Michigan Medicaid

Reminder: Michigan Medicaid Reimburses Medicare Part B Co-Insurance

This is a reminder to pharmacy providers that Michigan Medicaid continues to reimburse the Medicare Part B co-insurance for Medicare/Medicaid beneficiaries. Pharmacies must bill the Medicare Part B Carrier before billing Michigan Medicaid's PBM First Health Services Corporation for the Medicare Part B co-insurance amount(s). If you have questions on billing, contact First Health's Technical Call Center at 877-624-5204.

Procedure for Beneficiaries with coverage gap

CMS has developed a process for a point of sale solution to ensure full dual eligible individuals experience no coverage gap. If a beneficiary presents at a pharmacy with evidence of both Medicare and Medicaid eligibility, but they are not currently enrolled in a Part D plan, they can have the claim for their medication submitted to a single account for payment. This would allow the beneficiary to leave the pharmacy with their prescription. CMS is contracting with 2 vendors to coordinate eligibility verification and expedite the enrollment process. Click here for additional information on the basics of the contingency plan. Pharmacies can click here for further information on the actual steps of the point-of-sale faciliated enrollment process.

Helpful Medicare Part D Phone Numbers and Links

Beneficiaries
Medicare 800-MEDICARE (800-633-4227). TTY users should call 877-486-2048.
Michigan Medicare/Medicaid Assistance Program (MMAP) 800-803-7174 or http://www.mymmap.org/.
MDCH Beneficiary Helpline 1-800-642-3195. TTY users should call 866-501-5656.

Pharmacies
Medicare's Pharmacy Line 866-835-7595 or http://www.cms.hhs.gov/Pharmacy/.

• Enhanced E1 tip sheet for Pharmacists
• Wellpoint/Anthem Contingency Plan for Medicare Part D
• CMS Pharmacy Reference document for Pharmacists

Michigan Pharmacists Association 517-484-1466 or http://www.michiganpharmacists.org/.
First Health's Technical Call Center (the MDCH Pharmacy Benefit Manager) 877-624-5204.

To view September 2008 MPPL & PDL changes click here.

September 2008

Provider Reversal Notification - Update

As a result of concerns regarding a recent provider reversal notification dated September 16, 2008 (click here to see the notice), the Michigan Department of Community Health will NOT be requiring pharmacies to take action on the claims until further instructions are provided. We apologize for any confusion.

Notice on Infusion drug type edit

It was noted during a recent review that claims are being submitted with a PAMC code of "8", which indicates an infusion claim, that include drugs that are not suitable for infusion preparations. Effective 08/29/2008 First Health will deny claims submitted with a PAMC of 8 if the route of administration of the drug is not suitable for infusion preparation, such as "oral", "rectal", "topical", etc. If the provider feels that the denial is in error, they may call the First Health clinical call center and discuss the claim with a First Health representative.

To view July 2008 MPPL & PDL changes click here.

June 2008

Heparin Recalls

Please help FDA spread the word about recalls of injectable heparin products and heparin flush solutions that may be contaminated with oversulfated chondroitin sulfate (OSCS). Affected heparin products have been found in medical care facilities in one state since the recall announcement. Although product recall instructions were widely distributed, they may not have been fully acted upon at all sites where heparin is used. There have been many reports of deaths associated with allergic or hypotensive symptoms after heparin administration (see FDA link).

May 2008

NPI Cut over

Effective May 23, 2008, the Michigan Department of Community Health will only accept the NPI numbers for the Service Provider and the Prescriber ID. This requirement applies to all Michigan Governors Program (MiRx Prescription Drug Discount Card) claims submitted to First Health. When submitting claims using the NPI, Pharmacy Services providers are reminded to use the Service Provider ID qualifier of '01' in NCPDP field number 202-B2 and the Prescriber ID qualifier of “01” in the NCPDP field number 466-EZ. Claims that are not submitted with the service provider NPI will deny for NCPCP 05- M/I Pharmacy Number. And claims that are not submitted with the prescriber NPI will deny for NCPDP 25- M/I Prescriber ID.

FIELD	NAME OF FIELD	VALUE
2Ø1-B1	Service Provider ID	10 Digit NPI number (Pharmacy)
2Ø2-B2	Service Provider ID Qualifier	Ø1 = National Provider ID (NPI)
411-DB	Prescriber ID	10 Digit NPI number (Prescriber)
466-EZ	Prescriber ID Qualifier	Ø1 = National Provider ID (NPI)

April 2008

Unit of Measure Requirement

Effective 05/01/2008, MDCH will require the submission of the Unit of Measure (NCPDP Field 6ØØ-28). Claims without the Unit of Measure will reject with NCPDP 26 - Missing/Invalid Unit of Measure. In addition, the submitted Unit of Measure must match the national drug code's Drug Form reported by First Databank otherwise the claim will reject with NCPDP PZ - Non-matched Unit of Measure. Click here for the MSA 08-05 Policy Bulletin regarding this new requirement.

