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13.1
GENERAL INFORMATION ...................................................................................................... 4
13.1.A
OMNIBUS RECONCILIATION ACT OF 1990 (OBRA 90)................................................. 4
13.1.B
DRUG COVERAGE UNDER THE MISSOURI MEDICAID PHARMACY PROGRAM... 4
13.2
PROVIDER PARTICIPATION.................................................................................................. 5
13.2.A
NON-DISCRIMINATION ..................................................................................................... 5
13.2.B
RETENTION OF RECORDS ................................................................................................. 5
13.2.C
ADEQUATE DOCUMENTATION....................................................................................... 6
13.3
PARTICIPANT ELIGIBILITY .................................................................................................. 6
13.3.A
13.4
RECIPIENT NONLIABILITY............................................................................................... 6
DRUG PRODUCTS EXCLUDED FROM THE MISSOURI MEDICAID PHARMACY
PROGRAM ................................................................................................................................... 7
13.5
OVER-THE-COUNTER (OTC) DRUG COVERAGE............................................................. 7
13.6
NUTRITIONAL SUPPLEMENTS ............................................................................................. 7
13.7
DRUG PRIOR AUTHORIZATION PROCESS........................................................................ 8
13.7.A
SPECIFIC DRUG PRODUCTS AND CATEGORIES REQUIRING PRIOR
AUTHORIZATION................................................................................................................ 9
13.7.B
PRIOR CONTENTS NO LONGER APPLICABLE .............................................................. 9
13.7.C
PRIOR AUTHORIZATION APPROVAL NOTIFICATION ................................................ 9
13.7.D
PRIOR CONTENTS NO LONGER APPLICABLE .............................................................. 9
13.7.E
CLAIM SUBMISSION FOR PRIOR AUTHORIZED DRUGS............................................. 9
13.7.E(1)
Point of Service (POS) Claims Submission.................................................................... 9
13.7.E(2)
Paper Claims Submission ............................................................................................... 9
13.7.F
13.8
72 HOUR EMERGENCY SUPPLY ..................................................................................... 10
FEDERAL UPPER LIMITS AND MISSOURI MAXIMUM ALLOWABLE COST
(MAC) .......................................................................................................................................... 10
13.9
GENERIC REIMBURSEMENT OVERRIDE PROCEDURE.............................................. 10
13.10 SPECIAL LIMITATIONS......................................................................................................... 11
13.10.A QUANTITY LIMITATIONS ............................................................................................... 11
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13.10.B DOSE OPTIMIZATION....................................................................................................... 11
13.10.C ADMINISTRATIVE CLINICAL EDITS............................................................................. 12
13.10.D STEP THERAPY .................................................................................................................. 12
13.10.E PREFERRED DRUG LIST .................................................................................................. 13
13.10.F PRODUCTS COVERED UNDER THE NURSING HOME PER DIEM............................. 13
13.10.F(1) Personal Care ................................................................................................................ 13
13.10.F(2) Equipment ..................................................................................................................... 14
13.10.F(3) Nursing Care/Patient Care Supplies.............................................................................. 15
13.10.F(4) Therapeutic Agents and Supplies.................................................................................. 16
13.10.G LONG-TERM CARE MAINTENANCE DRUG BILLING ................................................ 16
13.11 RECIPIENT COST SHARING (COPAY, COINSURANCE, SHARED DISPENSING
FEE) ............................................................................................................................................. 16
13.11.A PROVIDER RESPONSIBILITY TO COLLECT SHARED PHARMACY
DISPENSING FEE ............................................................................................................... 17
13.11.B RECIPIENT RESPONSIBILITY TO PAY THE SHARED PHARMACY DISPENSING
FEE AMOUNTS................................................................................................................... 17
13.11.B(1) Exceptions to Shared Pharmacy Dispensing Fee.......................................................... 17
13.11.B(2) Pharmacy Dispensing Fees ........................................................................................... 18
13.11.C RECIPIENT RESPONSIBILITY TO PAY COPAY AMOUNTS ....................................... 18
13.11.C(1) Participants Who are Required to Pay a Copay.............................................................. 18
13.11.C(2) Services Requiring Copay............................................................................................. 18
13.12 MANAGED HEALTH CARE PLAN PHARMACEUTICALS............................................. 19
13.12.A PRIOR AUTHORIZATION ................................................................................................. 20
