► Managed Care Expansions in March Two new Medicaid Managed Care initiatives will begin on March 1, including the addition of nursing facility services to STAR+PLUS and the Texas Dual Eligible Integrated Care Project. Texas Health & Human Services Commission Medicaid/CHIP Division Vendor Drug Program Spring 2015 Vol. XXV ● Issue I ► Ingredient Cost & Dispensing Fee Changes Slated For Summer Last year the Vendor Drug Program contracted with Myers and Stauffer to conduct surveys of retail community pharmacies to perform an evaluation of the actual acquisition cost and perform a cost of dispensing study. Their results were published in August. Based on the stakeholder input received, VDP proposed a higher average dispensing fee based on the mean weighted by Medicaid volume. HHSC chose to implement a differentiated reimbursement methodology with ingredient costs that differ by pharmacy type and a dispensing fee formula with a variable component. The new Ingredient Cost methodology will utilize Wholesale Acquisition Cost (WAC) or National Average Drug Acquisition Cost (NADAC), the new benchmark of retail pharmacy acquisition costs developed by the Centers for Medicare & Medicaid Services (CMS). The new rates will be: • • Ingredient Cost o NADAC (or WAC minus 2 percent) for retail pharmacies and lower rates for specialty and long term care (LTC) pharmacies. Dispensing Fee o $7.93 + (1.96 percent of the ingredient cost) per claim. The new pricing methodology is scheduled for later this summer. This change only affects claims processed by VDP, including fee-for-service Medicaid, the Children with Special Health Care Needs (CSHCN) Services Program, the Kidney Health Care (KHC) program, and the Texas Women’s Health Program. These changes are not related to and do not impact managed care organization reimbursement rates. ■ ► 340B Reimbursement Changes Now in Effect On February 1, VDP changed the reimbursement methodology for calculating the ingredient cost of outpatient pharmacy claims processed by VDP and paid to eligible health care organizations participating in the Health Resources and Services Administration (HRSA) 340B Drug Pricing Program. The new methodology is as follows: • • • Human Immunodeficiency Virus (HIV) products o WAC minus 43 percent Hemophilia products o WAC minus 35 percent Brands and generics o WAC minus 60 percent The new 340B reimbursement methodology is not all-inclusive and some products may be priced manually. Pharmacies participating in the 340B Program can review VDP's pricing and rebate procedures in the VDP Pharmacy Provider Procedure Manual, available online at TxVendorDrug.com/downloads/. ■ ► VDP Field Offices Closing All Vendor Drug Program regional offices will close March 6, 2015. VDP no longer requests prescription documentation for monthly review. Please contact your assigned regional office in Fort Worth, Houston, McAllen, Midland, or San Antonio if there are outstanding issues or questions. After March 6, pharmacy providers should contact VDP Pharmacy Benefit Access at 1-800-435-4165. ■ Nursing Home Expansion STAR+PLUS managed care organizations will begin paying providers for most Medicaid nursing facility services for Medicaid recipients ages 21 and older. Medicaid members in nursing facilities will be transitioning to one of the following STAR+PLUS health plans: Amerigroup, Cigna-HealthSpring, Molina Healthcare, Superior Health Plan, or United Healthcare. To learn more visit hhsc.state.tx.us/medicaid/managed-care/mmc/starplus-addingnursing.shtml. Dual Eligible Integrated Care Project The goal of this project is to better coordinate the care that people receive who are eligible for both Medicare and Medicaid, known as dual eligibles. The plan involves a three-party agreement between a Medicare-Medicaid health plan, the state of Texas, and the federal Centers for Medicare and Medicaid Services (CMS) to provide the person with the full array of Medicaid and Medicare services. Members will be in the project if they meet all criteria: • Are age 21 or older; • Receive Medicare Part A, B and D, and receive full Medicaid benefits; • Enrolled in the Medicaid STAR+PLUS program. Participating counties in the demonstration include Bexar, Dallas, El Paso, Harris, Hidalgo, and Tarrant. To learn more visit hhsc.state.tx.us/Medicaid/managed-care/dual-eligible/. Schedules for statewide Medicaid Managed Care initiatives provider trainings are available at the HHSC Meetings and Events page at hhsc.state.tx.us/news/meetings.asp. VDP provides a number of online resources for the pharmacy community to assist with health plan claim processing and prior authorization at TxVendorDrug.com/claims/managed-care.shtml: • • • The Pharmacy Enrollment Chart identifies how pharmacy providers with questions pertaining to a new, pending, or existing contract can contact each health plan and pharmacy benefits manager (PBM). The Pharmacy Assistance Chart identifies the name and pharmacy billing information for each health plan and individual call center phone numbers. The Prescriber Assistance Chart identifies prior authorization and member call center phone numbers for each health plan. ■ ► Hepatitis C Virus Authorizations On January 23, VDP began allowing restricted Hepatitis C Virus (HCV) treatment approval for qualifying patients via prior authorization. The clinical edit applies to eligible clients enrolled in either fee-for-service Medicaid or managed care. The only Hep C treatment regimens available at this time include: • Sovaldi 400mg tablet (61958150101) • Olysio 150mg capsule (59676022528) The entire HCV drug class was reviewed at the January Texas Pharmaceutical and Therapeutics Committee meeting, and VDP will implement newly approved Hepatitis C treatments later this year. ■ ►Links To Health Plan’s Clinical Edit Criteria Certain clinical prior authorization edits must be performed for Medicaid Managed Care clients. Health plans may implement any other of the Vendor Drug Program’s edits but no more. Each health plan's pharmacy website must include a list of that plan's implemented clinical edits for