1. North dakota Medicaid update
Photo Credit:
North Dakota Tourism
Alexi Murphy, PharmD
Assistant Administrator, Pharmacy Services
North Dakota Department of Human Services

2. Learning Objectives
1. Discuss strategies to process common claim rejections and identify alternative products.
2. Describe resources to find information on new and upcoming coverage rule implementations.
3. Identify a patient who may benefit from the MTM program and list the required paperwork.

3. ND Medicaid pharmacy Websites
Pharmacy PA Website: Criteria and Forms, Preferred Drug List, Preferred Diabetic Supply List, Coverage Rules, Therapeutic Duplication
**Upcoming two separate links:
“NDC Drug Lookup”: Quantity limits, Prior Authorization, Age Limits, Payment details
“PA Form Lookup”: Prior Authorization Forms
State website: MTM information, Payer Sheets, Covered compound ingredients

4. Finding coverage Details
NDC Drug Lookup *NEW*
Type NDC or Drug name into Search
Expand correct drug and strength
Expand correct NDC
Pricing, Quantity Limit, Age, Copay, PA displayed
If PA is required, Form Search link will display and send you back to the HID designs home page
Then use PA Forms Search

5. Finding an alternate product
Error message text sent with POS claim with preferred product:
Eg. Mavenclad “PLEASE USE GILENYA OR AUBAGIO”
PDL or PA Criteria
CtrL F to search for drug “Mavenclad”
Use Table of Contents
Preferred Diabetic Supply List
Lists covered NDCs for test strips and meters

6. Find out about new coverage rules
Pharmacy Archive Link
See previous s
Join mailing list
At the bottom of each is a link to sign up
Newsletter
Notification mailed to providers

7. Finding PA form CoverMyMeds and Old Forms:
If we can get all the information from the PA, request will be processed
If incomplete, may not be processed
Best way to get PA Processed:
Use updated form from website:
“NDC Drug Lookup” by NDC or Name or “PA Forms” link

8. Calling for an override
Call provider relations at
Voic is covered 8a – 5p Monday to Friday with backups
boxes are not covered during leave
Information to leave: Questions are researched before calling back
ID number (either 000*** or ND***) and recipient name
Drug name
Description of situation
Pharmacy opinion of situation

9. Prior Authorization Required
NCPDP Reject Code 75
Age Edits, Step Therapy, Clinical Prior Authorization, Step Care and Concurrent Therapy
Visit
Use the “NDC Drug Lookup” and “PA Forms” to find the correct PA form to use
Upcoming – “PA Forms Lookup”
See “Preferred Drug List” and “PA Criteria” to view preferred products and clinical criteria
January 1, 2020 – These will be combined into one PDL

10. Medicaid coverage overview
Coverage Requirements:
Must be a medically accepted indication and dose based on the FDA label or Compendia (e.g. Micromedex, Facts & Comparisons, etc.)
Manufacturer must have rebate agreement with CMS for Medicaid to cover drugs
Does not fall into a non covered category (e.g. DESI, fertility, cosmetic, most vitamins and OTCs, erectile dysfunction, and weight loss)
Rebates: How brand drugs can be less expensive for ND Medicaid
Federal Rebates: Base Rebate (23.1% brand/13% generic) + CPI Penalty + Best Price (brand)
Supplemental Rebates: State can negotiate additional rebates with manufacturers (mostly brand)
Sec. 1927. [42 U.S.C. 1396r–8]

11. Brand Required Drugs
Pharmacy Issue - Brand name drugs are more expensive to purchase:
How do I get reimbursed properly?
Bill with a DAW 9 (payor requires brand name) to bypass generic pricing
What about first fill edits? I don’t want to end up with a partial bottle if the dose changes
Call for an override to do the first fill with a generic supply
What if you switch back to generic and I have not used my supply yet?
Call for an override to use up your brand supply or return unopened bottles if possible

12. Step Care and Concurrent Therapy
Visit
Visit “Coverage Rules on Medications”
Used with diagnosis requirements to reduce number of drugs requiring paper PAs.
Metformin 1000mg: Lookback for 500mg or 1000mg
GI tolerance
Ventolin inhaler: Lookback for inhaled steroid
Best practice / Appropriate therapy