13.12.B FAMILY PLANNING SERVICES ...................................................................................... 20
13.12.C BEHAVIORAL HEALTH SERVICES ................................................................................ 21
13.13 MANAGED CARE PLAN PROTEASE INHIBITOR CARVE-OUT .................................. 21
13.14 DRUG USE REVIEW (DUR) .................................................................................................... 21
13.14.A PROSPECTIVE DUR........................................................................................................... 21
13.14.A(1) Prospective Drug Use Review (DUR) Through the Electronic Claims Management
(ECM) or Point of Service (POS) System ........................................................................ 22
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13.14.A(2) Patient Counseling ........................................................................................................ 22
13.14.A(3) Documentation of Offer to Counsel.............................................................................. 23
13.14.A(4) Patient Profiles .............................................................................................................. 23
13.14.B RETROSPECTIVE DUR...................................................................................................... 23
13.15 EMERGENCY SERVICES ....................................................................................................... 24
13.16 OUT-OF-STATE, NONEMERGENCY SERVICES .............................................................. 24
13.16.A EXCEPTIONS TO OUT-OF-STATE PRIOR AUTHORIZATION (PA) REQUESTS....... 25
13.17 HOSPICE..................................................................................................................................... 26
13.17.A PHARMACY REIMBURSEMENT..................................................................................... 26
13.18 DIABETES SELF-MANAGEMENT TRAINING .................................................................. 26
13.18.A DIABETES SELF-MANAGEMENT TRAINING ENROLLMENT CRITERIA................ 26
13.18.B DIABETES SELF-MANAGEMENT TRAINING SERVICE LIMITATIONS................... 27
13.18.B(1) Procedure Codes for Diabetes Self-Management Training .......................................... 28
13.18.B(2) Diabetes Self-Management Training Billing Procedures ............................................. 28
13.19
DIABETIC SUPPLIES........................................................................................................... 29
13.20
MISSOURI MEDICAID DISEASE STATE MANAGEMENT PROGRAM................... 29
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SECTION 13-BENEFITS AND LIMITATIONS
13.1 GENERAL INFORMATION
13.1.A
OMNIBUS RECONCILIATION ACT OF 1990 (OBRA 90)
The 101st Congress of the United States passed in 1990 the Omnibus Reconciliation Act of
1990 (OBRA 90). OBRA 90 contained language which resulted in significant changes in the
provision of pharmaceutical services under state Medicaid programs. The major provisions in
this language affected the following areas of the Missouri Medicaid Pharmacy Program:
• The list of covered drugs,
• The mechanism for prior authorization of drugs, and
• Drug Utilization Review (DUR).
OBRA 90 indicates that no federal matching funds are available for expenditures for drugs
produced by manufacturers that have not entered into a rebate agreement with the federal
Department of Health and Human Services (HHS). With certain permissible exclusions and
restrictions, virtually all products of manufacturers that have entered into a rebate agreement
with HHS are reimbursable under state Medicaid programs.
13.1.B
DRUG COVERAGE UNDER THE MISSOURI MEDICAID PHARMACY
PROGRAM
All drug products (with the exception of Drug Efficacy Study Implementation (DESI) drugs
and drugs specified in Section 13.4 and Section 13.7), produced by manufacturers that have
entered into a rebate agreement with the Federal Government are reimbursable under the
Missouri Medicaid Pharmacy Program.
A list of manufacturers that have entered into an agreement with the Federal Government
(along with the first five digits of the NDC number by which products may be identified),
can be found in Drug Company Contact Information. Products for which the first five digits
of NDC numbers are not included on the list are not reimbursable under the Missouri
Medicaid Pharmacy Program and are not available through any prior authorization program.
In addition to other information required by the national rebate contract, the federal Centers
for Medicare & Medicaid Services (CMS) has required that participating manufacturers
identify products which are affected by the Drug Efficacy Study Implementation (DESI).
CMS has instructed state Medicaid programs that products so identified are not subject to
federal financial participation and are therefore not reimbursable under the Missouri
Medicaid Pharmacy Program.
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As rebates are to be paid by manufacturers to the state agency on a National Drug Code
(NDC) specific basis, it is essential that providers enter on each claim the precise NDC
identifying the product dispensed. A product without an NDC is not reimbursable.
Should a dispute arise between Medicaid utilization data and a manufacturer’s estimation of
product sold, data is supplied to the manufacturer to resolve the dispute. If necessary, zip
code or provider-specific utilization data is provided. Should data indicate that a provider is
billing fraudulently by using NDCs other than those identifying the actual product dispensed,
the information is referred to the Medicaid Investigation Unit and may result in legal action,
provider sanctions and possible termination from the program.