covered drugs. A link to each plan’s edit criteria will soon be available at TxVendorDrug.com/dur/clinical-edit-criteria.shtml to assist pharmacies in identifying which edits apply to which health plan. ■ Medicaid/CHIP Vendor Drug Program (MC-2250) Texas Health and Human Services Commission 4900 North Lamar Blvd. Austin, TX 78751 PRESORT STD. US POSTAGE PAID AUSTIN, TX PERMIT NO. 437 ► January Preferred Drug List Updates The Medicaid Preferred Drug List (PDL) was updated January 22. Changes include all Lantus products changing status from non-preferred to preferred, and all Saphris products changing status from preferred to non-preferred. The PDL is available online at TxVendorDrug.com/pdl/ and includes both cough/cold and prenatal vitamins lists and a summary document detailing changes by drug class and by drug name. The PDL, our formulary, and clinical edit criteria are also available for free on the Epocrates drug information system. The next update is scheduled for July 2015. ■ ► Advisory Committees Updates The Drug Utilization Review Board reviews and recommends outpatient pharmacy clinical prior authorization edit criteria for drugs and drug classes. The Pharmaceutical & Therapeutics Committee reviews drugs and drug classes for preferred/non-preferred drug status. Both advisory committees meet quarterly in Austin. • Drug Utilization Review Board o Thursday, April 23, 2015 o Thursday, July 23, 2015 • Pharmaceutical & Therapeutics Committee o Friday, April 24, 2015 o Friday, July 24, 2015 ■ ► Continuing Education Credits HHSC offers free computer-based training courses to enhance your ability to provide pharmacy services to Medicaid eligible children in Texas. In addition, pharmacists and pharmacy technicians can earn Category One Continuing Medical Education (CME) credit. The courses are accredited by the Accreditation Council of Pharmacy Education (ACPE). More than 40 CME courses are offered at TxHealthSteps.com. ■ ► Medicaid Comprehensive Care Program The Medicaid Comprehensive Care Program can cover medically necessary drugs and supplies that are not available through VDP for fee-for-service Medicaid clients birth through 20 years of age. Pharmacies should inform the family (or physician) that they can request coverage through CCP. Pharmacies not enrolled as CCP providers may direct the client to call TMHP at 1 800 3358957 to locate a CCP provider. Pharmacies that want to enroll should complete an application at TMHP.com. For assistance call the TMHP contact center at 1 800 925-9126 or your local TMHP representative. Pharmacies should inform the family (or physician) to contact the client's managed care organization for their specific comprehensive program coverage and procedures. ■ ►Email Notification Service The HHSC Email Notification Service is used to send notices to subscribers on behalf of the Medicaid/CHIP Division and Vendor Drug Program. Notices are sent when new content is published to our website and when important news is to be shared with providers. To receive notices, users must actively subscribe or "opt in" to the service. During the subscription process, the user must provide an email address, a delivery preference, and have the option to provide a password. Users may then choose the subscription categories that they wish to receive. ■ The Rx Update is published four times a year (February, May, August, and November) by the Texas Health and Human Services Commission Medicaid/CHIP Division Vendor Drug Program at 4900 North Lamar Boulevard, Austin, TX 78751. POSTMASTER: Send address changes to: HHSC, P.O. Box 85200 (MC-2250), Austin, TX 78751. ► What We Do The Medicaid/CHIP Vendor Drug Program enrolls pharmacy providers that want to provide Medicaid and CHIP services; manages the Texas Medicaid and CHIP formularies; and processes out-patient pharmacy prescription claims for fee-for-service Medicaid, the Texas Women's Health Program, the DSHS Children with Special Health Care Needs (CSHCN) Services Program, and the DSHS Kidney Health Care (KHC) program. Learn about what we do and find out how to contact us at TxVendorDrug.com/about/. VDP Pharmacy Benefit Access ..................................... 800-435-4165 KHC Program ............................................................... 800-222-3986 CSHCN Service Program .............................................. 800-252-8023 Texas Prior Authorization Call Center .......................... 877-728-3927 Texas Third-Party Call Center ...................................... 866-389-5594 Texas Third-Party Call Center ...................................... 866-389-5594 CCP Diabetic and Medical Supplies Pharmacy PA Assistance ..................................... 800-846-7470 Client assistance .................................................. 800-335-8957 Medicare ....................................................................... 800-633-4227 ► Managed Care Resources Most Medicaid clients and all Children’s Health Insurance Program (CHIP) clients receive their prescription drug benefits through the managed care service delivery model. Resources for pharmacy staff are available at the Vendor Drug Program website: TxVendorDrug.com/claims/managed-care.shtml ■ ► 72-Hour Emergency Overrides A 72-hour emergency supply of a prescribed drug should be provided when a medication is needed without delay and prior authorization (PA) is not available. This applies to all drugs requiring authorization either because they are non-preferred drugs on the Preferred Drug List or because they are subject to clinical prior authorization edits. Pharmacies will be paid in full for 72-hour emergency prescription claims. Full instructions are available for downloading and displaying in your pharmacy from TxVendorDrug.com. ■ ► KHC & CSHCN Billing Reminders BIN PCN Group KHC 61ØØ84 DRTXPRODKH KHC CSHCN 61ØØ84 DRTXPROD CSHCN Questions? 1-800-222-3986 1-800-252-8023 KHC and CSHCN are not Medicaid programs. Please contact the program directly or refer to claim submittal requirements at TxVendorDrug.com/downloads/. ■
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