FAQs - Pharmacy

The frequently asked questions for pharmacy are organized into the following categories:

General Information

Where can I find information about Indiana Medicaid?

Information regarding Indiana Medicaid can be found at www.indianamedicaid.com.

Note: This Web site does not provide complete information regarding the managed care organizations.

Where can I find information about the Indiana Medicaid pharmacy benefit?

Information regarding the Indiana Medicaid pharmacy benefit can be found at www.indianamedicaid.com under the Pharmacy Services button. Also, refer to Chapter 9 of the Indiana Health Coverage Programs Provider Manual.

How can I receive enrollment data regarding the Indiana Medicaid program?

E-mail DataManagement.Analysis@fssa.in.gov.

What are the medication copayments for pharmacy claims paid by Indiana Medicaid?

A $3 copayment is required for legend and nonlegend covered drugs in accordance with IC 12-15-6 and 405 IAC 5-24-7.

As of January 1, 2010, Hoosier Healthwise (HHW) members who do not pay a monthly premium (Package A and B members) follow the same $3 copay requirements as stated above. Also, HHW members who pay a monthly premium (Package C members) have a $3 copay for each generic drug and a $10 copay for each brand drug.

Healthy Indiana Plan (HIP) and Presumptive Eligibility (PE) members do not have a copay for drugs.

What are the days supply limitations on maintenance and nonmaintenance medications?

Maintenance medications have a 100 days supply limitation while nonmaintenance medications have a 34 days supply limitation. Refer to banner page BR200746 for additional information.

What type of drug benefit does Indiana Medicaid provide for full-benefit dually eligible members?

Indiana Medicaid provides coverage for Medicare Part D-excluded drugs that are a covered Indiana Health Coverage Programs (IHCP) benefit for people with Medicare and IHCP benefits. This includes, but is not limited to, barbiturates, benzodiazepines, and over-the-counter (OTC) drugs that are on the Indiana Medicaid Over-the-Counter Drug Formulary. For Medicare Part D-excluded prescription drugs that are in classes subject to the Preferred Drug List (PDL), all existing PDL limits and requirements are applicable. Medicare prescription drug plans (PDPs) may choose to cover Medicare Part D-excluded drugs; therefore, pharmacy providers should attempt to bill Medicare prior to submitting claims to the IHCP. For a comprehensive list of drugs covered by the IHCP for dually eligible members, see the Medicare D documents.

Where can I find information regarding coverage of nutritional products, medical devices, and supplies?

Information about medical supplies, durable medical equipment (DME), and home medical equipment (HME) policy and billing is available in the Indiana Health Coverage Programs Provider Manual Chapter 8 and 405 IAC 5-19.

Where can I find information regarding Care Select?

Where can I find information regarding the Healthy Indiana Plan (HIP)?

What are the provisions for coverage of legend medications for Indiana Medicaid?

Indiana Medicaid covers drugs in accordance with IHCP rule 405 IAC 5-24-3, which is as follows:

405 IAC 5-24-3 Coverage of legend drugs
Authority: IC 12-8-6-5; IC 12-15-1-10; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15 Sec. 3.

A legend drug is covered by Indiana Medicaid if the drug is:

  • Approved by the United States Food and Drug Administration;
  • Not designated by the Health Care Financing Administration (HCFA) as less than effective, or identical, related, or similar to a less than effective drug;
  • Subject to the terms of a rebate agreement between the drug's manufacturer and the HCFA; and
  • Not specifically excluded from coverage by Indiana Medicaid.

The following are not covered by Indiana Medicaid:

  • Anorectics or any agent used to promote weight loss.
  • Topical minoxidil preparations.
  • Fertility enhancement drugs.
  • Drugs when prescribed solely or primarily for cosmetic purposes.

Where can I find contact information for the Managed Care Organizations (MCOs)?

On the IHCP Provider Quick_Reference.

How can I contact the Office of Medicaid Policy and Planning (OMPP) pharmacy unit?

Contact information for the OMPP pharmacy unit:

Chris Johnson, R.Ph.
Director of Pharmacy
(317) 234-3635
Chris.Johnson@fssa.in.gov

Marc Shirley, R.Ph.
Pharmacy Operations Manager
(317) 232-4343
Marc.Shirley@fssa.in.gov

Emily Hancock, R.Ph.
Policy and Program Integration Manager
(317) 233-6467
Emily.Hancock@fssa.in.gov

Kristin Baldock, CPhT
Manager of Pharmacy Business and Audit Operations
(317) 233-6533
Kristin.Baldock@fssa.in.gov

John Ross, R.Ph., RN
Manager of Clinical Operations
(317) 232-4307
John.Ross@fssa.in.gov

 

Preferred Drug List and Prior Authorization Information

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What is the origin of the Indiana Medicaid Preferred Drug List (PDL)?

