Michael Silber, Author at In The States

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So far Michael Silber has created 2529 blog entries.

Illinois

The purpose of this Provider Notice is to inform pharmacy providers that the claims adjudication system is now able to process and pay compound claims. The processing system had been paying compound claims at zero since the Change Healthcare outage in March 2024.

At this time, pharmacy providers are encouraged to void and rebill those claims that were either paid at zero or held pending restoration. This applies to fee-for-service (FFS) billing only.

Please call the Bureau of Professional and Ancillary Services at 877-782-5565 and speak to a pharmacy consultant to obtain any necessary overrides on rejections that may occur while rebilling these claims.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Michael Silber2025-11-20T10:03:59-05:00November 20, 2025|Illinois|

Iowa

The Department of Health and Human Services (HHS), Medicaid posted the following. Please note effective December 1, the optional 90-day supply allowance will now be a required 90-day supply prescription list. The list of medications for this requirement is posted on the PDL website; see letter below for details.

INFORMATIONAL LETTER NO. 2713-MC-D: Commercial Lesser of Logic, effective, December 1

INFORMATIONAL LETTER NO. 2711-[MC]: Telehealth Services – Please of Service Codes Reimbursement, effective December 1

INFORMATIONAL LETTER NO. 2710-[MC-FFS-D]: Pharmacy 90-day Supply Requirement, effective December 1

For more information, contact NACDS’ Sandra Guckian at 703-774-4801.

Michael Silber2025-11-20T10:03:26-05:00November 20, 2025|Iowa|

Louisiana

The Department of Health (LDH) announced a webinar on December 4 from 10:00 am to 11:00 am Central Time. This event aims to inform stakeholders about LDH’s Rural Health Transformation Program (RHTP) submission.

For more information, contact NACDS’ Mary Staples at 817-442-1155.

Michael Silber2025-11-20T10:02:55-05:00November 20, 2025|Louisiana|

Minnesota

The Department of Health (MDH) released the final updated Form and Manner for Prescription Drug Data Sets, as well as an updated Frequently Asked Questions Document. Updates impact reporting by all reporting entities, including manufacturers, wholesalers, pharmacy benefit managers and pharmacies.

The updates reflect statutory changes from the 2025 legislative session (Laws of Minnesota, 2025 – 1st Special Session, chapter 3, article 2, sections 6-14) and responses to input received during the comment period. The updates include changes to align reporting elements, modified registration requirements and a change to the reporting period for reporting data on drugs of substantial public interest.

MDH has updated the Rx Data Portal to integrate the statutory changes and make additional enhancements to support reporting entities. These updates are now live and available to all reporting entities.

For more information, contact NACDS’ Jill McCormack at 717-592-8977.

Michael Silber2025-11-20T10:02:24-05:00November 20, 2025|Minnesota|

Nevada

Gov. Joe Lombardo (R) convened a special session of the state Legislature on November 13 to address several key issues, including expanding healthcare access and workforce training.

For more information, contact NACDS’ Mary Staples at 817-442-1155.

Michael Silber2025-11-20T10:01:48-05:00November 20, 2025|Nevada|

North Carolina

The latest Medicaid Pharmacy Newsletter, dated November 2025, is now available on the Medicaid website. In addition to the December 2025 check write schedule, this edition of the newsletter includes the following articles:

Reminder: Immunizing Pharmacist Enrollment in NC Medicaid Contraceptives and NRT Protocol Reimbursement to Pharmacies

Reminder on NC Medicaid Pharmacy Co-payment Requirements

NC Medicaid's Participation in Centers for Medicare & Medicaid Services Cell and Gene Therapy Access Model for Sickle Cell Disease

Discontinuation of Coverage: Xifaxan (Rifaximin)

North Carolina to Launch First-of-its-Kind NC Medicaid Managed Care Plan for Children and Families on December 1, 2025

Updates to Coverage for Wegovy and Zepbound for Clinical Indications Other than Weight Loss

Immunizing Pharmacist Enrollment and Medical Claims Billing Update

Providers are encouraged to review this important information. The 2025 Medicaid Pharmacy Newsletters can be viewed here.

Also in North Carolina, effective December 7, the Electronic Funds Transfer (EFT) Attestation will be added to the reverification provider application and to full Manage Change Requests (MCRs) when active electronic funds transfer (EFT) information is present. This attestation requires a signature from the Office Administrator (OA) on the provider's record.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Michael Silber2025-11-20T10:00:36-05:00November 20, 2025|North Carolina|

Ohio

The state's single Medicaid PBM, Gainwell, announced that, effective December 8, claims for preferred GLP-1 receptor agonists (listed below), will require a diagnosis of 'diabetes mellitus, type 2' to be documented in the member's medical record (as determined by medical claims data) or submitted on the pharmacy claim. For members with a diagnosis of 'diabetes mellitus, type 2' documented, claims will continue to be eligible for coverage under the state's Medicaid pharmacy benefit. For all other non-FDA approved uses (such as prediabetes or weight loss), coverage will not be available. Please note claims and associated diagnoses are subject to audit, and results will be reviewed by the Department of Medicaid for compliance. Diagnosis codes must be submitted by the prescriber on the original prescription or added by the pharmacy in consultation with the prescriber, with documentation of the date, time and name of the individual providing the diagnosis, in addition to the name of the pharmacy staff member verifying the diagnosis.

Preferred GLP-1 receptor agonists include:

Byetta/exenatide

Trulicity/dulaglutide

Victoza/liraglutide

For more information, contact NACDS’ Jill McCormack at 717-592-8977.

Michael Silber2025-11-20T10:00:00-05:00November 20, 2025|Ohio|

Oklahoma

The legislature convened an interim hearing to examine the influence of PBMs on prescription drug pricing and patient access to local pharmacies. Chaired by Sen. Spencer Kern (R) and pharmacist Rep. T.J. Marti (R), the session highlighted significant concerns regarding below-cost pharmacy reimbursements, opaque pricing structures and patient steering practices. Expert testimony by Antonio Ciaccia, 46brooklyn Research, and others underscored systemic incentives that diminish transparency and raise costs. The Attorney General’s office and the Insurance Department reported recovering $32 million through enforcement actions, positioning Oklahoma as a national leader in PBM oversight. Legislators signaled intent to pursue comprehensive PBM reform legislation again in 2026, aimed at enhancing transparency, safeguarding independent pharmacies and ensuring equitable drug pricing.

For more information, contact NACDS’ Mary Staples at 817-442-1155.

Michael Silber2025-11-20T09:59:14-05:00November 20, 2025|Oklahoma|

South Carolina

Effective for dates of service on or after December 1, the Department of Health and Human Services (SCDHHS) is updating its billing policy for providers who purchase physician-administered drugs through the Health Resources and Services Administration’s (HRSA) 340B drug pricing program. The changes described in this bulletin only apply to services rendered to Healthy Connections Medicaid members in an outpatient setting who are enrolled in the fee-for-service Medicaid program.

These policy updates will be published in the Physicians Services, Clinic Services, Hospital Services and Federally Qualified Health Center (FQHC) Services provider manual by December 1, 2025.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Michael Silber2025-11-20T09:58:43-05:00November 20, 2025|South Carolina|