Coverage of Pharmacy Claims for Certain Outpatient Physician-Administered Injectable Drugs
Effective for dates of service on and after July 1, 2015, eligible National Drug Codes (NDC)
for the following physician-administered injectable drugs administered on an outpatient basis may
be billed as a pharmacy benefit for program beneficiaries in Medicaid, the Healthy Michigan Plan,
and Maternity Outpatient Medical Services:
|Adrenalin Epinephrine Inject
||54505010101, 54505010102, 54505010201, 54505010202, 76329331601, 76329906100,
00409490118, 00409492134, 00409724101, 00409724125, 00409724161, 62250010301,
62250010310, 49502050002, 49502050102, 00024583102, 00024583302
|Inj Aripiprazole Ext Rel 1MG
||59148001870, 59148001871, 59148001970, 59148001971,
|Inj Benztropine Mesylate
||00143972901, 00143972905, 17478001202, 17478001202,
63323097002, 68382086002, 68382086010
||23155029431, 23155029442, 23155049731, 23155049742,
|Diphenhydramine HCL Injection
||00409229031, 00641037621, 00641037625, 63323066401,
||67457042600, 67457042612, 00703704104, 00730704101,
10147091101, 00703704501, 25021080601, 25021082310, 63323047401, 63323047410
|Haloperidol Decanoate Inj
||00703701103, 00703701301, 00703702103, 00703702301,
10147092103, 63323046901, 63323046905, 63323047101, 63323047105, 67457038100,
67457038158, 67457038200, 67457038258, 67457038200, 67457038258, 67457040900,
67457040913, 67457041000, 67457041013, 10147092205
||00409153931, 00409198505, 00409198530, 00409677802,
00409677902, 00409678002, 00409678102, 00641604401, 00641604425, 00641604501,
00641604525, 00641604601, 00641604610, 00641604701, 00641604710, 00641604801,
00641604825, 00641604901, 00641604925, 00641605001, 00641605010, 00641605101,
|Naltrexone, Depot Form
|Olanzapine Long-Acting Inj
||00002763511, 00002763611, 00002763711, 00002765801,
|Paliperidone Palmitate Inj
||50458056001, 50458056101, 50458056201, 50458056301,
50458056401, 50458060601, 50458060701, 50458060801, 50458060901
|Phenobarbital Sodium Inj
||00641047621, 00641047625, 00641047721, 00641047725,
|Fluphenazine decanoate 25 MG
|Risperidone, long acting
||50458030611, 50458030711, 50458030811, 50458030911
|Chlorpromazine HCL Injection
||00641139791, 00641139735, 00641139831, 00641139835
||00409127305, 00409127332, 00409321312, 11704060001,
21695088910, 35356037102, 35356037110, 54569604400
|Inj Olanzapine 2.5 mg
As a reminder, pharmacy providers may not dispense a physician-administered injectable
drug directly to the beneficiary – to ensure the content and integrity of the drug
administered to the beneficiary the drug must be delivered from the pharmacy directly to the
physician for administration. The method of delivery of the injectable drug to the physician
should be agreed upon by the pharmacy and physician. The refrigeration, stabilization, and
other storage and handling requirements of the drug must be met during delivery and at all
points of the transaction. The costs associated with the delivery of the injectable drug to
the physician are not reimbursable by the Michigan Department of Health and Human Services
The injectable drug must be administered to the beneficiary within 14 days of the arrival
of the drug to the physician’s office. For multi-dose vials, the first dose must be administered
to the beneficiary within 14 days of the arrival of the drug to the physician’s office. For the
safety of our program beneficiaries and to minimize waste, procedures should be established to
return unused medications to the pharmacy when appropriate. Restocking returned product should be
compliant with Michigan Board of Pharmacy guidelines.
Pharmacy Vaccine Administration
Effective June 1, 2015, all pharmacy providers who meet program requirements are eligible
to administer certain vaccines to beneficiaries ages 19 and older. In addition to flu vaccines,
the following vaccines are eligible for reimbursement:
Name||Ingredient Cost Allowed||Admin Fee Allowed
|TWINRIX VACCINE VIAL||$96.46||$7.00|
|TWINRIX VACCINE SYRINGE||$96.46||$7.00|
|VAQTA 25 UNITS/0.5 ML SYRINGE||$50.88||$7.00|
|VAQTA 50 UNITS/ML SYRINGE||$50.88||$7.00|
|VAQTA 25 UNITS/0.5 ML VIAL||$50.88||$7.00|
|VAQTA 50 UNITS/ML VIAL||$50.88||$7.00|
|00006412102||GARDASIL 9 SYRINGE||$155.03||$7.00|
|00006411903||GARDASIL 9 VIAL||$155.03||$7.00|
|HAVRIX 720 UNITS/0.5 ML VIAL||$50.88||$7.00|
|HAVRIX 720 UNIT/0.5 ML SYRINGE||$50.88||$7.00|
|HAVRIX 1,440 UNITS/ML VIAL||$50.88||$7.00|
|HAVRIX 1,440 UNITS/ML SYRINGE||$50.88||$7.00|
|RECOMBIVAX HB 5 MCG/0.5 ML VL||$59.71||$7.00|
|RECOMBIVAX HB 5 MCG/0.5 ML SYR||$59.71||$7.00|
|RECOMBIVAX HB 10 MCG/ML SYR||$59.71||$7.00|
|RECOMBIVAX HB 10 MCG/ML VIAL||$59.71||$7.00|
|RECOMBIVAX HB 40 MCG/ML VIAL||$119.42||$7.00|
|CERVARIX VACCINE SYRINGE||$135.68||$7.00|
|ENGERIX-B 20 MCG/ML SYRN||$59.71||$7.00|
|ENGERIX-B 20 MCG/ML VIAL||$59.71||$7.00|
|VARIVAX VACCINE WITH DILUENT||$88.10||$7.00|
|PNEUMOVAX 23 VIAL||$77.85||$7.00|
|PNEUMOVAX 23 SYRINGE||$77.85||$7.00|
|PREVNAR 13 SYRINGE||$153.96||$7.00|
|TETANUS TOXOID ADSORBED VIAL||$21.59||$7.00|
|TRUMENBA 120 MCG/0.5 ML VACCIN||$121.90||$7.00|
|46028020801||MENVEO A-C-Y-W-135-DIP VIAL||$82.66||$7.00|
|BEXSERO PREFILLED SYRINGE||$169.60||$7.00|
|ADACEL TDAP VIAL||$36.27||$7.00|
|ADACEL TDAP SYRINGE||$36.27||$7.00|
|BOOSTRIX TDAP VACCINE SYRINGE||$36.27||$7.00|
|BOOSTRIX TDAP VACCINE VIAL||$36.27||$7.00|
|TETANUS DIPHTHERIA TOXOIDS||$21.59||$7.00|
|M-M-R II VACCINE VIAL||$53.17||$7.00|
Consult the D.0 Pharmacy Claims Processing Manual for additional details on coverage and claim submission.
