Fillable Printable Ihs Chap10Pharmacy
Fillable Printable Ihs Chap10Pharmacy
Ihs Chap10Pharmacy
IHS/TRIBAL PROVIDER BILLING MANUAL
CHAPTER 10PHARMACY
Arizona Health Care Cost Containment System 10-1
IHS/Tribal Provider Billing Manual
REVISION DATES: 10/13/2015EFFECTIVE10/01/2015;
05/31/2012
Covered Services
Medically necessary federally reimbursable medications prescribed by a physician,
physician assistant, nurse practitioner, dentist or other authorized practitioner and
provided by a licensed participating pharmacy or dispensed under the direct supervision
of a licensed pharmacist, registered according to state law, are covered for all
recipients.
Specific Parameters of the AHCCCS Pharmacy Benefit
The AHCCCS Pharmacy Program and its Pharmacy Benefit Manager (PBM):
1.Shall utilize a mandatorygeneric drug substitution policyunless AHCCCS has
required the use of a brand name medication. The substitution of a generic drug in
place of a brand namedrug is required if the generic drug is available and contains
the same active ingredient(s) and both products, the brand name and generic, are
chemically identical in strength, concentration, dosage form and route of
administration. Generic substitutions shall adhere to Arizona State Board of
Pharmacy rules and regulations.
Exceptions to this policy include:
a.Members intolerant to a generic medication. The prescribing clinician may
be required to submit a prior authorization to the Contractor providing
clinical justification for the brand name medication.
b.AHCCCS has determined that the brand name medication is less costly to
the Program.
2.May utilize step therapy to ensure that the most clinically appropriate cost-effective
drug is prescribed and triedby the member priorto prescribing a more costly
clinically appropriate medication with the exception of members enrolled in a
managed care plan who have been stabilized andare transitioningfrom a T/RBHA
to aPCP for their behavioral health needs (anxiety, ADHD, and depression). The
medication, prescribed by the behavioral health practitioner and clinically
appropriate, must be continued at the point of transition.
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3.May utilize prior authorization to ensure clinically appropriate medication use.
Requests submitted for prior authorization of a medication must be evaluated for
clinical appropriateness based on the strength of the scientific evidence and
standards of practice that include, but are not limited to the following:
a.Food and Drug Administration (FDA) approved indications and limits. The
fact that the medication is not FDA approved for a specific diagnosis
and/or condition is not a basis to deny theprior authorization request if
there is supporting documentation with information specified in b-e below
as appropriate.
b.Published practice guidelines and treatment protocols,
c. Comparative data evaluating the efficacy, type and frequency ofside
effects and potential drug interactions among alternative products as well
as the risks, benefits and potential member outcomes
d.Member adherence impact, and
e.Peer reviewed medical literature, including randomized clinical trials,
outcomes, research data and pharmaco-economic studies.
4.May cover an over-the-counter medication under the pharmacy benefit when it is
prescribed in place of a covered prescription medication that is clinically appropriate,
equally safe and effective, and less costly than the covered prescription medication.
AHCCCS Minimum Required Prescription Drug List (MRPDL)
AHCCCS has developed a list of medications that must be available to all members
when medically necessary. The MRPDL is available on the AHCCCS website at:
//www.azahcccs.gov/commercial/pharmacyupdates.aspx
1.AHCCCS has developed the MRPDL to assist providers when selecting clinically
appropriate medications for AHCCCS members.
2.The MRPDL specifies medications that are available without prior authorization
as well as medications that have specific quantity limits, or require step therapy
and/or prior authorization prior to dispensing to AHCCCS members. The
AHCCCS FFS Program is required to cover all medically necessary, clinically
appropriate, cost effective medications that are federally and state reimbursable.
3.Federally reimbursable medications, not listed on the MRPDL or on the AHCCCS
FFS Drug List (ADL), may be available through the prior authorization process.
Prescribers may submit aprior authorization request to the AHCCCS FFS
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Pharmacy Benefit Manager (PBM), OptumRx, for review and coverage
determination. The Prior Authorization Form is Exhibit 10-1 or can be located on
the AHCCCS website under the PharmacyInformation section at
www.azahcccs.gov.
4.The AHCCCS Pharmacy & Therapeutics Committee shall:
a.Review the MRPDL at a minimum, annually.
b.Reviewnew drugs approximately 180 days from the date they become
commercially available.
c. Respond to questions and requests for medication additions, deletions or
MRPDL changes submitted to AHCCCS by Contractors
5. The MRPDL is not applicable to drugs provided by Tribal/Regional Behavioral
Heath Authorities (T/RBHAs).
