Rhode Island
Please see the most recent Provider Update for Medicaid. All provider updates may also be found here.
Also in Rhode Island, effective October 1, 2023, Katie Beckett recipients will now be enrolled in a managed care organization for Case Management Services only. Case Management services are provided by CEDARR Center Providers. All other services will still be reimbursed through Medicaid fee for service.
When checking eligibility on the Healthcare Portal (HCP) you will see the following (see sample picture below):
- A new row under Benefit Plan Details – Katie Beckett Case Management
- A new row under Managed Care Details – Displays the name and dates of the Managed Care Plan the recipient is enrolled in.
If you are a CEDARR provider and the recipient is enrolled in the Katie Beckett case management program, then you must bill your services to the managed care plan on file. All other providers will continue to bill Medicaid Fee for Service.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
South Dakota
The Board of Pharmacy posted their October 2023 Newsletter including the following sections:
- South Dakota Board Welcomes Newly Registered Pharmacists and Pharmacies
- DSCSA (Drug Supply Chain Security Act) Interoperability Standards Delayed Until November 2024
- USP Compounding Chapters Update
- Does a Pharmacy Need to be Licensed to Ship Medications to Other States?
- The Board Has a New Website
- The Board Will Propose a Bill to Increase License Fees in the 2024 Session
- DEA (Drug Enforcement Administration) Issues Multiple Guidance Documents in Recent Months
- PDMP (Prescription Drug Monitoring Program) Update
- Board Meeting Dates, Board of Pharmacy Members and Board of Pharmacy Staff Directory
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
Tennessee
To assist prescribers and providers, prior authorization (PA) requirements can be bypassed for certain medications when specific medical conditions exist. Those specific medications and diagnoses can be found here. Prescribers are encouraged to include the applicable diagnosis code on written prescriptions for inclusion on the electronic pharmacy claim. The submitted claim should include a Diagnosis Code Qualifier (Field # 492-WE) of "02," indicating ICD-10, as well as the appropriate Diagnosis Code (Field # 424-DO).
If you have any questions, contact the OptumRx Pharmacy Supports Center at 866-434-5520 or tnrxeducation@optum.com.
Also in Tennessee, the October 31 Drug Utilization Committee (DUR) Board meeting will be held virtually via Microsoft Teams. Please Click Here or Phone number: +1 952-222-7450 Phone Conference ID: 857 579 147#
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Texas
Gov. Greg Abbott (R) called lawmakers back to Austin this week for a third 30-day special session to advance border security measures, address school choice/vouchers and education savings accounts and tackle private employer COVID vaccine mandates.
Also in Texas, prior to the third special session, State Comptroller of Public Accounts Glenn Hegar (R) announced a certification revenue estimate (CRE) for the Fiscal Year 2024-25 biennium projecting a Rainy-Day Fund balance of $23.77 billion.
Also in Texas, the Health, and Human Services Commission (HHSC) Medicaid posted the September 2023 End of Continuous Medicaid Coverage Dashboard.
Also in Texas, the next quarterly meeting of the Board of Pharmacy (TSBP) is on November 7 in Austin. This will be the first meeting with the new Executive Director/Secretary Danny Carroll, PharmD.
Also in Texas, NACDS submitted comments to the State Board of Pharmacy (TSBP) on its strategic plan for fiscal years 2025-29, recommending statutory and regulatory changes to expand upon the temporary flexibilities under the federal PREP Act related to vaccinations and Test & Treat services. NACDS also urged TSBP to eliminate the ratio at a central fill Class A pharmacy and expand telepharmacy services beyond FQHCs (Federally Qualified Health Centers).
Finally in Texas, the Health, and Humans Services Commission (HHSC) Vendor Drug Program (VDP) Medicaid announced several changes in Preferred Drug list status effective on October 16, 2023, needed because of the shortage of several preferred brand name medications.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Washington
The five-member Prescription Affordability Board (PDAB) held its first hybrid meeting on October 20.
