Medicaid published an advisory regarding upcoming denials of prescription claims due to the prescribing provider not completing revalidation. The advisory also contains email and phone contacts for patients and provider issues.
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
MassHealth has issued a new draft of the Pharmacy Manual at 130 CMR 406. The new regulations make the following changes:
These changes will become effective on January 1, 2024.
For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.
Gov. Gretchen Whitmer (D) signed HB 4276. The bill requires PBMs to reimburse pharmacies with no more than seven retail outlets at NADAC plus a professional dispensing fee comparable to the state Medicaid Dispensing Fee. It also prohibits the Department of Health and Human Services (department) from entering into a contract with a Medicaid managed care organization if its pharmacy benefit manager (PBM) does not do the following: reimburse for a legally valid claim at a rate not less than the rate in effect at the time the original claim adjudication was submitted at the point of sale; agree to move to a transparent pass-through pricing model, in which the PBM discloses the administrative fee as a percentage of the professional dispensing costs to the department; agree to not create new pharmacy administration fees and to not increase current fees more than the rate of inflation; and, agree to not terminate an existing contract with a pharmacy with no more than seven retail outlets for the sole reason of the additional professional dispensing fee authorized.
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
The Department of Health and Human Services issued the following provider bulletins:
Also in Nebraska, the Department of Health and Human Services posted the Excel file of the fee schedule for Injectables October 1, 2023 (Revised).
Also in Nebraska, the Department of Health and Human Services received approval from CMS for State Plan Amendment 23-0015: Adult Vaccines related to coverage of vaccines and vaccine administration in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations.
Finally in Nebraska, the Department of Health and Human Services posted the meeting recording from the December 6 COVID-19 Provider Call. The next meeting will be held on January 3, 2024, at noon (Central). To participate, use either the meeting link or phone number and access code below.
Join from the meeting link:
https://sonvideo.webex.com/sonvideo/j.php?MTID=mc307e2dda218d1060adfed7f454cfc16
Join by phone:
408-418-9388 (access code: 2480 661 3098 )
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
The Legislative Health and Human Services Committee met on November 28 to discuss the Prescription Drug Purchasing Report and a presentation on reducing prescription drug prices to reduce healthcare costs.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
NYRx, the State Department of Health Medicaid Pharmacy Benefit Program, released updates to the NYRx Prior Authorization Programs and updated preferred drug list, changes were effective December 14.
The State Department of Health also released a reminder regarding pharmacy providers and members out-of-pocket costs. This communication was sent to all pharmacies to remind them of their responsibility for continued enrollment, to adhere to the policies and procedures of the Medicaid Program. Specifically, it is inappropriate to allow an eligible member to pay out-of-pocket for services that are covered by NY Medicaid (NYRx) beyond copay. Please be advised that out-of-pocket expenses are only reimbursable by Medicaid for Medicaid covered services when one of these three situations applies:
If there is an eligibility issue that is corrected in a timely manner, pharmacists should resubmit the claim when the issue is resolved and reimburse the member directly if the member paid out of pocket. There is support available to pharmacists to assist with claim issues. Questions regarding this communication may be directed to NYRx@health.ny.gov.
On December 12, A6779, a bill NACDS and the Community Pharmacy Association of New York (CPANY) had been supporting to expand the 2022 law allowing pharmacists to administer long-acting injectables, was sent to the Governor’s desk by the legislature. Gov. Kathy Hochul (D) has until December 22 to act on the legislation.
For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.
The Board of Pharmacy published a series of proposed rule changes and rescissions they intend to work on this winter. Comments are due to the board on January 17, 2024.
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
The Tenth Circuit Court of Appeals denied the State of Oklahoma’s petition for rehearing in PCMA v. Mulready. The state now has 90 days to petition the Supreme Court for further review.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
The Health and Human Services Commission (HHSC) Vendor Drug Program (VDP) now covers the 2023-2024 Pfizer-BioNTech, Moderna and Novavax commercial COVID-19 vaccines as a pharmacy benefit for both Medicaid managed care and fee-for-service, as well as the Children’s Health Insurance Program (CHIP).
Also in Texas, Medicaid will perform the semi-annual update of the Medicaid preferred drug list on January 25, 2024. The Health and Human Services Commission (HHSC) made the PDL changes based on recommendations made at the October 2023 Drug Utilization Review Board meeting. Drug list recommendations from the meeting are available. Drugs with preferred status drugs may include brand name medication which would not require a PDL prior authorization nor the value of “1” in the “Dispense as Written (DAW) Product Selection code” field (408-D8). Refer to the Dispense as Written section of the Formulary Coverage chapter of the Pharmacy Provider Procedure Manual for more information.
Also in Texas, the Health and Human Services Commission (HHSC) is soliciting comments on the prospective clinical prior authorization proposals likely to be presented at the Texas Drug Utilization Review (DUR) Board meeting on January 26, 2024. The board reviews and recommends clinical criteria and the preferred or non-preferred drug status on the Medicaid formulary.
Also in Texas, December 11 was the filing deadline for the March 5, 2024, primary election.
For more information, contact NACDS’ Mary Staples at 817-442-1155.