Medicaid Pharmacy Pricing Update

Arkansas Medicaid NADAC Pharmacy Pricing Update:

This week started the third week of the federally mandated changeover to the NADAC plus true professional dispensing fee in Arkansas Medicaid.  Our office continues to get calls and emails from member pharmacists about reimbursement below their invoice cost (or inadequate total reimbursement) on high dollar brand name medications including Enbrel, Humira, Symbicort, Flovent, Diazepam Gel, HIV medications, Hepatitis C medications, Vyvanse, Focalin XR, Novolog FlexPen, Lantus SoloSTAR and others.  On the other hand, we are hearing more positive information on generic medication reimbursement.  The pharmacies that have a high rate of generic use in their Medicaid claims are not hurting as bad as those with a high concentration of HIV, specialty or pediatric populations.  Despite this positive news on generic claims, all Arkansas pharmacies are struggling with brand name drug reimbursement and ongoing discussion with Arkansas Medicaid continues to be a high priority for APA about these concerns.

Immediate Call to Action:  If you have Arkansas Medicaid pharmacy claims that reimburse below your invoice cost, APA strongly encourages you to fill out the NATIONAL AVERAGE DRUG ACQUISITION COST (NADAC) – REQUEST FOR MEDICAID REIMBURSEMENT REVIEW and submit the form to both info@mslcrps.com (Myers and Stauffer) and matt.rocconi@dhs.arkansas.gov.  You may also fax to 888.860.0236 for Myers and Stauffer. Arkansas Medicaid prefers email over fax.

An example where the reimbursement will increase:

  • The research identifies a drug with a price increase with a corresponding WAC increase but the NADAC amount did not increase at the same time because the price increase occurred in between NADAC monthly surveys in community pharmacies. 
  • When a NADAC reimbursement increase happens, Arkansas Medicaid updates their reimbursement files on Saturday of each week.  Most pharmacies are attempting to rebill claims on Sunday or Monday after the pricing updates. 
  • We saw this example of an increase work this week.  APA heard from pharmacies that successfully reversed and rebilled Latuda claims from April at the increased NADAC.

Matt Rocconi and Jason Derden (Medicaid Pharmacy Director) can be reached at 501.683.4120 or at Matt.Rocconi@dhs.arkansas.gov.  Please reach out to them if you have followed these procedures and are not able to resolve your reimbursement challenge request or if you have further questions.

 

The Latuda timeline in Arkansas Medicaid:

John Vinson and Scott Pace have received dozens of calls from pharmacists that have lost between money on Latuda prescriptions since April 1st.  This issue is close to being resolved for this drug.  Latuda under reimbursement is a good example where the WAC increased in between NADAC surveys.  The timeline of what happened and when it will be resolved:

  • The March 29th NADAC for Latuda was loaded as the reimbursement for April 1, 2017
  • Latuda increased in price April 1
  • The April 12 NADAC list for Latuda increased reflective of the April 1 price increase found on the national Medicaid Pharmacy Pricing website: https://www.medicaid.gov/medicaid/prescription-drugs/pharmacy-pricing/index.html
  • Saturday April 15 (tomorrow), Arkansas Medicaid will load this new NADAC pricing information into the state computer system
  • Monday, April 17 – Most pharmacies are able to reverse Latuda claims and rebill on the original date of service.  The claim will reimburse at the new increased NADAC based on the price increase on April 1st.
  • Example:  Click https://www.medicaid.gov/medicaid/prescription-drugs/pharmacy-pricing/index.html
  • You can see what the new expected Latuda reimbursement will be by scrolling down and clicking the word “NADAC” next to the 2017 / April / 2017-04-12.
  • Once the file is open, type the word Latuda in the “Find in this Dataset” box on the right side of the page.
  • Hit the Enter Key
  • Find the NDC / strength of Latuda that you are looking for in the data on the page
  • Example:  Latuda 40 mg (NDC 63402030430) #30 is now $35.93072 per tablet.
  • (30 X 35.93072) = $1077.92  + $9 disp fee = $1086.92 new reimbursement rate available on Sunday April 16th
    • Previous reimbursement rate (April 1 - April 15):  32.69699 X 30 = $980.91 + 9 = $989.91
    • The new reimbursement of $1086.92 – the old 989.91 = $97.01 increased
       

The 5 most common complaints with the new Medicaid payment methodology that APA is hearing from pharmacists:

  1. The gross profits are not sufficient for medications that cost > $500 per month to purchase.  “The cost of dispensing for higher cost medications is greater than $10.50.” 
  2. 17 days is too long for pharmacists to be underpaid for a drug (Latuda).  When a price increase occurs, the reimbursement should be increased real time as soon as possible.
  3. The challenge to watch every claim one by one, challenge the bad claims one by one, wait patiently on a resolution, and manually reverse the claim and rebill at the new rate places too much burden on the pharmacist to be paid fairly.
  4. Filling out the Myers and Stauffer NADAC challenge form and sending it on every claim with a bad reimbursement is an administrative burden for pharmacists
  5. I don’t understand how Medicaid determines $9 vs $10.50 for the professional dispensing fee.  How do you know which drugs are preferred and which are non-preferred?

