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.

2023-10-06T09:53:54-04:00October 6, 2023|South Carolina|

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.

2023-10-06T09:53:01-04:00October 6, 2023|Tennessee|

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.

2023-10-06T09:52:00-04:00October 6, 2023|Texas|

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.

2023-10-06T09:50:46-04:00October 6, 2023|Utah|

Vermont

On October 5, the Department of Vermont Health Access (DVHA) updated the administration fee for the 2023-2024 commercial COVID-19 vaccines to $40.00, to align with Medicare reimbursement. This change is retroactive to September 11, 2023. DVHA-enrolled pharmacies may be reimbursed for injectable COVID-19 vaccinations administered to adults 19 years and older who are enrolled in Vermont’s Medicaid. Pharmacists must be enrolled with Vermont Medicaid, certified to administer vaccines in the State of Vermont and compliant with all Vermont laws governing vaccine administration. Failure to comply with all Vermont immunization regulations will subject these claims to recoupment. Participation in the Vermont Child Vaccine Program (VCVP) is mandatory for providers who wish to provide vaccinations to children under age 19 years insured by Vermont Medicaid.  If the pharmacy is not enrolled in VCVP please refer members through age 18 years presenting for vaccinations at pharmacies to their health care provider for State-supplied vaccines at no cost to the member.  Under the DVHA General Provider Agreement (Conditions 4.2), providers shall not bill a member for any covered service.

Also in Vermont, regarding currently covered COVID-19 vaccines:  Comirnaty® (Pfizer), Novavax®, Spikevax® (Moderna), pharmacies are reimbursed for the ingredient cost and administration fee for COVID-19 vaccines. No dispensing fee is paid for vaccine claims. Basis of Cost and Submission Clarification Codes are no longer required. Through the pharmacy POS system, the pharmacy must submit the code “MA” in the Professional Service Code field for the COVID-19 vaccine claim to document the administration of the vaccine and receive full reimbursement. There is no member copay for vaccines.

Required NCPDP Fields
NCPDP Field Number NCPDP Field Description Required Code
44Ø-E5 Professional Service Code MA
4Ø7-D7 Product/Service ID NDC for vaccine

For questions regarding this benefit, please contact the Change Healthcare Pharmacy Help Desk at 1-844-679-5362. Vermont providers can also send inquiries via email to PBA_VTHelpdesk@changehealthcare.com.

Also in Vermont, the Board of Pharmacy held its regular meeting on September 27. The board accepted the state pharmacist prescribing protocols for emergency contraception (limited to medications, not IUDs) and the ACIP-recommended vaccines. Those two protocols will be posted on the state OPR (Office of Professional Regulation) website soon.

The Board clarified the language regarding Rule 10.26 in the Board’s 2014 “Policy on Hydrocodone Combination Products as Schedule II Drugs” that limits future fill prescriptions to two. The Board chose to remove the 2014 policy and follow the DEA (Drug Enforcement Administration) policy instead.

Additionally, the Board, in response to a request from the Department of Vermont Health Access to clarify blood pressure monitors qualifying as “accessory devices” and pharmacists prescribing authority as described in described in 26 V.S.A. § 2023(b)(3), decided that it is considered over the counter as defined in section 5 in regard to insurance coverage.

Finally in Vermont, on September 18, the Department of Vermont Health Access (DVHA) made changes to the Pharmacy Manual regarding automatic refills for Medicaid members. Vermont Medicaid does not pay for prescriptions that are not medically necessary or for individuals who are no longer eligible for Vermont Medicaid. Providers may not use automatic refill systems to deliver or provide prescriptions to members. Members and providers may not agree to waive the requirements of this section. Providers may contact members to initiate a refill, but members must choose to fill each prescription, and providers must determine that the member remains eligible for Vermont Medicaid before providers deliver or dispense the prescription. Providers may not assume that, because a member’s prescription authorizes refills, the member has implicitly requested that the provider refill the prescription. For questions, please contact the Change Healthcare Pharmacy Help Desk at 1-844-679-5362. Vermont providers can also send inquiries via email to PBA_VTHelpdesk@changehealthcare.com.

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

2023-10-06T09:48:11-04:00October 6, 2023|Vermont|

Virginia

The Board of Pharmacy issued the following notice reminding pharmacy that the emergency rules on Workplace Conditions were effective September 29:

The Virginia Board of Pharmacy emergency regulations regarding pharmacy working conditions became effective today, September 29, 2023. All are strongly encouraged to read these important regulations addressing work environment requirements for pharmacy personnel that protect the health, safety, and welfare of patients. The regulations were adopted pursuant to HB 1324 introduced by Delegate Keith Hodges and passed by the 2022 General Assembly. The emergency regulations remain in effect until March 28, 2025. A public comment period will open on October 23, 2023, and remain open through November 22, 2023. Additional information regarding the status of the emergency regulations and public comment period may be found on Virginia Regulatory Town Hall. The Staffing Requests or Concerns Form referenced in the regulations will remain accessible on the Board’s website under Forms and Applications. Please review the requirements related to use of the form in the emergency regulations and listed at the top of the form.

Also in Virginia, the Department of Medicaid Services (DMAS) recently held a stakeholder call to discuss the implementation of SB 1538 of 2023, which requires pharmacy reimbursement for services. They are currently working on system changes to allow billing for the existing pharmacy testing and/or treatment protocols and our understanding is that they intend to further expand it to cover the protocols for flu, strep, COVID and UTI that were included in SB 948 of 2023 upon final approval of the rule. For more details, see the Enrolling Pharmacists as Providers slide deck.

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

2023-10-06T09:45:23-04:00October 6, 2023|Virginia|

Washington

Six years of litigation challenging the state’s below cost dispensing fees resulted in a stunning settlement agreement with an unprecedented windfall for Washington State pharmacies. In exchange for dismissal of our state lawsuit challenging Washington State’s failure to adopt cost-based dispensing fees in April 2017 as required by federal law, the three pharmacy groups, NACDS, NCPA and the Washington State Pharmacy Association (WSPA) secured a commitment from Washington State to conduct its belated cost of dispensing study, the results of which are expected to update Washington State’s illegally inadequate dispensing fees ranging from $4.24-$5.25. Additionally, as a part of the settlement, the state will make over $60 million in retroactive payments to fee-for-service pharmacies that have been victim of Washington’s unlawfully low dispensing fees.

Also in Washington, the Pharmacy Quality Assurance Commission (PQAC) created a new rule, implementing the optional unexpired prescription drug donation program law.

Finally in Washington, in an effort to improve patient outcomes and better contain healthcare costs, the state Health Care Authority (HCA) is embracing Value Based Care (VBC) quality performance measures within the Medicaid managed care contracts. HCA is working with Comagine Health to conduct annual reviews of the current performance measures and their results. Beginning in 2024, HCA will move toward outcomes-based measures, rather than continuing to use process of care measures.

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

2023-10-06T09:44:29-04:00October 6, 2023|Washington|

California

The Department of Health Care Services (DHCS) posted the following bulletins, notices, and alerts on the Medi-Cal Rx Web Portal.  

Also in California, Medi-Cal posted the following.  

For more information, contact NACDS’ Sandra Guckian at 703-774-4801.

2023-09-22T14:30:41-04:00September 22, 2023|California|

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 will occur 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.

2023-09-22T14:29:59-04:00September 22, 2023|Florida|

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