In addition, certain pharmacy providers have been selected by the Michigan Department of Health and
Human Services (MDHHS) to administer vaccines to beneficiaries ages 11 and older. Because these
providers can obtain vaccines at no cost through the Vaccines for Children (VFC) program, only the
administration fee is reimbursable for vaccines administered to adolescents. Pharmacy providers that
have not been selected by MDHHS to participate in the VFC program are not eligible to administer
vaccines to beneficiaries under age 19. For information on enrolling in the VFC program providers
should contact their local health department:
For beneficiaries enrolled in a health plan the pharmacy provider must confirm coverage of
pharmacist-administered vaccines with the health plan.
Pharmacy Seasonal Flu Vaccine Administration 2013-2014
MDCH policy of covering the administration and ingredient cost of seasonal flu vaccines as a Fee-for-Service
pharmacy benefit is still effective. The national drug codes for the 2013-2014 flu season will be coded to pay
at point-of-sale no later than September 30, 2013 and reimbursement amounts will align with the Department fee
screens when administered as a practitioner benefit – see table below for additional details. NOTE: Section
7.13.2 Seasonal Flu Vaccine within the D.0 Pharmacy Claims Processing Manual contains additional claim submission
and coverage details (e.g. covered only for beneficiaries 19 and older, etc.). Below is a list of the products for
the 2013-2014 Flu Season:
Name||Ingredient Cost Allowed||Admin Fee Allowed
|33332001301||AFLURIA 2013-2014 SYRINGE||$ 12.40||$ 7.00|
|33332001302||AFLURIA 2013-2014 SYRINGE||$ 12.40||$ 7.00|
|33332011310||AFLURIA 2013-2014 VIAL||$ 11.37||$ 7.00|
|58160088041||FLUARIX 2013-2014 SYRINGE||$ 12.40||$ 7.00|
|58160088052||FLUARIX 2013-2014 SYRINGE||$ 12.40||$ 7.00||
|58160090041||FLUARIX QUAD 2013-2014 SYRINGE||$ 12.40||$ 7.00||
|58160090052||FLUARIX QUAD 2013-2014 SYRINGE||$ 12.40||$ 7.00||
|19515089002||FLULAVAL 2013-2014 VIAL||$ 11.37||$ 7.00||
|19515089007||FLULAVAL 2013-2014 VIAL||$ 11.37||$ 7.00||
|66019030010||FLUMIST NASAL 2013-14 VACCINE||$ 23.46||$ 3.00||
|66521011602||FLUVIRIN 2013-2014 SYRINGE||$ 12.40||$ 7.00||
|66521011612||FLUVIRIN 2013-2014 SYRINGE||$ 12.40||$ 7.00||
|66521011610||FLUVIRIN 2013-2014 VIAL||$ 11.37||$ 7.00||
|49281001350||FLUZONE 2013-2014 SYRINGE||$ 12.40||$ 7.00||
|49281001388||FLUZONE 2013-2014 SYRINGE||$ 12.40||$ 7.00||
|49281039215||FLUZONE 2013-2014 VIAL||$ 11.37||$ 7.00||
|49281039278||FLUZONE 2013-2014 VIAL||$ 11.37||$ 7.00||
|49281001310||FLUZONE 2013-2014 VIAL (PF)||$ 12.40||$ 7.00||
|49281001358||FLUZONE 2013-2014 VIAL (PF)||$ 12.40||$ 7.00||
|49281039365||FLUZONE HIGH-DOSE 2013-14 SYR||$ 30.92||$ 7.00||
|49281039388||FLUZONE HIGH-DOSE 2013-14 SYR||$ 30.92||$ 7.00||
|49281070748||FLUZONE INTRADER 2013-2014 SYR||$ 18.98||$ 7.00||
|49281070755||FLUZONE INTRADER 2013-2014 SYR||$ 18.98||$ 7.00||
|49281011300||FLUZONE PEDI 2013-2014 SYRINGE||$ 12.40||$ 7.00||
|49281011325||FLUZONE PEDI 2013-2014 SYRINGE||$ 12.40||$ 7.00||
Notification of PDL Changes – effective September 17, 2013
A change scheduled for September 17, 2013 may affect one or more of your patients. Based on
recommendations by the Michigan Department of Community Health’s Pharmacy & Therapeutics
Committee (P&T), Michigan Medicaid will no longer have Ventolin® HFA (albuterol)
inhaler or budesonide nebulizer solution (generic for Pulmicort Respules) as preferred agents
on its Preferred Drug List (PDL). This change will be effective September 17, 2013.
Notification letters have been sent to prescribers and beneficiaries that may be affected by the change.
