DEPARTMENT OF HEALTH CARE POLICY AND FINANCING
Medical Services Board
MEDICAL ASSISTANCE - SECTION 8.800
10 CCR 2505-10 8.800
[Editor’s Notes follow the text of the rules at the end of this CCR Document.]
8.800
PHARMACEUTICALS
Prescribed drugs within certain limitations are a benefit of the Medical Assistance program.
DEFINITIONS
.01 Retail Pharmacy is a pharmacy whose sole pharmacy purpose is to provide drugs and related
services to non hospitalized people and is not subsidized by any governmental entity.
.02 Institutional Pharmacy is a pharmacy for which a majority of the overhead costs are included in the
inpatient rate and whose primary function is to provide drugs and services to hospitalized patients
and others receiving health care provided by the facility within which the pharmacy is located with
which the pharmacy is associated.
.03 Government Pharmacy is a pharmacy whose primary function is to provide drugs and services to a
facility whose operating funds are appropriated directly from a governmental body.
.04 Dispensing Physician is a duly licensed physician who prepares, dispenses and instructs patients to
self administer medication on a regular basis.
.05 Legend Drug is a drug bearing the statement: "Caution Federal Law Prohibits Dispensing without a
Prescription."
.06 Over the Counter Drug (O.T.C.) is a drug that can be purchased without a physician's prescription.
.07 Prescribed Drug is a drug which is ordered by a physician to be used by a patient to treat a disease
or condition.
.08 Usual and Customary Charge is the reimbursement amount the general public is requested by the
provider to pay for a good or service.
.09 Reimbursement Charge is the amount of payment requested for a provided benefit service. It shall
be the lesser of the provider's usual and customary charge or any amount the provider will accept
from any other third party program or from the public in the form of discounts, special rebates,
incentives, or coupons.
.10 Part D Eligible Individual has the same meaning as defined in 10 C.C.R. 2505-10, Section 8.1000.1.
.11 Medicare Part D means the prescription drug benefit provided to Part D eligible individuals pursuant
to the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA).
.12 Medicare Part D Drugs means prescription drugs defined at 42 U.S.C. Sections 1395w-102 and 141
and 42 C.F.R. Section 423, et seq.
8.820 CONDITIONS OF PARTICIPATION
.01 A pharmacy provider must be duly licensed or certified by the appropriate regulatory body in the state
in which it is located.
.02 Any pharmacy or dispensing physician whether in-state or out-of-state who wishes to submit claims
for payment must submit an application for participation to the Division. The Division will review
the application and notify the submitting provider whether or not they are accepted as a provider
and, if accepted, the effective date. An application may be denied, terminated or not renewed for
any of the grounds set forth in 8.051 or 8.130. An accepted application for participation must be
on file with the Division of Medical Assistance before any reimbursement for any item or service
will be made.
.03 An out-of-state pharmacy may participate and receive payment for dispensed drugs only if the
recipient has been injured or suffered a disease or illness while temporarily absent from
Colorado. The State will then reimburse for drugs dispensed on an emergency basis only.
Chronic or maintenance drugs are not a benefit in such cases. Exceptions to this requirement are
for those pharmacies located in towns outside but bordering the State of Colorado mat provide
regular services to Colorado recipients or those pharmacies who provide drags for foster care
children or other recipients that permanently reside in other states and are wards of the State of
Colorado.
8.830 DRUG BENEFITS
A. Only those drugs supplied by companies participating in the federally approved Medicaid drug rebate
program are regular drug benefits.
B. The following drug categories may be excluded from being a drug benefit or may be subject to prior
authorization:
1. Agents when used for anorexia or weight gain
2. Agents when used to promote fertility
3. Agents when used for cosmetic purposes or hair growth
4. Agents when used for symptomatic relief of cough and colds
5. Agents when used to promote smoking cessation
6. Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
7. Non-prescription drugs
8. Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that
associated tests or monitoring services be purchased exclusively from the manufacturer
or its designee
9. Less-than-effective drugs (LTE) identified by the Drug Efficacy Study Implementation (DESI)
program
10. Barbiturates
11. Benzodiazepines
C. Aspirin and insulin are the only OTC Drugs that are regular benefits without restriction. All other OTC
Drugs must be prior authorized before a client may receive them as a drug benefit.