13.2 PROVIDER PARTICIPATION
To participate in the Missouri Medicaid Pharmacy Program, the pharmacy provider must satisfy the
following requirements:
• Have a signed and accepted Participation Agreement in effect with the Missouri
Department of Social Services, Division of Medical Services.
Additional information on provider conditions of participation can be found in Section 2 of this
provider manual.
13.2.A
NON-DISCRIMINATION
Providers must comply with the 1964 Civil Rights Act, as amended; Section 504 of the
Rehabilitation Act of 1973; the Age Discrimination Act of 1975; the Omnibus Reconciliation
Act of 1981 and the Americans with Disabilities Act of 1990 and all other applicable Federal
and State Laws that prohibit discrimination in the delivery of services on the basis of race,
color, national origin, age, sex, handicap/disability or religious beliefs.
Further, all parties agree to comply with Title VII of the Civil Rights Act of 1964 which
prohibits discrimination in employment on the basis of race, color, national origin, age, sex,
handicap/disability, and religious beliefs.
13.2.B
RETENTION OF RECORDS
Medicaid providers must retain for 5 years, from the date of service, fiscal and medical
records that coincide with and fully document services billed to the Medicaid Agency, and
must furnish or make the records available for inspection or audit by the Department of
Social Services or its representative upon request. Failure to furnish, reveal and retain
adequate documentation for services billed to the Medicaid Program may result in recovery
of the payments for those services not adequately documented and may result in sanctions to
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the provider’s participation in the Medicaid Program. This policy continues to apply in the
event of the provider’s discontinuance as an actively participating Medicaid provider through
change of ownership or any other circumstance.
All prescriptions filled for eligible participants must be filed in accordance with requirements
of the Missouri Board of Pharmacy.
13.2.C
ADEQUATE DOCUMENTATION
All services provided must be adequately documented in the medical record. The Code of
State Regulations, 13 CSR 70-3.030, Section (1)(A) defines “adequate documentation” and
“adequate medical records” as follows:
Adequate documentation means documentation from which services rendered and the
amount of reimbursement received by a provider can be readily discerned and
verified with reasonable certainty.
Adequate medical records are records which are of the type and in a form from which
symptoms, conditions, diagnoses, treatments, prognosis and the identity of the patient
to which these things relate can be readily discerned and verified with reasonable
certainty. All documentation must be made available at the same site at which the
service was rendered.
13.3 PARTICIPANT ELIGIBILITY
A participant must be eligible for Medicaid on each date that a service is provided in order for a
provider to receive Medicaid reimbursement for those services.
Additional information regarding participant eligibility can be found in Section 1 of this provider
manual.
13.3.A
RECIPIENT NONLIABILITY
Medicaid covered services rendered to an eligible participant are not billable to the
participant if Medicaid would have paid had the provider followed the proper policies and
procedures for obtaining payment through the Medicaid Program as set forth in 13 CSR 704.030.
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13.4 DRUG PRODUCTS EXCLUDED FROM THE MISSOURI MEDICAID
PHARMACY PROGRAM
The pharmacy provisions of OBRA 90 list specific drugs and categories of drugs that state Medicaid
programs may exclude from coverage. The specific and up-to-date listing of the drugs and categories
of drugs that are excluded from coverage under the Missouri Medicaid Pharmacy Program may be
accessed by referencing Drugs with Coverage Limitations.
Pharmacies are encouraged to submit a claim and receive a denial prior to calling the Pharmacy Help
Desk.
13.5 OVER-THE-COUNTER (OTC) DRUG COVERAGE
As specified in Section 13.4, some over-the-counter (OTC) products are reimbursable through the
Missouri Medicaid Pharmacy Program upon prescription. While OTC preparations generally do not
require a prescription for sale to the general public, a prescription for this type of product is required
in order for the product to be reimbursable for a Medicaid participant under the Medicaid Program.
The specific and up-to-date information on the OTC products may be accessed at OTC Covered
Products.
Over-the-counter preparations listed in 13 CSR 70-10.010 continue to be included in the nursing
home per diem and should not be billed to the Pharmacy Program. Payment for these products is the
responsibility of the nursing home.