Condoms - Prescription NOT required
This is a reminder that, in accordance with Medicaid Provider Manual (Pharmacy Chapter - Section
14.4.A. Condoms), the Michigan Department of Community Health does NOT require a prescription for condoms
to be covered as a pharmacy benefit. A pharmacy may provide condoms at the beneficiary’s request. Both males
and females are eligible to receive condoms. When billing condom claims a pharmacy can report its NPI (Type 2)
in the Prescriber ID field and must either leave blank or report the value of zero (Not known) in the Prescription
Origin Code field (NCPDP field 419-DJ). There are quantity and payment limitations (e.g. 12 condoms per fill, max
36 condoms per 30 days). Please contact the Technical Call Center at 1-877-624-5204 or
MDCHPharmacyServices@michigan.gov mailbox with questions.
Electronic Funds Transfer and Electronic RA Agreement (EFT/835 Remittance Advice)
Effective immediately, any new pharmacy enrollments or updates to existing pharmacy enrollments must occur
in the Michigan Department of Community Health’s CHAMPS system. However, Magellan Medicaid Administration will
continue to manage the EFT and 835 Remittance Advice set-up. Magellan
Medicaid Administration Provider Relations
Department will contact the pharmacy provider (once MDCH has completed the enrollment process)to set up the
funding process. This step must be completed prior to claim submission. Questions pertaining to EFT and/or
835 Remittance Advice should be directed to the Magellan Medicaid Provider Support Line at 1-888-868-9219.
CHAMPS Pharmacy Provider Enrollment Transition
Effective immediately, any new pharmacy enrollments or updates to existing pharmacy enrollments must
occur in the Michigan Department of Community Health’s CHAMPS system. Please review the
CHAMPS Pharmacy Provider Enrollment Notice for additional details and resources. Questions pertaining
to pharmacy enrollment should be directed to the Department’s Provider Support Line at 1-800-292-2550, option 3.
MI Medicaid MAC Research Request
Reminder: MI Medicaid Pharmacy providers can request for a MAC price review. Pharmacy
providers may submit a MAC Price Research Request form located online with a copy of the invoice listing the
current acquisition cost for the product (s) in question to Magellan Medicaid Administration via fax (888-656-1951)
or email (StateMACProgram@MagellanHealth.com). For
additional information, please refer to the MAC
Frequently Asked Questions document.
Medicare Part D E1 Enhancement…
At the request of industry, CMS has authorized Relay Health to implement an enhancement to the Medicare Part
D E1 Transaction to facilitate Best Available Evidence when there is a discrepancy in the information received
from the beneficiary and/or Part D plan. On May 23, 2013, Relay Health will begin returning additional information
on the E1 Transaction by including the LIS/LICS level, (low income subsidy co-pay category), LIS/LICS effective
and termination dates (if applicable), and the Medicare Plan Type, when a beneficiary match is successful.
Additional technical information can be found in the attached memo.
Please validate that your pharmacy system can support the return of this information. If you have any questions
concerning this communication, please send all inquiries to TBTSupport@relayhealth.com.
ACA Endorsement Attestation – Checks/Warrants
If you receive paper checks instead of EFT payments, in accordance with ACA requirements outlined in
42 CFR § 455.19 Provider’s statement on check, the following statement will be printed on the back of your
Magellan Medicaid Administration check above the claimant’s endorsement area: "I understand in endorsing
or depositing this check that payment will be from Federal and State funds and that any falsification, or
concealment of a material fact, may be prosecuted under Federal and State laws."
ePrescribing Friendly Reminder (effective September 26, 2008)
Michigan Medicaid’s eligibility, utilization and formulary information has been available for ePrescribing
purposes since September 2008. Please see the original provider notice with additional information
and visit our ePrescribing page for additional information (http://michigan.fhsc.com/Providers/ePrescribing.asp).
Hemophilia Utilization Program management
As of 04/01/2013, Magellan Medicaid Administration will manage the Hemophilia Utilization Program on behalf of the
Michigan Department of Community Health. All requests should be directed to the MMA contact information below. Please
click here to access the updated Hemophilia Case review Form.
- Clinical phone number: 1-877-864-9014
- Faxes should be faxed to: 1-888-603-7696
FDA Recommends Lower Doses of Zolpidem for Women
New data show that blood levels of zolpidem in some patients may be high enough the morning after use to impair
activities that require alertness, including driving. Because use of lower doses of zolpidem will result in lower
blood levels in the morning, the Food and Drug Administration (FDA) is requiring the manufacturers of Ambien®,
Ambien® CR, Edluar®, and Zolpimist® to lower the recommended dose for women, from 10 mg to 5 mg for
immediate-release products and from 12.5 mg to 6.25 mg for extended-release products. For men, health care
professionals should consider lower zolpidem doses, but it is not required.
On February 2, 2013, First Data Bank (FDB) implemented a new gender edit for pharmacy point-of-sale (POS) claims
that limits these higher doses of zolpidem to only male beneficiaries. Currently, an override must be obtained from
the Magellan Medicaid Administration, Inc (MMA) call center for higher dose (i.e. 10 mg or 12.5 mg) claims for
zolpidem for females. A system modification is being made to allow provider-level overrides for these edits. This
modification will be implemented on Friday, February 8, 2013. The FDA press announcement that contains more
information on their recommendation is available at
Pharmacy EFT/Check Release Dates
Payments will be distributed one business day early (on Friday 12/21/2012) due to the Christmas holiday.
Medicare Part D Coverage of Benzodiazepines and Barbiturates 01/01/2013
As of January 1, 2013, Medicare Part D plans will cover benzodiazepines and barbiturates (used in the treatment of epilepsy, cancer, or a chronic mental health disorder).
For Medicare eligible beneficiaries, Michigan Department of Community Health (MDCH) coverage of barbiturates will be limited to only those claims for treatment of conditions
not covered by the Medicare Part D plan.
After receiving a rejection from the Medicare Part D plan, the following BARBITURATES will pay at POS when the COB claim reports:
- NCPDP Field # 3Ø8-C8 - Other Coverage Code value ‘3’ [3 = Other Coverage Exists, This Claim Not Covered]
- NCPDP Field # 34Ø-7C - Other Payer ID value ‘66666666’ [66666666 = Medicare – Enrolled in Medicare Part D]
- NCPDP Field # 472-6E - Other Payer Reject Code values of:
- MR - Product Not on Formulary; or
- A5 - Not Covered Under Part D Law
- SEDATIVE BARBITURATE
All other claims will deny NCPDP 41 – Submit bill to other processor or primary payer with supplemental message “Bill plan XYZ” or “No COB allowed, Bill Medicare Part D”.
