New York
On April 17, 2024, NYRx, the New York State Medicaid Pharmacy Benefit Program, held its monthly call for pharmacy providers. On the agenda were long-acting injectable administration, COVID-19 anti-virials, self-administered hormonal contraceptives and Extencilline coverage. Questions and Additional Information:
- NYRx claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
- NYRx Pharmacy coverage and policy questions should be directed to the NYS Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email.
Billing guidelines for Long-Acting Injectable administration:
Pharmacies will be reimbursed for the medication and an administration fee when billed to NYRx. The member will not have a copayment for drug administration.
- NYS legislation requires a patient specific prescription or order for administration. These orders must be kept on file at the pharmacy.
- If billing for both the drug and administration, these claims must be submitted separately.
- For the drug, the claim must be submitted using the ordering prescriber's NPI in the Prescriber ID field. The pharmacy will be reimbursed for the medication when billed via National Drug Code (NDC) using reimbursement methodology. For the administration, the claim must be submitted using procedure code 96372, and the pharmacy's NPI in the Prescriber ID field. A pharmacy will be reimbursed the administration fee of $13.36.
New York State Medicaid has also notified pharmacies that in response to the ending of the COVID-19 public health emergency on May 11, 2023, effective May 13, 2024, a fiscal order is not required for the first two tests per month. Furthermore, pharmacy reimbursement and covered products available on the pharmacy formulary will be modified. Additional tests may be covered with a fiscal order, when medically necessary. Coverage will be provided for OTC FDA-authorized COVID-19 test kits used in accordance with the Centers for Disease Control and Prevention (CDC) recommendations for antigen detection. This policy for coverage of at-home test kits via NYRx, the NYS Medicaid Pharmacy Program, will remain in effect until further notice.
If a member needs more than two (2) tests per month, and all other resources were utilized, and the member has a fiscal order, the pharmacy may call the Pharmacy Policy unit at 518-486-3209 for a review of medical necessity.
For more information, please contact NACDS’ Mike Sargent at 207-272-6435.
Oklahoma
The Health Care Authority (OHCA) is seeking comments on proposed policy changes on rules defining Pharmacists as Providers OK SPA 24-0002 effective July 1, 2024.
Also in Oklahoma, the Board of Pharmacy announced two staff retirements, Gary LaRue, and Mary Ann Terral.
Finally in Oklahoma, the Board of Pharmacy posted its April newsletter.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Oregon
The Prescription Drug Affordability Board posted the draft agenda and meeting materials for its next meeting on May 15. Please register in advance of the meeting.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
South Carolina
Effective July 1, 2024, the South Carolina Department of Health, and Human Services (SCDHHS) will implement a single, state-directed pharmacy benefit preferred drug list (PDL) for all providers enrolled in the Healthy Connections Medicaid program. SCDHHS currently operates a PDL exclusively for Medicaid members who are enrolled in the fee-for-service (FFS) Medicaid program, while each managed care organization (MCO) maintains and operates its own independent PDL.
The single PDL that will become effective July 1, 2024, will be based on SCDHHS' current FFS PDL, which is available on the pharmacy section of SCDHHS' website. A list of frequently asked questions (FAQs) is also available on pharmacy section of SCDHHS' website. SCDHHS will host two live provider training sessions via online seminar on May 22 from 7:30 am-9:00 am and from 12:30 pm-2:00 pm. Registration information for the provider training webinars, updates to the FAQs and other provider training resources will be announced via a provider bulletin. Providers should email any questions related to this bulletin to SCDHHS' Office of Pharmacy Services.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Tennessee
TennCare distributed an updated Preferred Drug List (PDL) effective May 1. Subscribe to the TennCare Pharmacy Updates newsletter to receive updates directly from TennCare.
Also in Tennessee, on May 1, Gov. Bill Lee (R) signed SB 869/HB 282 into law. This legislation, which takes effect immediately, will improve efficiencies in the health care system by providing pharmacists with independent prescriptive authority for various medication classes and disease states. The Tennessee Pharmacy Association is developing additional resources and education to assist pharmacists that want to implement this law into their practice settings.
Finally in Tennessee, the Department of Health will host three free in-person sessions for its Injectable Drug Diversion Workshop for pharmacists at the following times and locations: June 20 in Nashville, July 12 in Jackson, and July 22 in Knoxville. Learn more and RSVP!
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Texas
The Health and Human Service Commission's (HHSC) Vendor Drug Program (VDP) extended the comment period for the annual prescriber survey for the Prescription Drug Monitoring Program (PDMP) to May 14.
