Massachusetts

MassHealth issued the following two updates on March 26: 

  • Transmittal Letter ALL-246 – This letter transmits updates to 130 CMR 450.000: Administrative and Billing Regulations. Subsection 130 CMR 450.130 has been amended to reflect that MassHealth members will no longer be required to make copayments. Copayments have been temporarily eliminated since May 1, 2023; this update extends this policy indefinitely. These regulations are effective April 1, 2024.  
  • Managed Care Entity Bulletin 112 – This bulletin relates to certain drugs that may be used for the treatment of obesity that a provider purchased through the 340B Drug Pricing Program (340B stock). The bulletin applies to Accountable Care Partnership Plans (ACPPs), Managed Care Organizations (MCOs), One Care Plans and Senior Care Organizations (SCOs) (collectively referred to as “Managed Care Entities”). In MCE Bulletin 109, the Executive Office of Health and Human Services (EOHHS) directed Managed Care Entities not to pay for specified GLP-1 agonist drugs if those drugs were purchased through the 340B Drug Pricing Program, effective April 1, 2024. Through this Bulletin, EOHHS is delaying the effective date of this policy until July 1, 2024.  

For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.

2024-04-04T10:33:21-04:00April 4, 2024|Massachusetts|

New York

On March 27, the State Department of Secondary Education published the following emergency orders in the New York Register (March 27, 2024, Vol XLVI, Issue 13).  

Also in New York, the State Department of Health also issued a billing guidance on issuance of hormonal contraceptives. For NYRx billing, see below:  

  • To bill for the self-administered hormonal contraception, the pharmacy must submit a valid National Drug Code (NDC). Pharmacies must bill the Usual and Customary (U&C) price and will be reimbursed according to NYRx payment methodology and a $10.18 dispensing fee.
  • To bill for the evaluation and management associated with the ordering of self- administered hormonal contraception, pharmacies will submit using the National Council for Prescription Drug Programs (NCPDP) D.0 claim format and enter one of the Healthcare Common Procedure Coding System (HCPCS) codes identified below. 
  • NYRx members may receive up to 12 months of prescription contraceptives at one time for family planning purposes as authorized by the Title 18 NYCRR Section 505.3(e). 
  • Pharmacies are expected to dispense up to the quantity limit of the prescription or Standing Order, one year supply, at the time of dispensing, pursuant to patient preference or primary insurance coverage limitations.
  • Submitting any assessment code more than once a year requires cause.

For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.

2024-04-04T10:32:49-04:00April 4, 2024|New York|

Pennsylvania

Gov. Josh Shapiro (D) announced he will be issuing Guidance for Health Insurers to Improve Coverage for Over-the-Counter Contraception. Specifically, the Pennsylvania Insurance Department (PID) will issue guidance to insurers to provide coverage for over-the-counter contraception with or without a prescription. He further stated that PID will hold insurers accountable, requiring additional information from companies who chose not to cover OTC contraception.

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

2024-04-04T10:31:54-04:00April 4, 2024|Pennsylvania|

South Carolina

The Department of Health and Human Services (SCDHHS) is announcing a further extension of telehealth flexibilities issued during the COVID-19 federal public health emergency (PHE). 
  
SCDHHS previously issued guidance via Medicaid bulletins announcing the status of telehealth flexibilities upon the expiration of the federal PHE (Medicaid bulletin MB# 23-018). Flexibilities were grouped as those that were made permanent, continued for one year after the expiration of the federal PHE or expired upon the end of the federal PHE May 11, 2023.  
  
Flexibilities continued for one year after the expiration of the federal PHE are now extended by SCDHHS through December 31, 2024. This extension aligns with a similar policy announced by the Centers for Medicare and Medicaid Services that extended telehealth flexibilities issued during the COVID-19 federal PHE for Medicare providers through December 31, 2024. 
  
As a reminder, these extended flexibilities, including telehealth flexibilities, were included in the applicable Medicaid provider manuals prior to the end of the federal PHE. Provider manuals can be found on the SCDHHS website. 
  
South Carolina Healthy Connections Medicaid managed care organizations (MCOs) are responsible for the coverage and reimbursement of services described in this bulletin for members enrolled in an MCO. 
  
Providers may direct any questions related to this bulletin to the Provider Service Center (PSC). PSC representatives can be reached at (888) 289-0709 from 7:30 am-5:00 pm Monday-Thursday and 8:30 am-5:00 pm Friday. Providers can also submit an online inquiry.

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

2024-04-04T10:30:39-04:00April 4, 2024|South Carolina|

Tennessee

TennCare is continuing the process of reviewing all covered drug classes. Changes to the PDL (preferred drug list) may occur as new classes are reviewed, and previously reviewed classes are revisited. As a result of these changes, some medications your patients are now taking may be considered non-preferred agents in the future. Please inform your patients who are on these medications that switching to preferred products will decrease delays in receiving their medications. We encourage you to share this information with other TennCare providers. The individual changes to the PDL have been in this notice. The new PDL will be posted April 1, 2024. For details on clinical criteria, please visit OptumRx-TennCare.

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

2024-04-04T10:29:56-04:00April 4, 2024|Tennessee|

Texas

The next meeting of the Texas Pharmaceutical Initiative Board will be in Austin at 10:00 am on April 9. The meeting agenda includes instructions for webcasting. 

Also in Texas, Rep. Dr. Tom Oliverson (R) announced his candidacy for Speaker of the Texas House today for the 89th Session that convenes in January of 2025. 

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

2024-04-04T10:29:14-04:00April 4, 2024|Texas|

Washington

NACDS applauds the enactment of ESSB 5213, a new law signed by Gov. Jay Inslee (D) on March 25 that will hold PBMs accountable. Although the law exempts the Employment Retirement and Security Act (ERISA) plans, it enhances the Insurance Commissioner’s enforcement authority, establishes an appeals process, opens the network, includes anti-steering and mail order provisions, prohibits spread pricing, and expands Maximum Allowable Cost appeals to all prescriptions, not just generic drugs. The bill sponsor, Sen. Patty Kurderer (D) who is running for the office of Insurance Commissioner in November, plans to enforce this new law and actively seek further PBM reforms if elected.

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

2024-04-04T10:28:27-04:00April 4, 2024|Washington|

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