June 2004 PROVIDER NOTICE NUMBER 421 PHARMACY PROVIDERS

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1 June 2004 PROVIDER NOTICE NUMBER 421 Kansas Medical Assistance Program Vertical Perspective PHARMACY PROVIDERS Information about the Kansas Medical Assistance Program as well as provider manuals and other publications can be found at the KMAP web site: New Federal MACs Recent changes pertaining to pharmaceuticals are listed below. Prices effective with dates of service March 20, 2004 Decreases Erythromycin mg cap Isosorbide Dinitrate 5mg tab mg tab Methocarbamol 500mg tab Increases Carbidopa/Levodopa 25mg/100mg mg/250mg Doxycycline Hydrochloride 50mg cap mg cap Isosorbide Dinitrate 20mg tab Primidone 250mg tab Trazadone Hydrochloride 50mg tab mg tab Triamcinolone Acetonide 0.5% cream Verapamil Hydrochloride 180 mg tab (extended release) Additions Acetaminophen/Butalbital/ Caffeine 500mg/50mg/40mg tab Acetaminophen/Hydrocodone Bitartrate 500mg/2.5mg tab Albuterol Sulfate 4mg tab Amoxicillin 250mg/5ml powder Hydroxyzine Hydrochloride mg tab Metformin Hydrochloride 500mg tab mg tab Methocarbamol 750mg tab Propafenone Hydrochloride 150mg tab mg tab Page 1 of 5 is the fiscal agent and administrator of the Kansas Medical Assistance Program for the Kansas Department of Social and Rehabilitation Services

2 NOTE: The following have recently been removed rom Federal MAC pricing by the Centers for Medicare & Medicaid Services: Bisoprolol Fumarate/Hydrochlorothiazide Chlorthalidone Orphenadrine Citrate Promethazine Hydrochloride Trifluoperazine Hydrochloride 10mg/6.25mg tab 25mg and 50mg tabs 100mg tab extended release 6.25mg/5ml syrup 5mg tab REMINDERS! ULTRACET is indicated for the short-term (5 days or less) management of acute pain per package insert. KMAP is not required to pay for drugs used for off-label use.! DRUGS NONCOVERED by Kansas Medicaid include those with a DESI that declares them less-thaneffective. This can be referenced in the Pharmacy Provider Manual in section Examples of these drugs are Estratest and Estratest HS which became non-covered effective 09/01/03.! SPLIT CLAIMS (Correct Billing): When submitting a split bill claim to KMAP the total charge submitted to the primary insurance MUST be the total charge submitted to KMAP. For KMAP, this total charge is submitted in the NCPDP 5.1 Gross Amount Due field 430-DU. In addition, continue to indicate the primary insurance response and paid amount by the primary if greater than zero. KMAP will consider any balance for payment.! According to the NCPDP Version 1.1 and 5.1 Transactions Payer Sheets, the field for Prescriber Identification (411-DB) should be a 9-digit provider number plus the 1-character location code. KMAP has noticed that some providers are only submitting 9 characters instead of 10. Please contact your software vendor to make sure that KMAP is receiving 10 characters. Decimal Billing on Multi-Dose Vials and Fractional Package Sizes Providers must bill the metric decimal quantity of the NDC on injectable drugs that are packaged in multi-dose vials. The previous practice of rounding up is no longer accepted. If only a portion of a multi-dose vial is used, the actual amount dispensed must be billed. As noted in the September 2003 bulletin, providers must bill the decimal quantity of NDC s that are packaged in Fractional Package Sizes. An example would be Atrovent Inhaler which comes in a package size of 14.7GM. State Maximum Allowable Cost (SMAC) Addition & Retroactive Price Increase Effective for claims with dates of service on and after June 18, 2004, the following drugs have a new SMAC price: Benazepril 5mg tab $ mg tab $ mg tab $ mg tab $ Note: See Preferred Drug List changes for Benazepril in this bulletin. Page 2 of 5

