in the near future. The Arkansas Medicaid Program will notify pharmacies as to the effective date as soon as they receive word from CMS. In the meantime, when you see this message at the POS saying there is other insurance coverage, confirm this with your patient and submit the claim accordingly. If there is an error and the patient does not have additional coverage, then the beneficiary should call Medicaid's TPL Unit at 501-682-6711 to clarify. Please remember when dealing with a Medicaid recipient who has other insurance coverage, Medicaid is the payor of last resort.

CMS Termination Date Notice

Effective October 10th, 2006, Arkansas Medicaid will reject drug claims with a date of service equal to or greater than one year after the termination date of the National Drug Code (NDC) submitted on the claim. The termination date represents the shelf-life expiration date of the last batch produced, as supplied on the Centers for Medicare and Medicaid Services (CMS) quarterly update. The date is supplied to CMS by the drug manufacturer/distributor. Claims rejecting for this edit will post rejection code 77 (Drug Discontinued)as well as the error code 9050 (Discontinued prior to DOS).

As printed in the 2006 Spring Issue of "The Arkansas Pharmacist"

Arkansas Medicaid Prescription Drug program maintains a Drug Utilization Review committee that is responsible for reviewing drug claims submitted by pharmacies that are enrolled in the Arkansas Medicaid Program. Information submitted by these pharmacy claims are submitted to the prescribers for comments or concerns. In order for Arkansas Medicaid to correctly identify the prescribers, the prescriber's Arkansas Medicaid ID number (if enrolled) must be indicated on the claim. During the review process two situations have been noted that interfere with identifying the correct prescriber on the claims: a high volume of NP+last name in place of the provider ID and entering an incorrect prescribing provider ID number on the claim.
In order for the drug utilization reports to work properly it is imperative that the correct prescriber's Arkansas Medicaid ID number be listed on the Pharmacy claim. The NP + last name designation is reserved for a "truly non-enrolled prescriber". As an example, Nurse Practitioners within the following specialties may enroll as Medicaid providers: Family Nurse Practitioner, Pediatric Nurse Practitioner, Obstetric-Gynecologic Nurse Practitioner, and Gerontological Nurse Practitioner. The NP + last name format would be appropriate for all other nurse practitioners. For a nurse practitioner OR FOR ANY OTHER PRESCRIBER, the NP + last name designation should only be entered on a pharmacy claim when the pharmacy has confirmed the prescriber is not enrolled as an Arkansas Medicaid provider and has not been assigned a temporary prescriber identification number.
Prescribers receive Protected Health Information (PHI) from Drug Utilization Review based on data received from pharmacy claims. We have been receiving complaints from many prescribers indicating that they have not prescribed or have never seen the patient indicated on the reports. Please assure the accuracy of the prescriber information prior to submitting a claim to Arkansas Medicaid.
The Arkansas Medicaid prescriber list was recently mailed to those pharmacies that have billed using the NP+last name format. If you have a prescriber that does not appear on the report, you can email the prescriber's name and address and request for verification of provider ID number to Glenda Dye at glenda.matchett-dye@medicaid.state.ar.us.
Another issue that we would like to bring to pharmacists' attention is identifying potential recipient misuse or abuse of the extension of the prescription drug benefit limit. If you feel a Medicaid client is abusing their extension of benefits or is a candidate for pharmacy lock in, you can email the client's name and Medicaid ID number to Glenda Dye at the above email address. She can review the client's drug history for necessary action.
As mis-bill issues and appropriate care issues are identified, the Medicaid Pharmacy Program continues to add prospective drug utilization edits to the system in the way of quantity limit edits and clinical edits. The edits can be reviewed online at the following url: http://www.medicaid.state.ar.us/InternetSolution/Provider/pharm/scripinfo.aspx.

As printed in the 2006 Winter Issue of "The Arkansas Pharmacist"
Effective January 18, 2006, all promethazine and promethazine containing preparations will be denied at the point of sale by Arkansas Medicaid for recipients less than two years of age. 

Effective January 18, 2006, the following Sedative/Hypnotic oral dosage forms: estazolam (Prosom®), eszopiclone (Lunesta®), flurazepam (Dalmane®), ramelteon (Rozerem®), quazepam (Doral®), temazepam (Restoril®), triazolam (Halcion®), zaleplon (Sonata®) and zolpidem tartrate (Ambien®) will be denied at the point of sale by Arkansas Medicaid for claims with a dose greater than one daily. 

Effective February 15, 2006, drug claims that are submitted at point of sale (POS) for Fentanyl transdermal patches, Infergen, PEG Intron, Pegasys, Climara Patches, Estrogen Patches, Betaseron, Avonex Admin Pack, Actonel, Actonel weekly,  Actonel-Calcium, Boniva, Depo-SubQ Provera 104mg/ml syringe, Depo-Provera Contraceptive Injection 150mg/ml syringe and vial, Prozac weekly, EpiPen and EpiPen Jr. will have quantity limits established. 

 The edits can be found on the Arkansas Medicaid website at www.medicaid.state.ar.us.  Click on  Provider, next click on Prescription Drug Information, then Prescription Drug Claim Edits for drugs with quantity and dose limits. 

As  printed in the 2005 Fall Issue of "The Arkansas Pharmacist"
To assure that pharmacies are aware of the information available by Arkansas Medicaid, here are some resources. The following sites are available for your assistance at www.medicaid.state.ar.us . Click on provider, then on prescription drug information, which will take you to the following links:


Prescription Drug Clinical Edits
Prescription Drug Claim Edits
Evidence-Based Prescription Drug Program
Prescription drug PA forms
Alternate drugs that do not require prior authorization through the VRS nor Clinical Edits
NDCs for reference in initiating PAs through the VRS
Generic upper limits
Capped upper limits
MedWatch forms and information
Cough and cold list
Over-the-counter list
Covered labelers
Exclusions from coverage
Voice response system brochure
Tobacco cessation programs


The EDS Prescription Drug Help Desk numbers are available for information regarding any of the links listed above with the exception of the Evidence-Based Prescription Drug Program. EDS Prescription Drug Help Desk: 1-800-707-3854 (in-state, not local) or 1-501-374-6609 ext. 500 (Little Rock, out-of-state).

For assistance regarding the Evidence-Based Prescription Drug Program and the Arkansas Medicaid Preferred Drug List you may contact the UAMS College of Pharmacy Help Desk at 1-866-250-2518 (toll free) or 526-4200 (Little Rock).