13.6 NUTRITIONAL SUPPLEMENTS
Nutritional supplements such as Ensure and Sustacal and infant formulas such as Enfamil and
Similac are not reimbursable through the Missouri Medicaid Pharmacy Program. This is due to the
federal interpretation that such products are food products rather than drug products and as such are
not affected by national rebate agreements.
Nutritional supplements and infant formulas are included in the nursing home per diem.
For children under 21 years of age, all nutritional supplements, infant formulas, related enteral
supplies and equipment and supplies and pumps related to intravenous therapy are available only
through the Durable Medical Equipment (DME) Program if prior authorized. For persons 21 and
over, the above mentioned items are available through the Missouri Medicaid Exception Process
with restrictions. Refer to Section 20 for further information.
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13.7 DRUG PRIOR AUTHORIZATION PROCESS
As specified in OBRA 90, any Medicaid drug prior authorization process must meet certain criteria.
Such a process must:
• provide a response by telephone or other telecommunication device within 24 hours of a
request for prior authorization.
• except with respect to the drugs on the list of drugs permissible for exclusion, provide for
the dispensing of at least a 72-hour supply of a covered outpatient drug in an emergency
situation.
In accordance with OBRA 90 requirements, patient-specific drug prior authorization requests are
accepted and responded to via telephone (800) 392-8030 or by faxing the Drug Prior Authorization
form to (573) 636-6470, Monday through Friday, 8:00 a.m. to 5:00 p.m., excluding state holidays
and weekends. All requests for drug prior authorization must be initiated by a physician or prescriber
with prescribing authority for the drug category for which prior authorization is being requested. All
requests must include all required information. Requests received that have sufficient information
and are initiated by a physician or other authorized prescriber receive a response either during the
requestor’s call or by return FAX or phone call. Requests received with insufficient information for
review or received from someone other than a physician or other authorized prescriber do not initiate
a prior authorization review or the 24-hour response period.
The following information must be supplied with each patient-specific drug prior authorization (PA)
request:
• Participant DCN
• Participant name
• Drug, strength, dosage form and dosing schedule requested
• Diagnosis for which the requested drug is to be used
• Requested duration of approval
• Prescriber's name, address, phone number, fax number (if available) and original signature
In addition, detailed drug/patient information is required to enable a decision to approve prior
authorization. Drug or category-specific prior authorization criteria have been developed by the
University of Missouri-School of Pharmacy with review and approval by the Drug Prior
Authorization Committee and the Division of Medical Services.
Providers are reminded that no prior authorization process exists for products of manufacturers that
have not signed the national rebate agreement.
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13.7.A
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SPECIFIC DRUG PRODUCTS AND CATEGORIES REQUIRING PRIOR
AUTHORIZATION
Reference the Drug Prior Authorization Policy for specific and up-to-date information on
drug products that require prior authorization (PA) to be reimbursable under the Missouri
Medicaid Pharmacy Program. The provider may review the specific policy requirements to
expedite processing of requests. These policies are dynamic and are revised as necessary to
remain current.
Prior authorization is not granted for uses other than those specified.
13.7.B
PRIOR CONTENTS NO LONGER APPLICABLE
13.7.C
PRIOR AUTHORIZATION APPROVAL NOTIFICATION
Prescribers are notified of approvals or denials of drug prior authorization requests either
during the requestor’s call or by return FAX or phone call. In addition to the approval, the
requesting physician is given an approval end date. The approval end date must be
communicated to the dispensing pharmacy either on the face of the prescription or verbally.
This information should also be recorded in the patient’s chart for future reference.
Pharmacies may record this information for this purpose, as well.
Providers may contact the Pharmacy Help Desk at (800) 392-8030 to obtain approval
information, as necessary.
13.7.D
PRIOR CONTENTS NO LONGER APPLICABLE
13.7.E
CLAIM SUBMISSION FOR PRIOR AUTHORIZED DRUGS
13.7.E(1)
Point of Service (POS) Claims Submission
Claims may be submitted for prior authorized drugs via the point of service system.
13.7.E(2)
Paper Claims Submission
As is true for non-prior authorized products, providers must use the precise national
drug code (NDC) of the product dispensed when submitting claims for
pharmaceutical services. A product without an NDC is not reimbursable.
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72 HOUR EMERGENCY SUPPLY
OBRA 90 required that prior authorization programs must provide for the dispensing of a 72
hour emergency supply. For these purposes, the dispensing of a 72 hour emergency supply is
reimbursable only when dispensed outside of the state office regular working hours, during a
weekend or a state holiday.