Also in Texas, the Vendor Drug Program (VDP) posted information for pharmacies on the following three topics:
- Provider Portal training materials available
- Pharmacy Education Information and Opportunities
- Pharmacy Email Addresses Must Be Current in PEMS (Provider Enrollment and Management System)
Also in Texas, Gov. Greg Abbott (R) touted that according to the federal Bureau of Economic Analysis, the Texas economy continues to grow faster than the nation as a whole. In the fourth quarter of 2023, the real gross domestic product (GDP) for Texas grew at an annual rate of 5.0%. Texas added 270,700 jobs from March 2023 to March 2024, the most in the nation.
Also in Texas, House Speaker Dade Phelan (R) established the House Select Committee on Artificial Intelligence and Emerging Technologies, a new committee chaired by State Rep. Giovanni Capriglione (R). At the April 29 hearing, several AI (Artificial Intelligence) experts presented an overview of what is and is not considered AI. Lawmakers expressed concerns regarding data privacy and the spread of disinformation. Testimony from law enforcement highlighted how AI was helping fight the proliferation of child pornography and human trafficking.
Also in Texas, pharmacies and other stakeholders can request expedited formulary coverage, an expedited preferred drug list change or notify HHSC (Health and Human Services Commission) about potential drug shortages impacting prescribing choice and pharmacy claim processing by using the Drug Shortage Notification and Expedited Formulary or Preferred Drug List Request (HHS Form 1315).
Also in Texas, the Vendor Drug Program (VDP) posted the Pharmacy Provider Procedure Manual to learn more information about the following topics:
- 72-hour emergency overrides for prior authorization-required drugs
- Medicaid managed care pharmacy claims billing information
- Enrolling in the Medicaid Comprehensive Care Program
- Enrolling as a durable medical equipment pharmacy provider
- Eligibility verification tools
Finally in Texas, the Vendor Drug Program (VDP) is offering free pharmacy continuing education courses available for credit:
- The pharmacy continuing education course is accredited and includes requirements related to pharmacy enrollment, using the Preferred Drug List (PDL) and online formulary, obtaining prior authorization, and dispensing a 72-hour emergency supply of medication.
- A five-minute Dispenser's Guide to Texas Medicaid Outpatient Pharmacy Benefits quick course for pharmacy providers.
- A five-minute Prescriber's Guide to Texas Medicaid Outpatient Pharmacy Prior Authorization quick course for prescribing physicians.
- A five-minute Texas Medicaid Mosquito Repellent Benefit quick course for pharmacy providers.
Refer to the Outreach and Education Resources for links to downloadable materials.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Vermont
The Department of Vermont Health Access (DVHA) previously reported that Change Healthcare (CHC), which operates Vermont's Medicaid pharmacy claims system, experienced a significant cybersecurity issue on February 21, 2024. To reduce pharmacy and provider burden and allow for claims processing, DVHA temporarily removed select reject codes. DVHA thanks pharmacy providers for continuing to support members and for following VT Medicaid policies and requirements. Although pharmacy prior authorizations are not back to full functionality, providers are reminded to refer to the Preferred Drug List (PDL) & Clinical Criteria. This will help ensure smooth transitions when prior authorizations become available again. Please note, DVHA continues to prefer brands in some cases as these agents have lower net cost to the state. Examples:
PREFERRED AGENTS
- SUBOXONE® sublingual FILM
- VYVANSE ® (lisdexamfetamine) capsule QTY LIMIT: 1 cap /day
- ALBUTEROL HFA (Teva labeler code 00093 is the only preferred form) PROAIR® Respiclick (albuterol) VENTOLIN® HFA (albuterol) XOPENEX® HFA (levalbuterol)
- SYMBICORT® (budesonide/formoterol) QTY LIMIT: 9 inhalers (91.8gm)/90 days
- CONCERTA® (methylphenidate SA OSM IR/ER, 22:78%)
- ADVAIR® DISKUS (fluticasone/salmeterol) (Age ≥ 4 years) QTY LIMIT: 3 inhalers/90 days ADVAIR® HFA (fluticasone/salmeterol) (Age ≥ 12 years)
Vermont Medicaid advises pharmacies to contact the Optum Pharmacy Helpdesk with any questions (including Early Periodic Screening Diagnostic Treatment (EPSDT) requests) at 1-844-679-536 or email.
For more information, please contact NACDS’ Mike Sargent at 207-272-6435.
Washington
NACDS was alerted that an error has occurred when the Health Care Authority (HCA) made the Retroactive Time Period payments to the pharmacies under Section 4(b) of the Washington State Medicaid lawsuit Settlement Agreement, and that HCA is taking steps to correct the error which will impact some pharmacies' reimbursement. HCA discovered that it had overpaid 197 pharmacies while underpaying 334 pharmacies and will be correcting the erroneous payments.
