Important Notice for Medicaid Pharmacies and Prescribers!

Tamper-Resistant Prescription Pad Deadline Delayed Until April 1, 2008

On Saturday, September 29, 2007, President George W. Bush signed the “Extenders Law,” delaying the implementation date for all paper Medicaid prescriptions to be written on tamper-resistant paper. Under the new law, all written Medicaid prescriptions must be on tamper-resistant prescription pads effective April 1, 2008.

CMS will issue additional guidance on this implementation delay as it becomes available. The Office of Pharmacy Services will pass any additional information on to our providers in regard to this regulation as soon as it is made available to us.

 

 

For Your Information:

 

 PRODUCT COVERAGE:

 

Wyoming Medicaid covers all legend drugs that:

• Have a signed rebate agreement in place
• Are registered with First Data Bank

 

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 PROVIDER?

 

If you are interested in becoming a provider for Wyoming EqualityCare, please contact Affiliated Computer Systems (ACS) to complete the required paperwork at:

 wyequalitycare.acs-inc.com 

 

 

 

 

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 ACS 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 DAW code of 1 MUST be used with brand-name medications with multi-sourced generics.
• A med cert code 8 can only be used once per drug per month for brand-name medications.
• A med cert code 8 can only be used twice per drug month for non-preferred prior authorization required medication.
• A dispensing fee WILL NOT apply on emergency fills.

 

MANDATORY GENERIC PROGRAM:

 

On November 1, 2005, Wyoming Medicaid implemented a Mandatory Generic Program for prescription services. The program requires that brand name drugs with A-rated generics will only be reimbursed if there is a documented allergy or adverse reaction to two or more of its generic versions, i.e., Vasotec (enalapril maleate), Soma (carisoprodol), Motin (ibuprofen).

 

For example, if a prescription claim for Darvocet-N-100 brand name rejects because two or more A-rated generics have not been tried, the pharmacy will receive a rejections message. (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 and fax it to the Wyoming Department of Health’s Office of Pharmacy Services at (307) 777-8623.
• If the request is approved, a prior authorization will be granted within 72 hours of the Office of Pharmacy Services 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 either fax or phone of the denial and the reasons for the denial.
• If a prescription is written for a brand-name drug, it will automatically be filled with a generic medication (if one is available) when “Brand Name Medically Necessary” is not written on the prescription.

 

The following medications are exempt from the Mandatory Generic Program:

Coumadin

Depakene

Dilantin

Lanoxin (including Lanoicaps)

Levothroid

Levoxyl

Mysoline

Synthroid

Tegretol (not including XR)

 

 

Effective December 1, 2006, the preferred brand name co-payment of $2.00 was applied to those brand-name drugs exempt from the Mandatory Generic Program.

 

 

CO-PAYMENT STRUCTURE:

 

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

 

• Generics (Multi-source medications) = $1.00
• Preferred Brand-Name Medications and Exempt drugs from the Mandatory Generic Program = $2.00
• Non-preferred Brand-Name Medications = $3.00

 

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

 

 

USE OF DAW CODES:

 All claims for generic medications must have a co-pay of $1.00.

• If the billing process returns any co-payment other than $1.00 for a generic medication, the claim should be processed with a DAW of 6.
• If the use of a DAW 6 results in a co-pay other than $1.00, please contact the ACS Help Desk at 1-866-556-9320 and request an override.

A DAW 6 will not return a $1.00 co-payment if the generic drug is hard-coded in the system as a braded generic. An override will have to be authorized in order to return a $1.00 co-payment.

 

 

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 Myers and Stauffer to manage our SMAC list. Please contact Myers and Stauffer for any dispute issues pertaining to SMAC pricing, and to review our SMAC list please click on:

  Myers and Stauffer 

 

 

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 Preferred Drug List Advisory Committee (PDLAC).  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 PDLAC meetings, visit our PDL website at http://uwacadweb.uwyo.edu/PDL/.