D. Restrictions may be placed on drugs in accordance with 42 U.S.C. Section 1395r-8(d) which is
incorporated herein by reference. U.S.C. refers to the United States Code. The Custodian of
Records, Department of Health Care Policy and Financing may be contacted at 1570 Grant
Street, Denver, Colorado 80203, for a copy of 42 U.S.C. 1396r-8, or the materials may be
examined at any state publications depository library. Without limiting the foregoing, restrictions
may be placed on drugs for which it has been deemed necessary to address instances of fraud or
abuse, potential for, and history of, drug diversion and other illegal utilization, overutilization, other
inappropriate utilization or the availability of more cost-effective comparable alternatives.
E. Drugs not covered by rebate agreements may be reimbursed only if the Department has made a
determination that the availability of the drug is essential, such drug has been given 1-A rating by
FDA, and prior authorized.
F. Medicare Part D Drugs shall not be covered as Medicaid drugs for Part D Eligible Individuals.
G. The excluded drugs listed in Section 8.830.B above shall be covered for Part D Eligible Individuals in
the same manner as they are covered for all other eligible Medicaid clients.
Drugs or drug categories which are subject to prior authorization, maximum reimbursement constraints
such as State Maximum Allowable Cost (M.A.C.) or the Federal Upper Limit (FUL) are identified in
provider bulletins. Advice from the Drug Use Review Board is used to determine which drugs will be
subject to, prior authorization or exclusion, or State M.A.C.
8.831 DRUGS ADMINISTERED OR PROVIDED IN PHYSICIAN OFFICES
Injectable drugs administered in a physician's office are considered part of the physician's services and
shall be billed on the physician claim form. An exception to this are allergen extracts provided by the
physician. They shall be submitted as a service on the physician's claim form.
8.832 COMPOUNDED PRESCRIPTIONS
Compounded prescriptions containing only drugs, which are regular benefits, shall be billed by submitting
a separate claim for each ingredient in the prescription. The provider will be reimbursed for each
ingredient of the prescription according to 8.850.02, and will also be reimbursed for the dispensing fee
according to 8.850.1. A compounding fee, over and about the stated dispensing fee, will not be paid.
8.834 PRIOR AUTHORIZATION REQUIREMENTS
Prior authorization shall be obtained before drugs which are subject to restrictions may be provided as a
benefit except for injectable drugs administered in physicians' offices described in 8.831 or for emergency
drugs. The prior authorization request shall be made to the Fiscal Agent and include the following:
A. Recipient name, state identification number, and birth date;
B. Patient diagnosis, prognosis, and other pertinent information;
C. Other drugs currently prescribed for the patient;
D. Name of the drug(s) requested - (can be single or multiple request);
E. Requesting physician's name and address.
When the request is received, it will be reviewed and a determination made whether or not to add
the drug as a limited benefit for the recipient.
If the prior authorization request is incomplete or additional information is needed, an inquiry to
the physician will be initiated within one working day from the day the request was received. If no
response is received from the physician's office within 24 hours, the prior authorization will be
denied. The physician's office will be notified of the approval or denial of the prior authorization
via telephone, at the time the request is made. The verbal decision will be confirmed in writing.
The provider may dispense at least a 72-hour supply of a covered outpatient prescription drug in
an emergency situation.
Emergency prior authorization may be given retroactively if the drug had to be dispensed
immediately for the patient's well-being. The physician must call in a prior authorization the next
business day and must include a description and justification of the emergency and follow the
same procedure as discussed above.
The Department shall solicit and maintain a list of any interested parties that wish to comment on
proposed changes to prior authorized classes of prescribed drugs. The list of interested parties
shall be notified of any proposal and shall be given a reasonable time, not to exceed 30 days, to
comment or recommend changes before a class is prior authorized.
8.836 CLARIFICATION OF CERTAIN BENEFIT LIMITATIONS
The following are not benefits of the Medicaid Program:
A. Spirituous liquors of any kind;
B. Dietary needs or food supplements unless prior authorized within Department guidelines;
C. Personal care items i.e., mouth wash, deodorants, talcum powder, bath powder, soap (of any kind),
dentifrices, etc.;
D. Medical supplies unless due to their therapeutic or diagnostic characteristics are essential for care in
the home which the physician has ordered for the treatment and diagnosis of the recipient's
illness or injury. Prior authorization may be required to obtain Medicaid reimbursement;
E. I.V. equipment (i.e., venopaks) dispensed without the I.V. solutions to an out patient (Nursing homes
must furnish I.V. equipment for their patients);
F. Drugs classified by the Food and Drug Administration as "investigational" or "experimental";
G. Drugs for which there is no federal financial participation;
H. Medicare Part D Drugs for Part D Eligible Individuals.
8.837 PRESCRIPTION REQUIREMENTS
Reimbursement shall be made for prescribed drugs provided to eligible recipients when the following
conditions are met:
A. The item dispensed is a covered prescription drug by a participating company, a compounded
prescription as described in 8.832, or has been prior authorized;
B. The person prescribing the item is authorized to do so by appropriate Colorado statutes;
C. The prescription is dispensed in accordance with applicable federal and state laws, rules, and
regulations;
D. The prescription is dispensed in accordance with the law, rules, and regulations governing the
Colorado Medical Assistance Program.