The Medicaid program is no longer covering benzodiazepines for dual eligible recipients.
The following BENZODIAZEPINES will deny for NCPDP 41 – Submit bill to other processor or primary payer at POS and return the PART D plan information to the provider for
claim submission: If the claim is billed with the COB segment, the claim will deny NCPDP 13- M/I Other coverage code.
- CHLORDIAZEPOXIDE HCL
- CLORAZEPATE DIPOTASSIUM
- MIDAZOLAM HCL
- FLURAZEPAM HCL
Michigan Medicaid 835 Remittance Advice
As of 11/22/2012, MMA's internal process to create the unique reference number (ICN), will change to a more efficient process.
The new internal process will not impact the provider's current use of the reference number, the value count or format.
Pharmacy EFT/Check Release Dates
Paper checks will be delayed one business day (i.e. on Tuesday) following Thanksgiving. EFT payments will be released as normally scheduled.
XEROX ACS Pharmacy Audits
Please visit the Xerox ACS provider portal for MDCH pharmacy providers at www.michiganmedicaidrxaudit.com for important
audit information. This provider portal is being enhanced and will soon identify the top
post payment audit discrepancies. The portal also offers pharmacy providers ability to login
securely to review information pertaining to their individual audits. MDCH post payment audits
questions can be directed to:
- Xerox Audit & Compliance Solutions
- 700 Packer Avenue Suite 101
- Philadelphia, PA 19148
- Toll free: 1-800-742-7638
- Direct: 1-215-551-3838
- Fax: 1-888-772-1632
CMS Webinar – Payment Error Rate Measurement (PERM)
CMS will be conducting the next round of Payment Error Rate Measurement (PERM) audits beginning
early November. Pharmacy providers are encouraged to participate in the CMS webinar on October 24,
2012 (see additional details below). If you have any questions regarding the PERM review please
contact MDCHPharmacyServices@michigan.gov or (517) 241-8055. Click
here for more information about PERM Audits.
- Wednesday October 24, 2012
- 2:00 – 3:00 PM EST
- Toll free Dial-In #: (877) 251-0301
- Phone Conference ID: 72421618
- To join on-line meeting:
COB Claim Submission
When submitting a COB claim, please populate both the Patient Responsibility Amount Qualifier
( Field 351-NP) and Patient Responsibility Amount fields (352-NQ and 353-NR) for each payer when
the patient has more than one primary insurance and the Other Coverage Code (OCC) = 2.
Claims that do not have all appropriate fields populated will deny for one of the following of the
NCPDP Error Codes:
- NCPDP 536 - OP Pat responsibility Amt Qlfr Value not supported
- NCPDP NP - M/I Other Payer Patient Responsibility Amt Qualifier
- NCPDP NQ- M/I Other Payer Patient Responsibility Amount
- NCPDP NR - M/I Other Payer Patient Responsibility Amount Count
Psychotropic Prescribers CE Opportunity - EnhanceMed
Hurry space is limited!
The Michigan Department of Community Health’s Medicaid program encourages psychotropic
prescribers RSVP right away before they miss this CE opportunity on its new Academic
Detailing Initiative (EnhanceMed) targeting Behavioral Health/Psychotropic Prescribing.
For additional details and RSVP contact information, please review the Provider Forum Series flyer.
EnhanceMed Provider Forum Series:
- Monday, September 17, 2012: McCormick & Schmick’s Seafood Restaurant, Troy (6:00 p.m. – 8:00 p.m.)
- Tuesday, September 18, 2012 –Troppo, Lansing (6:00 p.m. – 8:00 p.m.) - to be rescheduled
- Wednesday, September 19, 2012: Mangiamo!, Grand Rapids (6:00 p.m. – 8:00 p.m.) - to be rescheduled
Independent Pharmacy Claim Reprocessing Update
Claims that were reprocessed in August and failed to pay at the higher reimbursement
are currently being reviewed and providers will be contacted for an update.
Health Plan Carve-Out Additions
Effective October 1, 2012, in accordance with MDCH policy bulletin MSA 12-46,
drugs used to treat coagulopathies such as hemophilia and orphan drugs used to treat rare
metabolic conditions are excluded from the Medicaid Health Plan contract. Beginning October
1, 2012, drugs within the Michigan Pharmaceutical Product List (MPPL) drug classes identified
below will be added to the Health Plan carve-out list and billed as a Fee-for-Service benefit
to the Department’s PBM vendor (i.e. Magellan Medicaid Administration Inc.). Review the MPPL for additional
drug product details.
CSHCS/MA beneficiaries enrolling in Medicaid Health Plans
As required by Section 1204 of Public Act 63 of 2011, effective October 1, 2012, Medicaid
beneficiaries who have full Medicaid benefits and are also eligible for CSHCS coverage (hereafter
referred to as CSHCS/MA) will transition from an excluded population to a mandatory population for
purposes of Medicaid Health Plan (MHP) enrollment. The MHP enrollment process begins October 1,
2012. For additional details please review the MSA 12-46 policy bulletin.
Pharmacy Seasonal Flu Vaccine Administration 2012-2013
MDCH policy of covering the administration and ingredient cost of seasonal flu vaccines as a
Fee-for-Service pharmacy benefit is still effective. The national drug codes for the 2012-2013
flu season will be coded to pay at point-of-sale no later than August 31, 2012 and reimbursement
amounts will align with the Department fee screens when administered as a practitioner benefit –
see table below for additional details. NOTE: Section 7.13.2 Seasonal Flu Vaccine within the
D.0 Pharmacy Claims Processing Manual contains additional claim submission and coverage details
(e.g. covered only for beneficiaries 19 and older, etc.). Below is a list of the products for
the 2012-2013 Flu Season:
Claim Reprocessing Delay
Independent pharmacy providers who received a notice informing them of an adjudication error,
claim reprocessing has been delayed until the week of August 13 impacting the August 16, 2012 and
August 23, 2012 check write.