APA will continue to monitor these challenges and continue the dialogue with Arkansas Medicaid to improve the process.


Arkansas completes 200 claim study in Arkansas Medicaid in April:

  • April 1 – April 6
  • Only 2 claims from 200 total claims reimbursed below invoice cost
  • Less than 25 claims reimbursed below the $9 gross profit
  • The average gross profit over 200 claims including the claims below cost was greater than $10

This study is consistent with what we expected in the federally mandated cost recovery model. 

Insulin Syringes and Insulin Pen Needles in Arkansas Medicaid:

APA has received many calls and emails about insulin syringes and insulin pen needles no longer being covered in the prescription drug plan.  This is only partially true.  Certain NDCs and products are still covered, while some are not (including the popular BD brand).

Background:  Arkansas Medicaid decided many years ago to cover insulin syringes and insulin pen needles on the prescription drug plan.  Under the new Pharmacy Pricing methodology, AWP is no longer recognized and many insulin syringes and insulin pens have an AWP but no WAC.  In addition, most states only cover insulin syringes and insulin pen needles under the medical plan as durable medical equipment therefore there is no ability to produce a national NADAC.  A few of the NDCs of insulin syringes and insulin pen needles have WACs.  Typically, those that have a WAC are covered and those that don’t have a WAC are not covered.  It is possible in the future that if a product gets a WAC, it would become covered.  If a patient requires a specific brand that is not covered under the drug plan, they could be referred to a pharmacy or durable medical equipment facility that bills Medicaid durable medical equipment and provides insulin syringes and pen needles.  We have heard that there are not too many of these in the state of Arkansas.  We would like to hear from pharmacies who offer this service for Arkansas Medicaid.  You can email John Vinson to john@arrx.org

Covered products per Matt Rocconi (Matt.Rocconi@dhs.arkansas.gov) from Arkansas Medicaid as of 4.4.2017

 

Insulin Syringes:

  • Advocate Syringes
  • Comfort EZ
  • Easy Comfort Insulin Syringes
  • Easy Touch Insulin Syringes
  • Freestyle Precision
  • Life Touch
  • Monoject Insulin Safety Syringe
  • Prodigy Insulin Syringe
  • Ultra-Thin II
  • Vanishpoint

Insulin Pen Needles:

  • 1st Tier Unifine Pentips
  • Advocate Pen Needle
  • Carefine Pen Needle
  • Clickfine
  • Comfort EZ
  • Easy Comfort Pen Needles
  • Easy Touch Pen Needles
  • Healthy Accents Unifine
  • Incontrol Pen Needle
  • Lite Touch
  • Pen Needle (yes, that generic of a name)
  • Pen Needles (yes, that generic of a name)
  • Pentips
  • Sure Comfort
  • Sure-Fine
  • Unifine Pentips

For more help with this issue, you can email Arkansas Medicaid Pharmacy Department to Matt Rocconi at Matt.Rocconi@dhs.arkansas.gov  or call Matt at 501.683.4120.  There is also evolving information postedon the Facebook AR Medicaid Pharmacy Provider Help Group Page.  Matt can also help you join this Facebook page if you are not already a member.

 

Arkansas Medicaid pays either a $9 or $10.50 professional dispensing fee in addition to the ingredient cost. How do I know which one and why?

The Professional Dispensing Fee for covered outpatient legend and non-legend drugs shall take into consideration the State’s Preferred Drug List status for the drug being dispensed and equals the average professional dispensing fee in the aggregate:

  • Brand and Non-Preferred Brand = $9.00
  • Brand Preferred and Generic Medication drug = $10.50

The Brand Preferred medication list can be found at:

                  Preferred Brand Medication List:  https://arkansas.magellanrx.com/provider/docs/rxinfo/PDL.pdf

                  You can navigate to this page from the Magellan Medicaid website at:

                  https://arkansas.magellanrx.com/provider/documents/

                  Click “Evidence-Based Prescription Drug Program (PDL)”.  Then click PDL.pdf next to Preferred Drug List.

                 

You can read more detail about brand preferred medications and the clinical criteria needed for PA and/or point of sale claim approval in the Prior Authorization clinical edit document.  Click “Prescription Drug Clinical Edits” and then click the Prior Authorization Criteria file “PACriteria.pdf”

https://arkansas.magellanrx.com/provider/docs/rxinfo/PACriteria.pdf