Also in Washington, the State Chief Science Officer Dr Tao Sheng Kwan-Gett signed an updated statewide standing order to dispense naloxone.
Also in Washington, the Department of Health (DOH) Immunization Division is hosting a COVID-19 and RSV Vaccine Updates Webinar (online registration) on Tuesday, October 24 from 12:00 PM – 1:00 PM Pacific. Topics will include COVID-19 vaccine updates and RSV vaccine recommendations for older adults and pregnant persons, as well as recommendations for infants. The online seminar will be recorded.
Finally in Washington, the Health Care Authority's Health Care Cost Transparency Board met on October 18.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Alaska
Effective July 15, 2023, there is no longer a requirement for facilities or pharmacies to submit an application for changes to ownership, location or names.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
Arizona
The Board of Pharmacy’s final rule to permanently authorize pharmacy technicians to administer vaccines under the delegation and supervision of a pharmacist was published in the Arizona Administrative Register, Volume 29, Issue 38 (see pages 2191-2195) with an effective date of September 6, 2023.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
California
The Department of Health Care Services (DHCS) posted the following alerts and monthly bulleting on the Medi-Cal Rx Web Portal:
- Diabetic Supplies: Updates to the Quantity and Fill Limitations for Diabetic Testing Supplies (October 5)
- Updates to Enteral Nutrition Prescription Requirements (October 4)
- 90-Day Countdown: Medi-Cal Managed Care Plan Transition (October 3)
- Respiratory Syncytial Virus (RSV) Vaccines ArexvyTM and AbrysvoTM Now on the Contract Drugs List (October 3)
- How to Resolve Reject Code 76 – Plan Limitations Exceeded (October 2)
- COVID-19 Antigen Over-the-Counter Test Coverage Updates, Effective November 1, 2023 (October 1)
- Medical Supplies: Future Changes to Continuous Glucose Monitoring Systems Coverage Criteria and Prior Authorization Bundling (October 1)
- Diabetic Supplies: Updates to the Dexcom G7® Continuous Glucose Monitoring Sensor Package Size Description, Effective October 1, 2023 (October 1)
- Medi-Cal Rx Monthly Bulletin for October (October 1)
- Changes to the Medi-Cal Rx Contract Drugs List (October 1)
- Changes to Medi-Cal Rx Contract Drugs List – Authorized Drug Manufacturer Labeler Codes (October 1)
- Changes to Medi-Cal Rx Pharmacy Reimbursable Physician Administered Drugs (October 1)
- Updates to the Medi-Cal Rx Provider Manual (October 1)
- Medi-Cal Rx Weekly Wrap-up for September 22-28 (September 29)
- Reinstatement Spotlight (September 29)
- Update: Reimbursement for New Commercial COVID-19 Vaccines (September 22).
Also in California, NACDS submitted a letter of support to Gov. Gavin Newsom (D) urging him to sign AB 1341. The governor subsequently signed AB 1341 (Chapter 276, Statutes of 2023) on September 30. The newly bill enacted permits pharmacists to provide COVID-19 medication as well as offer broader options of substance use disorder treatments as specified in the bill.
Also in California, NACDS submitted a letter to Gov. Gavin Newsom (D) urging him to veto AB 1286, legislation that would impose arbitrary staffing limits and impede pharmacies’ ability to optimize the use of pharmacy technicians to assist with technical duties that do not require a pharmacist’s professional judgement.
Finally in California, NACDS submitted a letter of support to Gov. Gavin Newsom (D) urging him to sign AB 317, legislation helping to support patient access to essential healthcare services provided by pharmacists by requiring healthcare service plans that cover care that is otherwise within pharmacists’ scope of practice to reimbursement pharmacy providers for delivering those services.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
Connecticut
The Department of Consumer Protection urges pharmacists to continue to offer to prescribe naloxone for patients, when appropriate. This includes when filling prescriptions for:
- Medications within the opioid class of drugs;
- Patients with a history of opioid use disorder;
- Family members and friends of individuals with a history of opioid use disorder and
- Upon request by a patient.