Senate Bill 228 established a Therapeutics subcommittee (T committee) of the Drug Utilization Review (DUR) Board and charged this committee with the task of developing a Preferred Drug List effective in September 2002.

What is a Preferred Drug List (PDL) and how are medications placed on the PDL?

PDL is an acronym for Preferred Drug List, which is a subset of all drugs covered under the fee-for-service pharmacy benefit. A subcommittee of the Drug Utilization Review (DUR) Board, the Therapeutics Committee, advises and makes recommendations to the Board on the content of the PDL. Drugs in classes that are subject to the PDL are designated as either preferred or non-preferred; preferred drugs typically do not require prior authorization, whereas non-preferred drugs generally do require prior authorization. Designation of drugs as either preferred or non-preferred is dictated first and foremost by clinical considerations, and second by financial/fiscal factors.

Where is the Preferred Drug List (PDL) located?

The PDL can be found at www.indianapbm.com under the Pharmacy Services buttons.

What medications require prior authorization (PA)?

In general, medications that are categorized as non-preferred require prior authorization. Note: There are exceptions to this rule. Some preferred medications may require prior authorization. Also, claims with excessive quantities, Step Therapy requirements, Brand Medically Necessary requirements, and medications with age limitations may be subject to prior authorization.

How are providers notified of any changes made to the Preferred Drug List (PDL)?

Pharmacy providers and prescribers enrolled as Indiana Health Coverage Programs providers are notified of any PDL changes 30 days prior to the change via an HP Provider Bulletin. These bulletins are posted on the Indiana Medicaid Web site on the Bulletins page. Refer to Provider Bulletin BT200912 for additional information.

How does a Preferred Drug List (PDL) help cut prescription medication costs?

Medications that require prior authorization have been determined to have no significant clinical advantage over preferred counterparts, and also have the added liability of potential misutilization or abuse. Prior authorization serves to ensure the use of the most clinically appropriate, cost-effective medications.

What is the difference between Preferred Drug List (PDL) neutral and PDL neutral reviewed?

A PDL neutral drug is a new drug in a class, that class having been reviewed for PDL status, but the drug itself has not yet been up for review by the Therapeutics Committee/Drug Utilization Review Board.

A PDL neutral reviewed drug is a new drug in a class, that class having been reviewed for the PDL status, when the drug HAS been up for review by the Therapeutics Committee/Drug Utilization Review Board, but the drug has not been assigned a preferred or non-preferred status.

How do manufacturer representatives ask to have their drugs reviewed for Preferred Drug List (PDL) status?

Refer to the information provided at http://www.indianapbm.com and submit the necessary documentation to the pharmacy benefit manager.

What is the coverage status for new medications?

If a new drug is in a class that is subject to the PDL, then it is considered PDL neutral (refer to question above), and the drug is covered by the program and does not require prior authorization. If a new drug is in a class that is not subject to the PDL, and is not included in the list of non-covered legend drugs at 405 IAC 5-24-3, the drug is covered by the program and does not require prior authorization.

What is the coverage status for new strengths or formulations of existing medications?

For purposes of the Indiana Medicaid Preferred Drug List, a 'line extension' of a drug product is a new strength, formulation, or dosage form of the chemical entity that was the subject of the original new drug application as approved by the Food and Drug Administration. The PDL status of such drugs is the same as the status of the chemical entity that was the subject of the new drug application, unless determined otherwise by the Therapeutics Committee and Drug Utilization Review Board.

How can I get a prior authorization (PA) form?

Prior authorization forms can be found on the Forms page.

What is the Preferred Drug List (PDL) status of mental health medications?

In accordance with Indiana law, all antianxiety, antidepressant, antipsychotic, and "cross indicated" drugs are considered preferred. Drugs that are (1) classified in a central nervous system drug category or classification (according to Drug Facts and Comparisons) created after March 12, 2002, and (2) prescribed for the treatment of a mental illness (as defined by the most recent publication of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders) are also considered preferred.

Where can I locate information regarding the blood factor products that are included in the State Maximum Allowable Cost (SMAC) Program?

