Programs: Maryland Medical Assistance Program (MA)

MH Drug Restrictions

Age Limitations:

1. 
   Non-legend chewable tablets of any ferrous salt when combined with vitamin C, multivitamins, multivitamins and minerals, or other minerals in the formulation:
   

1. 
   Covered for age <12 years
   
2. 
   Claims for age >/= 12 will deny (not covered)
   

(e.g., Retin-A)

1. 
   Covered for age < 60 years.· PA required >/= 60
   
2. 
   Otherwise, NCPDP 60 and message text: "Product/Service Not Covered for Patient Age - Call DHMH at 1-410-767-1755", MD will handle PA requests.
   

This rule pertains to 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; or HSN = 001025, 001029, 006485, 001024, 001095, 001086; and Dosage Form = TC; and OTC. Minimum quantity per fill = 60 tabs.

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

1. 
   Claim contains Patient Location code = ‘11’ (NCPDP field 307-C7)
   
2. 
   Client Specific Reporting field on Recipient Eligibility file = "HI"
   
3. 
   The Date of Service is within an active coverage span on the Recipient Eligibility file
   
4. 
   Facility ID (NCPDP field # 336-8C) is on list of institutions (see appendix OOEP-14)
   

The system will determine LTC claims by the following conditions:

1. 
   Claim contains Patient Location code = ‘04’ (NCPDP field 307-C7)
   
2. 
   Facility ID (NCPDP field # 336-8C) is on list of institutions (see appendix OOEP-14)
   
3. 
   Pharmacy Provider ID is on the list of LTC providers (see appendix OOEP-15)
   

ACS will determine RECIPIENTS with BOTH LTC/HOSPICE

1. 
   Client SPECIFIC REPORTING field = "HI" on the recipient's enrollment record with a date span that includes DOS, AND
   
2. 
   PATIENT LOCATION (NCPDP field # 307-C7) = "11", AND
   
3. 
   FACILITY ID (NCPDP field # 336-8C) any value on the list of institutions, AND
   
4. 
   Designated LTC providers in the SERVICE PROVIDER ID (NCPDP field # 201-B1)
   

Emergency Fill

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

1. 
   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 Appendix OOEP-20. These medications are not limited to a 72-hour supply.
   
2. 
   Nursing Home recipients will be allowed a 30 days supply of non-PDL drugs
   
3. 
   
   

The system will deny brand drugs when a generic is available with edit 22 (M/I /DAW code) and the message text: “Generic Available – Call State at 410-767-1755, MedWatch form required” when submitted as Brand Medically Necessary (DAW = 1) with the exception of the following (pay at EAC):

Levothyroxine HICL seq Num = 002849

Brimonidine eye drops GSN = 48333 and 27882

0 - default, no product selection

1 - Physician request

5 - Brand used as generic

6 – Override

Pricing

Reimbursement for Maryland Medicaid claims will follow the structure listed below:

Payment is Lesser of:

U/C -or- Allowable Cost + Dispensing Fee

Allowable Cost lesser of:

1. IDC,

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

3. FUL

2) Chewable Ferrous Sulfate with Multivitamins

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%

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 – Claims will be available for State re-pricing through a process developed by ACS and approved by the State.

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

Payment is Lesser of:

U/C -or- Allowable Cost + Dispensing Fee

Allowable Cost: AWP

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

Dispensing fees:

Brand not on PDL: $2.69;

PDL and generic: $3.69

NH:

1. 
   Brand not on PDL = $3.69;
   
2. 
   PDL and generic: $4.69
   

1. 
   Brand name drug not on PDL - $3.69
   
2. 
   Generic drug or brand name drug on PDL $4.69
   

1. 
   Brand name drug not on PDL - $3.69·
   
2. 
   Generic drug or brand name drug on PDL - $4.69
   

1. 
   Brand name drug not on PDL - $3.69·
   
2. 
   Generic drug or brand name drug on PDL - $4.69
   

1. 
   ½ dispensing fee at initial fill
   
2. 
   ½ dispensing fee at completion fill
   
3. 
   Copay paid on initial fill.
   

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

1. 
   Generally not covered, (note exceptions in Drug List appendix OOEP-7).
   
2. 
   Covered OTC drugs must be rebateable. Non-rebateable drugs will deny, NCPDP 70, ‘NDC Not Covered’. Note: MD staff will have the ability to override these denials for exceptional cases (not routine), calls should be referred to the DHMH PA Unit.
   