Also in Washington, the Pharmacy Quality Assurance Commission (PQAC) filed a CR-103E Emergency Rulemaking order codifying in rule the Food and Drug Administration's (FDA) approval of certain naloxone hydrochloride nasal sprays as over the counter. PQAC considers the ongoing opioid epidemic to be a public health emergency in Washington state. This rule, filed on April 5, 2024, took effect immediately and will remain in effect for 120 days but will be refiled as needed while permanent rulemaking is in progress.
Also in Washington, the Health Care Authority Apple Health (Medicaid) added the new over the counter (OTC) birth control pill – Norgestrel oral tablets (Opill) – to the list of covered drugs that also includes family planning supplies without a prescription, such as condoms, emergency contraception and spermicides.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Alaska
Prior to the quarterly meeting on April 11, the Board of Pharmacy posted the agenda and the meeting packet.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Arkansas
The 94th General Assembly fiscal session convened on April 10 with Gov. Sara Huckabee Sanders (R) giving her state-of-the-state address, asking the legislature to approve a $6.3 billion budget.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
California
The Department of Health Care Services posted a weekly notice, “Medi-Cal Rx Weekly Wrap-up for March 29-April 4”.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
Florida
The Department of Revenue has announced that, effective June 1, 2024, the state sales tax rate imposed under section 212.031, Florida Statutes (F.S.), on the total rent charged for renting, leasing, letting, or granting a license to use real property (also known as “commercial rentals”) is reduced from 4.5% to 2.0%. Information about the proper reporting of tax due on commercial rentals is available on the Department’s website at floridarevenue.com/forms. For more information, please review the Department’s Taxpayer Information Publication.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Illinois
The April 4, 2024, provider notice includes an update to pharmacies on billing for the COVID-19 vaccine administration fee. This update applies only to the Medicaid fee-for-service program for dates of service beginning September 11, 2023, through December 31, 2023.
A September 28, 2023, provider notice stated the Department of Healthcare and Family Services (HFS) was still finalizing programming for the administration fee for the COVID-19 vaccine, and providers could not include administration fee charges on their claims at that time. Pharmacies could still provide COVID-19 vaccinations and submit claims to HFS for reimbursement for the cost of the vaccine and a professional dispensing fee, without an administration fee.
HFS has completed part of the programming for pharmacies to receive the applicable administration fee for COVID-19 vaccines. Pharmacies can now void and rebill claims that were initially submitted without the administration fee for dates of service beginning September 11, 2023, through December 31, 2023. Pharmacies must use "MA" in the Professional Service Code Field, in addition to identifying the administration fee.
Claims with dates of service beginning January 1, 2024, must continue to be billed without an administration fee until further notice.
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's (FSSA) Indiana Health Coverage Programs (IHCP) announced a Roadshow at six locations throughout the state to be held April 30 through June 6, 2024. Providers are encouraged to come prepared with any policy-related questions. Please do not bring actual claims or claim-related questions to the event.
Also in Indiana, IHCP issued a bulletin BT202434 detailing the program beginning on May 1, 2024, that will align the fee-for-service continuity of care with managed care.
Finally, the Office of Medicaid Policy and Planning (OMPP) is hosting an informational webinar on the PathWays for Aging program April 18. OMPP staff will provide an overview of the PathWays program which is set to launch on July 1, 2024.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Kentucky
Gov. Andy Beshear (D) signed HB 274, sponsored by pharmacist Rep. Danny Bentley (R). The bill authorizes pharmacists to order and administer vaccines to patients aged 5 years and older under a prescriber-approved protocol. The law takes effect 90 days after the General Assembly adjourns sine die. This date will officially be set by the attorney general after April 15.
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
Louisiana
The Department of Health (LDH) provided new Policy memos on a variety of subjects:
- Louisiana Medicaid Pharmacy Point of Sale Quantity Limit – Effective April 1, 2024
- Louisiana Medicaid Pharmacy Point of Sale Age Requirements – Effective April 1, 2024
- Louisiana Medicaid Pharmacy Point of Sale Edits for Therapeutic Duplication and Prior Use – Effective April 1, 2024
- Louisiana Medicaid Pharmacy Point of Sale Diagnosis Code Requirement – Effective April 1, 2024
- Louisiana Medicaid Pharmacy Point of Sale Clinical Authorization and Updates – Effective April 1, 2024
- Louisiana Medicaid Pharmacy Compound Drug Coverage for Managed Care Organizations (MCOs) – Effective April 1, 2024
Also in Louisiana, the PBM (Pharmacy Benefit Managers) Monitoring Advisory Council met on April 11 to discuss these agenda items. The draft minutes from the February 7 meeting are available.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Maine
Office of MaineCare Services provided this notice regarding claims filed by Pharmacy Providers during the outage period (February 21 through March 26). In collaboration with Optum Change Healthcare, Maine has updated the technical instructions to reflect recent feedback received from pharmacy providers about claims denials.