Pharmacy Exclusions
The following medications or drug therapeutic classes are excluded from coverage
under the outpatient pharmacy benefit and are not included on the AHCCCS FFS Drug
List:
1.DESI Drugs that are determined to be “less than fully effective” by the Food
and Drug Administration
2.Anti obesity agents
3.Experimental / research drugs
4.Cosmetic drugs
5.Cosmetic drugs for hair growth
6.Immunizations
7.Nutritional / diet supplements
8.Blood and blood plasma products with the exception of hemophilia factor
Products
9.Fertility drugs
10.Erectile dysfunction drugs unless prescribed to treat a condition other than
sexual or erectile dysfunction and the Food and Drug Administration has
approved the medication for the specific indication
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11.Drugs from manufacturers that do not participate in the FFS Medicaid Drug
Rebate Program
12.Diagnostic products
13.Intrauterine devises
14.Medical supplies except:
a. Syringes
b. Needles
c. Lancets
d. Alcohol Swabs
e. Blood glucose meters and test strips
15.Medications that are personallydispensed by a physician, dentist or other
provider except in geographically remote areas where there is not a
participating pharmacy or when accessible pharmacies are closed.
16.Outpatient medications for members under the Federal Emergency Services
Program.
17.Medical Marijuana. Refer to AMPM Policy 320-M, Medical Marijuana.
18.Drugs covered under Medicare Part D for AHCCCS members eligible for
Medicare whether or not the member receives Medicare Part D coverage.
Pharmacy Coverage Limitations
Prescriptions are limited to a 30-day supply or 100-unit doses, whichever is more,
except:
for prescriptions for chronic illnesses, which are limited to a 100-day supply or
100-unit doses, whichever is more
When the member will be out of the provider’s service area for an extended
period of time and the prescription is limited to the extended time period, not to
exceed 100 days or 100-unit dose, whichever is greater
Contraceptive medications are limited to no more than a 100-day supply.
Non-prescription drugs and medicines are not covered except when appropriate
alternative non-prescription drugs are available and less costly than prescription drugs
and prescribed by a physician or other authorized practitioner.
Drugs personally dispensed by a physician or dentist, or other authorized prescriber are
not covered. Exceptions may be granted upon application and approval by AHCCCS for
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registration as a pharmacy provider in geographically remote areas where there is no
participating pharmacy.
Refills of a prescription in excess of the number specified and any refill dispensed more
than one year from the original order date are not covered.
Drugs designated under the Drug Efficacy Study Implementation (DESI) as ineffective
are not covered. The information AHCCCS receives from First Data Bank indicates
which drugs are so designated with a "DESI" beside the drug name.
Prescription drugs for covered transplantation services will be provided in accordance
with AHCCCS transplantation policies.
AHCCCS covers the following for members eligible to receive Medicare:
Medically necessary barbiturates except those prescribed for the treatment of
epilepsy, cancer or a chronic mental health condition; and
Over the counter medication that are not covered as part of the Medicare Part D
prescription drug program and meet the requirements of the AHCCCS step
therapy program as described on page 1 of this policy.
AHCCCS Pharmacy Benefits Manager (PBM)
Prior to date of service 10/01/2015 MedImpact Health Systems, Inc., a pharmacy
benefits manager (PBM), administered the fee-for-service pharmacy benefit. For
information regarding pharmacy claims, contracted providers, or the formulary, contact
MedImpact at (800)788-2949.
Claims must be submitted electronically to MedImpact. Claims are processed
electronically using a point-of-sale process.
For assistance with on-line claim submission, contact the MedImpact Customer Service
Help Desk at (800)788-2949. The MedImpact Help Desk hours of operation are:
Monday – Friday: 6:00 AM – 6:00 PM Pacific Standard Time
Saturday and Sunday: 6:00 AM – 2:30 PM Pacific Standard Time
MedImpact will continue to assist with any unresolved issues with fill dates through
September 30, 2015. They can be reached at (800)788-2949.
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Effective on date of service 10/01/2015 the new pharmacy benefits manager is:
OptumRx
For information regarding prescription claims, contracted network pharmacies, or the
medication formulary, please contact OptumRx at (855) 577-6310.
General questions may be directed to AHCCCS Director of Pharmacy Services
Program Administrator at (602) 417-4726.
If a claim is rejected for "NDC Not Covered" or "Prior Authorization Required," ask the
prescribing physician to consider an appropriate alternative formulary medication or
submit a Prior Authorization Request to OptumRx
.
Some drugs on the formulary require prior authorization from OptumRx. The prescribing
physician must submit all Prior Authorization Request forms. If a patient meets the
criteria for authorization, the prescribing physician should fax the OptumRx Prior
Authorization Request form (See Exhibit 10-1) to (866) 463-4838
.
Drugs not listed on the formulary also require PA from OptumRx. Authorization of a
non-formulary medication will be considered for compelling medical reasons such as
documented treatment failure or severe adverse drug reactions with formulary drugs.
