California
Last week, the State Assembly passed an amended version of SB 966, PBM Reform legislation, and the State Senate concurred with the amended version. Upon passage, the bill was ordered to “engrossing and enrolling” after which it will be presented to Gov. Gavin Newsom (D) for signature. The governor has until September 30 to act. The bill requires PBMs to apply for a licensure from the California Department of Insurance by January 1, 2027; clarifies the State Attorney General retains all authorities to maintain or restore competitive, fair and honest markets and prosecute state and federal antitrust and unfair competitive violations; prohibits retroactive fees; and would allow a pharmacy that is not owned by the PBM to participate in a PBM network as a preferred provider if the pharmacy is willing to accept the same terms and conditions. NACDS sent a letter to Gov. Gavin Newsom (D) urging him to sign SB 966 to help preserve and expand patient access to pharmacists, pharmacies of all sizes and the Californians they serve.
Also in California, last week, AB 3063 passed the state legislature and was ordered to “engrossing and enrolling” after which it will be presented to Gov. Gavin Newsom (D) who has until September 30 to act. This legislation states the addition of a flavoring agent to a conventionally manufactured product is not considered compounding if certain conditions are met. It also requires the addition of the flavoring agent to be documented in the prescription record.
Also in California, the Department of Health Care Services posted the following alerts and weekly notice and monthly bulletin on the Medi-Cal Rx Web Portal. Please note the MAIC 30-day pharmacy provider notice; rates will be effective October 1, 2024, and were to be posted to the Mercer Medi-Cal Rx website no later than September 1, 2024.
- COVID-19 Vaccines and Vaccine Administration Coverage for Family PACT End-Dated
- COVID-19 Antigen Over-the-Counter Test Coverage Updates, Effective October 1, 2024
- Updates to the List of Contracted Enteral Nutrition Products, Effective October 1, 2024
- Maximum Allowable Ingredient Cost 30-Day Pharmacy Provider Notice
- Medi-Cal Rx Monthly Bulletin for September
- Changes to the Medi-Cal Rx Contract Drugs List
- Changes to the Medi-Cal Rx Contract Drugs List – Over-the-Counter Drugs and Cough/Cold Preparations
- Updates to the Medi-Cal Rx Provider Manual
- Vaccines for Children Program Policy and Billing Guidance for Pharmacy Providers
- Medi-Cal Rx Weekly Wrap-up for August 23-29
Finally in California, the Board of Pharmacy posted the agenda and meeting materials for the Full Board Meeting on September 12, 2024. Please note the discussion and action related to awarding a contract for medication error reporting.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
Colorado
Gov. Jared Polis (D) announced his new chief of staff, David Oppenheim, replacing Alec Garnett, who has been in that role since January 1, 2023. Garnett has accepted the position of vice president for government and regulatory affairs for the University of Colorado Health.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Florida
The purpose of this alert is to provide an update to the previous provider alert issued on August 4, 2024, regarding Hurricane Debby.
The following flexibilities/waivers offered to providers in the alert issued on August 4, 2024, expired at 11:59 pm on September 3, 2024:
- Waiver of prior authorization requirements for critical Medicaid services
- The lifting of early prescription refill edits will remain in place in accordance with Gov. Ron DeSantis’ emergency executive orders issued for Hurricane Debby
- Waiver of service limitations to ensure a recipient requiring critical Medicaid services during the storm receives such care
- Temporary postponement of the Preadmission Screening and Resident Review processes
Additional questions from providers may be directed to the Florida Medicaid Contact Center at 1-877-254-1055
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Illinois
The Department of Healthcare and Family Services’ (HFS) Pharmacy Benefit Management System (PBMS) for the fee-for-service program, Change Healthcare, experienced a nationwide system outage as noted in the provider notice dated February 22, 2024. During the system outage, HFS was unable to add new National Drug Codes (NDCs) to the formulary. Providers were asked to hold fee-for-service (FFS) claims until the issue was resolved.