3 Effective for claims with dates of service listed the following drugs have a SMAC price increase: February 1, 2004: April 1, 2004: Nefazodone HCl Nefazodone HCl 50mg tab $ mg tab $ mg tab $ mg tab $ mg tab $ Claims submitted for Nefazodone on and after February 1, should reflect the prices listed above. If you submitted a claim for nefazodone HCl 200 mg tablets between April 1, 2004 and April 29, 2004, you may submit an adjustment for each claim. DIAGNOSIS CODE REMINDERS A diagnosis code is not required on a pharmacy claim unless one of the following conditions is present: 1. Pre-natal vitamins prescribed for pregnant or lactating women (up to 3 months postpartum): enter diagnosis code Partial fills for C-II drugs and the patient has a terminal illness: enter diagnosis code V If billing for amphetamines, amphetamine-mixtures and amphetamine-like drugs: a diagnosis code is required to be entered on the claim. For a diagnosis of Attention Deficit Disorder (ADD): enter diagnosis code For a diagnosis of Attention Deficit Disorder with Hyperactivity (ADHD): enter diagnosis code 31401, for narcolepsy: enter Provigil prescribed for narcolepsy: enter diagnosis code 347, or for hypersomnia: enter diagnosis code NOTE: If a diagnosis code is entered on a claim where it is not required, the diagnosis code must be in valid format and it must be one that is currently an active diagnosis. If a diagnosis code is entered that is not valid and active, the claim will be denied. For diagnosis-related claim denials (where a diagnosis is not required), either resubmit the claim without a diagnosis code or resubmit with a corrected diagnosis code. ORTHO EVRA Ortho Evra is available under two NDC s: = 3 patches per box = 1 patch per box (Replacement Patch) ALL dispensing and billing for this product should use NDC , UNLESS dispensing the replacement patch, NDC , under the manufacturer s replacement patch guidelines. Due to the manufacturer s Ortho Evra program, KMAP will recoup any claims billed with NDC where it is not a replacement patch situation. If you have any additional questions regarding the replacement patch program, please contact Ortho-McNeil Pharmaceuticals. Page 3 of 5

4 Restasis and Diastat Billing Guidelines In order to avoid over or under payment, please bill KMAP the following units related to each NDC. Diastat NDC s: Each kit (NDC) contains two syringes. BUT, providers must bill the NDC as a kit. Therefore, bill one unit when dispensing a kit and not two units (representing syringes). Restasis NDC: Each tray (NDC) comes with ml single use vials. This NDC must be billed per unit; not per ml. Therefore, one tray would be billed as 32 units. In the case of Diastat, if a provider bills per syringe, an overpayment may occur. In the case of Restasis, if a provider bills per ml, an underpayment may occur. Both cases of incorrect billing could result in Drug Rebate related recoupments. Addition to Preferred Drug List Effective for claims with dates of service on and after June 18, 2004, Benazepril will become a Preferred Drug on the Preferred Drug List. Exclusions to the five single source per month limit Effective with dates of service on and after July 16, 2004, preferred drugs,and drugs used to treat mental illness will be systematically excluded from the five single source scripts per month limit. Overrides will not be required. Provider Manual Revisions Go to the web site at the beginning of this notice for Pharmacy Provider Manual revisions that include: An updated SMAC/ Federal MAC pricing list - Appendix An NCPDP Rejection Code and Reason table. This is a crosswalk of NCPDP reject codes KMAP may send back on a POS claim and possible reasons for the error. Page 4 of 5

5 DOCUMENTATION OF MEDICAL NECESSITY FOR BRAND NAME DRUGS WHEN BIOEQUIVALENT GENERIC SUBSTITUTES ARE AVAILABLE In order for the Kansas Medical Assistance Prescription Drug Program to increase patient safety, decrease unnecessary expenditures, and assist in monitoring drug products, effective May 28, 2004, prescribers will be required to fill out the FDA MedWatch form 3500 if Dispense as Written is specified on the prescription when there are bioequivalent generic substitutes available. The prescriber must submit the completed form to the dispensing pharmacy AND to the FDA. The dispensing pharmacy will then submit the MedWatch form to the KMAP prior authorization unit for evaluation and receive approval if medical necessity is met. The criteria to meet medical necessity for a brand name drug when a bioequivalent generic substitute is available is listed below. 1. A. Adverse Reaction(s) to the generic: Documentation by prescriber that the adverse reaction caused by the generic meets one of the following criteria: 1. life threatening 2. hospitalization 3. disability 4. required intervention to prevent impairment or damage OR B. Allergic Reaction(s) to the generic: Prescriber must document the beneficiary s experience of allergic reaction to the generic product of one or more manufacturers. The dates and clinical details with the names of specific companies and the generic versions involved must be included. OR C. Therapeutic Failure(s) of the the generic: Prescriber must document the clinical failure due to beneficiary s suboptimal drug plasma concentration for the generic drug when compared to published full pharmacokinetic profiles for the brand name drug. AND 2. Prescriber must submit the completed FDA MedWatch form to the dispensing pharmacy AND to the FDA. The dispensing pharmacy will then submit the MedWatch form to the KMAP Prior Authorization unit for evaluation. Additional Comments: Claims submitted with a DAW value of 1 (Substitution Not Allowed by Prescriber) will not price any higher unless Prior Authorization has been obtained in the manner described above. NDC s considered to be single source are already priced at AWP 13%; therefore the DAW/PA process would not provide a higher payment. Drugs such as Coumadin, Tegretol, Klonopin, Clozaril and Mysoline will continue to pay at higher rate with the current PA process and the FDA MedWatch form does not need to be filled our and faxed. The FDA MedWatch forms can be obtained at: Send requests for a hard copy of the revised provider manual to: Publications Coordinator, 3600 SW Topeka Blvd, Suite 204, Topeka, Kansas or publications@ksxix.hcg.eds.com. Specify the bulletin by provider type, date, and include your mailing address with a specified individual or office if possible. Page 5 of 5