.01 Participating pharmacy providers must maintain the original copy of all prescriptions for which
payment from the Medical Assistance Program is requested. The original prescription shall be a
hard copy either written by the prescriber or reduced to writing when received by the pharmacist
by telephone or other electronic means. Information required by the Colorado State Board of
Pharmacy shall be recorded on each prescription but must include, name of patient, name of
drug, quantity ordered, directions, name of prescribing practitioner, date written and date filled,
and initials of pharmacist filling the prescription or responsible for its contents.
.02 In addition, if a substitution for a prescribed brand name drug is made or the prescription is written
generically, the name and manufacturer of the drug dispensed shall be recorded on the face of
the prescription. A copy of a label which is created to accompany the drug will not suffice as the
prescription.
Any refill prescription records shall be maintained in accordance with Colorado State Board of
Pharmacy requirements and contain the same information as required above.
Such files and records shall be maintained in an orderly manner and shall promptly be available
for inspection by authorized personnel of the Colorado State Department of Health Care Policy
and Financing, the U. S. Department of Health and Human Services, and the Colorado Medicaid
Fraud Control Unit.
8.838 DRUG USE REVIEW
8.838.1 PATIENT RECORDS
The pharmacist shall be responsible for assuring that reasonable efforts have been made to obtain,
record, and maintain the following patient information generated at the individual pharmacy and from the
patient or his/her apparent agent for each new prescription:
A. Name, address, telephone number, date of birth or age, and gender;
B. Individual history where significant, including known allergies and drug reactions, and a
comprehensive, chronological list of medications and prescribed relevant devices; and
C. Additional comments relevant to the patient's pharmaceutical care as defined in Section 8.838.2,
Prospective Drug Review, and Section 8.838.3, Patient Counseling of this staff manual.
.11 CONFIDENTIALITY OF PATIENT RECORD INFORMATION
All patient information collected by an individual pharmacy for the purpose of performing drug use review
and patient counseling shall be considered confidential. Pharmacies shall establish safeguards which
prohibit access to this information by unauthorized individuals.
8.838.2 PROSPECTIVE DRUG REVIEW
A. A pharmacist shall review the available patient record information with each prescription drug order
presented for dispensing for purposes of promoting therapeutic appropriateness by considering
the following:
1. over-utilization or under-utilization;
2. therapeutic duplication;
3. drug-disease contraindications;
4. drug-drug interactions;
5. incorrect drug dosage or duration of drug treatment;
6. drug-allergy interactions;
7. clinical abuse/misuse.
B. When in the pharmacist's professional judgement a potential problem is identified in the above review,
the pharmacist shall take appropriate steps to avoid or resolve the problem which may, if
necessary, include consultation with the prescriber.
8.838.3
PATIENT COUNSELING
A.
A pharmacist or pharmacist designee shall offer counseling regarding the drug therapy to each
Medicaid patient with a new prescription. The offer to counsel shall be face-to-face
communication whenever practicable or by telephone.
B.
If the offer to counsel is accepted, and following a review of the patient's record, a pharmacist or
pharmacy intern shall personally discuss matters which enhance or optimize drug therapy with
each patient or caregiver of such patient Such discussion shall be in person, whenever
practicable, or by telephone and shall include those matters listed below that in the exercise of his
or her professional judgment, the pharmacist considers significant as well as other matters the
pharmacist considers significant:
1.
the name and description of the drug;
2.
the dosage form, dose, route of administration, and duration of drug therapy,
3.
intended use of the drug and expected action;
4.
special directions and precautions for preparation, administration, and use by the patient;
5.
common severe side or adverse effects or interactions and therapeutic contraindications that
may be encountered, including their avoidance, and the action required if they occur;
6.
techniques for self-monitoring drug therapy;
7.
proper storage;
8.
prescription refill information;
9.
action to be taken in the event of a missed dose; and
Alternative forms of patient information shall not be used in lieu of the personal discussion requirement for
patient counseling but may be used to supplement this discussion when appropriate. Examples to include
written information leaflets, pictogram labels, video programs, etc.