The new NDCs are now available and have been added to the formulary; therefore, providers may release all FFS claims that have been held pending the update.
Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Indiana
The Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) is hosting an informational online seminar on the PathWays for Aging program on September 12 at 9:00 am. The presentation by OMPP staff will provide a post-implementation update of the PathWays program which launched on July 1, 2024. The online seminar will be recorded and posted on the PathWays stakeholder engagement website. You can view the online seminar on Zoom or the FSSA YouTube page at the time of the event.
Also in Indiana, FFSA pharmacy updates were approved by Drug Utilization Review Board at the August 2024 meeting.
Finally in Indiana, the Health Coverage Programs (IHCP) posted a bulletin reminding providers of administrative review requirements for fee-for-service prior authorization.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Iowa
The Department of Health and Human Services (HHS) announced the intent to award a Managed Care Organization (MCO) contract to Iowa Total Care. The new Iowa Medicaid contract period begins July 1, 2025, with no change in operations. This RFP and resulting contract aligns all three MCO contracts (Iowa Total Care, Molina, and Wellpoint Iowa, Inc.) to provide health care services to Iowans to the same contract cycle. All three MCO contracts will have a final contract end date of June 30, 2031.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
Louisiana
Medicaid issued a bulletin revising the launch date for its Medicaid Provider Enrollment Rebaseline, which means new managed care organization (MCO) credentialed providers that have not enrolled with Medicaid will receive an invitation letter to enroll through the web portal. The invitation letter will provide specific provider information along with detailed instructions needed for the enrollment process.
Also in Louisiana, Medicaid issued a revised bulletin with contact information outlining the available options to providers for pursuing resolution of issues with Medicaid managed care organizations (MCOs) and the state’s fee-for-service claims processor, Gainwell Technologies. Unless explicitly notated, providers should first seek resolution with the MCO or Gainwell directly, prior to engaging the Department of Health or other third parties.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Maine
On September 5, the Board of Pharmacy held its regular meeting. The agenda included licensure by endorsement and a central fill data collection pilot project.
For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.
Maryland
The Prescription Drug Affordability Board (PDAB) has rescheduled its September 23 Board meeting for September 10. Registration is required to participate. The Board welcomes public comment and input on all its work. Additional information about providing public comment can be found on the Board Meetings page of the PDAB’s website.
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
Massachusetts
The Board of Pharmacy issued notice that licensing of non-resident pharmacies will become available in the coming months. At least one pharmacist at each non-resident pharmacy must hold a Massachusetts pharmacist license. (This pharmacist does not have to be the store’s pharmacist-in-charge.) In preparation for non-resident pharmacy licensing, it is strongly recommended to begin the licensing process for the pharmacists as the process can take 30-60 days. Applications and instructions can be found online. Please see the FAQ document for other information regarding non-resident pharmacy licensing.
For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.
Michigan
The Department of Health and Human Services issued a final bulletin related to the end of COVID flexibilities for OTC (Over-the-Counter) COVID tests and pharmacies as labs.
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
Missouri
Effective September 6, 2024, brand name Adderall XR® will no longer be preferred on the MO HealthNet Preferred Drug List (PDL). Dextroamphetamine/Amphetamine ER capsules (generic Adderall XR®) is currently a preferred agent on the PDL and will continue to remain a preferred agent. Please reference the List of Preferred & Non-Preferred Products, as well as the ADHD, Amphetamines Long Acting PDL edit for more information. Maximum Allowable Cost (MAC) rates will apply to brand and generic products. Providers who dispense the brand product without a prior authorization (based on medical necessity) will receive MAC reimbursement.
Also in Missouri, on August 29, the Medicaid Audit & Compliance (MMAC) launched the new secure Provider Communications Portal, which is an efficient method for providers and MMAC to communicate and exchange information and records.