As some insurance providers, including Medicaid, may continue to cover Narcan and ReVive, pharmacists should continue to submit claims when dispensing naloxone prescribed by a pharmacist or other authorized prescriber. Patients whose insurance providers do not cover these medications should contact their insurance provider for more information. Additional information can be found on the Drug Control Division website.
For more information, please contact NACDS’ Mike Sargent at 207-272-6435.
Florida
Gov. Ron DeSantis (R) and members of the Florida Cabinet approved rules to implement several provisions of the Prescription Drug Reform Act (SB 1550). The rules increase accountability among pharmaceutical middlemen known as pharmacy benefit managers (PBMs). As signed by the Governor earlier this year, SB 1550 institutes the most comprehensive reforms to Florida’s prescription drug market in state history. Additional information on the bill can be found here.
Also in Florida, the Agency for Health Care Administration (Agency), along with its fiscal agent, Gainwell Technologies, is introducing enhancements implemented as part of the new NPI initiative. A new Taxonomy Master List (TML) Tip Sheet, an updated Provider Master List (PML) Tip Sheet and an updated Pending Provider List (PPL) Tip Sheet is now available. The updated PML and PPL test examples are now available. The release of the updated PML and PPL changes will occur on October 26, 2023. After the release, a copy of the former version of the PML and PPL will remain archived on the Registration page of the Managed Care section of the Florida Medicaid Public Web Portal for reference. The release of the updated TML changes occurred on September 28, 2023. The release will replace the current version of the TML on the Florida Medicaid Public Web Portal. To access a copy of the new TML Tip Sheet and the updated PML and PPL Tip Sheets, please visit the Florida Medicaid Public Web Portal at mymedicaid-florida.com, navigate to the Agency Initiatives tab, and select NPI Initiative.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Indiana
The Department of Health issued the standing order and protocol for pharmacists to provide without a prescription self-administered hormonal contraceptives products.
- Statewide Standing Order for Administration of Hormonal Contraceptives (updated 9/1/23)
- Appendix A
- Appendix B
- Appendix C
- Appendix D
- Statewide Protocol for Hormonal Contraceptives (updated 9/1/23)
Also in Indiana, the state’s Health Coverage Programs (IHCP) Medicaid issued several bulletins:
- Pharmacy updates approved by Drug Utilization Review Board September 2023
- IHCP updates Preferred Diabetes Supplies List
- IHCP expands coverage for Vaxneuvance to the pediatric population
- Correcting the ages covered through the VFC (Vaccines for Children) program for members ages 6 weeks through 18 years of age
- IHCP updates pharmacy benefit long-acting reversible contraceptive coverage
IHCP removes cost-sharing obligations for pharmacist-administered adult vaccines
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Iowa
The Department of Health and Human Services, Iowa Medicaid posted INFORMATION LETTER NO. 2503-MC-FFS – 2023 Annual Provider Training.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
Kansas
The Board of Pharmacy announced that the Collaborative Drug Therapy Management Committee adopted several protocols for testing and initiation of therapy for:
– Suspected Influenza in Adult Patients
– Suspected Influenza in Patients under 18 years of age
– Suspected Acute Group A Streptococcal Pharyngitis in Adult Patients
– Suspected Acute Group A Streptococcal Pharyngitis in Patients under 18 years of age
– Suspected Acute Uncomplicated Lower Urinary Tract Infection in Women
Also in Kansas, the Board of Pharmacy approved a new emergency opioid antagonist (EOA) protocol adding an opioid antagonist drug ready-to-use nasal spray device to the drugs that may be dispensed.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Kentucky
It is NACDS’ understanding that pharmacy claims for the updated Pfizer-BioNTech and Moderna COVID-19 vaccines have been rejecting under the pharmacy benefit through MedImpact. The Kentucky Pharmacy Association shared with us that Medicaid has decided to cover the new vaccines under the pharmacy benefit. MedImpact is working on system edits to accommodate pharmacy billing and will notify pharmacies when it is implemented. Additionally, managed care coverage will begin for the Abrysvo (Pfizer) and Arexvy (GSK) RSV vaccines effective October 6. For more information on Medicaid vaccine coverage, please see the updated version of MedImpact’s Vaccine Coverage Expansion.
