Pharmacy Services - Indiana Medicaid Provider Home

1 Indiana HEALTH COVERAGE PROGRAMS. Provider REFERENCE MODULE. Pharmacy Services LIBRARY REFERENCE NUMBER PROMOD00042. PUBLISHED: JULY 13, 2017. POLICIES AND PROCEDURES AS OF APRIL 1, 2017. VERSION: Copyright 2017 DXC Technology Company. All rights reserved. Revision History Version Date Reason for Revisions Completed By Policies and procedures as of New document FSSA, OptumRx, October 1, 2015 and HPE. Published: February 25, 2016. Policies and procedures as of Scheduled update FSSA, OptumRx, April 1, 2016 and HPE.

2 Published: June 23, 2016. Policies and procedures as of CoreMMIS update FSSA, OptumRx, April 1, 2016 and HPE. (CoreMMIS updates as of February 13, 2017). Published: February 13, 2017. Policies and procedures as of Scheduled update: FSSA, OptumRx, April 1, 2017 Edited and reorganized text and DXC. Published: July 13, 2017 throughout the module Changed HIP Link references to HIP Employer Link Changed Hewlett Packard Enterprise references to DXC. Added references to the Pharmacy Supplements Formulary where appropriate Updated the Introduction section to reflect that Pharmacy benefits are no longer carved out of Hoosier Healthwise Updated Tables 1 and 2 and added Table 3 in the Introduction section Added the Medically Accepted Indication section Added NDC information to the Federal Rebate Program section Updated Table 7 in the Tamper-Resistant Prescriptions section Replaced the Legend Drug Reimbursement and Nonlegend (Over-the-Counter)

3 Drug Coverage and Reimbursement sections with the new Legend and Nonlegend Product Reimbursement section Library Reference Number: PROMOD00042 iii Published: July 13, 2017. Policies and procedures as of April 1, 2017. Version: Pharmacy Services Revision History Version Date Reason for Revisions Completed By Updated the Professional Dispensing Fee section Updated the Medical Supplies (Including Preferred Diabetic Supplies) and Durable and Home Medical Equipment section Updated the Coverage of Drug Products for Treating Tobacco Dependence section Added the Pharmacy Claims for Hepatitis C Drugs section Added note regarding Package E to the POS Transaction section Updated the Common Billing Errors section Added the Patient Gender Code and Pregnancy Indicator section Updated contact information for the TPL Unit in the Third- Party Liability, Coordination of Benefits.

4 And Cost Avoidance section Updated the IHCP Policy Regarding the 340B Program section Added a documentation requirement to the Returned Medications section Updated the Prospective Drug Utilization Review section Added the Self-Audits section Added the Invoice Reconciliation Audits section Updated the On-Site Audits section Updated the Proof of Delivery section Updated the Emergency Supply section regarding prior authorization iv Library Reference Number: PROMOD00042. Published: July 13, 2017. Policies and procedures as of April 1, 2017.

5 Version: Table of Contents Section 1: Introduction .. 1. Section 2: Pharmacy Coverage and Reimbursement .. 7. Overview .. 7. Legend Drug Coverage .. 7. Medically Accepted Indication .. 8. Federal Rebate Program .. 8. Federal Drug Efficacy Study and Implementation Program .. 8. Dispense-as-Written Codes .. 9. Mandatory Generic Substitution and Brand Medically Necessary .. 9. Brand Medically Necessary .. 9. Tamper-Resistant Prescriptions .. 10. Legend and Nonlegend Product Reimbursement .. 11. State Maximum Allowable Cost Program.

6 11. Professional Dispensing Fee .. 12. Adult Vaccination Administration Fee .. 12. Blood Factor Reimbursement .. 13. Usual and Customary 13. OTC Drug Formulary and Pharmacy Supplements Formulary .. 13. Active Pharmaceutical 13. Medical Supplies (Including Preferred Diabetic Supplies) and Durable and Home Medical 14. NDC Required on All Procedure-Coded Drug Claims .. 14. Pharmacy Copayment .. 15. Emergency Services Only: Package E .. 16. Pharmacy Services Provided Prior to Indiana Medicaid Eligibility Determination.

7 16. Coverage of Drug Products for Treating Tobacco Dependence .. 16. Pharmacy Reimbursement of Methadone .. 17. Pharmacy Claims for Hepatitis C Drugs .. 17. Compounded Pharmacy Claims Equal to or Greater Than $500 .. 17. Pharmacy Claims Equal to or Greater Than $5,000 .. 17. Pharmacy Claims Equal to or Greater Than $10,000 .. 19. Section 3: Pharmacy Billing Policy and Procedures .. 21. Overview .. 21. POS Transaction .. 21. Paper Pharmacy Claim 21. Professional Billing Paper and Electronic Claims.

8 21. Administrative Reconsideration and Appeal Process for Claims .. 22. Claim Reimbursement 22. Mandatory Reversal of Paid Claims for Unclaimed Return-to-Stock Prescriptions .. 22. General Billing Information .. 22. Pharmacy Drug File Medi-Span .. 22. Billing Units .. 22. Common Billing 23. National Drug Codes Configuration .. 23. Patient Residence 24. Patient Gender Code and Pregnancy Indicator .. 25. National Provider Identifier .. 25. Ordering, Prescribing, and Referring Practitioners .. 26. Third-Party Liability, Coordination of Benefits, and Cost Avoidance.

9 26. Billing Procedures for Specific Services and Programs .. 27. Billing Procedures for Compounds and Drug Products Requiring Reconstitution .. 27. Library Reference Number: PROMOD00042 v Published: July 13, 2017. Policies and procedures as of April 1, 2017. Version: Pharmacy Services Table of Contents Billing Procedures for Enteral Nutrition Therapy .. 28. IHCP Policy Regarding the 340B Program .. 28. Billing Procedures for HIP Employer Link .. 28. Billing Procedures for Emergency Services Only: Package E.

10 29. Electronic Funds Transfer 29. Section 4: Medicare Prescription Drug Coverage .. 31. Overview .. 31. IHCP Drug Coverage for Medicare and Medicaid Dual-Eligible Members .. 31. Claim Processing for Medicare and Medicaid Dual-Eligible Members .. 31. Section 5: Medicaid -Certified Long-Term Care Facilities .. 33. Overview .. 33. Medical and Nonmedical Supplies and Equipment .. 33. Unit Dose Packaging .. 33. Returned Medications .. 34. Section 6: Drug Utilization Review Processes .. 35. Overview .. 35.