Finally in Missouri, effective August 29, MO HealthNet expanded coverage of Continuous Glucose Monitors (CGMs) to participants currently diagnosed with Gestational Diabetes allowing this vulnerable population to obtain a CGM without prior authorization. Claims for a CGM will auto-approve if the participant has had a gestational diabetes diagnosis billed to MO HealthNet recently or if the pharmacy submits the appropriate gestational diabetes diagnosis code with the claim. Any MO HealthNet participant who currently utilizes insulin can also obtain a CGM without prior authorization.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Nebraska
The Board of Pharmacy posted the agenda (revised August 29, 2024) for its September 9 meeting.
Also in Nebraska, new income guidelines increased the number of families who could qualify for the Women, Infants and Children (WIC) supplemental nutrition assistance program. The WIC program is a federally funded program and is an equal opportunity provider. The maximum income allowed for participation in WIC increased. Some families not eligible for the program in the past may now be eligible. Nebraska WIC serves every county in the state with 13 main agencies and over 100 sites.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
North Carolina
Medicaid is committed to supporting increased adoption and utilization of the Board of Pharmacy statewide protocols authorized by legislation. As part of this commitment, effective August 1, 2024, immunizing pharmacists began to receive reimbursement for clinical services provided when utilizing the statewide Nicotine Replacement Therapy (NRT) Protocol. This bulletin applies to Medicaid Managed Care and Medicaid Direct. The claim should be submitted using a medical claim and payment will be issued to the pharmacy.
Also in North Carolina, effective September 1, 2024, Medicaid began covering condoms and spermicides as over-the-counter products, through the pharmacy benefit. This coverage applies to both Medicaid Direct and Managed Medicaid Plans. Coverage supports reproductive health care for Medicaid beneficiaries, including prevention of unintended pregnancy and sexually transmitted diseases. Medicaid beneficiaries will be able to obtain condoms and spermicides from pharmacies enrolled in Medicaid with a prescription from a Medicaid-enrolled provider, with no cost sharing responsibility.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Ohio
The Board of Pharmacy issued draft rules to implement SB 144, the new pharmacy immunization expansion law that passed in July. We have reviewed the rule and found no issues or concerns and intend to file a letter of support. However, if members have any concerns or comments, please share them with Jill McCormack by September 13.
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
Oregon
The Prescription Drug Affordability Board (PDAB) posted the draft agenda for its next meeting on September 18. Please note the “Medicare MFP modeling presentation and SB 192 upper payment limit discussion” by PDAB staff and Myers and Stauffer on the draft agenda. You must register in advance of the meeting to participate.
Also in Oregon, NACDS, as a participant in the PBM Working Group, submitted a letter to Rep. Rob Nosse (D), Chair, House Behavioral Health and Health Care Committee, to provide comments and pharmacy reimbursement concepts in advance of the next working group meeting scheduled to be held on September 18.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
Tennessee
During the most recent Board of Pharmacy meeting, the Board confirmed that rules for technician immunizations will not be finalized before the PREP Act expires. However, technicians should still be able to vaccinate after receiving a waiver from the Board’s Executive Director Lucy Shell. NACDS and Tennessee Pharmacy Association are working to confirm details of this process and will share more information as it becomes available.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Texas
The Health and Human Services Commission (HHSC) implemented a new STAR+PLUS contract in seven managed care organizations (MCOs) on September 1, 2024. Pharmacy claims billing codes and contact information for these MCOs are available.
Also in Texas, HHSC’s Vendor Drug Program (VDP) revised the Pharmacy Payer Specification Manual, separating them by program. The three separate manuals are the Traditional Medicaid and the Healthy Texas Women Program, the Children with Special Health Care Needs Services Program and the Kidney Health Care Program. The three new manuals are available on the VDP Provider Portal.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Virginia
The Department of Medical Assistance Services (DMAS) held an initial virtual meeting with pharmacy associations to discuss the upcoming pharmacy cost-of-dispensing survey (slide deck). The survey instrument has not been finalized; however, Myers & Stauffer intends to send it to pharmacies on September 12. Additional informational webinars for all pharmacy stakeholders are tentatively scheduled for September 24 and September 26.