Michigan Department of Community Health's D.0 COB Reference Guide
Please click here for D.0 COB Reference Guide.
Michigan Department of Community Health's Carrier ID Listing
Please click here for the list of MI Carrier IDs.
Pharmacy Liaison -2012 Quarterly Pharmacy Liaison Meetings
- March 15 (Conf room F)
- June 14 (Conf room E & F)
- Sept 6 (Conf room E & F)
- Dec 13 (Conf room E & F)
Acceptable Reject Codes updated for NCPDP vD.0
Several NCPDP reject codes new to new vD.0 have now been added to the list of Other Coverage Code (OCC) 3 Acceptable Reject c=Codes allowed for. Click here for a comprehensive list of codes allowed to process when submitted
on COB claims with OCC 3 indicating the primary payer(s) were billed but the claim was not covered.
NCPDP D.0 Reminder
Effective January 1, 2012, the Michigan Department of Community Health (MDCH) will be adopting the HIPAA 5010/NCPDP D.0 standards for all electronic healthcare
transactions. MDCH encourages pharmacies to submit Point-of-Sale (POS) claims in D.0 format no later than 1/1/2012. If you are unable to submit D.0 claims on
1/1/2012, paper claims may be utilized until your software is HIPAA compliant.
CHAMPS System Outage notice
Effective January 1, 2012, the Michigan Department of Community Health (MDCH) will be adopting the
HIPAA 5010/NCPDP D.0 standards for all electronic healthcare transactions. Due to this implementation,
the Community Health Automated Medicaid Processing System (CHAMPS) will be experiencing a complete
system outage beginning at 7:00 P.M. on Thursday, December 29, 2011 and will continue until Tuesday,
January 3, 2012. During this four-day outage, CHAMPS access will not be available for any services it
provides to users. The CHAMPS outage will not impact the availability of the Point-of-Sale (POS)
pharmacy operated by the Department’s Pharmacy Benefit Manager, Magellan Medicaid Administration,
Inc. Please see notification attached.
Pharmacy Liaison - Meeting Cancellation Notice - December 08, 2011
Please note that the quarterly Pharmacy Liaison Meeting scheduled for Thursday, December 8, 2011,
at Capitol Commons Center has been cancelled. Meeting for the next quarter will be held on March 15,
If you have questions, feel free to contact Raji Dnyate at 517-241-9170 or e-mail email@example.com.
Pharmacy EFT/Check Release Dates - Upcoming Holidays
Paper checks will be mailed the Tuesday following Thanksgiving, Christmas and New Years, instead of Monday. EFT
payments will be delayed one business day (i.e. on Tuesday) following Christmas and New Years but will occur as
usual on the Monday following Thanksgiving.
NCPDP vD.0 Transition Date of Service Contingency
Magellan Medicaid Administration is pleased to accept NCPDP vD.0 claims prior to the mandatory submission beginning 1/1/2012.
However, please note that during this dual processing period (10/3/2011-12/31/2011) claims submitted in vD.0 must have a Date of
Service (NCPDP Field# 4Ø1-D1) on or after 10/3/2011. If you are submitting a NCPDP D.0 claim and receiving a rejection, please
check the Date of Service on the submitted claim to ensure the Date of Service is on or after 10/3/2011. If needed, please call
the Magellan Help Desk at 1-877-624-5204 for additional assistance.
The Department is reviewing claims that may have priced based on expired AWP pricing data in lieu of current WAC markup or MAC.
Once the review is finalized, claims impacted have been identified and a provider mailing is scheduled for the week of 11/07/2011
to allow for claim reprocessing for potentially higher reimbursement based on the WAC markup or MAC. Please direct related
questions to the contact number identified on your provider letter.
NCPDP D.0 Update (October 2011)
After additional testing and review, the Michigan Department of Community Health has updated its Appendix A of the Claims Processing Manual for Payer Specifications and Claims Processing Manual to
reflect that Medicaid ID Number (115-N5) and Medicaid Indicator (36Ø-2B) are Optional. Earlier versions indicated these would be required fields. The NCPDP vD.0 Quick Reference was also updated.
Clotting factors MAC pricing is not currently included in web Drug Lookup. The most recent MAC pricing updates are located Clotting Factor MAC Pricing.
Pharmacy Seasonal Flu Vaccine Administration 2011-2012
MDCH policy of covering the administration and ingredient cost of seasonal flu vaccines as a Fee-for-Service pharmacy
benefit is still effective. The national drug codes for the 2011-2012 flu season will soon be coded to pay at point-of-sale
and allowed reimbursement amounts will align with the Department fee screens when administered as a practitioner benefit.
Discontinuing Average Wholesale Price (AWP)
Effective for dates of service on or after December 1, 2010, the Michigan Department of Community Health (MDCH) added
the Wholesale Acquisition Cost (WAC) markup equivalent of the current Average Wholesale Price (AWP) discount to its
'Lower of' pricing logic for pharmacy claims. MDCH implemented this budget-neutral policy change as a result of First Data
Bank's intent to cease publishing Average Wholesale Price (AWP) data by September 2011. The WAC plus markup is identified
||AWP Discount or WAC Markup
|Pharmacies with 1-4 stores
||AWP minus 13.5% or WAC plus 3.80%
|Pharmacies with 5 or more stores
||AWP minus 15.1% or WAC plus 1.88%
|Pharmacies who serve beneficiaries with a level of care (LOC) 02
||AWP minus 15.1% or WAC plus 1.88%
Pharmacy EFT/Checks Release Date - Monday 08/22/2011
Checks were released on Tuesday 08/23/2011, instead of the regular scheduled Monday; therefore checks
may be delayed by one business day. EFT's were released as scheduled on Monday 08/22/2011
Refilling a prescription when your pharmacy is no longer in business
If your pharmacy is no longer open or in business and it's time for you to refill one of your
prescription medicines you can: 1) Take your prescription bottle to a new pharmacy or 2) Contact your
doctor and request a new prescription be called or faxed to your new pharmacy. If you take your
prescription bottle to a new pharmacy, the pharmacy will need to verify the original prescription. Please
note that if the doctor who wrote your original prescription is no longer open or in business to verify
the original prescription, you'll need to make an appointment with a new doctor to get a new prescription. Disclaimer: Existing coverage and billing limitations still apply.