C.
Patient counseling by a pharmacist or pharmacy intern, as described above shall not be required for
patients of a hospital or institution where other licensed health care professionals administer the
prescribed drugs pursuant to a chart order.
D.
A pharmacist shall not be required to counsel a patient or caregiver when the patient or caregiver
refuses such consultation. The pharmacist shall keep records indicating when counseling was not
or could not be provided.
8.838.4
DRUG USE REVIEW BOARD (DUR BOARD)
The DUR Board shall serve in an advisory capacity to the Department and is responsible for making
recommendations in three areas: application of standards (as described in Section 8.838 of this manual),
retrospective DUR, and ongoing interventions with pharmacists and physicians concerning therapy
problems identified in the course of the DUR program.
.41
The DUR Board shall consist of nine members appointed by the executive director based upon
recommendations of relevant professional associations. Membership on the Board shall consist
of four physicians, four pharmacists who are licensed and actively practicing in the State of
Colorado and one non-voting representative from the pharmaceutical industry.
The membership of the DUR Board shall include health care professionals who have recognized
knowledge and expertise in one or more of the following:
.42
A.
A.
the clinically appropriate prescribing of covered outpatient drugs;
B.
the clinically appropriate dispensing of outpatient drugs;
C.
drug use review, evaluation and intervention;
D.
medical quality assurance.
DRUG USE REVIEW BOARD ACTIVITIES
Application of Predetermined Standards
The DUR Board shall perform the following activities:
B.
1.
Review and make recommendations of predetermined standards submitted to it by the
department or the department's contractor.
2.
Evaluate the use of the predetermined standards, including assessing the operational effect
of the predetermined standards in use and make recommendations to the department or
department's contractor concerning modification or elimination of existing predetermined
standards or the addition of new ones.
3.
Recommend guidelines governing written predetermined standards that pharmacies not
using approved software must use in conducting prospective DUR.
Retrospective DUR
The DUR Board shall perform the following activities:
C.
1.
Review and make recommendations on predetermined standards submitted to it by the
department or department's contractor.
2.
Make recommendations to the department or the department's contractor concerning the
modification or elimination of existing predetermined standards or the addition of new
ones.
Education Intervention Program
1.
The DUR Board must establish an educational program under the direction of the
Department or the Department may contract with accredited health care educational
institutions (e.g. pharmacy or medical schools, retrospective DUR contractor, pharmacy
associations, medical societies, for the purpose of educating practitioners with regard to
common therapy problems to improve prescribing and dispensing practices.
2.
This program may include the following intervention activities:
3.
4.
D.
a.
Information dissemination;
b.
Written, oral or electronic reminders;
c.
Face to face discussions; and
d.
Intensified review or monitoring.
The DUR Board, based upon the Department's reports on the application of standards shall:
a.
Identify general education topics and develop educational materials;
b.
Share information on general education topics with other entities involved in
continuing education of pharmacists and physicians;
c.
Determine circumstances for use of each type of provider specific intervention
method (e.g. written, oral, electronic reminders, face to face discussion, etc.);
and,
d.
Reevaluate no less often then semiannually the appropriateness of existing
intervention methods and make changes when appropriate.
The DUR Board under the direction of the Department may delegate to the retrospective
DUR contractor the responsibility of preparation of continuing education programs and
the conduct of interventions.
Drug Use Review Board Annual Report
The Board is responsible for preparing and submitting a report to the State an annual basis. This
report shall contain the following information:
8.840
1.
A description of the activities of the Board, including the nature and scope of the prospective
and retrospective drug use review programs;
2.
A summary of the interventions used;
3.
An assessment of the impact of these educational interventions on quality of care
4.
An estimate of the cost savings generated as the result of the program.
BILLING PROCEDURES
Charges for prescribed drugs which are a benefit of the Medical Assistance Program shall be submitted
on an appropriate pharmacy claim form. All entries shall be legible. The signature of an owner/employee
pharmacist must appear on each claim form. A rubber stamp or other facsimile signature is not permitted.
Each claim must identify the recipient, prescribing physician, date of service, National Drug Code number
of the drug actually dispensed as it is listed in the formulary, its supplements or a prior authorization
request, prescription number, quantity dispensed and the reimbursement charge as defined in 8.800.09.
The Medicaid program is to be considered the same as a private pay patient who immediately pays for
the prescription.