Why do some preferred medications say prior authorization (PA) is required?

There are preferred medications which do require a prior authorization based on certain criteria that need to be met prior to approval.

Why are some brand-name medications preferred over their generic versions?

In certain situations, the cost to the Indiana Medicaid program for the generic may be higher than that of its brand-name equivalent. This situation is due to federal and/or state supplemental rebates that result in the net cost to the Indiana Medicaid Program of the brand-name drug being less.

I cannot find certain drugs listed on the Preferred Drug List (PDL). What does this mean?

Medications that are not listed on the PDL are covered by the Indiana Medicaid Program, to the extent they are not specified by 405 IAC 5-24-3 as noncovered.

How often does the prescriber have to request a prior authorization (PA) for a given drug?

In general, a PA is good for one year. However, there are instances when a PA will be approved for a shorter time period.

Is the pharmacy notified of the prior authorization (PA) decision?

The pharmacy will be notified of the PA decision only if the pharmacy contacted the call center to initiate the PA request.

Can pharmacies initiate prior authorizations?

Pharmacies can initiate prior authorizations for early refill requests and drug-to-drug interactions only if one of the medications has been discontinued.

Can a doctor initiate a prior authorization (PA) request before the recipient arrives at the pharmacy and receives a claim denial?

Yes, the prescriber can contact the PBM Call Center at (866) 879-0106 or fax the appropriate PA request form to (866) 780-2198.

How quickly will a prior authorization (PA) request be approved or denied?

The PA request must be approved or denied within 24 hours of receipt of the request.

Where can I find information regarding the edits that are in place for mental health medications?

Where can I find information regarding utilization edits (quantity limits) for mental health medications?

Utilization edits for mental health medications

Where can I find information about the Emergency Supply Provisions regarding covered drugs?

www.indianapbm.com/emergencysupply

Does the Indiana Medicaid pharmacy benefit have a limit on the number of prescriptions or number of branded medications members can receive each month?

No.

How do I submit an appeal for a denial of a prior authorization?

Refer to Chapter 9 of the Indiana Health Coverage Programs Provider Manual for the Prior Authorization Denial Appeal Process.

How do I submit claims for procedure-coded drugs?

Refer to Provider Bulletins BT200703, dated January 30, 2007; BT200713, dated May 29, 2007; and BT200908, dated March 12, 2009, for more detailed information.

How do I submit claims for drug-related medical supplies and medical devices?

Refer to the EDI Solutions Trading Partner Registration Procedure and IHCP Provider Manual Chapter 3: Electronic Solutions (page 7) for additional instructions on how to enroll as a trading partner with the IHCP and on how to submit these medical claims.

Pharmacy Benefit Consolidation

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What is a pharmacy benefit consolidation?

The Office of Medicaid Policy and Planning (OMPP) will assume responsibility for the administration of the Hoosier Healthwise (HHW) and Healthy Indiana Plan (HIP) pharmacy benefits.

What are the advantages of a pharmacy benefit consolidation?

A consolidation of pharmacy benefits among the health plans will achieve significant savings and will result in administrative simplification in the areas of prescribing, dispensing, claims submission, program analytics, and prior authorization related to pharmaceutical services. A pharmacy benefit consolidation will improve the quality of healthcare services provided to members and also increase the overall access to pharmaceuticals available to members. A consolidation eases the burden on pharmacists and prescribers of tracking multiple pharmaceutical benefits and navigating different claims processing help desks and prior authorization requirements. Complexity is reduced, thus resulting in an overall increase in administrative efficiency. Prescribing options will be expanded in terms of the number of pharmaceuticals available without prior authorization (PA).

What is the effective date for pharmacy benefit consolidation?

The pharmacy benefit consolidation is effective for pharmacy claims with dates of service on or after December 31, 2009.

What Preferred Drug List (PDL) will be used?

The fee-for-service PDL will be used and can be found at www.indianapbm.com under Pharmacy Services.

Are there services which are excluded from the pharmacy benefit consolidation?

Hoosier Healthwise (HHW) and the Healthy Indiana Plan (HIP) remain responsible for the following services:

  • Procedure coded drugs billed by entities other than IHCP-enrolled pharmacy providers
  • Medical supplies and medical devices not included in Table 1 in IHCP Provider Bulletin BT200948
  • Durable medical equipment
  • Enteral or oral nutritional supplements

Will members need to change pharmacies due to the pharmacy benefit consolidation?