Transitioning to NCPDP D.0
In preparation of the transition from the NCPDP 5.1 to NCPDP D.0 format, an updated Pharmacy Claims Processing
Manual including Payer Specifications is available for download. Magellan Medicaid Administration, Inc. is
currently coordinating testing efforts with pharmacy software vendors in anticipation of allowing interested
pharmacy providers to begin submitting the NCPDP D.0 claim format at Point-Of-Sale this fall. Please contact
Dorothea Roane, 804.217.7900 or DMRoane@magellanhealth.com if you
are interested in engaging in the testing efforts. As we've been indicating at the March and June 2011 pharmacy
provider liaison meetings, MDCH is planning for dual processing this fall (i.e. accepting vD.0 as early as October
but not requiring until 01/01/2012). The Department will also be including some basic information regarding this
in an upcoming proposed policy bulletin.
To view July 2011 MPPL & PDL changes click
Web Provider Enrollment Application
Beginning 05/20/2011, a new web-based provider enrollment application became publicly available on the website
to streamline the provider enrollment process. You'll find the Web Provider Enrollment on the website at http://michigan.fhsc.com then clicking on the Providers tab. A helpful user
guide for this new tool can be found within the Providers tab then selecting on the link to Manuals or from the link
to References in the upper right corner of this home page
To view April 2011 MPPL & PDL changes click
CHAMPS Contact Information Change
CHAMPS Provider Helpline and E-Mail Address The CHAMPS Provider Helpline number (1-888-643-2408) and
the CHAMPS e-mail address (CHAMPS@michigan.gov) will be disabled effective March 30, 2011. Providers
should direct all CHAMPS and Medicaid-related questions to the Medicaid Provider Inquiry Helpline at 1-800-292-
2550 or to the Provider Support e-mail address at firstname.lastname@example.org. In addition, the CHAMPS website located at www.michigan.gov/medicaidproviders >> CHAMPS is updated
frequently. Providers should reference this website for CHAMPS information.
System Maintenance Announcement
Magellan Medicaid Administration, Inc. will be performing scheduled system maintenance during the
month of March. The scheduled downtime will begin Saturday, March 26th, at 5 p.m. ET and will remain
down for approximately 6 hours. POS claim processing for the Michigan Department of Community Health
will not be affected, however please note that the Magellan web applications (Web PA, Web RA, Drug
Lookup, UAC) as well as First Decision and First IQ will be unavailable to authorized users during
this maintenance window.
Transitioning to NCPDP D.0
In preparation of the transition from the NCPDP 5.1 to NCPDP D.0 format, an updated Pharmacy Claims
Processing Manual including Payer Specifications will be available for download in the next few months.
Once the new claim submission requirements are finalized, Magellan Medicaid Administration, Inc. (on
the Michigan Department of Community Health's behalf) will begin coordinated testing efforts with
pharmacy software vendors in anticipation of allowing interested pharmacy providers to begin submitting
the NCPDP D.0 claim format at Point-Of-Sale this fall (as early as October 2011). Check back to the
website often for additional details.
Pharmacy EFT/Checks Release Date - Tuesday, 01/18/2011
Several banks will be closed this coming Monday 01/17/2011 in observance of Martin Luther King Jr. Day.
Pharmacy Provider payments will therefore be released on Tuesday 01/18/2011.
New Toll-Free MAC Pricing Fax Number
Effective 01/03/2011: The new MAC pricing fax number is 1-888-656-1951. The Michigan MAC Pricing Request
Form has been updated with this new toll-free number
FDA Drug Safety Communication: FDA recommends against the continued use of propoxyphene
On 11/19/2010, the U.S. Food and Drug Administration (FDA) announced their recommendation against continued prescribing and use
of the pain reliever propoxyphene because new data show that the drug can cause serious toxicity to the heart, even when used at
therapeutic doses. FDA has requested that companies voluntarily withdraw propoxyphene from the United States market. Please visit
the FDA website at http://www.fda.gov/Drugs/DrugSafety/ucm234338.htm for more details.
New Fax Form for Adult ADHD
A new PA request fax form is now available on the website for Adult ADHD therapy for ages over 17 years. This new form
can be found within the Providers tab then by selecting the link to Forms. The purpose of the new form is to identify the
necessary information that must be provided by the prescriber when requesting a prior authorization for Adult ADHD drug
therapy. Please be sure to fully complete the fax form as incomplete forms will be denied.
Reminder: NCPDP 20.9 Scenario
Effective for dates of service on or after October 1, 2010, claims submitted with Other Coverage
Code 2 must now begin reporting the primary insurance co-pay responsibility in the Patient Paid Amount
Submitted field (NCPDP field 433-DX). Please refer to the Department's Policy Bulletin MSA 10-13 for additional details.
When submitting OCC (NCPDP field # 308-C8) with a value equal to “2” in the Claim Segment for a COB
claim when the primary insurer made a payment, report the following information:
- Report the amount of any beneficiary liability (co-payment, co-insurance, and or deductible) in
the Patient Paid Amount Submitted field (NCPDP field 433-DX) in the Pricing Segment.
- Report a zero dollar ($0.00) amount if there is no beneficiary liability under the primary insurer
in the Patient Paid Amount Submitted field (NCPDP field 433-DX) in the Pricing Segment.