An exception to the requirement for submitting claims for reimbursement on a pharmacy claim form may
be made when claims are submitted electronically in a State approved format.
8.850
BASIS FOR REIMBURSEMENT
Benefit drugs shall be reimbursed at the lesser of the Medicaid allowable reimbursement charge, or the
provider's reimbursement.
The Medicaid allowable reimbursement charge is the sum of the ingredient cost of the drug dispensed
and the provider's dispensing fee.
8.850.01
DISPENSING FEE
The dispensing fee is a pre-determined amount paid to a provider for dispensing a prescription. It is
established and periodically adjusted within appropriated funds based upon the results of a cost survey
which is designed to measure actual costs of filling prescriptions. The results of the survey shall be
reported to the Medical Services Board at the next regular meeting following delivery of the report to the
Department of Health Care Policy and Financing.
The pharmacy dispensing fee for retail pharmacies shall be $4.00.
Institutional pharmacies shall receive a dispensing fee of $ 1.89.
Governmental pharmacies that have the cost of dispensing covered as part of an all-inclusive Medicaid
payment shall receive no fee.
Dispensing physicians shall not receive a dispensing fee unless their offices or sites of practice are
located more than 25 miles from the nearest participating pharmacy. In the latter case, a fee of $ 1.89 will
be paid.
.02
INGREDIENT COST
Ingredient cost for retail pharmacies (estimated acquisition cost) is the price of the drug actually
dispensed as defined in (c) below or the M.A.C. or the high volume E.A.C., whichever is less.
Benefit drugs dispensed in unit of use (unit dose) packaging will be reimbursed based upon the bulk
package size of 100 or pints or if not available in those sizes, the most common size which most closely
matches the standard sizes defined above.
The ingredient cost for institutional and government pharmacies is defined as the actual cost of
acquisition for the drug dispensed or the M.A.C., or the high volume E.A.C., whichever is less.
A.
Maximum Allowable Cost (M. A. C.)
The state M.A.C. is the maximum ingredient cost allowed by the Department for certain multiplesource drugs. The establishment of a MAC. is subject, but not limited to, the following
considerations:
1.
multiple manufacturers;
2.
broad wholesale price span;
3.
availability of drugs to retailers at the selected cost;
4.
high volume of Medicaid recipient utilization;
5.
bioequivalence or interchangeability.
When Federal M.A.C. limits for multiple source drugs are announced, they will be adopted if they
are less than state M.A.C. or if no state M.A.C. exist.
Section II of the ColoRx shall identify the generic drugs subject to M.A.C.
The ingredient cost of any drug subject to M.A.C. shall be limited to M.A.C. or wholesale price as
determined by the Department, whichever is less. Exceptions which will allow reimbursement
greater than M.AC. for a drug entity are obtained through the prior authorization mechanism. An
exception will be granted if the patient's response to the generic drag is not therapeutic, an
allergic reaction is involved, or any similar situation exists.
If a recipient requests a brand name for a prescription which is subject to M.A.C., then he/she
may pay the ingredient cost difference between the M.A.C. and brand name drug. The recipient
must sign the prescription stating that he/she is willing to pay the difference in ingredient cost to
the pharmacy. The pharmacy will be paid M.A.C. plus a dispensing fee or reimbursement charges
whichever is lower.
B.
High Volume Estimated Acquisition Cost (E.A.C.)
Reimbursement for single source drugs or certain multiple source drugs which are most
frequently prescribed will be based upon average wholesale prices or direct manufacturers' prices
for package sizes containing quantities greater than 100 dosage units or less if not available in
100's. Basis for inclusion in the high volume estimated acquisition cost list includes but is not
limited to:
1.
Single source manufacturers;
2.
High volume Medicaid recipient utilization;
3.
Interchangeability problems with multiple source drugs;
4.
Package sizes in excess of 100;
These drugs will be identified in Section III of the ColoRx.
C.
Drug Pricing
A drug pricing file will be maintained and updated monthly by the Department. The modified
average wholesale price of a drug as determined by the Department, State M.A.C., and Federal
Upper Limit (FUL), will be the basis for setting the prices in the drug pricing file.
Modified average wholesale price shall be defined as the average wholesale price less 13.5%,
effective July 1, 2002 for name-brand drugs. For generic drugs, modified average wholesale price
shall be defined as the average wholesale price less 35%, effective July 1, 2002. The average
wholesale price will be determined by the Department and placed in the drug pricing file as
follows:
1.
By subtracting 13.5% from the average wholesale price for name-brand drugs and 35% from
the average wholesale price for generic drugs, as determined by the Department.
2.
If the average wholesale price cannot be determined by the Department, then the distributors'
or manufacturers' prices will be used to estimate average wholesale price to be modified
and used in the drug pricing file as the price of the drug.
The following pricing methodologies are used, noting that the pricing methodology resulting in the
lowest price will be used:
1.
Average wholesale price (AWP) minus 13.5% for name-brand drugs
2.
Average wholesale price (AWP) minus 35% for generic drugs
3.
Direct price plus 18%
4.
State M.A.C., pharmacy acquisition cost of generic drugs available in the state market place
plus 18%.
5.
Federal Upper Limit (FUL)
Any pharmacy which is the only pharmacy within a twenty mile radius may submit an invoice to
the Department for the difference in price between AWP minus 13.5% and AWP minus 12% for
name-brand drugs and AWP minus 35% and AWP minus 12% for generic drugs. The invoice shall
be submitted to the Department, within 30 days of sale, and shall contain all the information set
forth in Section 8.840 as well as the difference between prices as set forth above and
documentation that the pharmacy is the only pharmacy available within a twenty mile radius. The
pharmacy shall be reimbursed for the difference between pricing methodologies.
Information on current pricing may be obtained by contacting: the Rates Section, Medical
Assistance Office at the Department.
8.870
.01
PRESCRIPTION QUANTITIES
NEW PRESCRIPTIONS
A new prescription is an order for a drug which is being initially prescribed to treat a current illness
or condition. The drug has not been used during the most recent course of therapy. In this case,
the quantity prescribed will be at the discretion of the physician. Merely assigning a new
prescription number or creating a new prescription each time the drug is dispensed to provide
continuous treatment for a condition or illness does not meet the definition of a new prescription,
but will be considered and governed by the rules pertaining to refill prescriptions.
.02
REFILL PRESCRIPTIONS
For chronic conditions requiring maintenance drugs, refill prescriptions shall be for quantities
sufficient for a minimum 30-day supply. Maximum quantity which can be dispensed is one which
will supply drugs sufficient for 100 days.
.03
PAYMENT OF DISPENSING FEE
When prescriptions for the same drug used to treat chronic conditions are dispensed more than
twice, only one dispensing fee a month thereafter will be paid to the pharmacy unless the
prescription is ordered for an allowable package size as described above which is less than a 30day supply. Only ingredient cost will be reimbursed for those prescriptions which are not a
package size and less than a 30-day supply.
.04
PRESCRIPTION QUANTITIES EXCEPTIONS
The 30-day policy does not apply to drugs prescribed for short-term illnesses.
.05
MINIMUM QUANTITIES
The State may set minimum quantities of certain drugs which shall be dispensed based upon the
advice of the Drug Use Review Board.
.06
PRESCRIPTION TRACKING AND CLAM REVERSALS
The pharmacy provider shall keep 1) a chronological log that contains the client's name, his or
her signature or agent's signature and date of the receipt of the prescription, or 2) an electronic
prescription tracking system that records the status of prescriptions through the fill process
including the date and time that the prescription was transferred to a person verified by pharmacy
personnel to be the client or agent of the client.
Pharmacies using a chronological log shall review all Medicaid prescriptions in will-call status
(filled not released to patient or patient's agent) at least weekly. All prescriptions billed to Medicaid
for fourteen (14) days or more shall be reversed on the day of review. In no case shall
prescriptions be kept in will-call status for more than twenty-one (21) days. The pharmacy shall
maintain a record of each reversal for audit purposes.
Pharmacies using an electronic prescription tracking system shall review prescriptions in will-call
status on a daily basis and enter a reversal of prescriptions not picked up within ten (10) days of
billing. In no case shall prescriptions be kept in will-call status for more than fourteen (14) days.
The pharmacy shall maintain a record of each reversal for audit purposes.
Upon receipt of a written request from the Department of Health Care Policy and Financing or the
Medicaid Fraud Unit for a record of Medicaid Claims and reversals, the pharmacy may have up to
72 hours or three working days to provide the requested information or to enter into an agreement
with the Departments) stating the specific time within which the data will be produced.
Editor’s Notes
10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07,
Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior
versions can be accessed from the History link that appears above the text in 10 CCR 2505-10. To view
versions effective on or after 3/4/07, select the desired section of the rule, for example 10 CCR 2505-10
8.100, or 10 CCR 2505-10 8.500.
History
[For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]