Programs: Maryland Medical Assistance Program (MA)

OTC drugs are generally not covered by BCCDT but there are exceptions and they are in the grid below:

The system will pay coinsurance for QMB recipients (plan 910) if claims contain an other coverage code of 3 or 4 for Med-B covered drugs only.

ACS will ensure that QMB recipients (plan 910) have pharmacy coverage except for drugs covered by Medicare B such as Xeloda- then BCCDT pays only denied claims. Pharmacies then must bill Medicare and then Medicaid and BCCDT will be the payer of last resort for coinsurance.

The system will reject QMB claims (plan 910) where the Other Coverage Code is not equal to ‘3-4’; the response will contain reject code edit 70 (Drug Not Covered) and the message text “BCCDT Only Reimburses Non-Covered Medicare B covered drugs"

The system will require claims for COB copay only billing to adhere to the following NCPDP parameters:

1. 
   NO COB SEGMENT SUBMITTED
   
2. 
   OCC = 8
   
3. 
   Other Amount Claimed Qualifier = 99
   
4. 
   Other Amount Claimed = Amount of copay
   
5. 
   Gross Amount Due = Equal Other Amount Claimed/Amount of copay
   
6. 
   No Ingredient Cost or Dispensing fields are expected (however, these could be submitted with zeros). The recommendation allows partners to stay in compliance to the definition of Gross Amount Due.
   
7. 
   Other Amount Claimed Submitted must be the entire patient copay as charged by the pharmacy
   

The following is a list of drugs not covered by Medicare B:

BCCDT will cost avoid for Medicare D recipients. Providers are required to ensure COB claims for Medicare D to contain “77777” in the Other Payer ID (NCPDP field 340-7C). The Other Payer ID is not required for non-Medicare D carriers.

Below is a list of drugs not covered by Medicare D but covered by BCCDT:

Description	Code Level	Code Values
Medical Supplies	TC	00 Exceptions: Part D Must Cover GSN = 009797 HSN = 004348 HSN = 008966 DCC = Q, R
Agents used for anorexia, weight loss or weight gain	DCC	F
Agents used for symptomatic relief of cough/cold	TC	16 17
Rx vitamins and minerals, except prenatal vitamins and fluoride products	TC	80 81 82(Except HIC3=C6F) 83 84 85
OTC	Rx Required Field	N = OTC Drugs Exceptions: Part D Must Cover HSN = 011115 & OTC HSN = 007605 & OTC & Generic
Benzodiazepines:
Alprazolam	HSN	001617
Chlordiazepoxide	HSN	001611
	HSN	001610
Clorazepate	HSN	001612
Diazepam	HSN	001615
Halazepam	HSN	001618
Lorazepam	HSN	004846
Oxazepam	HSN	001616
Prazepam	HSN	001613
Estazolam	HSN	006036
Flurazepam	HSN	001593
Midazolam	HSN	001619
Quazepam	HSN	001595
Temazepam	HSN	001592
Triazolam	HSN	001594
Clonazepam	HSN	001894

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Copay Only Claim Submission

BCCDT will allow for the submission of copay only claims but the following rules must be followed in order for the claim to be reimbursed:

• 
  There is a $60.00 maximum on all copay only claims. Claims submitted for amounts greater than the maximum will have to be approved by BCCDT.
  
• 
  BCCDT will pay copayments for PAC (plan 930 - formerly MPAP) recipients if claims contain an "8" in NCPDP field 308-C8, Other Coverage Code.
  
• 
  The system will reject PAC claims (plan 930) where the Other Coverage Code is not equal to ‘8’ (Copay Only) with reject code edit 70 (Drug Not Covered) and the message text “BCCDT Only Reimburses Copayments – Please bill PAC
  
• 
  The following fields must be populated when submitting a copay only claim:
  
  • 
    Other Coverage Code (308-C8) = 8
    
  • 
    Other Amount Claimed Submitted Count = 1
    
  • 
    Other Amount Claimed Submitted Qualifier = 99
    
  • 
    Other Amount Claimed Submitted = copay amount and must equal the amount in Gross Amount Due
    
  • 
    Gross Amount Due = copay amount and must equal the amount in the Other Amount Claimed Submitted
    

BCCDT has a generic mandatory program in place. The system will deny brand drugs when a generic is available with edit 22 (M/I Dispense As Written/DAW code) when submitted as Brand Medically Necessary (DAW = 1).

