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.

On January 11, the Department of Health released the following notice regarding increased RSV cases and its strain on the health system. Reports have been sent to the Department that pregnant patients have been turned away from pharmacies. The Department asked that pharmacies are aware that: 

• Pregnant individuals are eligible for Abrysvo.  

• • If a particular pharmacy does not have Abrysvo, please refer the pregnant individual to a location that does have it.  
  • We have Immunization Registry (IMR) data showing that pharmacies are administering Abrysvo to women of childbearing age. The IMR does not collect pregnancy status.  

• Adults 60 years of age and older are eligible and encouraged to receive either Arexvy or Abrysvo vaccine.  

• • IMR data shows that pharmacies are giving doses to older adults.        

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

The Board of Pharmacy is scheduled to hold its regular meeting on December 20; the agenda has been posted.

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

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.

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.