To view changes to drug coverage from March 2008 P&T Meeting click here.

March 2008

Tamper Resistant Prescription Pads

Effective 04/01/2008, Michigan Medicaid is mandated to require tamper resistant prescription pads in accordance with the federal law, U.S. Troop Readiness, Veteran's Care, Katrina Recovery and Iraq Accountability Appropriations Act of 2007 (Public Law 110-28). Michigan Medicaid policy bulletin MSA 08-03 provides the Center for Medicare & Medicaid Services' (CMS) guidelines related to the use of the tamper resistant prescription pads for the Medicaid Program. An FAQs guide is available at http://www.michiganpharmacists.org/index2.htm.

CHAMPS Provider Notices

Pharmacies that are also enrolled as a type 87 medical supplier with the Department should review the recent MDCH Policy Bulletin MSA 08-13 for upcoming CHAMPS changes. (Bulletin is posted on the Provider tab under "Bulletins".) Enrolled medical suppliers will soon receive a letter asking them to access the CHAMPS system and revalidate their enrollment information. This applies only to medical suppliers - not pharmacy providers. If you are a medical supplier and have questions about the letter you received, you can contact the CHAMPS hotline at 1-888-643-2408 or email CHAMPS@michigan.gov.

Prescription Origin Code

This is a reminder that beginning 04/01/2008, the Michigan Department of Community Health will require pharmacies to report the type of prescription presented at the pharmacy. Claims will deny if one of the following NCPDP values for the Prescription Origin Code are not submitted: 1 = Written, 2= Telephone, 3= Electronic, 4= Facsimile. Please refer to the Department's policy bulletin MSA-08-05 for more details. Refill claims submitted 4/1/2008 or later with original Prescription Date Written prior to 4/1/2008 will not reject if the Prescription Origin Code is not populated.

Elimination of Dispense Fees for Medical Supplies

Effective March 1, 2008, the Michigan Department of Community Health will no longer reimburse a dispensing fee for a medical supply covered under the pharmacy benefit. Please refer to the policy bulletin MSA-08-04 for more details. Click here for the bulletin. For your convenience, click here to retrieve a list of products that no longer have a dispensing fee. Please note that condoms dispensed under the pharmacy benefit will continue to be reimbursed without a dispensing fee.

Brand vs. Generic Drug Co-pay Changes

Effective April 1, 2008, due to a First DataBank coding change (elimination of Generic Price Indicator), the Michigan Department of Community Health (MDCH) will employ new variables to determine if drug products will incur the generic or brand co-pay. Some drug products that were previously assigned a $3 brand co-pay will now be assigned a $1 generic co-pay and vice versa. Notification of this change was sent to beneficiaries, who may inquire about their co-pay amount(s) at your pharmacy. To assist pharmacies in responding to inquiries on co-pay changes, click on the following lists to see the drug product(s) with an increase (click here) or decrease (click here) in co-pay amount. These lists should be used for your general reference. The point of sale system will return the beneficiary's co-pay amount that is in effect at the time of claim submission. MDCH Program(s) drug coverage limitations still apply (e.g., prior authorization, quantity limits, etc.).

January 2008

Prescriber NPI Requirement (now delayed until 01/15/2008)

The Michigan Department of Community Health (MDCH) is now postponing the Prescriber NPI requirement (previously planned to occur on 10/01/2007). Now, effective 01/15/2008, MDCH will accept only the Prescriber's NPI number in the Prescriber ID field. The Prescriber’s DEA # will no longer be accepted. This requirement applies to all pharmacy claims submitted at point-of-sale to First Health. When submitting claims using the Prescriber NPI, pharmacy service providers are reminded to submit a Prescriber ID qualifier of '01' in NCPDP field number 466-EZ. Claims will deny if Prescriber's NPI number is not submitted in the Prescriber ID field. Click here to search the national NPI Registry for Prescriber NPIs.
Please refer to the following MDCH policy bulletins for more information on MDCH NPI requirements:
1) MSA 07-17 Reporting the NPI with Prescription Orders and Prescription Drug Claims,
2) MSA 07-22 contains the Pharmacy NPI Contingency Plan and
3) MSA 07-48 end of MDCH NPI Contingency Plans and,
4) MSA 07-56 Announcing Prescriber NPI requirement delayed until 01/15/2008.