13. Plan Limitations Exceeded
NCPDP Reject Code 76
Morphine Milligram Equivalents
First Fill
Quantity Limits
Visit “NDC Drug Lookup” to lookup quantity limit
Set based on FDA labeling/compendia recommendations OR preference for one strength (ie. allow 2 x 5mg instead of 10mg)

14. Morphine Milligram Equivalents
90 MME/Day Allowed
Calculator:
100% Overlap
Oxycodone 10mg 4x/day 30-day supply = 60 MME/day filled 8/2
Refill 8/31 – 29 days used = 96% utilized
Will not reject for REFILL TOO SOON because more than 87% utilized.
Will reject for PLAN LIMITATIONS EXCEEDED because with a 1 day overlap of oxycodone 10mg 4x/day (x2)= 120 MME/day > 90 MME/day

15. Albuterol – What is covered?
ProAir HFA –
Quantity Limit = 2 inhalers every 6 months (over 2 puffs per day)
Ventolin HFA
Quantity Limit = 2 inhalers every 4 months (over 3 puffs per day)
Concurrent Steroid Inhaler Required (Can be single or combination inhaler or neb)
Albuterol Nebulizers –
Quantity Limit = 7 doses per day
Inhalers and Nebulizers are not paid together

16. Albuterol – WHY?
To optimize Asthma/COPD Treatment & communicate with prescriber how much albuterol patient is using (how poorly controlled the asthma/COPD is)
If used >2 days/week (except as needed for exercise-induced asthma), the patient may need to start or increase long-term control medications.
Several times per day = Very poorly controlled asthma/Consider oral steroids = Current limit
Neb + Inhaler = 10 rescue breaths per day
Using 2 canisters of SABA per month (13 puffs per day) = Risk of asthma related death = Previous Limit
Exceptions?
End Stage COPD Patients on optimal treatment
Children generally on an albuterol inhaler but want nebulizer as one time request for acute illness
The Journal of Allergy Clinical Immunology, 120(5), S94–S138. DOI: National Asthma Education and Prevention Program.. (2007). Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma–Summary Report 2007

17. First fill
Limited day supply allowed for safety, cost savings, and to prevent waste:
Visit Visit “Coverage Rules on Medications” to see list of drugs
Narcotics: 7 Days
Brand antipsychotics: 10 days
Long acting ADHD: 14 days (Prefer 10 days)
30 days allowed after initial supply
Continue to fill initial supplies (7-14 day supply) until patient is stable
30 days supply should only be filled for patients that are stable on a dose
Overrides for medication/dose changes are not allowed for first 30 days after an initial fill
Fill initial supply for times when dose changes are expected even when patient is stable
E.g. First month back to school

18. DUR Reject Error Therapeutic Duplication Underutilization
Visit
Visit “Therapeutic Duplication”
Use of multiple medications in the same class or multiple strengths to form an “in between” dose lie outside of compendia or guideline recommendations
Use of other strengths would provide the most efficient use of funds.
Underutilization

19. Therapeutic Duplication
Changing Medications/Strengths:
Use up current supply if possible:
If patient has been on medication for a long period of time, it is usually not necessary to switch until current supply is gone
If patient experiencing side effects, call for override
If patient has been on medication for a short time, may not be a long enough trial to become effective

20. Underutilization
Message of __ days missed since “date” with Payment: All maintenance meds
Message with Denial: Meds that are unsafe or expensive to miss doses
Long Acting Opioids
Opioid Use Disorder Treatments - Buprenorphine
Metformin 1000mg
Toujeo and Tresiba
Antipsychotics
Generally an override will be given one (or two) times with instructions to notify prescriber and counsel, then medication may no longer be covered.

21. Refill Too Soon DUR Code: er, m0, 1b NCPDP Reject Code 79
80% for non-controlled medications
Hydroxyzine #60 filled for 30 day supply. Changed to 3x/day. 20 days/30 days = 67%
Hydroxyzine #90 filled for 30 day supply. Patient comes on day 25 for refill. 25 days/30 days = 83%
87% for controlled medications
Hydrocodone 5/325mg #60 for an 15 day supply on 7/15.
Refill on 7/ days/15 days = 67%
Refill on 7/ days/15 days = 93%
DUR Code: er, m0, 1b
Overrides non-controlled substance early refills >61% utilized