- If the Patient Paid Amount Submitted field is not populated, the claim will reject with NCPDP
reject code DX – Missing/Invalid Patient Paid Amount Submitted. An override will not be granted.
- Report the amount paid by primary insurer in the Other Payer Amount Paid field (NCPDP field 431-DV).
Refer to the Pharmacy Claims Processing Manual for Michigan Department of Community Health for additional
information on reporting COB claims. The Manual is available online at http://michigan.fhsc.com.
Reminder: Medicaid Health Plan Carve-out PA Grandfathering to end 09/30/2010
As outlined in the Michigan Department of Community Health's MSA-10-08 Policy Bulletin, products that
were previously part of the 60/40 carve-out but became carved-out 100% at Point-of-Sale effective 04/01/2010.
To facilitate a smooth transition, edits were implemented to 'grandfather' coverage and bypass PA requirements
04/01/2010 to 09/30/2010. Effective 10/01/2010, these products will be subject to current FFS pharmacy policies
and coverage limitations, including prior authorization requirements.
Seasonal Flu Vaccine Administration
Effective 09/01/2010, the Michigan Department of Community Health will allow pharmacists to administer seasonal flu
vaccines. Policy Bulletin MSA 10-30 contains additional details. Please note: claims submitted with the pharmacy's NPI as the Prescriber ID will reject
with NCPDP 25 - M/I Prescriber ID. As outlined in the policy bulletin, Section 9204 of the Michigan Public Health
Code, MCL 333.9204, authorizes health professionals other than physicians to administer an immunizing agent as long
as the agent is being administered under the direction of a physician. Standing orders are required from a
Michigan-licensed physician who is responsible for the clinical practice of the vaccine operations. The physician's
NPI must be reported as the Prescriber ID (411-DB).
MAC Look Up at NDC Level
Beginning 08/10/2010, a hyperlink to the web drug look up formulary tool has been added to the Maximum
Allowed Cost (MAC) tab. The hyperlink will allow providers to access the web-based drug lookup tool to
obtain MAC pricing information at the national drug code (NDC) level. There is a helpful user guide in the
upper right corner of the main page within the web drug look up tool and the user guide can also be found
within the Providers tab then selecting on the link to Manuals.
Web Drug Formulary Lookup
Beginning 07/12/2010, a new web-based drug lookup tool will be publicly available on
the website to assist providers, beneficiaries, pharmaceutical manufacturers and other
end-users in researching various Michigan Department of Community Health drug coverage
parameters. The look-up tool contains information at the national drug code (NDC) level,
including whether the NDC requires Prior Authorization (PA), has a Maximum Allowed Cost
(MAC), etc. You'll find the Web Drug Formulary Lookup on the website at http://michigan.fhsc.com then
clicking on the Providers tab. A helpful user guide for this new tool can be found within
the Providers tab then selecting on the link to Manuals.
MDCH Pharmacy Wholesaler Survey
The Michigan Department of Community Health (MDCH) is encouraging the participation of enrolled
pharmacy providers in a wholesaler survey. The purpose of this survey is to collect information on
the wholesalers you utilize and various purchasing provisions that may apply. The surveys can be
completed anonymously. The Department will review the survey results to further evaluate current
MAC pricing resources and processes. Click here to download the survey and THANK YOU for your participation!
Important Information about Takeda Pharmaceutical Products and Michigan Medicaid
Click here to read the notice
concerning Takeda Pharmaceuticals.
New Web RA Enrollment Process
MDCH is offering providers participating in the Michigan Medicaid programs the capability
to eliminate paper remittance advices by registering to download their RA using Medicare Remit
Easy Print (MREP). Providers currently receiving paper R/A’s could choose to retrieve their
remittance advice from the MI website once they have registered through UAC. Registration will
enable providers to obtain a PIN which they will use to gain access to their RA. There is no
cost to participate in this feature. Click here to proceed to UAC registration.
New Claim Processing Edits
To enforce existing Michigan Department of Community Health policy and payer specifications, two claim
submission edits are being deployed:
- First Name Validation: Effective 05/12/2010, claims will deny with NCPCP Error Code CA - M/I
Patient First Name when the first two characters of the submitted Patient First Name (NCPDP Field#
310-CA) do not match the Department of Community Health's eligibility record.
- Relationship Code Submission: Effective 06/10/2010, claims will deny for NCPDP Error Code
11- M/I Patient Relationship Code when any value other than 1 (Cardholder) is submitted in
Relationship Code (NCPDP Field #306-C6).
Eligibility Verification Tools
The Michigan First Health Call Center has been experiencing an unusual volume of eligibility verification
inquiries which has resulted in longer than expected wait times. The Department of Community Health
encourages providers to use MPHI's free web-based eligibility verification system called the MI Healthplan
Benefits Website and/or their HIPAA X12 270/271 Transaction (Real time & Batch).
For more information:
Providers without Internet Access may use the following options:
- Contact the CHAMPS HelpLine at 888-643-2408
- Out-Of-State Providers - Email: CHAMPS@michigan.gov or Phone: 517-708-4901
To view April 2010 MPPL & PDL changes click
Mail Order Co-pay Reimbursement Claim Form Address Change
Effective April 1, 2010, all mail order co-pay reimbursement claim forms should be mailed to:
Paper Claims Processing Unit
Post Office Box 85042
Richmond, VA 23261-5042
Changes to website on April 1, 2010:
The following items have new homes on this website:
- Pharmacy Liaison meeting items have their own area under the Committees tab
- Dose Optimization, Li Net notice, The Clinical Alert and all items from the Pharmacy
tab are now located under the Providers tab
- A new tab has been added for Beneficiaries
- MAC pricing information is on new tab.
Medicaid Health Plan Carve-Out Changes
Medicaid Health Plan Carve-Out Changes Effective for service dates on or after April 1, 2010,
the Therapeutic Drug Classes commonly known as the Medicaid Health Plan (MHP) 60/40 carve-outs will
no longer be covered as part of the MHP benefit. Medications within these drug classes will be added
to the existing MHP 100% carve-out and billed at point-of-sale (POS) directly to the Michigan Department
of Community Health's (MDCH) contracted Pharmacy Benefit Manager (PBM). Click here to view carve out drug list.