Each claim for the dispensing of a 72 hour supply must be submitted on paper to: Pharmacy
Unit, Division of Medical Services, P.O. Box 6500, Jefferson City, MO 65102-6500. In
addition, the following documentation is required to be attached to each claim:
• A copy of the prescription;
• A statement of the circumstances of the emergency.
The intent of this provision is to assure that participants have access to prior authorized drugs
when necessary, not to circumvent the prior authorization process. Claims submitted for the
dispensing of an emergency supply are tracked and reviewed for possible abuse by
participants and providers. If such abuse is detected, appropriate action is taken.
13.8 FEDERAL UPPER LIMITS AND MISSOURI MAXIMUM
ALLOWABLE COST (MAC)
The Missouri Medicaid Pharmacy Program includes nearly all products manufactured or distributed
by companies that have signed the national rebate agreement and a number of these drugs are subject
to a Federal Upper Limit.
Reference the Missouri Maximum Allowable and Federal Upper Cost for Specific Drug Products
list.
13.9 GENERIC REIMBURSEMENT OVERRIDE PROCEDURE
The current procedure prescribers must follow to obtain an override to a generic reimbursement
limitation (such as the limitations listed in the Missouri Maximum Allowable and Federal Upper
Cost for Specific Drug Products listing) in order to allow for reimbursement at a trade name level is
as follows:
The prescriber must submit a written Drug Prior Authorization request form by mail to the Pharmacy
Unit, P.O. Box 4900, Jefferson City, MO 65102-4900 or by FAX at (573) 636-6470 or via the Drug
Prior Authorization Hotline (800) 392-8030. This Drug Prior Authorization must be on behalf of a
specific Missouri Medicaid participant and must document whether or not the patient had a trial of a
generic product. If the generic product was tried, the result must be documented and a Federal Food
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and Drug Administrative (FDA) MedWatch form must be completed and submitted for review.
These forms are available on the Internet at the FDA website. If the generic product was not tried,
the medical reason that such a trial is inappropriate in the specific patient’s case must be
documented.
13.10 SPECIAL LIMITATIONS
13.10.A QUANTITY LIMITATIONS
There is a 31-day maximum supply restriction on claims submitted for prescriptions
dispensed to Missouri Medicaid participants. The following categories are exempt from this
restriction:
MAXIMUM LIMITATION
(IF APPLICABLE)
DRUG OR CATEGORY
Antiretroviral agents
Contraceptives, oral
Drug
products
limited
packaging requirements
One year
by Packaging requirements
Vitamins, Children's
100 days supply
Vitamins, Prenatal
100 days supply
Pharmacy claims submitted for a days supply greater than allowed under this policy are
denied. Quantity restrictions, such as for aspirin and acetaminophen, in effect prior to
December 1, 2000, effective date of this policy, are removed.
NOTE: Effective December 1, 2000, all spenddown participants are exempt from the
Missouri Medicaid 31-day supply maximum restriction on pharmacy services. For
questions, contact the Provider Relations Communications Unit at (573) 751-2896.
13.10.B DOSE OPTIMIZATION
Pharmacy claims submitted are subject to edits to identify claims for pharmacy services that
fall outside expected patterns of use for certain products. Overrides to these edit denials are
processed through a help desk at 800-392-8030. The help desk is available seven days a
week, Monday-Friday, 8:00 a.m. to 9 p.m. and Saturday, Sunday and major national holidays
8:00 a.m. to 6:00 p.m. A menu directs callers to select options based on the nature of the call.
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Justification for utilization outside expected patterns, such as FDA approved labeling, are
required for approval of such an override.
Reference the Dose Optimization Edit listing for specific and up-to-date information on the
Missouri Medicaid Dose Optimization Edit.
13.10.C ADMINISTRATIVE CLINICAL EDITS
Administrative clinical edits are designed to enhance patient care and optimize the use of
program funds through appropriate clinical and fiscal use of medications. Point of service
pharmacy claims are routed through an automated computer system to apply edits
specifically designed to assure effective drug utilization. The edits are based on evidencebased clinical criteria and available nationally recognized peer-reviewed information.
Through the clinical editing process, therapy is automatically and transparently approved for
patients who meet the system approval criteria. For patients who do not meet the criteria,
therapy requires a call from the physician's office or the pharmacy to the Medicaid Pharmacy
Help Desk at (800) 392-8030 or the Clinical Edit/Step Therapy Authorization form faxed to
(573) 636-6470 to initiate a review and potentially authorize claims. Pharmacist and
physician providers with additional information specific to the rejected claim can call the
hotline for assistance seven days a week, Monday-Friday, 8:00 a.m. to 9 p.m. and Saturday,
Sunday and major national holidays 8:00 a.m. to 6:00 p.m.