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
Louisiana
Effective October 1, 2023, the Department of Health (LHD) is increasing the professional dispensing fee (PDF) $0.82 to $11.81 for local pharmacies only for all Medicaid Fee-for-Service (FFS) and Managed Care Organization (MCO)claims. The current PDF is $10.99.
Also in Louisiana, the Department of Health (LDH) Bureau of Health Services Financing’s Interim Medicaid Executive Director Kimberly Sullivan announced the new implementation date for the Single Pharmacy Benefits Manager (PBM) for Managed Care Organizations (MCOs) is now October 28, 2023. Magellan Medicaid Administration Inc. will serve as the single PBM processor for all six MCOs (Aetna, AmeriHealth Caritas, Healthy Blue, Humana Healthy Horizons, Louisiana Healthcare Connections and United Healthcare).
Also in Louisiana, the Board published five final rules in the September 20, 2023, edition of the Louisiana Register, with immediate effective dates.
- Regulatory Project 2023-03 – Pharmacy Benefit Managers
- Regulatory Project 2023-04 – Healthcare Workplace Violence Prevention
- Regulatory Project 2023-05 – Pharmacy Change of Ownership
- Regulatory Project 2023-06 – Staffing Ratios
- Regulatory Project 2023-08 – DATA-Waiver Registration Elimination
Finally in Louisiana, the Department of Health (LDH) Medicaid issued several documents detailing changes also effective October 1:
- Louisiana Medicaid Pharmacy Maintenance Medications Professional Dispensing Fee for Managed Care Organizations (MCOs) – Effective October 1, 2023
- Louisiana Medicaid Pharmacy Single Pharmacy Benefits Manager (PBM) for Medicaid Managed Care – Effective October 1, 2023
- Louisiana Medicaid Pharmacy Clotting Factor Products Update – Effective October 1, 2023
- Louisiana Medicaid Pharmacy Counseling for Vaccines – Effective October 1, 2023
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Maryland
Medicaid has issued Advisory #251 from the Office of Pharmacy Services in reference to the COVID-19 Home Test Kit Coverage for The Maryland Medicaid Fee-for-Service (FFS) Program. Anyone interested in directly receiving upcoming Advisories may forward his/her name, company affiliation and email address directly to: Deborah.washington@maryland.gov.
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
Michigan
The Board of Pharmacy has posted the public notice and agenda for the October 30 Rules Committee Work Group meeting and the minutes from the September 11 Rules Committee Work Group meeting.
Also in Michigan, MDHHS (Michigan Department of Health and Human Services) has proposed a rule regarding documenting patient consent for automatic refills that aligns with 2014 CMS guidance. Comments are due November 7 to the email noted on the policy’s transmittal sheet.
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
Missouri
On September 28, the Board of Pharmacy issued a statement on working conditions recommending that pharmacies review current operations and address any issues that may impede safe patient care, including pharmacy staffing and any metrics/quotas that may hinder safe patient services. The Board also recommends pharmacies provide any additional resources or protections needed to minimize any job-related stressors of pharmacy personnel.
Also in Missouri, the Board of Pharmacy posted the September newsletter which includes detailed information on pharmacists’ new immunization authority, and the recently revised statewide naloxone standing order.
Also in Missouri, the state’s Department of Social Services Division of Health published rules in the State Register (p13-15) establishing a Pharmacy Federal Reimbursement Allowance and methodologies to determine the formula for the amount of allowance each pharmacy is required to pay for the privilege of providing outpatient prescription drugs.