22. Accumulation Early Refill
Look back 180 days:
15 days allowed for non-controlled medications
10 days allowed for controlled medications
Where did the 10 / 15 days of extra medication go?
January 1 – 30 days
January 27 – 30 days = 4 days early
February 24 – 30 days = 2 days early (6 days total)
March 24 – 30 days = 2 days early (8 days total)
April 19 – 30 days = 4 days early (12 days total) – Rejects for controlled medication
May 15 – 30 days = 3 days early (15 days total) – Rejects for non-controlled medication

23. Accumulation Early Refill
Deliveries/Mail Outs
Needs to be dispensed 5 days “early” each month to allow for delivery
December 27th – 30 days (For January 1st start date) – 5 days early
January 26th – 30 days (For January 31st start date) – 0 days early
February 25th – 30 days (For March 2nd start date) – 0 days early
Where denials happen?
January 22nd – 30 days (For January 31st start date) – 4 days early (9 days total)
February 15th – 30 days (For March 2nd start date) – 6 days early (15 days total) – Rejects

24. Other claim Rejections
39 – Inv. Diagnosis Code
Submit ICD-10 diagnosis
FDA diagnoses and compendia (e.g. Micromedex, Fact & Comparisons) diagnoses are accepted
19 – Inv Days Supply
34 day is the max day supply for almost all medications.
90 day is the max day supply for some inexpensive medications that have stable maintenance dosing.
ED – INV Compound Ingredient Qty
Ingredients must add up to total quantity of compound. Total quantity is not a volume field.
60 tablets + 50 mL + 50 mL = = 160 total quantity
Medical billing: “PLEASE BILL VIA 837P TRANSACTIONS NOT POS”
Must be submitted by physician in office billing through a professional medical claim

25. Medication therapy management
Help find patients
Prepare paperwork
Submit billing
Medicaid point of contact

26. Medication therapy management
Workflow for Technician:
Identifying patients at pharmacy OR by Department request
Submit MTM Service Authorization Request (SFN 1106)
Make appointment with patient
MTM Provider conducts MTM visit with patient & completes documentation
Submit bill by using provider portal or CMS 1500 form

27. Medication therapy management
Identifying Patients – Technicians are often in the best position to know which patients need help
Not adherent to maintenance medications:
Diabetes, High Blood Pressure, Antipsychotic, Antidepressant, etc.
Getting 88 – DUR REJECT ERROR underutilization message (claim may either pay or reject)
Dose increases, new medications, additional medications, poor disease control
Exceeding ProAir HFA quantity limits (2 inhalers per 6 months)
Receiving discharge prescriptions / several new prescriptions at once
Receiving refill requests for benzodiazepines, muscle relaxants, opioids, insomnia medications, proton pump inhibitors
OneRx – high risk for overdose or opioid use disorder
PDMP NarxCare > 650

28. Medication therapy management
Submit MTM Service Authorization Request (SFN 1106)
Fax to “Attention Pharmacy”
What we do with it? Communicate with medical claim staff
Verify provider – these codes can only be billed for services provided by pharmacist enrolled as MTM providers
Number of Visits – based on what service is being provided
Intent to provide services – tracking which patients/# services/MTM providers to expect a claim
What we don’t do?
Request chart notes or documentation to verify patient eligibility
Our “criteria” is a guide – We rely on pharmacies to know which patients need help

29. Medication therapy management
Submit bill by using provider portal or CMS 1500 form
Instructions for how to bill:
The provider portal (electronic EDI 837P):
Paper CMS 1500:
Your MTM software may be able to bill us directly

30. Medication therapy management
Call center can help you bill through the portal or fill out CMS 1500 form.
Authorized Representatives:
Staff of a pharmacy that can bill through the portal or assign a billing role to another person in their organization

31. Medication therapy management
Call center can help you bill through the portal or fill out CMS 1500 form.

32. Announcements October 1st 2019 - No copays for brand or generic drugs
January 1st Prescription Drug Benefit for Medicaid Expansion / Children’s Health Insurance Program (CHIP) recipients will be administered by the State
Sanford Health (Medicaid Expansion) / Blue Cross Blue Shield (CHIP) will still administer the Medical Benefit
New positions at the State:
Pharmacist
Pharmacy Provider Relations

33. Questions or suggestions?
What is most helpful?
What would you like more information on?
What is the biggest annoyance?
What would make working with ND Medicaid easier?
Contact Information
Alexi Murphy, PharmD
Office Phone:
Fax Number:
600 E. Boulevard Ave Dept 325
Bismarck, ND