Reference the Clinical Edit/Step Therapy documents for up-to-date information on the
administrative clinical and fiscal edits. To assist providers in preparing for future change to
drug coverage, reference the Clinical/Edit/Step Therapy Proposed Implementation Schedule
for scheduling information.
13.10.D STEP THERAPY
The Missouri Medicaid Pharmacy Program, University of Missouri-Kansas City School of
Pharmacy Drug Information Center, and the Drug Prior Authorization Committee perform
evidence based reviews of specific therapeutic classes of drugs responsible for a significant
part of program cost increases. The clinical reviews determine what scientific evidence
exists, if any, to support the use of newer products over older therapies in the same
therapeutic class in treating specific diseases. Efficacy and safety information from primary
literature sources is evaluated and compared along with a pharmacoeconomic analysis, to
determine a reference drug from the therapeutic class for a specific diagnosis.
The reference drug(s) becomes the only drug(s) from that class for that diagnosis that may be
used at the onset of therapy without prior authorization. Established patients who are
adhering to a therapy other than the reference drug are automatically approved to continue
the therapy on which they have been stabilized. New patients require a trial on the reference
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drug for a period determined by appropriate drug use parameters. After the trial period, if the
reference agent is not effective, the enhanced screening software allows the prescriber to
change therapy within the therapeutic class without prior authorization.
If there are unique circumstances that require the most recently available non-reference drug
at the onset of therapy, the prescriber can pre-certify that need through the Pharmacy Help
Desk. Pre-certification requires the prescribing physician to submit a request for an
individual patient by calling the help desk at (800) 392-8030 or by faxing the Clinical
Edit/Step Therapy Authorization form to (573)636-6470. The vast majority of claims are
electronically screened by drug regimen, diagnosis and medical procedures, with no direct
action required by the providers.
Reference the Clinical Edit/Step Therapy documents for up-to-date information on step
therapy drugs and reference the Clinical/Edit/Step Therapy Proposed Implementation
Schedule for scheduling information.
13.10.E PREFERRED DRUG LIST
In an effort to ensure economic and efficient provision of the Medicaid pharmacy benefit, the
Missouri Medicaid Pharmacy Program has implemented a Preferred Drug List (PDL),
including supplemental rebates from drug manufacturers. Point of sale pharmacy claims are
routed through predetermined criteria standards to review drug therapies prior to payment.
These edits are built upon evidence-based clinical criteria and available nationally recognized
peer-reviewed information. The list of products included in the clinical editing process
continues to evolve as additional products are identified for appropriate clinical and fiscal
limitations. As the PDL process is fluid, providers are encouraged to frequently refer to the
specific and up-to-date information on the PDL and the system approval criteria may be
accessed by referring to the Preferred Drug List.
13.10.F PRODUCTS COVERED UNDER THE NURSING HOME PER DIEM
Products that are reimbursable under the nursing home per diem are not to be billed to
Missouri Medicaid by pharmacy providers. These services cannot be billed to the participant.
All routine care items are considered included in the Medicaid reimbursement to long term
care facilities. Pharmacy providers MUST NOT bill the Medicaid Program or the participant
for items or services included on this list. The following is a list of covered services and
supplies.
13.10.F(1) Personal Care
Baby powder
Bedside tissues
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Bib, all types
Deodorants
Disposable underpads of all types
Gowns, hospital
Hair care, basic including washing, sets, brushes, combs, non-legend shampoo
Lotion, soap and oil
Oral hygiene including denture care, cups, cleansers, mouthwashes, tooth
brushes and paste
Shaves, shaving cream and blades
Nail clipping and cleaning-routine
13.10.F(2) Equipment
Arm slings
Basins
Bathing equipment
Bed frame equipment including trapeze bars and bedrails
Bed pans, all types
Beds, manual, electric
Canes, all types
Crutches, all types
Foot cradles, all types
Glucometers
Heat cradles
Heating pads
Hot pack machines
Hypothermia blanket
Mattresses, all types
Patient lifts, all types
Respiratory equipment: compressors, vaporizers, humidifiers, IPPB machines,
nebulizers, suction equipment and related supplies, etc.
Restraints
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Sand bags
Specimen container, cup or bottle
Urinals, male and female
Walkers, all types
Water pitchers
Wheelchairs, standard, geriatric and rollabout
13.10.F(3) Nursing Care/Patient Care Supplies
Catheter, indwelling and non-legend supplies
Decubitus ulcer care: pads, dressings, air mattresses, aquamatic K pads (water
heated pads), alternating pressure pads, flotation pads and/or turning frames,
heel protectors, donuts and sheepskins
Diabetic blood and urine testing supplies
Douche bags
Drainage sets, bags, tubes, etc.
Dressing trays and dressings of all types
Enema supplies
Gloves, non-sterile and sterile
Ice bags
Incontinency care including pads, diapers and pants
Irrigation trays and non-legend supplies
Medicine droppers
Medicine cups
Needles including but not limited to hypodermic, scalp, vein
Nursing services: regardless of level, administration of oxygen, restorative
nursing care, nursing supplies, assistance with eating and massages provided
by facility personnel
Nursing supplies: lubricating jelly, betadine, benzoin, peroxide, A & D
ointment, tapes, alcohol, alcohol sponges, applicators, dressings, and bandages
of all types, cotton balls, and aerosol merthiolate, tongue depressors.
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Ostomy supplies: adhesive, applicant, belts, face plates, flanges, gaskets,
irrigation sets, night drains, protective dressing, skin barriers, tail closures and
bags
Suture care including trays and removal kits
Syringes, all sizes and types including asepto
Tape for laboratory tests
Urinary drainage tube and bottle
13.10.F(4) Therapeutic Agents and Supplies
Drugs, stock (excluding insulin)
Enteral feedings (including by tube) and all related supplies
I.V. therapy supplies: arm boards, needles, tubing and other related supplies
Oxygen, (portable and stationary), oxygen delivery systems, concentrators and
supplies
Special diets
Any and all non-legend antacids, non-legend laxatives, non-legend stool
softeners and non-legend vitamins. Providers may not elect which non-legend
drugs in any of the four categories to supply; and all must be provided to
residents as needed and are included in a facility’s per diem rate.
13.10.G LONG-TERM CARE MAINTENANCE DRUG BILLING
Long-term maintenance and/or therapy drugs are required to be prescribed for no less than a
one-month supply when, in the prescriber's professional judgement, the patient's diagnosis
has been established, the condition stabilized, and the drug has achieved the desired effect
and may be safely prescribed. Pharmacy providers are to dispense in the manner prescribed.
Regardless of the dispensing system utilized, long term maintenance medications may be
billed no more frequently than one time per month.
13.11 RECIPIENT COST SHARING (COPAY, COINSURANCE, SHARED
DISPENSING FEE)
Participants eligible to receive certain Missouri Medicaid services are required to pay a small portion
of the cost of the services. This cost sharing amount is referred to as copay, coinsurance, or shared
dispensing fee (pharmacy). The cost sharing amount is paid by the participant at the time services
are rendered. Services of the Pharmacy Program described in this manual are subject to a cost
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sharing amount. The provider must accept in full the amounts paid by the state agency plus any cost
sharing amount required of the participant.
The Pharmacy Program is subject to the cost sharing (shared pharmacy dispensing fee) amount, and
a copay amount applies for some participants.
13.11.A PROVIDER RESPONSIBILITY TO COLLECT SHARED PHARMACY
DISPENSING FEE
Providers of service must charge and collect the shared pharmacy dispensing fee amount.
Providers of service may not deny or reduce services to persons otherwise eligible for
benefits solely on the basis of the participant's inability to pay the fee when charged. A
participant's inability to pay a required amount, as due and charged when a service is
delivered, shall in no way extinguish the participant's liability to pay the amount due.
As a basis for determining whether an individual is able to pay the charge, the provider is
permitted to accept, in the absence of evidence to the contrary, the participant’s statement of
inability to pay at the time the charge is imposed.
The provider of service must keep a record of cost sharing amounts collected and of the cost
sharing amount due but uncollected because the participant did not make payment when the
service was rendered.
13.11.B RECIPIENT RESPONSIBILITY TO PAY THE SHARED PHARMACY
DISPENSING FEE AMOUNTS
Unless otherwise exempted, it is the responsibility of the participant to pay the required
shared pharmacy dispensing fee amount due. Whether or not the participant has the ability to
pay the required shared pharmacy dispensing fee amount at the time the service is furnished,
the amount is a legal debt and is due and payable to the provider of service.