Finally in Missouri, the Department of Health and Senior Services’ Division of Regulation and Licensure issued an emergency regulation on Controlled Substances.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Ohio
The Senate Health Committee will hold a proponent hearing on SB 144, sponsored by Sen. Mark Romanchuk (R), on October 11 at 9:30 a.m. The legislation would authorize pharmacists and pharmacy technicians to administer routine childhood vaccines to patients 5 years of age and older and remove the prescription requirement for these vaccines. The Ohio Council of Retail Merchants and the Ohio Pharmacists Association will be testifying and NACDS will submit written testimony in support. Testimony and letters of support are due at 9:30 a.m. on October 10. If any members wish to weigh in, either in person or with written testimony, please contact Jill McCormack for further details.
Also in Ohio, the Board of Pharmacy has issued a lengthy agenda for the October 24 public hearing.
Finally in Ohio, the Board of Pharmacy has posted Proposed Compounding Rules related to USP 795 and 797. Comments are due October 24.
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
Oklahoma
Gov. Kevin Stitt (R) convened a special session of the legislature on October 3 to address tax reforms.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
New York
Effective September 11, 2023, the State Department of Health’s NYRx, the Medicaid Pharmacy Fee-For-Service program, will provide reimbursement for qualified and enrolled pharmacies for COVID-19 vaccines and administration as approved by the FDA or authorized for emergency use. Billing codes and other guidance provided in the announcement.
Also in New York, on September 12, the State Education Department withdrew the proposed central fill pharmacy regulations. The Department and the Board of Pharmacy will convene stakeholders and restart the regulatory process. NACDS and members had been actively advocating for a change and delay in the proposed regulations, that amongst its provisions would have created a new central fill pharmacy registration class, prohibited central fill pharmacies from being open to the public, require that central fill pharmacies only prepare and fill prescriptions sent from an originating pharmacy, prohibited direct-to-patient central fill models and required the originating pharmacy to obtain consent from the patient in writing before a prescription may be prepared by a central fill pharmacy. A broad coalition of pharmacy interests are unified in opposition and pushed for support for delayed consideration. NACDS also previously submitted a letter during the public comment period.
Also in New York, on September 20, the State Department of Health held its monthly industry call for NYRx, the Medicaid fee-for-service program. The Education and Outreach team for NYRx holds virtual office hours on Tuesdays and Thursdays from 12:00 noon to 1:00 p.m. Eastern.
Finally in New York, on September 22, the State Department of Health, on behalf of NYRx, relayed to pharmacies that Medicaid patients are prohibited from paying out of pocket for covered services. The COVID vaccine is covered, and no Medicaid recipient should be asked to pay. The Department noticed that some Medicaid members were mistakenly informed that the vaccine was not covered and may have paid out of pocket. These claims should be promptly resubmitted, and the member contacted and reimbursed for all out-of-pocket costs. The State Department of Health has posted the “Medicaid Coverage Policy and Billing Guidance for the Administration of COVID-19 Vaccines.”
For more information, please contact NACDS’ Mike Sargent at 207-272-6435.
South Carolina
Effective October 1, 2023, the Medicaid State Plan will be updated to allow South Carolina pharmacists to bill for hormonal contraception services in accordance with the Pharmacy Access Act and as described in this bulletin.
To be eligible for reimbursement for these services, pharmacists must complete a Healthy Connections Medicaid provider enrollment application. Pharmacists may apply on or after September 18, 2023. Interested pharmacists are encouraged to apply on the providers page of the Department of Health and Human Services’ (SCDHHS) website and enroll as an “individual pharmacist” under the provider type “other medical professional.” In addition to the standard enrollment information, pharmacists must provide information on the pharmacy or pharmacies where they will be providing this service. Training on completing this application and enrollment process is available on the SCDHHS website.