1. 
   Needles and syringes are covered through POS.
   
2. 
   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.
   
3. 
   Questions should be addressed to the Program Specialist at DME/ DMS at (410) 767-1739.
   

1. 
   Needles & Syringes, Drug Category = M, N, O, P, Q, R
   
2. 
   Pen Needles, HSN = 008966
   

1. 
   OTC (including needles, syringes, and nutritional supplements) are not covered except for insulin and Schedule V cough preps.
   
2. 
   All normally covered medications in Unit Dose form
   
3. 
   
   

AHFS = 28:08.08

This will be denied with edit 75, PA required and the message: “Bill Hospice – Call State with any questions”. State staff will handle override approvals.

ACS will ensure that LTC/Hospice:

1. 
   Covers all unit dose items
   
2. 
   Coverage exclusions: OTC (including needle, syringes, & nutritional supplements
   
3. 
   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 in appendix OOEP-8. Message text to providers: “Unit Dose Package”.

Package Size:

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

1. 
   Drug Category = C, T - Contraceptives, Oral & Topical
   
2. 
   TC = 63 - Systemic Contraceptives
   

The following gender specific coverage will be enforced and deny with edit 70, Female only:

1. 
   Drug Category C - contraceptives, oral
   
2. 
   HIC3: X1B - Diaphragms/Cervical Cap
   
3. 
   Drug Category = W, except Depo-Provera: GSN = 017584, 026098, 003268, 003270, Contraceptives, Systemic, non-oral
   

MEDICARE RECIPIENTS:

QMB (Qualified Medicare Beneficiaries):

There are no special processing requirements for QMB recipients (coverage group S03).

 The system will deny claims for QMB recipients (coverage group S03, S06, S07, S14, S15, D01, D03) with error 70 (NDC not covered) and message text: “No Rx Coverage for Group”.



Medicare Part B:

Program and the claim is submitted as secondary to Maryland Medicaid, the claim will deny.

If a recipient is in group S16, S17 or S18 (Maryland Pharmacy Program) and has Medicare Part B coverage (as defined by ‘Secondary’ on the patient enrollment record), the drugs on this list will deny for NCPDP 70 – Drug Not Covered with the additional message “Collect Patient Share”. Once the pharmacy has billed Medicare and obtained the amount paid by Medicare, the provider may bill MARYLAND with the actual amount Medicare has paid in the TPL field. The claim will function as any other TPL claim; reimbursement will be based on the “lesser of” logic, taking the TPL amount into consideration. The 65% copayment will be assessed on the final payment amount and subtracted from the amount to be paid to the pharmacy. The pharmacy should NOT enter payments collected from recipients in the PATIENT PAID field when submitting the claim as this would cause the recipient additional copayments and also reduce payments to the pharmacies by the amount submitted in the PATIENT PAID field.

Medicare Covered Drugs - NCPDP 70- NDC Not Covered, Bill Medicare. Providers will contact ACS Call center for PA if not covered by Medicare.
Medicare D:
The following rules will be implemented for MED D:

1. 
   OOEP will not be processing COB claims for part D eligible patients
   
2. 
   Denied claims for Part D covered products will return a NCPDP 41 – Submit Bill to Other Processor or Primary Payer
   
3. 
   See appendix OOEP-5 for a list of Medicare Part D Excluded Drugs that are covered by OOEP.
   

Breast and Cervical Cancer Diagnosis and Treatment (BCCDT)

• 
  A maximum of 11 refills for Non-Controlled Covered Drugs.
  
• 
  Refills are not allowed on non-controlled drugs to be filled 360 days or more from the date prescribed.
  
• 
  A maximum of 5 refills for Schedules III, IV and V controlled covered drugs.
  
• 
  Refills are not allowed on controlled drug to be filled 180 days or more from the date prescribed.
  

ACS will ensure the claims reimburse at the following pricing:

- U & C

1. IDC

3. FUL

There are no copays for BCCDT recipients

BCCDT has the following dispensing fee structure:

• 
  BRAND products = $2.69
  
• 
  Generic Products = $3.69
  
• 
  Partial Fill dispensing fee will be paid ½ at the initial fill and ½ at the completion fill
  

Prior Authorization requests will be handled either by the BCCDT office or at the ACS Technical Call Center. Below is a list of drugs that are handled by each entity: