The Board of Pharmacy will be holding its regularly scheduled meeting on September 25, 2024, at 9:00 am. The meeting will be hybrid and recorded.

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

Medicaid has updated its contact information due to the transition of Change Healthcare (CHC) to Optum.

Also in Vermont, the Department of Vermont Health Access (DVHA) continues a phased recovery following the outage that occurred in February 2024, due to the national cyber security issue affecting Optum/Change Healthcare. Beginning August 7, 2024, edits for Reject-75, Prior Authorization Required, will return to normal functioning in the pharmacy claims system.

• Claims for non-preferred items on the Preferred Drug List (PDL), including medications obtained during the outage, that do not have an active Prior Authorization on file, will now begin to reject. This also includes preferred medications subject to clinical review and medications requiring step therapy. Please refer to the PDL for medication specific coverage criteria.
• An emergency fill can be dispensed when a required prior authorization has not been secured, and the need to fill the prescription is determined to be an emergency. If the prescriber cannot be reached to obtain the required prior authorization, the pharmacist may dispense an emergency supply to last up to 72 hours.

Please continue to refer to the Preferred Drug List to review preferred and non-preferred medications. Providers requiring assistance with submitting a prior authorization may contact the Optum Pharmacy Helpdesk at VermontHD@Optum.com, the Prescriber Helpdesk at (1-844-679-5363) or the Pharmacy Helpdesk at (1-844-679-5362).

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

On June 10, the Department of Vermont Health Access (DVHA) informed pharmacy providers of some important updates in the restoration of pharmacy services that were implemented in the Medicaid system, effective June 8.

• Drug Pricing Updates:

NADAC (National Average Drug Acquisition Cost), AWP (Average Wholesale Price), FUL (Federal Upper Limit) and SMAC (State Maximum Allowable Drug Cost) drug pricing will be updated to reflect the most accurate and up-to-date pricing information.

• New Drug Products and NDC (National Drug Code) Updates:

The Medicaid system will be updated to include the latest Medispan drug files which will add new drug products and NDCs that have been missing during the restoration process. This update will enhance Medicaid’s database with comprehensive information regarding the latest medications available.

• SMAC Disputes:

Medicaid updated its contact information for SMAC disputes. Please note the updated email address below:

• Email: smacdisputes@optum.com

• Rejected Claim Issues:

Pharmacy Providers with claims still requiring assistance from the system outage (February 21, 2024 – March 18, 2024), please contact the Pharmacy Helpdesk at CHC/Optum for assistance.

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

As the Department of Vermont Health Access (DVHA) has previously reported, Change Healthcare (CHC), which operates Vermont’s Medicaid pharmacy claims system, experienced a significant cybersecurity issue on February 21. The cybersecurity incident impacted enrolled pharmacy providers’ ability to process and submit claims for Medicaid services. In response to the outage, Vermont Medicaid is temporarily increasing the Professional Dispensing Fee for retail pharmacies.  

Vermont Medicaid will provide an enhanced Professional Dispensing Fee for prescribed drugs to account for the manual and time-consuming procedures pharmacies had to perform due to the Change Healthcare outage. The Professional Dispensing Fee for pharmacy claims of $11.13 will increase by $3.26 per claim to $14.39, from June 3, 2024, to June 30, 2024. This change will be automatically implemented for pharmacy claims, excluding specialty drug and 340B drug claims. Providers are not required to enroll or apply for the enhanced professional dispensing fee. Standard payment of covered outpatient drugs, including over the counter (OTC) drugs, billed to DVHA on a primary basis and dispensed by an enrolled pharmacy is detailed in the Pharmacy Provider Manual. All manuals and rules are available online.  

This change is one of several temporary flexibility and changes being made to support providers impacted by the Change Healthcare cybersecurity incident. Additional information on these changes can be found in Global Commitment Register 24-029 Change Healthcare Outage—Medicaid Response. Please contact the Change Healthcare Pharmacy Help Desk with any questions at 1-844-679-5362. 

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

On May 22, the Board of Pharmacy held its regular monthly meeting. The agenda included a legislative update, license review and an election for a new vice chair. The rules revisions the board has been working on will be sent soon to the Interagency Committee on Administrative Rules. The next meeting will be held June 24.

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

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’ Ben Pearlman at 617-515-2603.

Effective February 21, Change Healthcare started to experience network issues expected to continue throughout the weekend. To ensure Medicaid members receive necessary prescriptions and pharmacies have necessary guidance the agency offered the following:   

• Claim Processing/Prescription and Emergency Fills: Claims are not processing currently. Existing federal law requires that a 72-hour emergency supply of a prescription drug be dispensed to Medicaid patients when the medication is needed without delay. Claims will be processed once the Change Healthcare system issues have been resolved. It is expected that providers will adhere to the provider agreements, which prohibit billing members when Medicaid will pay for services. Please refer to the provider manual for the limitations on billing members Vermont Medicaid Provider Manual (vtmedicaid.com). 
• Eligibility: Eligibility must be verified through the automated Voice Response System (VRS), 800.925.1706, option 1 and then option 1 again or by utilizing online Transaction Services (https://vtmedicaid.com/#/home). For those members indicating new enrollment as of February 23, please call Maximus at 855-899-9600 during business hours and for afterhours please call the automated Voice Response System (VRS).  
• Pharmacy Procedures: Many pharmacies have established internal procedures to handle such situations and we encourage dispensing medications to affected members to ensure continuity of care. 
• Prior Authorizations: The outage is impacting the ability to issue prior authorizations. Therefore, prior authorization will be retroactively reviewed and applied for prescriptions filled during the system outage. Pharmacies must review the PDL to ensure the criteria is met prior to issuing new medications. Preferred Drug List (PDL) & Clinical Criteria | Department of Vermont Health Access 
• Refills should be issued as requested based on the member’s history and clinical judgement. These claims will also be subject to a retroactive review. 
• Controlled substance prescriptions: Please review the Vermont Prescription Monitoring System (VPMS) system as required.  
• Helpdesk Access: Due to the outage, pharmacies are temporarily unable to contact the pharmacy helpdesk via phone or fax. Change Healthcare has indicated that the cause of the outage has been identified and they are working actively to restore normal operations. For questions, contact the Department of Vermont Health Access Pharmacy team at 802-879-5000 or ahs.dvhaph@vermont.gov.  

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

On February 28, the Board of Pharmacy will be holding its regularly scheduled meeting at 9:00 am. The agenda has been posted.

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

On January 24, the Board of Pharmacy held its regularly scheduled meeting. The board welcomed new members, elected a new chair, and provided a legislative update. The next meeting is scheduled for February 28 at 9:00 am virtually via Teams.

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