For additional details, please refer to the new Medicaid Health Plan 100% Carve-out list that will
be effective 04/01/2010,
the MSA Bulletin 10-08 for providers,
and the Beneficiary Letter 10-02 that
was mailed to MHP member households that may be impacted by this change. If you have any billing
questions, please contact the FHSC Technical Call Center at (877) 624-5204.
Plan First! Pharmacy Coverage
Plan First! is a family planning waiver program. This program covers low income women who do not
qualify for Medicaid. A woman with insurance that does not cover family planning may qualify for Plan
First!. Plan First! covers services related to family planning including a yearly pap and pelvic exam,
office visits for family planning, and contraceptives. Plan First! beneficiaries may see any Medicaid
enrolled physician or clinic they choose. Although Plan First! is a separate program and does not offer
the same coverage as Medicaid, a miHealth card is issued to Plan First! beneficiaries and they would
present a miHealth card to their pharmacy provider as their prescription insurance card. For additional
details regarding Plan First! covered services, including pharmaceuticals, please refer to the Family
Planning Waiver Codes - Plan First! that can be viewed at: www.michigan.gov/medicaidproviders under Billing
and Reimbursement>>Provider Specific Information>>Family Planning.
Dispensing Fee Change
Effective December 1, 2009, the Michigan Department of Community Health increased the standard pharmacy provider
dispensing fees by $0.25. For additional information, please refer to the MSA 09-58 Provider Bulletin. Click here to view bulletin.
To view October 2009 MPPL & PDL changes click
Reimbursement for Administration of H1N1 Vaccines by Pharmacies
Effective September 30, 2009, in an effort to improve access to the 2009 Influenza A (H1N1)
monovalent vaccine, the Michigan Department of Community Health (MDCH) will begin reimbursing
eligible pharmacies to administer this vaccine to Medicaid, ABW, MOMS, and CSHCS beneficiaries.
View additional details in the MSA Bulletin
09-52. If you have any billing questions, please contact the FHSC Technical Call Center
at (877) 624-5204.
Automated Voice Response System
Emdeon informed the Michigan Department of Community Health that the Automated Voice
Response System (AVRS) at 888-696-3510 will be decommissioned effective Tuesday, September
29th. Providers without internet access needed to utilize one of the web-based eligibility
verification systems can still contact the CHAMPS HelpLine at 888-643-2408.
Provider Eligibility Verification Assistance
Michigan Department of Community Health providers should
contact the CHAMPS Helpline at 888-643-2408 with questions about verifying eligibility through the MI
Healthplan Benefits (MPHI), Emdeon, Netwerkes, web-DENIS or CHAMPS web-based systems. Click here for instructions
on how to update your pharmacy access profile should you experience any difficulties with MI Healthplan
Benefits (MPHI) web-based eligibility verification. Click here to view bulletin on Pharmacy
Beneficiary Eligibility Verification
Beginning 07/29/2009, a claim submitted with a pharmacy's NPI as the Prescriber ID will reject as NCPDP 25 -
Missing/Invalid Prescriber ID.
Note: For condom claims, MDCH will continue to allow the submission of the pharmacy's NPI in the Prescriber ID
field. Condom claims will not reject in this instance.
Effective July 1, 2009, the Michigan Department of Community Health is required to reduce the
pharmacy provider dispensing fees back to the rates in effect prior to the April 1, 2009 increases.
For additional information about this change and other Medicaid reductions resulting from Executive
Order 2009-22, please refer to the MSA-09-28 Provider Bulletin. Click here to view bulletin.
Co-pay Level Changes
The Michigan Department of Community Health (MDCH) received notification of upcoming drug database
updates that will change the co-pay levels of select products for our program beneficiaries. The B 09-02 letter was sent to beneficiaries that may be affected by an increase in certain medicine co-pays.
To view April 2009 MPPL & PDL changes click
Pharmacy Eligibility Verification Alternative
The Michigan Department of Community Health (MDCH) recently issued Policy Bulletin MSA 09-04 announcing the
elimination of the free phone Automated Voice Response System (AVRS) to verify beneficiary eligibility as a result
of Executive Order 2008-21. MDCH providers, including pharmacies, were directed to a free alternative using
web-DENIS. MDCH has now been informed that some pharmacies (i.e. those not also enrolled as DME/Medical Suppliers
with MDCH) may experience difficulty being granted web-DENIS access due to Blue Cross internal policies/procedures.
We sincerely apologize for the inconvenience. In lieu of web-DENIS the MDCH has made arrangements for another free
web-based alternative for pharmacy providers through the Michigan Public Health Institute (MPHI). Please click here for additional details. Your
National Provider ID (NPI) must be submitted on the access form.
Pharmacy Provider Re-Enrollment Process
All pharmacy providers who serve beneficiaries of MDCH must re-enroll by March 01, 2009 in order to
avoid delays in claim processing.
A Pharmacy Re-Enrollment Profile Application (MSA-1626-R) containing the current information on your
Trading Partner Agreement will be mailed to you on 12/01/08. Please review and make any needed changes
to the Pharmacy Re-Enrollment Profile Application (MSA-1626-R) as well as complete any blank fields,
sign and return to FHSC by 02/02/09. A confirmation fax will be sent once the updated Pharmacy Provider
Revalidation Profile Application (MSA-1626-R) has been successfully processed. Please call FHSC Provider
Enrollment Unit at 804-965-7619 or 804-965-7748 with any questions.
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.
||NAME OF FIELD
||Service Provider ID
||10 Digit NPI number (Pharmacy)
||Service Provider ID Qualifier
||Ø1 = National Provider ID (NPI)
||10 Digit NPI number (Prescriber)
||Prescriber ID Qualifier
||Ø1 = National Provider ID (NPI)
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.
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.).
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.
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.
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.
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.
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
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.