Members may continue to utilize the same pharmacy.

What if a member has a pharmacy prior authorization (PA) with his or her plan? Will the member need a new PA?

Existing pharmacy prior authorizations for Hoosier Healthwise and Healthy Indiana Plan members will be systematically converted to the FFS claims processing system and honored through their expiration date. This process will be completed prior to implementation, but it may still be necessary for providers to obtain another prior authorization if the PA was not available for conversion.

What are the medication copayments for pharmacy claims?

Effective January 1, 2010, Hoosier Healthwise Package A members will follow the $3 copayment requirements outlined in 405 IAC 5-24-7. Hoosier Healthwise Package C members will have a $3 copayment for each generic drug and a $10 copay for each brand drug. As in the past, HIP and PE (Presumptive Eligibility) members will not have a copayment for drugs.

Will members receive new identification cards?

Healthy Indiana Plan (HIP) members will receive new member ID cards. HIP members should contact their member services if they have not received their new member identification card by March 31, 2010. All Hoosier Healthwise members will continue to use their current member identification card.

What drug-related medical supplies are reimbursable by the fee-for-service medical benefit?

Please refer to Table 1 in IHCP Provider Bulletin BT200948.

Will the pharmacy receive a message if the claim is submitted to the wrong plan?

Any pharmacy claims submitted to the Hoosier Healthwise (HHW) program or the Healthy Indiana Plan (HIP) with dates of service on or after December 31, 2009, will be denied by the HHW or HIP health plans. The pharmacy provider will receive a text message indicating the claim needs to be submitted to BIN 610467.

How long do I have to submit claim adjustments and reversals for claims with dates of service prior to December 31, 2009?

Claims for Hoosier Healthwise and Healthy Indiana Plan members with dates of service prior to December 31, 2009, will be available for claim adjustments and reversals until March 31, 2010. HHW and HIP health plans are responsible for all claims with dates of service on or before December 31, 2009.

For claims with dates of service prior to December 31, 2009, what days supply and quantities should be submitted on the claims?

Claims with dates of service prior to December 31, 2009, billed to the managed care organizations/Hoosier Healthwise program and the Healthy Indiana Plan should not be submitted with a shortened days supply. All claims should be dispensed with the appropriate days supply as outlined by each plan. Example: A prescription written for a 30 days supply submitted on December 20, 2009, should not be submitted with a quantity sufficient for only 11 days, but should be submitted with a quantity sufficient for a 30 days supply.

Do the tamper-resistant prescription policies apply to Hoosier Healthwise (HHW) and the Healthy Indiana Plan (HIP) claims written prior to December 31, 2009, but filled after December 31, 2009?

Due to the pharmacy benefit consolidation, HHW and HIP health plan members receive their pharmacy services through the fee-for-service (FFS) delivery system. Federal law is that all non-electronic prescriptions paid for by the FFS program must be written on tamper-resistant prescription pads. Refills of prescriptions written for HHW and HIP health plan members prior to December 31, 2009, to be filled on or after December 31, 2009, must meet TRPP requirements. Refer to Provider Bulletin BT200947, dated December 22, 2009, for additional information regarding TRPP requirements.

Indiana Medicaid Contractors

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Who is the Indiana Medicaid pharmacy benefit manager (PBM)?

Affiliated Computer Services (ACS) State Healthcare, LLC is currently contracted with the State of Indiana to perform pharmacy benefit management services.

What services does the pharmacy benefit manager (PBM) provide?

The PBM's major responsibilities for Indiana Medicaid include the clinical call center and prior authorization requests, rebate management, Preferred Drug List development and maintenance, retrospective Drug Utilization Review (retro-DUR) activities, OTC Drug Formulary maintenance and development, and support of activities related to the Drug Utilization Review Board and Therapeutics Committee.

How do I contact the pharmacy benefit manager (PBM) for prior authorization requests?

You may contact the PBM Call Center at 1-866-879-0106 or fax the appropriate prior authorization request form to 1-866-780-2198. Prior authorization forms can be found on the Forms page.

Does the Indiana Medicaid pharmacy benefit have a state supplemental rebate program in addition to the federal rebate program?

Yes, information can be found at www.indianapbm.com.

Who handles drug rebates, disputes, and invoicing?

ACS State Healthcare, LLC

Who processes pharmacy claims for the Indiana Medicaid pharmacy benefit?

