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P&T Committee sets 2008 Schedule
The following dates have been set for Pharmacy and
Therapeutics Committee meetings in 2008: January 18, February 15, July 18, and August 15, 2008.
Unless otherwise posted in the agenda, meetings start at 9 a.m., with public testimony received from 9:30 to 10:30 a.m. All meetings are held at Idaho Medicaid, 3232 Elder Street, Boise.
Professional letters regarding a drug under P&T review must be received 7 days prior to the meeting.
Tamper-Resistant Prescription Forms
For new information on Tamper-Resistant Prescription forms please click here.
Are Generic Drugs Always Cheaper?
Not necessarily.
Idaho Medicaid covers the least expensive AB-rated product—which, on occasion, is the brand name product.
When a drug first becomes available as generic, the generic price is sometimes higher than a brand name product which has a federal and/or supplemental rebate. Therefore, it is more cost effective for Idaho Medicaid to continue paying for the branded drug until the price of the generic becomes more competitive.
The government is the largest pharmaceutical payor in the country. As such, it has established relationships with pharmaceutical manufacturers to allow their products into the Medicaid program as long as rebates are provided. These rebates allow the government to obtain the lowest contract price.
An example of a brand name drug being cheaper than generic can be found in the Long-Acting Narcotic Analgesic drug group. The weighted average unit cost for the brand name Duragesic patch is $12.65, while the generic fentanyl patch is $28.88.
(added 10-23-07)
72-Hour Emergency Supplies
Medicaid will pay for point-of-sale (POS) pharmacy claims for a 72-hour emergency supply of medications requiring prior authorization (PA) if the pharmacist in his/her professional judgment believes a participant has an immediate need. The appropriate prior authorization process must be used during regular business hours. All the following conditions must be met for an emergency supply:
- The participant is Medicaid eligible on the date of service
- The prescription is new to the pharmacy
- The medication requires prior authorization.
- The supply for the emergency period does not exceed three days
The override codes for billing for a 72-hour emergency supply are:
- Reason for Service Code: TP (Payer/Processor Question)
- Professional Service Code: MR (Medication Review)
- Result of Services Code: 1F (Filled, with different quantity)
A completed PA request must be faxed to the Medicaid Pharmacy at (208) 364-1864.
Information noted in Idaho Medicaid Provider Handbook, Pharmacy Guidelines, Section 3.4.2
(added 6/25/07)
Information on the DUR Site
See the Idaho Drug Utilization Review (DUR) link listed under Resources in the right column of this page for a variety of information reports. Patient educational leaflets on asthma and hypertension are available. There are also more than 20 leaflets for healthcare professionals on subjects ranging from trends in gestational diabetes to appropriate treatment of allergic rhinitis.
Idaho State University’s DUR program was created in 1990 to improve patient care and reduce drug costs in the state. DUR’s accomplishments include:
- Creating drug-use criteria for 14 drug classes.
- Developing educational interventions for physicians and pharmacists.
- Establishing a clinical database for Idaho Medicaid to determine prescribing patterns that are unnecessary, too expensive, and/or potentially dangerous.
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CONTACT NUMBERS
Claims Processing—
EDS at 1-800-685-3757
TIP: To speak to a person, say the word “agent.” EDS has 48 hours to return voice-mail messages.
TIP: Faster Reimbursement for Compound Claims
If your pharmacy provides compounding services, there is a way to receive faster reimbursement. Electronic billing expedites your compound claims and provides notification to you immediately if there are problems with your claims.
The Medicaid Provider Handbook, which is available through the Medicaid website, is a great resource for your claims billing questions. To quickly access the Handbook go to the Provider Handbook link under Prescriber Information in the right column of this page.
Prior Authorization issues—
1-866-827-9967
P&T Committee—
Bob Faller @ 364-1850
J-Code questions—
Arla Farmer @ 364-1958
Eligibility Questions—
334-5815
Durable Medical Equipment— including diabetic supplies,
incontinence supplies, and
nutritional supplies—
DME Unit, 364-1830 or 364-
954.
OTHER INFORMATION
Link for PA forms/criteria:
Preferred Drug List:
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Drug Notes:
- Proctor and Gamble (P&G) has notified Health and Welfare of erroneous billings for Prilosec OTC. The package contains both a national drug code (NDC) and a universal product code (UPC). P&G states that use of the UPC for drug claims is invalid. Medical billings must use the NDC number.
- Brand name Flonase does not re-quire prior authorization, but the generic form (fluticasone) does.
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Note to Providers re: Medicare Part D
The only drug classes covered by Medicaid for dual eligible clients are barbiturates, benzodiazepines, some legend cough/cold medicines, legend folic acid, injectable vitamin
B-12, iron salts, insulin syringes, legend vitamin D, and vitamin K. |