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
Washington
The State Department of Health Office of Immunizations is hosting a 2024-2025 Respiratory Virus Season: Vaccine Recommendations, Ordering and Distribution webinar on September 17. Presenters will discuss influenza, COVID-19, and RSV epidemiology, vaccine recommendations and vaccine ordering and distribution.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Alaska
Effective September 2024, Medicaid will now permit pharmacists to enroll as providers and bill for pharmacy services. This significant development results from collaborative efforts by various pharmacy organizations, including the Alaska Pharmacy Association. The change aligns with HB 145 of 2022. It allows pharmacists to enroll as rendering providers and get paid for their services through medical benefits while affiliated with a pharmacy professional group, Tribal Health Organization, Federally Qualified Health Center or Rural Health Clinic.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Arkansas
NACDS sent a letter to the Arkansas Insurance Commissioner Alan McClain (R) in support of proposed Emergency Rule 128, Pharmacy Benefits Manager Compensation Requirements for Network Adequacy, Fair and Reasonable Pharmacy Reimbursements. This rule is needed to protect pharmacy providers from the abusive PBM business practices that can jeopardize the future of pharmacy and the sustainability of providing pharmacy services and patient access to care.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
California
This week the Assembly passed SB 966, PBM Reform legislation. The bill returns to the Senate for concurrence with the Assembly amendments. The legislature will adjourn no later than midnight on August 31.
Also in California, the Department of Health Care Services posted the following alerts and weekly notices on the Medi-Cal Rx Web Portal:
- State of Emergency Override Activation: Submission Clarification Code 13
- Medi-Cal Rx Weekly Wrap-up for August 16-22
- Mass Adjustment for Impacted Blood Factor Claims with a Date of Service October 1, 2021, through December 31, 2021
- Medi-Cal Rx Weekly Wrap-up for August 9-15
- CalAIM Justice-Involved Reentry Initiative Implementation for Inyo, Santa Clara, and Yuba Counties
- Vaccines for Children Program: Medi-Cal Reference Guide
- Coming Soon: Medi-Cal Reimbursement for Vaccines for Children-Enrolled Providers
Also in California, effective for dates of service on or after September 1, 2024, the Department of Health Care Services has updated the List of Contracted Incontinence Creams and Washes.
Also in California, the Board of Pharmacy proposed the following rules:
- Pharmacy Technician Certification Program Documents
- Notice of Proposed Action
- Initial Statement of Reasons
- Proposed Text
- 45-Day Comment Period: August 23, 2024, to October 7, 2024
- Quality Assurance Programs
- Notice of Proposed Action
- Initial Statement of Reasons
- Proposed Text
- 45-Day Comment Period: August 9, 2024, to September 23, 2024
- Please send your company’s comments on the proposed rule to Sandra Guckian by September 10.
- Pharmacy Technician Fee Schedule
- Notice of Proposed Action
- Initial Statement of Reasons
- Proposed Text
- 45-Day Comment Period: July 26, 2024, to September 9, 2024
Finally in California, the Board of Pharmacy’s Licensing Committee added an additional meeting on September 4, 2024, to continue its work on the Standard of Care Model. The agenda, meeting materials and written comments received were posted to the Board’s website.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
Colorado
NACDS is continuing to work with a coalition urging Gov. Jared Polis (D) to expedite implementation of SB24-168, a new law that expands diabetes care access for Medicaid enrollees.
Also in Colorado, Gov. Jarod Polis (D) convened a special session on August 26 to address property tax reform.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Indiana
The Health Coverage Programs (IHCP) issued a bulletin reminding providers requesting an administrative review, also known as a reconsideration, of a denied or partially approved fee-for-service (FFS) nonpharmacy prior authorization (PA), that they must submit a written request to the FFS prior authorization and utilization management (PA-UM) contractor within seven business days of receipt of the PA decision notification.
For more information, contact NACDS’ Mary Staples at 817-442-1155.