November 2007

Announcement concerning 10-digit ID numbers

Pharmacy providers should continue to report a 10-digit Cardholder ID (CØ2-C2) on NCPDP claims submitted to First Health. Apparently some confusion resulted after pharmacy providers received provider bulletin MSA 07-59 from the Michigan Department of Community Health's (MDCH) regarding the new 10-digit beneficiary IDs. To clarify further, if the beneficiary's ID is only 8 digits, two leading zeros should continue to be added so that the Cardholder ID submitted is 10-digits as usual. However, for newer IDs that are actually 10 digits, no leading zeros are needed. Additional questions pertaining to this provider bulletin should be directed to MDCH Provider Inquiry via email at ProviderSupport@michigan.gov or phone toll-free 1-800-292-2550.

October 2007

Michigan Pharmacy Quality Improvement Project (PQIP)

The Michigan Department of Community Health (MDCH) is engaged in a collaborative project, entitled the Michigan Pharmacy Quality Improvement Project (PQIP) to provide information about the psychiatric medication utilization of Michigan medicaid patients. Educational alerts are sent to providers when patients are prescribed medications in ways that may vary from generally accepted evidence-based or consensus-based guidelines. This information can be linked to by selecting Committees > PQIP.

Provider associations were recently notified regarding changes to PQIP (see Association Notice). The document entitled "Child Behavioral Pharmacy Management Program Changes" (see Michigan PQIP Dosing Table), reflects highest customary doses for children and adolescents when prescribing behavioral health drugs. The PQIP workgroup composed of Prepaid Inpatient Health Plan and Michigan Medicaid Health Plan medical directors has reviewed these suggested changes and approved them for use in Michigan. This is informational only. Be aware any prescribing and treatment decisions must be based on the prescriber's clinical judgement and the patient's particular needs.

August 2007

Injectable Drugs (Update)

Due to a coding oversight, pharmacy requests for prior authorization (PA) exceptions will be granted to both home infusion and long term care pharmacies to cover injectable drugs that have been denying as a result of new point-of-sale edits effective 07/19/2007. The coding will be updated soon. Thank you for your patience.

July 2007

Injectable Drugs

Effective 07/19/2007, an enhancement of the point-of-sale edits will prevent payment for physician administered injectable drugs that were being covered incorrectly as a pharmacy benefit. This change is in accordance with Section 1.4 in the Pharmacy Chapter and Section 4.13 in the Practitioner Chapter of the Michigan Medicaid Provider Manual. To link to this policy for additional information, click on Providers >> Manuals. When following the rules of a primary insurance, there may be instances that an exception to cover as a pharmacy benefit would be appropriate. These exception requests and questions related to coordination of benefit claim submission should be directed to the First Health Technical Call Center at 877-864-9014.

MOMS Drug Coverage

Effective 07/19/2007, point-of-sale edits will reflect MOMS program drug coverage. To review the list of covered products, click here or go to Providers>>Drug Information>>MOMS Drug Coverage.

New 07/01/2007- Pharmacy Level TPL Override

Pharmacies can now submit a pharmacy level override using Prior Authorization Type Code (461-EU) = '1' to override the NCPDP 70 - NDC Not Covered w/ additional transaction message "TPL amount collected must be greater than $2.00" instead of calling or faxing the First Health call center.

June 2007

Emergency Services Only Coverage (Update)

Effective 06/27/2007, refill claims submitted with dates of service 05/01/2007 or after will deny at point of sale for beneficiaries with Emergency Services Only Medicaid. For pharmacy coverage information for this beneficiary population, review the "Emergency Services Only" chapter of the Michigan Medicaid Provider Manual by clicking on Providers>>Manuals.

Announcing a new on-line tool for Pharmacy Prior Authorizations: WEB PA

The Michigan Department of Community Health, in conjunction with First Health Services Corporation, is pleased to offer an alternative means to submit pharmacy prior authorization (PA) requests for prescription drugs. This web-based process is designed to save prescribers time by providing a real-time pharmacy prior authorization. This process will supplement the more traditional means of requesting PAs by phone or fax, which will still be available to providers. The product will be available on Monday, June 4, 2007. In order to use WebPA, provider designees will need to register to receive a log on and password for the WebPA system. Detailed information on user registration, including a web based tutorial, can be accessed by clicking here. For more information about WebPA, including a tutorial and a complete instruction manual click here. For questions or assistance with registration, call the First Health Services Web Support Call Center at 1-800-241-8726.

Looking for WebPA? Check under the Pharmacy tab above, or click here.