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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 [email protected] (Myers and Stauffer) and [email protected]. You may also fax to 888.860.0236 for Myers and Stauffer. Arkansas Medicaid prefers email over fax.
Matt Rocconi and Jason Derden (Medicaid Pharmacy Director) can be reached at 501.683.4120 or at [email protected]. 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 5 most common complaints with the new Medicaid payment methodology that APA is hearing from pharmacists:
APA will continue to monitor these challenges and continue the dialogue with Arkansas Medicaid to improve the process.
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 [email protected] Covered products per Matt Rocconi ([email protected]) from Arkansas Medicaid as of 4.4.2017
Insulin Syringes:
Insulin Pen Needles:
For more help with this issue, you can email Arkansas Medicaid Pharmacy Department to Matt Rocconi at [email protected] 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:
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 |