For more information, please contact NACDS’ Mike Sargent at 207-272-6435.
Minnesota
On April 12, the House Health and Finance Policy Committee will hear HF 3902, legislation that would increase the Medicaid Fee-for-Service Professional Dispensing Fee from $10.77 to $11.55 to match the most recent state cost of dispensing survey. Companion legislation in the Senate has already been heard and laid over for possible inclusion in the House Health Omnibus bill.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
Mississippi
Save the date for the Mississippi Pharmacists Association’s Back to the Basics Consultant Seminar on April 18, 2024. Class offerings include “Consulting 101/Pharmacology,” “Appendix PP,” “Mental Health,” “Antibiotic Stewardship” and more. Attendees may receive eight hours of continuing pharmacy education (CPE).
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Nevada
The agenda and meeting materials for the Board of Pharmacy’s April 17 – 18 meeting in Reno are available.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
New York
The State Medicaid Pharmacy Benefit Program, NYRx, issued guidance for billing of long acting injectables for mental health and substance abuse treatment.
For more information, please contact NACDS’ Mike Sargent at 207-272-6435.
Oregon
Gov. Tina Kotek (D) signed HB 4149, PBM legislation that requires pharmacy benefit managers to be licensed by the Department of Consumer and Business Services beginning January 1, 2025; modifies the definition of "pharmacy benefit manager" and imposes new requirements on PBMs (Pharmacy Benefit Managers); restricts audits of pharmacy claims for reimbursement; requires PBMs to report specified information to the department on an annual basis; and imposes new requirements with respect to the insurance coverage of 340B drugs.
Also in Oregon, Gov. Tina Kotek (D) signed HB 4002, legislation permitting pharmacist dispensing of opioid use disorder medication refills and requires health insurers and community care organizations (CCOs) to reimburse the cost of refills of substance use disorder medications.
Finally in Oregon, the Prescription Drug Affordability Board posted the draft agenda and meeting materials for its next meeting on April 17. Please register in advance of the meeting.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
Pennsylvania
HB 1993, a companion bill to SB 1000, a comprehensive commercial and Medicaid PBM reform bill has been introduced by Rep. Jessica Benhem (D). Both bills have strong bi-partisan co-sponsorship and support. NACDS continues to work collaboratively with the Pennsylvania Association of Chain Drug Stores and the Pennsylvania Pharmacy Coalition and legislators to advance these bills.
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
Tennessee
The Department of Commerce and Insurance (TDCI) shared a rule filing regarding PBMs. The TDCI regulations on audits of PBMs were approved and will take effect on June 26, 2024.
Also in Tennessee, congratulations to Dean Bill Gentry of South College School of Pharmacy, who announced his upcoming retirement effective July 2, 2024.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Texas
The Texas Pharmaceutical Initiative (TPI) three-member Board held a hybrid meeting on April 9. Five of the largest state agencies on the Advisory Council (TIPAC) provided testimony, addressing issues such as prescription drug pricing, the potential for savings with a single PBM, specialty pharmacies drug pricing, the most expensive prescription drugs prescribed, drug shortages and rebates. HB 4990 passed during the 2023 Regular session requires TPI to present a plan for the legislature by October 1, 2024. The Board also has the authority to explore a distribution network and partnerships to launch a manufacturing facility for generic or biosimilar drugs. The Health and Human Services Commission (HHSC) recommended that the prescription drug importation program law aimed at providing lower cost prescriptions by importing them through Canada (HB 25-2023), also be addressed by TPI.
Also in Texas, the Gainwell point-of-sale claims system, the VDP (Vendor Drug Program) Provider Portal and the VDP eCOI (Electronic Certification of Information) Portal are now active.
Finally in Texas, the Board of Pharmacy posted proposed rules for prescription drug deliveries and non-sterile compounding in the March 22 Texas Register (see pages 1852-1863). Written comments on the proposed rules may be submitted to Eamon D. Briggs, Deputy General Counsel, Texas State Board of Pharmacy, 1801 Congress Avenue, Suite 13.100, Austin, Texas 78701-1319, FAX (512) 305-8061. Comments must be received by 5:00 pm on April 30, 2024.
For more information, contact NACDS’ Mary Staples at 817-442-1155.