Information for Pharmacists and Medical Providers About the Medicaid Pharmacy Program
- Prescription services may be provided by and reimbursed to a licensed enrolled retail pharmacy upon the order of a licensed practitioner allowed to prescribe medications.
- A licensed pharmacist or pharmacy intern(s), under the direct supervision of a licensed pharmacist, must provide prescription services, such as medication counseling, prescription verification, dispensing verification, etc.
Medispan Product Information
According to the Centers for Medicare and Medicaid Services (CMS), “the Medicaid drug rebate program was created by the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) and requires a drug manufacturer to enter into and have in effect a national rebate agreement with the Secretary of the Department of Health and Human Services (HHS) for states to receive Federal funding for outpatient drugs dispensed to Medicaid patients”.
Please note that even though a product may be listed as covered by Medicaid (such as diapers or catheters), a particular manufacturer’s product may not be covered if the manufacturer has not submitted all product information to Medi-Span®. It is the manufacturer’s responsibility to submit their product information to Medi-Span®.
Legend Drug Exclusions
The Wyoming Medicaid Pharmacy Program will not cover the following Legend Drugs:
• Anorexiant products
• Androgenic or Anabolic steroids used for weight gain
• Agents used to promote fertility
• Acne agents for clients who are 21 years of age or older
• Agents used for the stimulation of hair growth
• Erectile Dysfunction medications
• DESI, as well as similar, related or identical drugs considered to be less-than-effective by the Food and Drug Administration (FDA)
• Compound prescriptions, which include a DESI drug, will deny (refer to Compound Drugs section of the Medicaid Pharmacy Provider manual for instructions on billing non-DESI ingredients.)
• Promethazine for children 2 years of age and younger
• Orphan drugs
• Medications not approved by the FDA
Some medications require prior authorization. Additional information may be found by clicking on the Preferred Drug List/Prior Authorization (PDL/PA) menu tab on the Office of Pharmacy Services home page.
For additional information on product coverage, including over-the-counter products, please refer to our provider manual at http://wyequalitycare.org.
Prior Authorization/Preferred Drug List
To review information for medications which are subject to prior authorization, please visit our prior authorization website at http://wyequalitycare.org.
Following introduction to the market, new drugs and new formulations of existing drugs, and new indications that are covered through the pharmacy services program will require prior authorization until published literature is available through standard literature review processes. The drug will be considered at the next scheduled P&T Committee meeting, and its coverage status will be reviewed at that time. Exceptions to this rule will be handled on a case by case basis.
For information regarding therapeutic classes currently listed on our Preferred Drug List (PDL), a timeline for future review of therapeutic classes, and agendas for upcoming Pharmacy &Therapeutics (P&T) meetings, please click on the following link to visit our P&T website at http://www.uwyo.edu/DUR/pandtcommittee.
The following reimbursement algorithm applies to all legend drugs, diabetic supplies, medical supplies and OTC medications for all Medicaid Plans:
Providers will be reimbursed the lesser of SMAC, FUL, AWP-11%, or Ingredient Cost Submitted + $5.00 dispensing fee, GAD, U&C, or Lowest Advertised Price, whichever is less.
SMAC is the maximum allowable cost that the State of Wyoming will pay for generic multi-source medications. Pharmacy Services has contracted with Goold Health Systems (GHS) to manage our SMAC list. Please contact GHS for any questions or dispute issues pertaining to SMAC pricing or reimbursements. All questions should be directed to the GHS POS Help Desk at:
Goold Health Systems
Provider Relations Unit
P.O. Box 21719
Cheyenne, WY 82003-7032
In the event of an emergency the pharmacy is authorized to dispense up to a seventy-two (72) hour emergency supply. An emergency supply may only be used twice for each drug per month. For PDAP clients, any emergency supply claims will count as one of the three prescriptions those clients are limited to per month. A dispensing fee will not apply. Please refer to the payer sheet for instructions for PA code type and PA number field. Use of the emergency supply for non-emergency situations or to override the PA process will result in recovery of claim payment and further audit proceedings.
Mandatory Generic Program
On May 28, 2009, Wyoming Medicaid implemented a Mandatory Generic Program for prescription services. The program requires that brand name drugs with A-rated generic equivalents will only be reimbursed if there is a documented allergy or adverse reaction to ALL generic versions, i.e., Vasotec (enalapril maleate), Soma (carisoprodol), Motrin (ibuprofen).
(Please note: “Brand Name Medically Necessary” is still required to be written in the prescriber’s own handwriting on the prescription if the prescriber wants the brand name to be dispensed.)
- The prescriber must be notified and asked to fill out a Brand Name Drug Request form. (Please note: “Brand Name Medically Necessary: is still required to be written in the prescriber’s own handwriting on the prescription if the prescriber wants the brand name to be dispensed.)
- Physicians should submit their reports of generic inequivalence directly to the FDA via the MEDWATCH. A copy of the MEDWATCH report must be included with the PA request.
- Completed information should be faxed to the Goold Health Services’ (GHS) Prior Authorization Department at 866-964-3472.
- If the request for the brand medication is approved, a prior authorization will be granted within 72 hours of GHS receiving the request. Both the prescriber and the pharmacy will be notified of the approval and the pharmacy will then be able to process the claim.
- If the request is denied, both the prescriber and pharmacy will be notified by fax and phone of the denial and the reasons for the denial.
The following medications are exempt from the Mandatory Generic Program requirements:
**Please refer to the Pharmacy Provider Manual for more detailed information on the medications listed above at http://wyequalitycare.org.
Client Co-payment Fees
The Wyoming Medicaid Pharmacy Program’s co-payment structure is as follows:
- Generics (Multi-source medications) = $0.65
- All Brand-name mediations = $3.65
Wyoming EqualityCare clients exempt from the co-payment requirement are:
- Clients under age 21
- Nursing Facility Residents
- Pregnant Women*
- American Indians and Alaska Natives
- Family Planning Services
- Emergency Services
- Hospice Services
* The pregnancy co-payment exemption ends on the day of delivery.
Pharmacy Services is responsible for detecting fraud and/or abuse within the Medicaid Pharmacy Program. This is accomplished by the review of paid claims history and by conducting field reviews and investigations to determine provider/recipient abuse, deliberate misuse, and suspicion of fraud.
Additional information regarding Program Integrity may be found by clicking on the Program Integrity menu tab on the Pharmacy Services home page.
PLEASE REPORT! To report any and all fraudulent activity with Wyoming Medicaid, please call 1-855-846-2563 or visit http://stopwyomedicaidfraud.com.
INTERESTED IN ENROLLING AS A PHARMACY PROVIDER?
If you are interested in becoming a pharmacy provider for Wyoming EqualityCare, please contact Goold Health Systems (GHS) to complete the required paperwork at www.wyequalitycare.org.