The system will accept the following Dispense as Written (DAW) values (NCPDP field 408-D8):

0 - default, no product selection

1 - Physician request

5 - Brand used as generic

QMB Recipients
The system will pay coinsurance for QMB recipients (plan 910) if claims contain an other coverage code of 3 or 4 for Med-B covered drugs only.

ACS will ensure that QMB recipients (plan 910) have pharmacy coverage except for drugs covered by Medicare B such as Xeloda- then BCCDT pays only denied claims. Pharmacies then must bill Medicare and then Medicaid and BCCDT will be the payer of last resort for coinsurance.

The system will reject QMB claims (plan 910) where the Other Coverage Code is not equal to ‘3-4’; the response will contain reject code edit 70 (Drug Not Covered) and the message text “BCCDT Only Reimburses Non-Covered Medicare B covered drugs"

Edits and Messaging:

Claims for recipients in all plans, regardless of diagnosis with edit 75 and message text: PA required, call MD BCCDT 410-767-6787.

Claims for recipients in plan BCCDT1, breast cancer will deny with edit 75 and message text: PA required, call MD BCCDT 410-767-6787.

Claims for drugs for recipients in plan BCCDT2, cervical cancer will deny with edit 75 and message text: PA required, call MD BCCDT 410-767-6787

Claims will deny drugs with edit 75 (PA Required) for recipients in plan BCCDT3 (unknown diagnosis). Provider will receive the message text: Prior Authorization Required: MD Call 410-767-6787 FOR PA.

Claims that deny for exceeding the max quantity will return edit 76 (plan limitations exceeded) and the message text: max quantity Exceeded - Call BCCDT at (410) 767-6787.

The specific Maryland AIDS Diagnosis Assistance Program information is listed in this section. The basic information is covered in the beginning of this manual in the ALL section. In this section you will find some repetitive information but new, special rules as well.

Generic Mandatory

The system will deny brand drugs when a generic is available and the DAW code = 1 (Physician request) with edit 22 (M/I DAW code) and the message “PA required – Brand Medically Necessary”.

ACS will ensure that the only valid DAW codes will be 0, 1, and 5:

0 - default, no product selection

1 - Physician request

5 - Brand used as generic

Date 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:

1. 
   If DEA = 2 (CII) – 5 (CV), then 30 days
   
2. 
   If DEA = 0, then 120 days
   
3. 
   Edit only applies to original prescriptions
   

The following reimbursement structure is used by the MADAP program:

• 
  Payment for all except Syringes is Lesser of:
  

• 
  Allowable Cost:
  

1. IDC,

3. FUL

• 
  Payment for syringes
  

U&C or AWP + Dispensing Fee

Brand Products = $3.69

Generic Products = $4.69

Partial fills = ½ + ½ dispensing fee.

Drug Coverage

NOTE:

The following is a list of covered injectables:

• 
  Nutritional Supplements are not covered.
  
• 
  OTC products are not covered.
  

Prior Authorization

PA Drug List

Drug		Performed by
HSN 025044	Enfuvirtie (Fuzeon)	PDCSx2
HSN 004553	Epoetin Alpha (Epogen, Procrit)	SmartPA
HSN 006070	Filgrastim (Neupogen)	SmartPA
HSN 001412	Oxandrolone (Oxandrin)	SmartPA
HSN 024035	Peginterferon alfa 2a (Pegasys)	PDCSx2
HSN 021367	Peginterferon alfa 2b (Peg-Intron)	PDCSx2
HSN 004184	Ribavirin (Rebetol, Copegus)	PDCSx2

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