HP Enterprise Services (formerly EDS, Electronic Data Solutions)

What other services does the claims processor provide?

The claims processor is also the fiscal agent for the Indiana Medicaid Pharmacy Benefit. Primary responsibilities include:

  • Adjudication of and payment for pharmacy claims
  • Provider enrollment functions
  • Provider assistance functions
  • Systems support

How do I contact the claims processor?

See the IHCP Provider Quick Reference for contact information.

What services does Myers & Stauffer perform for the Indiana Medicaid pharmacy benefit?

Myers & Stauffer provides support services for the Indiana Medicaid pharmacy benefit. Primary responsibilities include:

  • Administration and maintenance of the State Maximum Allowable Cost (SMAC) program, including development of SMAC rates
  • Development and maintenance of OTC Drug Formulary MAC rates, including drafting of provider communications regarding same
  • Performance of state statute-required "dispensing fee survey."

Where can I find the State Maximum Allowable Cost (SMAC) rates?

http://in.mslc.com/StateMacServices

Where can I find the OTC Drug Formulary?

http://in.mslc.com/StateMacServices

What is the current reimbursement methodology for medications?

According to 405 IAC 5-24-4, the office shall reimburse pharmacy providers for covered legend drugs at the lowest of the following:

  • The estimated acquisition cost (EAC) of the drug as of the date of dispensing, plus any applicable Medicaid dispensing fee.
  • The state maximum allowable cost (State MAC) of the drug as determined by the office as of the date of dispensing, plus any applicable Medicaid dispensing fee.
  • The provider's submitted charge, representing the provider's usual and customary charge for the drug, as of the date of dispensing.

For purposes of this section, the Indiana Medicaid EAC is:

  • For brand-name legend drugs, 84 percent (84%) of the Average Wholesale Price (AWP) for the National Drug Code (NDC), according to the Medicaid contractor's drug database file.
  • For generic drugs, 80 percent (80%) of the AWP for each NDC, according to the Medicaid contractor's drug database file.

Where can I find information regarding HMS (formerly Prudent Rx) and pharmacy auditing?

Go to www.prudentrx.com/provider/index and then refer to Indiana Providers on the left-hand side of the Web page.

Boards and Committees

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What is the role of the Drug Utilization Review (DUR) Board?

On the DUR Board page of this Web site.

Where can I find out about upcoming Drug Utilization Review (DUR) Board meetings?

On the Drug Utilization Review Board page.

What is the Indiana Medicaid Therapeutics Committee?

www.indianapbm.com

Is there a schedule showing which drugs will be reviewed at each Therapeutics Committee?

www.indianapbm.com/meetingSchedule

Is there public comment at the Drug Utilization Review (DUR) Board and Therapeutics Committee meetings?

See the Drug Utilization Review Board page.

For the Therapeutics Committee: The time remaining at the end of Meeting 1 will be allocated for public comment. Comment will be limited to two speakers per product and one minute per speaker. Speakers may only present new product information (changes since the last review) or new products. There will only be one sign-in sheet for speakers. There will not be a sign-in sheet for each class. The sign-in sheet will be available the morning of the meeting.

What is the role of Mental Health Quality Advisory Committee (MHQAC)?

The MHQAC was a result of HEA 1325 and was implemented to develop guidelines and programs that would allow open and appropriate access to mental health medications. The MHQAC provides educational materials to prescribers and pharmacy providers concerning the appropriate use of mental health medications.

Where can I find meeting dates and times for the Mental Health Quality Advisory Committee (MHQAC)?

On the Mental Health Quality Advisory Committee page.

Reporting Requirements and Manuals

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Where can I find the Preferred Drug List Evaluation Reports, CMS DUR Annual Report, and Indiana Medicaid Drug Utilization Review Board Newsletters?

On the Drug Utilization Review Board page.

Where can I find the Dispensing Fee Survey?

On the Related Information page.

Where can I find the Indiana Health Coverage Programs (IHCP) Manual?

On the Manuals page.

Where can I find the Managed Care Organization (MCO) Annual Report?

Managed Care Organization Annual Report

Federal Requirements

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Where can I find information regarding Tamper Resistant Prescription Pads (TRPP)?

Where can I find information about National Provider Identifier (NPI)?

Where can I locate the CMS listing of covered outpatient medications?

www.cms.hhs.gov/MedicaidDrugRebateProgram/DrugProdData

Where can I find the NDC submission requirements for physician-administered medications?