Prescription Drug Program Examples: > Prescriptions written by dentists will be paid fee-for-service without any special comments when the dentist's performing provider number is placed on the claim in the prescriber ID field. > Antibiotics, anti-infectives, non-narcotic analgesics, and oxytocics prescribed following abortion procedure are reimbursable on a fee-for-service basis for clients enrolled in a Healthy Options managed health care plan. > Over-the-counter contraceptives from a non-plan contracted pharmacy. > Protease Inhibitors. Healthy Options Clients Who Self Refer Healthy Options managed care clients may self-refer to any of the following entities and receive prescriptions related to the therapeutic classifications listed below. The prescriptions are reimbursable on a fee-for-service basis and, clients may take these prescriptions to any Medicaid- participating pharmacy. Pharmacists must document the prescribing entity (e.g., mental health center) on the original prescription. All other fee-for-service rules apply to claims for the therapeutic classes listed below, including prior authorization requirements. -Community Mental Health Centers may prescribe mental health drugs within the following therapeutic drug classes: Attention Deficit Hyperactive Disorder (ADHD) drugs (e.g., Cylert, Methylphenidate) Antianxiety Anticonvulsants Antidepressants Antipsyschotics Central Nervous System (CNS) drugs Pharmacies may bill MAA for selected ancillary drugs used as an integral part of the total mental health therapy when prescribed by a Community Mental Health Center. These drugs may be prescribed in addition to the therapeutic classes listed above. December 1998 Cuent Eugib1Lty -B.5- Prescription Drug Program The following is a list of Community Mental Health ancillary drugs. Any strength or dose form not listed below will not be covered under these provisions. Aldneton 2 mg tab Amantadine 100 mg caps-and 50 mg/5 ml liquid Atenolol 25 mg, 50 mg, and 100 mg tabs Benztropine mesylate 0.5mg, 1mg, 2mg tabs Carbamazepine 100mg chew tab or 200mg tab Clonazepam 0.5mg, 1.0mg, and 2mg tabs Clonidine 0.1 mg, 0.2mg, and 0.3mg tabs (no patches) Cytomel (T4) 5mcg, 25mcg, and 50mcg tabs Depakote 125mg and 250mg tabs Diphenhydramine 25mg and 50 mg caps Guanfacine lmg and 2mg tabs Hydroxyzine Pamoate 25mg caps, 25mg/ml, 50mg caps, 50mg/ml, 100mg caps Kemadrin 5mg tab L-Thyroxine all strengths Nadolol 20mg, 40mg, 80mg, 120mg, and 160mg tabs (no sustained action - SA) Neurontin 100mg, 300mg, and 400mg caps Pindolol 5mg and 10mg tabs Propranolol 10mg, 20mg, 40mg, 60mg, 80mg, and 90mg tabs (no sustained action - SA) Tegretol 100 mg chew tab, 100mg/5m1, or 200mg tab Trihexyphenidyl 2mg tabs, 5mg, SA, and tabs Vitamin E (expedited prior authorization only for Tardive Dyskensia) Family Planning Agencies may prescribe sexually transmitted disease (STD) drugs (excluding HIV drugs), abortion-related drugs and prescription contraceptives within the following therapeutic drug classes: Analgesics Antibiotics Anti-emetics (refer to list on page B.7) Anti-infectives Anti-inflammatories Contraceptive drugs/devices Oxytocics Health Departments may prescribe STD drugs (excluding HIV drugs), tuberculosis drugs, and prescription contraceptives within the following therapeutic drug classes: Antibiotics Anti-emetics (refer to list on page B.7) Anti-infectives Contraceptive drugs/devices Tuberculosis drugs (Revised September 1999) Client Eligibility # Memo 99-52 MAA - B.6 - Prescription Drug Program Coverage/ Program Limitations What drugs and pharmaceutical supplies are covered? The Medical Assistance Administration (MAA) will reimburse for. I. Outpatient legend drugs. 2. Over-the-counter (OTC) drugs when the drug is: • Prescribed; and • A less costly therapeutic alternative; and • Formulary. 3. Compounded prescriptions. 4. Non-formulary drugs when prior authorized by the department. 5. Family planning supplies used in conjunction with family planning, including OTC supplies. Covered family planning OTC supplies include, but are not limited to, hormonal contraceptives, spermicidal contraceptives and barrier contraceptives. 6. Oral, topical and/or injectable drugs, vaccines for immunizations, and biologicals, prepared or packaged for individual use and dispensed or administered to a client by an authorized provider. 7. Diabetic supplies such as insulin syringes and needles, blood/urine test strips and tape, lancets and lancet devices, glucose monitor control solutions. December 1998 Coverage/Program Limitations -C.1- Prescription Drug Program What drugs and pharmaceutical supplies are not covered? The Medical Assistance Administration (MAA) does not reimburse for the followings items or services: 1 • Drugs supplied by drug manufacturers who have not entered into a drug rebate agreement. Exceptions are listed in the Drug Rebate section of these billing instructions. 