Once enrolled, pharmacies will be able to bill dates of service on or after October 1, 2023, for Medicaid members. This includes members enrolled in the full-benefit Medicaid program and those enrolled in the Family Planning limited benefit program. Pharmacies will be reimbursed for the procedure and diagnosis codes listed below under the Healthy Connections Medicaid member’s medical benefit utilizing the CMS form 1500. These services will be reimbursed in parity with nurse practitioners and physician assistants at 80% of physician rates. The reimbursement rates for these services are available in the Base Physician Fee Schedule available on SCDHHS website. Covered services and billing guidance will be added to the Physicians Services provider manual by October 1, 2023.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Tennessee
To assist prescribers and providers, prior authorization (PA) requirements can be bypassed for certain medications when specific medical conditions exist. Those specific medications and diagnoses can be found here. Prescribers are encouraged to include the applicable diagnosis code on written prescriptions for inclusion on the electronic pharmacy claim. The submitted claim should include a Diagnosis Code Qualifier (Field # 492-WE) of “02,” indicating ICD-10, as well as the appropriate Diagnosis Code (Field # 424-DO). If you have any questions, contact the OptumRx Pharmacy Supports Center at 866-434-5520 or tnrxeducation@optum.com
Also in Tennessee, TennCare held a webinar on the results of the recent Cost of Dispensing survey. During this event, TennCare disclosed the increased, updated professional dispensing fees (PDFs) applicable to all pharmacies within the TennCare Pharmacy network. Also, beginning November 1, 2023, pharmacies that have not responded to three or more TennCare surveys in the past will have their PDF set at $5.00. Based on the findings, the dispensing fees will be as follows:
Ambulatory
- $13.16 for low-volume pharmacies (<65,000 prescriptions)
- $9.02 for high-volume pharmacies (>65,000 prescriptions)
Specialty
- $52.46 for non-blood factor medications
- $172.69 for blood factor medications
Other
- $13.16 for long-term care
- $16.92 for 340B
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Texas
Gov. Greg Abbott (R) issued a Proclamation convening a third special session on October 9 focused on public education funding, illegal immigration and private employer COVID vaccine mandates.
Also in Texas, the Health and Humans Services Commission’s (HHSC) September 2023 biannual specialty drug list is now available.
Also in Texas, the Legislature approved funding for the Board of Pharmacy (TSBP) to offer statewide integration of the Prescription Monitoring Program (PMP) in pharmacy management systems and NarxCare access at no cost to pharmacies beginning September 1, 2023.
Also in Texas, state Medicaid and Healthcare Partnership (TMHP) is gearing up to participate in a town hall meeting on the enrollment process for the Medicaid Vendor Drug Program (VDP), including Medicaid managed care. All pharmacy providers must enroll or complete their revalidation enrollment with HHSC through the Provider Enrollment and Management System (PEMS). Register here.
Also in Texas, after two weeks of the impeachment trial of Attorney General Ken Paxton (R), on September 16, the Senate voted to acquit the Attorney General on all 16 impeachment articles. A total of 21 senators would have had to approve at least one article of impeachment for Attorney General Paxton to be convicted and removed from office.
Also in Texas, HEB pharmacist Doug Read, R.Ph., PharmD. was reappointed to serve a three- year term on the Prescription Monitoring Program Advisory Committee, established under section 481.067 of the Texas Controlled Substances Act.
Also, the Board of Pharmacy (TSBP) adopted several new rules at its August meeting.
Also in Texas, on September 22, the TSBP convened a special hybrid meeting to review and approve the search committee’s recommendations for a new Executive Director/Secretary, replacing Tim Tucker who was terminated by the Board last February. By unanimous vote, Board members offered the job to Daniel (Danny) Carroll, a Pharm.D. graduate from The University of Texas at Austin College of Pharmacy who is currently the Director of Pharmacy at Northwest Hills Surgical Hospital in Austin. Carroll accepted and will begin in mid-October.
Finally in Texas, the Health and Human Services Commission (HHSC) published a report on the End of Continuous Medicaid Coverage September 2023 Monthly Enrollment Report to CMS.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Utah
The Department of Health & Human Services released the results of its recent survey of the average cost of dispensing a Medicaid prescription in the state. The mean cost of dispensing, weighted by Medicaid prescription volume, was $11.57 per prescription for all pharmacies including specialty pharmacies. For non-specialty pharmacies only, the mean cost of dispensing, weighted by Medicaid prescription volume, was $11.24 per prescription.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.