Programs: Maryland Medical Assistance Program (MA)

MH Drug Restrictions

1. Depo-Provera

Maryland Medicaid will enforce the following Age Restrictions:

Non-legend chewable tablets of any ferrous salt when combined with vitamin C, multivitamins, multivitamins and minerals, or other minerals in the formulation:

• 
  Covered for age <12 years
  
• 
  Claims for age >/= 12 will deny (not covered)
  

Topical Vitamin A Derivatives, HIC3 = L9B; and Route = Topical (e.g., Retin-A)

• 
  Covered for age < 60 years.· PA required >/= 60
  

The system will determine Hospice-Only claims by the following conditions:

• 
  Claim contains Patient Location code = ‘11’ (NCPDP field 307-C7)
  
• 
  Client Specific Reporting field on Recipient Eligibility file = "HI"
  
• 
  The Date of Service is within an active coverage span on the Recipient Eligibility file
  
• 
  Facility ID (NCPDP field # 336-8C) is on list of institutions below
  

The system will determine LTC claims by the following conditions:

• 
  Claim contains Patient Location code = ‘04’ (NCPDP field 307-C7)
  
• 
  Facility ID (NCPDP field # 336-8C) is on list of institutions below
  
• 
  Pharmacy Provider ID is on the list of LTC providers below
  

The system will determine LTC/Hospice claims by the following distinct conditions:

• 
  Client SPECIFIC REPORTING field = "HI" on the recipient's enrollment record with a date span that includes DOS, AND
  
• 
  PATIENT LOCATION (NCPDP field # 307-C7) = "11", AND
  
• 
  FACILITY ID (NCPDP field # 336-8C) any value on the list of institutions below, AND
  
• 
  Designated LTC providers in the SERVICE PROVIDER ID (NCPDP field # 201-B1)
  

LTC PHARMACIES

HOSPICE INSTITUTION IDs

Emergency Fill

The system will allow emergency fills when claims contain a ‘3’ in the Level of Service field (emergency).

• 
  Pharmacy Program recipients will be allowed two 72-hour emergency fills per Rx (no dispensing fee on second emergency refill) for non-PDL drugs except for those medications listed in the table below. These medications are not limited to a 72-hour supply.
  
• 
  Nursing Home recipients will be allowed a 30 days supply of non-PDL drugs
  

72 Emergency Supply Drug Exceptions

Pricing

1) Legend Drugs, Schedule V Cough Preps, Enteric Coated Aspirin, Oral Ferrous Sulfate Prods

Payment is lesser of:

U/C -or- Allowable Cost + Dispensing Fee

Allowable Cost lesser of:

1. IDC,

3. FUL

Payment is lesser of:

U/C -or- Allowable Cost + 50% -or- Allowable Cost + Dispensing Fee

Allowable Cost is lesser of:

1. IDC

2. EAC (lesser of): WAC+8% -or- Direct+8% -or- AWP - 12%

3) Condoms

Payment is lesser of:

U/C -or- Allowable Cost + 50%

Allowable Cost:

EAC (lesser of): WAC+8% -or- Direct+8% -or- AWP – 12%

4) Home IV Claims – See subsequent section titled “Compounded Home Infusion (Home IV) Claims”

5) Medical Supplies and Durable Medical Equip (Needles and Syringes)

Payment is lesser of:

U/C -or- Allowable Cost + Dispensing Fee

Allowable Cost: AWP

6) DAW 1 and 6 Claims

Payment is lesser of:

U/C -or- Allowable Cost + Dispensing Fee

Allowable Cost:

EAC (lesser of): · WAC+8% -or- Direct+8% -or- AWP – 12%

7) Other OTC Drugs (Insulin and Nutritional Supplements)

Payment is lesser of:

U/C -or- Allowable Cost + 50% -or- Allowable Cost + Dispensing Fee

Allowable Cost: AWP

• 
  Brand not on PDL: $2.69
  
• 
  PDL and generic: $3.69
  
• 
  LTC Dispensing Fee:
  

Generic drug or brand name drug on PDL $4.69

* Limit of 1 dispensing fee/month /NDC for NH patient: (can be overridden by PA type code = 5).

• 
  Hospice Dispensing Fee:
  

Generic drug or brand name drug on PDL - $3.69

• 
  LTC/Hospice Dispensing Fee
  

Generic drug or brand name drug on PDL - $4.69

• 
  Partial Fills:
  

½ dispensing fee at completion fill

Copay paid on initial fill.
RETURN TO STOCK (For prescriptions to recipients residing in nursing homes

Full Returns:

A claim will be recognized as a return to stock if position one of NCPDP field 462-EV (Prior Authorization Number Submitted) is equal to 1 The pharmacy enters code above and re-bills (B3) the claim with a quantity equal to the quantity that was originally submitted. The claim will pay with only a dispensing fee.

Partial Returns:

The pharmacy must change the quantity to the quantity that was used, and re-bill the claim (B3). There is no need to enter a value in the Prior Authorization field. Payment will include the quantity used plus the dispensing fee.
Drug Coverage

ACS will ensure that all drugs in Therapeutic Classes 01-99 are covered, except where exclusions are noted in this section below.

The following rules will be enforced for OTC Drugs:

• 
  Generally not covered,
  
• 
  Covered OTC drugs must be rebateable. Non-rebateable drugs will deny, NCPDP 70, ‘NDC Not Covered’.
  

OTC Coverage Exceptions

The following rules apply to DME/DMS :

• 
  Needles and syringes are covered through POS.
  
• 
  All other DME/ DMS (durable medical equipment/ disposable medical supplies) should be billed on a HCFA 1500 form and forwarded to the DME/ DMS Unit.
  
• 
  Questions should be addressed to the Program Specialist at DME/ DMS at (410) 767-1739.
  

• 
  Needles & Syringes, Drug Category = M, N, O, P, Q, R
  
• 
  Pen Needles, HSN = 008966
  

• 
  OTC (including needles, syringes, and nutritional supplements) are not covered except for insulin and Schedule V cough preps.
  
• 
  All normally covered medications in unit dose form
  

• 
  AHFS = 28:08.08
  
• 
  This will be denied with edit 75, PA required and the message: “Bill Hospice – Call State with any questions”.
  

• 
  Covers all unit dose items
  
• 
  Coverage exclusions: OTC (including needle, syringes, & nutritional supplements
  
• 
  Coverage exclusions: AHFS = 28:08.08. will be denied with edit 75, PA required and the message: “Bill Hospice – Call State with any questions”. State staff will handle override approvals.
  

The system will deny unit dose drugs with edit 70 (drug not covered) with the exception of drugs listed below. Message text to providers: “Unit Dose Package”.

Package Size:

The system will ensure that products commonly billed with incorrect quantity (i.e.: Ophthalmics, prefilled injectable syringes, etc.) are submitted in multiples of correct package size, otherwise claims will be denied for missing/invalid quantity.

Family Planning

The following are covered under family planning:

Drug Category = C, T - Contraceptives, Oral & Topical

TC = 63 - Systemic Contraceptives

Gender

Drug Category C - contraceptives, oral

HIC3: X1B - Diaphragms/Cervical Cap

Drug Category = W, except Depo-Provera: GSN = 017584, 026098, 003268, 003270, Contraceptives, Systemic, non-oral