After 5:00 p.m. on weekdays, on weekends, and holidays, you may fill and dispense a
prescription that requires prior authorization or is not covered under the formulary if the
drug belongs to one of the following drug classes:
Antibiotics
Analgesics (NSAID)
Muscle relaxants
Anticonvulsants
Antiarrhythmic Agents
On the next business day, you must fax a Prior Authorization Request form to OptumRx
and indicate on the request that the prescription was filled after hours. OptumRx will
enter the PA request in the system for adjudication.
A prescribing physician should not submit a PA request for after hours emergency drugs
on the next business day. After hours emergency drug requests will be approved
automatically when submitted by the pharmacy on the next business day.
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After HoursInstructions
Forhospitaldischarge prescriptions presented afterhoursat the retailpharmacy, the
pharmacy staff should contact the OptumRx Customer Service Desk at (855)577-6310 to
requesta hospital discharge override.
Return of andCredit for UnusedMedications
The AHCCCS FFS Program and its Contractors shall require the return of unused
medications to the outpatient pharmacy from nursing facilities (NFs) upon the
discontinuance of prescriptions due to the transfer, discharge or death of a Medicaid
member. A payment credit shall be issued for unused prescription medications by the
outpatient pharmacy to the AHCCCS FFS PBM or the appropriate Contractor. The
pharmacy may charge a reasonable restocking fee as agreed upon with the AHCCCS
FFS Program or its PBM. The return of unused prescription medication shall be in
accordance with Federal and State laws. Arizona Administrative Code (A.A.C. R4-23-
409) allows forthis type of return and the redistribution of medications under certain
circumstances.
Documentation must be maintained and must include the quantity of medication
dispensed and utilized by the member. A credit must be issued to AHCCCS when the
unused medication is returned to the pharmacy for redistribution.
Prior Authorization Protocol for Smoking Cessation Aids
AHCCCS has established a prior authorization protocol for smoking cessation aids.
Refer to the AHCCCS Medical Policy Manual (AMPM) Policy 320-K, Tobacco
Cessation Product Policy.
Prior Authorization & Prescription Claims Billing
Some medications on the formulary and all non-formulary medications may require
prior authorization approval. If a prescription claim rejects at the point-of-sale for "NDC
Not Covered" or "PriorAuthorization Required," the pharmacist should contact the
prescribingclinician to request a formulary alternative. If there isnot a formulary
alternative, the pharmacist should inform the clinician that a prior authorization request for
the medication must be submitted to the PBM for review.
All prior authorization requests must be submitted by the prescribing clinician and
faxed to OptumRx.
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The OptumRx PA Request Form (See Exhibit 12-1) is to be faxed to 866-463-4838.
The OptumRx Prior Authorization Department’s hoursof operation are:
Monday – Friday: 7:00 AM – 6:00 PM Central Standard Time
Saturday: 8:00 AM – 4:30 PM Central Standard Time
Prior Authorizations may be faxed 24/7, 365 days per year.
All Fee-For-Service prescription claims must be submitted electronically at the point-of-
sale to the AHCCCS contracted PBM.
Forassistance with on-line claim submission, contactthe OptumRx Customer Service
Help Desk at (855)577-6310.The OptumRx Help Deskhoursof operation are 24 hours
per day, 365 days per year.
Billing for Pharmacy Services
Claims for Title XIX (Medicaid) recipients
Claims for Title XIX recipients should be submitted to the AHCCCS Administration on
the UB-04 claim form (or 837I for electronic claims) or submitted via the AHCCCS
website.
Use revenue code 519 (Other Clinic).
Use bill type 131 (Hospital outpatient, admit through discharge) or 711 (Clinic,
rural health, admit through discharge).
Enter the outpatient All Inclusive Rate (AIR) in the Total Charges field (Field 47).
The AHCCCS Claims System will reimburse the pharmacy claim at the outpatient AIR
rate.
When Title XIX recipient is DUAL eligible (Medicare):
and the pharmacy billing is for covered diabetic supplies (syringes, needles,
lancets, alcohol swabs, blood glucose meters and test strips) then the Medicare
Part B EOMB for these supplies must be submitted with the claim if the member
is eligible for Medicare Part B benefits.
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then refer to the AHCCCS Dual Formulary on the AHCCCS Pharmacy website at
//www.azahcccs.gov/commercial/Downloads/PharmacyUpdates/AHCCCSDu
alFormulary.pdf
for the medications that can be billed (not covered under Medicare Part D).
Claims for Title XXI (KidsCare) recipients
Claims for Title XXI (KidsCare) recipients must be submitted to OptumRx as described
in this chapter.
These claims will be reimbursed in accordance with the formulary.
REVISION HISTORY
Date
Description of changes
Page(s)
10/13/2015
Newformatting;
NewPBM vendor effective 10/01/2015
NewExhibit 10-1 OptumRX Prior Authorization Form
All &
Exh 10-1
12/31/2012
Section title alpha corrections
All
10/01/2012
NewPBM vendor –MedImpact effective 10/01/2012
All
