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Information for Pharmacists and Medical Providers About the Medicaid Pharmacy Program

 

 PRODUCT COVERAGE:

 Wyoming Medicaid covers all legend drugs that:

  • Have a signed rebate agreement in place
  • Are registered with Medispan

 Wyoming Medicaid will not cover:

  • Agents used for weight loss, hair loss or fertility
  • Cosmetic agents, including Retin-A and Differin products for clients over the age of 21
  • Agents used for weight gain, including anabolic and androgenic steroids.
  • 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.

 

 

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 

 

 

 

EMERGENCY DAYS SUPPLIES OF PRIOR AUTHORIZED MEDICATIONS:

Pharmacies are authorized to dispense an emergency 72-hour supply of a brand-name medication with multi-source generics or a non-preferred, prior authorization required medication.

 

In the event of an emergency and the GHS Clinical Call Desk is closed, the pharmacy is authorized to dispense up to a 72-hour emergency supply to the client by:

  • Entering a med cert code 8 in the PA medical certification field, the first position of NCPDP field number 416.

 

Please note:

  • A med cert code 8 can only be used twice a month for both non-preferred prior authorization required medications and brand-name medications.
  • A dispensing fee WILL NOT apply on emergency fills.

 

 

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 and require a ‘preferred brand’co-payment of $2.00:

Coumadin

Depakene

Dilantin

Lanoxin (including Lanoxicaps)

Levothroid

Levoxyl

Mysoline

Synthroid

Tegretol (not including XR)

 

**Please refer to page 12 of the Pharmacy Provider Manual for more detailed information on the medications listed above.

 

 

 CO-PAYMENT STRUCTURE:

The Wyoming Medicaid Pharmacy Program’s co-payment structure is as follows:

  • Generics (Multi-source medications) = $1.00
  • All Brand-name mediations = $2.00

 Wyoming EqualityCare clients exempt from the co-payment requirement are:

  • Residents of a nursing facility or in swing beds
  • Pregnant clients
  • Clients under the age of 21
  • Family planning services
  • Emergency services
  • Hospice services

  

 

REIMBURSEMENT:

Drugs billed through the pharmacy claims system are reimbursed at the lower of AWP - 11% + $5, usual and customary, Federal Upper Limit (FUL) or State Maximum Allowable Cost (SMAC). 

SMAC is the maximum allowable cost that the State of Wyoming will pay for generic multi-source medications. The Office of 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 at the following number:

1-877-206-4714

 

 

PROGRAM INTEGRITY:

The Office of 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 Office of Pharmacy Services home page.

If you suspect fraud or abuse of the Wyoming Medicaid Pharmacy Program, please contact our Program Integrity Pharmacist at 1-(800) 438-5785.

 

 

PRIOR AUTHORIZATION/PREFERRED DRUG LIST: 

To review information for medications which are subject to prior authorization please visit our prior authorization website at http://uwacadweb.uwyo.edu/DUR/PriorAuthorization.asp. 

If your product is a drug which falls in a therapeutic class currently listed on the Preferred Drug List, it may require prior authorization.  Specifically, if your product is a new formulation of an existing chemical entity (longer acting, sustained release, etc) it will likely automatically require prior authorization. 

If your product is a combination of two or more drugs, one of which falls into a therapeutic class currently listed on the Preferred Drug List, it will likely not automatically require prior authorization. 

The status of your product will be revisited following additional review of the therapeutic class by the Pharmacy and Therapeutics Committee (P&T). 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 P&T  meetings, visit our PDL website at http://uwacadweb.uwyo.edu/PDL/.