Nebraska Medicaid program

Welcome to the website for the Nebraska Medicaid Pharmacy Program - Point of Sale System (POS). The Nebraska Department of Health and Human Services, Medicaid and Long Term Care division has contracted with Magellan Medicaid Administration, Inc. as the Nebraska Pharmacy Benefits Administrator.

Nebraska Medicaid provides for health care services to eligible elderly and disabled individuals and eligible low-income pregnant women, children and parents. Medicaid provides health care for more than one in every ten Nebraskans.

Magellan Medicaid Administration, Inc. is responsible for:

• Operations Support of the Point of Sale System
• Call Center Operations for Providers
• Clinical Consultation Services
• Education and outreach activities for Providers

December 2013

FDA Revised Zolpidem Dosing Guidelines: Limits To Be Implemented for Zolpidem Immediate-Release Products

The FDA revised the dosing guidelines for zolpidem. The new guidelines can be accessed at http://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm334738.htm. The recommended initial dose of immediate-release zolpidem products is 5 mg for females and either 5 mg or 10 mg for males. Limits will be put in place on January 23, 2014 to deny claims for females for the 10mg immediate-release dosage strength and quantity limits of one tablet per day will be implemented for both dosage strengths of zolpidem immediate-release products for both males and females.

July 2013

Preferred Drug List (PDL) Update: Brand Lovenox® and Enoxaparin Statuses

The statuses of generic ENOXAPARIN and brand Lovenox® announced in March 2013 must be changed. Brand Lovenox® has been changed back to preferred on the PDL and no longer requires prior authorization. Generic ENOXAPARIN will retain preferred status until August 26, 2013, when it will again become non-preferred.

March 2013

Preferred Drug List (PDL) Update

The status of generic ENOXAPARIN has been changed to preferred on the PDL, and no longer requires prior authorization. Brand name Lovenox® will retain preferred status until May 29, 2013, when it will become non-preferred.

January 2013

SMAC pricing

Effective January 22, 2013, the Department of Health and Human Services, Division of Medicaid & Long-Term Care (MLTC) will begin contracting with Magellan Medicaid Administration (MMA) for SMAC pricing. MMA will provide assistance in establishing and maintaining the SMAC rates for medications covered in the pharmacy program. As new SMAC rates are developed, the rates will be posted on the nebraska.fhsc.com website. Please visit this website regularly for changes to the SMAC list.
Providers may submit a MAC Price Research Request Form if there are concerns with current rates established. This form can also be obtained online at nebraska.fhsc.com and can be submitted via email to StateMACProgram@magellanhealth.com or faxed to 888-656-1951. A copy of the purchasing invoice for the medication must accompany the MAC Price Research Request form in order to evaluate a MAC price inquiry

December 2012

Medicare Improvement for Patients and Providers Act of 2008 (MIPPA)

Nebraska Medicaid currently provides coverage of generic benzodiazepines and barbiturates for all Medicaid eligible clients. Beginning January 1, 2013 Nebraska Medicaid will no longer cover these two classes of medications for Medicare eligible clients. Coverage for these medication classes will become the responsibility of the client’s Medicare Part D plan as required under MIPPA. Pharmacies will need to update their system to ensure claims for these medications are billed to the correct processor.

Please email questions to dhhs.MedicaidPharmacyunit@nebraska.gov.

August 2012

Medication Prior Authorization (PA) Forms

Currently, there are specific prior authorization (PA) forms for Proton Pump Inhibitors (PPIs), NSAIDs: CoxI, Single Entity or Combination Brand Name, and Low/Non-Sedating Antihistamines (LSAs) located at separate links on the website (nebraska.fhsc.com) on the tab, Prior Authorization, and the drop down for PA Forms. Beginning August 27, 2012, these drug class specific PA forms will be replaced by the Documentation of Medical Necessity form which currently exists at its own link under PA forms. When going to the link for these drug class specific forms, the Documentation of Medical Necessity form will be provided and should be used to request prior authorization. Additionally, the PDL Exception Request form will also be replaced by the Documentation of Medical Necessity form and will be provided at the link on the same website on the tab, Preferred Drug List, and the drop down for PDL Exception Request.

Standard Dispensing Fee

Currently the State has thirteen different dispensing fees across participating Medicaid providers. Standardization to one dispensing fee is being implemented in order to be equitable to all providers. Analysis was done where all dispensing fees were compared. A dispensing fee of $4.45 reflects the average fee paid. Effective September 4, 2012 the dispensing fee of $4.45 will be paid to all participating providers.

March 2012

Universal Claim Form

With the implementation of NCPDP version D.0 for pharmacy claims submission, there is a new version of the Universal Claim Form (UCF). This new version 1.1 has an expanded number of fields, some of which were not present on the previous version but are now required. Providers are encouraged to begin using the new form as soon as possible. Claims received after April 15, 2012 will be required to utilize the new form. The NCPDP Universal Claim Forms may be purchased from NCPDP vendor, CommuniForm. The forms can be ordered online at www.Communiform.com/NCPDP or (800) 869-6508.

