Programs: Maryland Medical Assistance Program (MA)
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* Y Indicates Prior Authorization Required NOTE: Peginterferon alfa (including 2b and 2a) and ribavirin covered in combination, and only for treatment of HCV infection in HIV co-infected clients. The following is a list of covered injectables:
Maintenance Drug List The MADAP maintenance drug list = antiretroviral therapies (NNRTIs, NRTIs, PIs, Fusion Inhibitors).
There are three places providers can obtain a prior authorization for the MADAP program: ACS, MADAP and SmartPA. Below will outline which entity gives the Prior Authorization for which category of drug. PA Drug List
The ACS Technical Call Center will handle the following prior authorization requests for MADAP: EarlyRefill Quantity
Price per claim limit ≥$2500.00 The ACS PA Call Center will handle the following prior authorization requests for MADAP: Epoetin Alpha (Epogen, Procrit) Filgrastim (Neupogen) Oxandrolone (Oxandrin) The MADAP staff will handle all other prior authorization requests. SmartPA SmartPA is a rules engine driven program that will search existing claim and medical history to evaluate whether or not the recipient has met the set criteria to receive the drug being billed. If the recipient meets criteria then the system generates a Prior Authorization and the claim is paid. If the recipient does not meet criteria, the claim is denied with a SmartPA specific edit advising which criteria was not met. The following categories are submitted to SmartPA for evaluation: Epoetin Alpha (Epogen, Procrit) Filgrastim (Neupogen) Oxandrolone (Oxandrin) Copay Only Claim Billing Guidelines MADAP will allow providers to bill for a copay only claim. In order for the claim to be processed correctly, the following guidelines must be followed. The system will require claims for COB copay only billing to adhere to the following NCPDP parameters: NO COB SEGMENT SUBMITTED OCC = 8
Other Amount Claimed Qualifier = 99 Other Amount Claimed = Amount of copay Gross Amount Due = Equal Other Amount Claimed/Amount of copay Other Amount Claimed Submitted must be the entire patient copay as charged by the pharmacy SECTION X MARYLAND KIDNEY DISEASE PROGRAM (KDP) SPECIFICS This section will outline program specific information that is not covered in the beginning of this manual. Generic Mandatory and Dispense as Written Code Usage KDP has a generic mandatory program in place that must be followed. When providers submit a claim for a drug that has a generic equivalent and there is no active PA on file or appropriate DAW code, the claim will deny with an NCPDP Reject code ‘22’ – M/I DAW Code. KDP accepts the following DAW codes: ACS will ensure that the only valid DAW codes will be 0, 1, 5 and 6: 0 - default, no product selection 5 - Brand used as generic 6 – Client Override
Duragesic NDCs: 50458003305, 50458003405, 50458003505, 50458003605, 50458003705 Rebetol NDCs: 00085119403, 00085132704, 00085135105, 00085138507 Flonase NDCs: 00173045301 LTC The KDP system has no LTC recipients and will reject claims submitted with LTC identifiers (NCPDP field 307-C7, Patient Location = 3 – Nursing Home or 4-Long Term/Extended Care) with NCPDP edit 70 and message text: “LTC Claims Not Allowed for Reimbursement”. Minimum / Maximum Quantities The KDP program enforces the following Minimum / Maximum quantity limits: A maximum quantity limit of 350 for the following Immunosuppressive Oral tablets/capsules will be enforced. Azathioprine Cyclosporine Mycophenolate Mofetil (Cellcept) Sirolimus (Rapamume) Tacrolimus (Prograf) HSN = 004523, 004524, 010086, 010012, 020519, 008974; and Route = Oral There is a max quantity limit of 350 for Immunosuppressants, Oral tablets/capsules. The max quantity limit for Oxycontin (GSN = 024505, 024506, 025702, 024504, 045129) is 120. Note: This is a per fill quantity limit, not an accumulation limit.
There is a minimum quantity limit of 100 tablets for Ferrous sulfate 325mg tablets (GSN = 001645, 001646, 017378). A minimum quantity limit of 480 ml for Ferrous sulfate elixir (220mg/5ml), GSN = 001639) will be applied. KDP will enforce a minimum quantity limit of 60 tablets for non-legend chewable tablets of any ferrous salt when combined with vitamin C, multivitamins, multivitamins and minerals, or other minerals in the formulation (HIC3 = C3B; and Dosage form = TC). Date of Rx Written and Date of Service The system will enforce the following rules regarding the amount of time allowed between Date RX Written and Date of Service: No greater than 10 days. Claims greater than this 10 day limit will deny for NCPDP Error Code M4 (Prescription Number/Time Limit Exceeded). Edit only applies to original prescriptions. UNIT DOSE The system will deny claims for unit dose medications with the exception of drugs listed below with error 70 (drug not covered) and message text: “Unit Dose Package Size”.
Pricing
ACS will ensure the claims reimburse at the following pricing: 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 is lesser of: 1. IDC,
2. EAC (lesser of): WAC+8%· Direct+8%· Distributors + 8%· AWP - 12%, 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- Distributors + 8% -or- AWP - 12% 3. FUL
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- Distributors + 8% -or- AWP – 12% 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
Payment is lesser of: U/C -or- Allowable Cost + Dispensing Fee Allowable Cost: AWP ACS will ensure that KDP claims do not have copays. ACS will ensure that claims will reimburse with the following dispensing fee: Dispensing Fee Brand Products = $2.69 Generic Products = $3.69 Partial fills – ½ + ½ dispensing fee. COPAY KDP recipients do not have a copay. PRIOR AUTHORIZATIONS The ACS Technical Call Center will handle the following prior authorization requests for KDP: Early Refill Quantity
Price per claim limit ≥ $2500.00 The KDP staff will handle the following prior authorization requests: Directory: docs -> common docs -> Application for acem docs -> Observational Assessment of Teaching Practices Teaching Assessment Initiative Proposal Submitted to The Teachers for a New Era project docs -> Traditional British values docs -> From Warfighters to Crimefighters: The Origins of Domestic Police Militarization docs -> Borzoi Club of America Register of Merit Program I. What is a Register Of Merit docs -> Protecting the rights of the child in the context of migration docs -> United Nations E/C. 12/Esp/5 docs -> 9th May 1950 the schuman declaration docs -> Getting To Outcomes® in Services for Homeless Veterans 10 Steps for Achieving Accountability common -> Programs: Maryland Medical Assistance Program (MA) Download 3.34 Mb. Share with your friends:
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