2. Drugs regularly supplied as an integral part of program activity by other public agencies such as the United States Veteran's Administration, United States Department of Health and Human Services, Indian Health Services, local health departments, etc. 3. Drugs prescribed: • For weight loss or gain. • To promote fertility, treat impotence or frigidity. • For cosmetic purposes or hair growth. • To promote smoking cessation; or • For an indication which is not medically accepted as determined by MAA in consultation with federal guidelines, the Drug Utilization Education Council (DUEC), and MAA medical and pharmacy consultants. 4. Over-the-counter (OTC) drugs/supplies requested solely by the client. (When prescribed by a licensed prescribing authority, prior MAA authorization may be required.) (See OTC list.) Exceptions: Condoms (including female condoms), vaginal spermicidal foam with applicator and refills, vaginal jelly (with applicator), vaginal contraceptive sponge, vaginal contraceptive film, and vaginal suppositories. 5. Drugs listed in the federal register as "less-than-effective" ("DES!' drugs) or which are identical, similar, or related to such drugs. (See Less-Than-Effective Drug Index section.) 6. Prescription vitamins and mineral products in the absence of a condition that is clinically documented to produce a deficiency state, except prenatal vitamins and fluoride preparations. Prenatal vitamins are covered only when prescribed and dispensed to pregnant women. Fluoride preparations are covered only for children, under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT or "Healthy Ki(&) services. December 1998 Coverage/Program Limitations -C.2- Prescription Drug Program 7. Drugs that are experimental, investigational, or of unproven efficacy or safety. 8. Preservatives, flavoring, and/or coloring agents used in the process of compounding. 9. Prescriptions written on pre-signed prescription blanks filled out by nursing facility operators or pharmacists. 10. Drugs used to replace those taken from nursing facility emergency kits. 11. Free pharmaceutical samples. 12. Obsolete National Drug Code (NDC) 13. Terminated drug products. 14. Any drug, biological product, or insulin provided as part of, or incident to and in the same setting as, any of the following: • Inpatient hospital setting. • Hospice services. • Dental services, except as authorized under the state plan. • Physician's services. • Outpatient hospital services emergency room visit. • Other laboratory and x-ray services; or • Renal dialysis. 15. Any of the following drugs: • Outpatient nonprescription drugs. • Covered outpatient drugs for which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee. 16. Medical supplies (non-drug items) are not covered under the prescription drug program. Exceptions: - Contraceptive devices. > Insulin syringes and needles. > Blood/urine test strips and tape. > Lancets and lancet devices; or Glucose monitor control solutions. All other medical supplies should be billed to the Durable Medical Equipment or Non- Durable Equipment & Supplies Program on a HCFA-1500 claim form. December 1998 Coverage/Program Limitations -C.3- Prescription Drug Program Where to call for prior authorization For drug products requiring authorization, please call: 8 Drug Utilization & Review 1-800-848-2842 Mail or fax your information to: Division of Health Services Quality Support Drug Utilization & Review PO Bo=-45506 Olympia, WA 98584.5506 9 Far. (360) 586.5299 What to do if a pharmacist receives a denial code The following table indicates the type of Denial Edit/Conflict Code providers will receive if they submit a POS claim for a drug that requires prior authorization number. Please have your MMIS 7-digit provider number (beginning with a "6") available when you contact MAA to request prior authorization. DENIAL EDIT/ CONFLICT CODE REASON CLAIM DENIED ACTION 0 Expedited drugs requiring prior authorization. Pharmacy should submit A Required using appropriate expedited PA procedure. 5 Brand Name Medications listed below Pharmacy or physician require prior authorizations: should call MAA for A Required authorization. Percodan Tuinal Percocet Seconal Valium Nembutal Vicodin Demerol w/APAP Xanax Anexsia Non-HCFA Rebate Company Products: Duofilm Rimso-50 Other Drugs: All non-formulary products. December 1998 Prior Authorization -G.2-