December 2011

D.0 and Prescriber NPI

Beginning 01/01/2012, Nebraska Medicaid will only accept claims submitted in the NCPDP D.0 format. Due to unforeseen circumstances there will not be a dual-format period where claims can be submitted in either the current 5.1 format or the new D.0 format. Any claim submitted in the current 5.1 format on or after 01/01/2012 will deny and need to be re-submitted in the D.0 format to be considered for payment.

As a reminder Governmental COB requires full disclosure of all amounts paid and patient responsibility. Medicaid is the payer of last resort and, as such, is obligated to determine the Medicaid allowed amount without regard to the allowed amount of any upstream payer. DHHS allowed Other Payer Amounts Paid from upstream processors is deducted from the Medicaid Allowed Amount to determine the final DHHS financial responsibility for the claim. In the event upstream payers impose a co-pay or coinsurance amount this value is also used to determine DHHS’ fiscal responsibility.

As a condition of participation, providers participating in Nebraska Medicaid agree to accept as payment in full the amount paid according to the Department’s payment methodologies after all other sources have been exhausted. In the event final calculated amounts demonstrate that DHHS’ fiscal responsibility has been met or that the DHHS fiscal responsibility is below the submitted Other Payer Patient Responsibility the amount returned as DHHS Amount Paid is considered payment in full and any amount submitted in the Other Payer Patient Responsibility above the amount paid by the Department is not to be collected from the patient/client.

Prescriber NPI will be required on all claims as of January 1, 2012. Until then, claims may continue to be submitted with the state license number. On 01/01/2012 or after if you have submitted a claim using the prescriber’s NPI and are receiving a message stating missing or invalid prescriber ID (NCPDP reject code 56), the NPI submitted is not yet on our files. During regular business hours, please have the prescriber contact the Nebraska Provider Enrollment area at 877-255-3092. All other times please contact the Pharmacy Help Desk at 800-368-9695.

Urgent Notice: D.0 Pharmacy Claims

Due to unforeseen circumstances, Nebraska Medicaid will not be accepting pharmacy claims in D.0 format beginning on December 14, 2011 as previously communicated. An announcement will be forthcoming as to the new implementation date.

September 2011

Notice: Upcoming system maintenance

On Saturday, September 17, 2011, Magellan Medicaid Administration will be performing network maintenance from 10 PM (CT) until the morning of Sunday, September 18th at approximately 8 AM (CT). During that time, the normal POS pharmacy claims processing system will be out of service.

May 2011

March 2011

Notice: Upcoming system maintenance

On Saturday, March 26, 2011, Magellan Medicaid Administration will be performing network maintenance from 4 PM (CT) until approximately 10 PM (CT). During that time, WebPA, Web Claims Submission and the Drug Lookup on the nebraska.fhsc.com website will be out of service. This maintenance does not affect claims processed via the normal POS claims processing system.

January 2011

Compounded Prescriptions with APIs and Excipients

An API is a bulk drug substance, which is defined by the FDA as any substance that is represented for use as a drug and that, when used in the manufacturing, processing or packaging of a drug, becomes an active ingredient of the drug product. APIs may be included in extemporaneously compounded prescriptions and may serve as the active drug component in a compounded formulation.

State Medicaid programs have been informed by the Centers for Medicare & Medicaid Services (CMS) that many active pharmaceutical ingredients (APIs) and excipients used in compounding do not meet the definition of a covered outpatient drug as defined in section 1927(k)(2) of the Social Security Act and effective January 1, 2011, are not eligible for coverage as drugs in Medicaid programs. Therefore, Nebraska Medicaid will no longer cover such products for dates of service on and after January 1, 2011.

Lists of APIs and excipients identified in the Medicaid Drug Rebate system are posted on the CMS website at http://www.cms.gov/Reimbursement/02_Spotlight.asp. Please note that these are not definitive lists and additional products will be added as they are identified.

If you are treating a recipient who is currently receiving a prescription containing one of the APIs or excipients to be deleted, you must identify an alternative therapy that meets the definition of a covered outpatient drug and is eligible under the federal drug rebate program. Information regarding products covered by NE Medicaid can be found on the Drug Lookup posted at https://nebraska.fhsc.com.

If you have any questions regarding this bulletin please contact Barbara Mart, R.P., Pharmacy Consultant, at (402) 471-9301 or barbara.mart@nebraska.gov.

August 2010

Upper Limit on Compounded Prescriptions

Nebraska Medicaid is implementing an upper limit on compounded prescriptions. Beginning August 26,2010 claims designated as compounds with a calculated reimbursement over $140.00 will require authorization by DHHS. Compounded PPI and sildenafil suspensions for children are exempted. Before calling for an override please verify the claim you are submitting is a valid compound claim and that you are using the most cost-effective ingredients. Please call DHHS at 877-255-3092 if you determine an override is required.

June 2010

ATTENTION PHARMACY PROVIDERS

Nebraska Medicaid is implementing an upper limit on Over-The-Counter (OTC) claims. Beginning June 2, 2010 OTC claims with a calculated payment over $40.00 will require authorization. BEFORE calling for an override please review that you are dispensing the most cost-effective product or reduce the quantity to be dispensed. For situations that cannot be resolved with the above changes please call DHHS at 877-255-3092. Be sure to have documentation to support the medical necessity of the product, quantity and dose when calling.