13.11.B(1) Exceptions to Shared Pharmacy Dispensing Fee
Under current pharmacy dispensing fee policy all Missouri Medicaid eligible
participants are subject to the fee requirement when provided covered pharmacy
services, with the exception of the following which are excluded:
• Participants under age 19;
• Institutionalized participants who are residing in a skilled nursing facility, a
psychiatric hospital, a residential care facility or an adult boarding home;
• Foster care children up to 21 years of age;
• All Medicare/Medicaid crossover claims as primary coverage;
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• Those drugs specifically identified as relating to family planning services;
• Emergency services; and
• Services provided to pregnant women which are directly related to the
pregnancy or a complication of the pregnancy.
Participation in each plan’s pharmacy network shall be limited to providers who
accept, as payment in full, the amounts paid by the plan plus any fee amount
required of the participant and collected by the provider.
13.11.B(2) Pharmacy Dispensing Fees
Pharmacy dispensing fees are to be collected according to current Medicaid policy
for fee-for-service participants and individuals enrolled in an MC+ managed health
care plan. The Missouri Medicaid pharmacy fee requirement is considered a
portion of the professional dispensing fee and is not deducted from reimbursement
to providers.
Ingredient Cost for Each Prescription
0 - $10.00
$10.01 - $25.00
$25.01 - higher
Member Fee Amount
$0.50
$1.00
$2.00
13.11.C RECIPIENT RESPONSIBILITY TO PAY COPAY AMOUNTS
It is the responsibility of the participant to pay the required copay amount due. Whether or
not the participant has the ability to pay the required copay amount at the time the service is
furnished, the amount is a legal debt and is due and payable to the provider of service.
The copay requirement is not to be confused with or added to the shared pharmacy
dispensing fee amount described in Section 13.11.B. The copay only applies to identified
services and participants with certain ME codes.
13.11.C(1) Participants Who are Required to Pay a Copay
Individuals with an ME code of “75,” must pay a $9.00 copay for each prescription
billed. The copay amount applies whether the individual receives services on a feefor-service basis or is enrolled in a health plan.
13.11.C(2) Services Requiring Copay
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The pharmacy copay requirement of $9.00 per prescription for children with ME
code “75” applies to each prescription filled, except vaccine billed on a Pharmacy
Claim form. There are no other exceptions to this copay requirement. The
pharmacy copay requirement for children with ME code “75” is the only copay that
applies, and is not to be confused with, or added to the pharmacy dispensing fees
applicable to the current Medicaid fee-for-service program requirements, or the
current pharmacy dispensing fee requirement of MC+ managed health care plans.
The prescription copay requirement for uninsured adults is based on the ingredient
cost of the drug dispensed, as follows:
Ingredient Cost
Copay and Dispensing Fee
0 - $10.00
$10.01 - $25.00
$25.01 - higher
$5.50
$6.00
$7.00
The copay amount to be collected from a participant is $5.50, $6.00 or $7.00. Of
these amounts, $5.00 is deducted from the provider’s reimbursement. The
remaining $0.50, $1.00 or $2.00, which corresponds to the participant’s portion of
the dispensing fee under Missouri Medicaid, is retained by the provider. The $5.00
copay is deducted from the Medicaid Maximum Allowable for fee-for-service
claims reimbursed by the Division of Medical Services.
If the usual and customary amount plus the shared dispensing fee is less than the
$5.00 copay to be charged to the participant, the provider should charge the lesser
amount of the shared dispensing fee plus the usual and customary amounts.
For example, if the total of the usual and customary amount for a drug ($4.25) plus
the shared dispensing fee ($0.50) equals $4.75, the provider should only charge the
participant $4.75 because the total is less than the copay amount of $5.00. Do not
charge the participant $5.00 or $5.50. If the usual and customary amount is $5.00
or more, the provider should charge the copay and shared dispensing fee.
13.12 MANAGED HEALTH CARE PLAN PHARMACEUTICALS
The MC+ contract states the following policy regarding the coverage of pharmaceuticals under the
Missouri MC+ managed health care program. Every product that is covered under the Medicaid
Pharmacy Program either without restriction or through prior authorization, except for protease
inhibitors, must be covered by the health plans either without restriction or through prior
authorization. However, it is not essential that health plans cover pharmaceutical products without
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restriction to the same extent that the fee-for-service program does. Health plans may have a more
extensive list of products requiring prior authorization, but health plans may not exclude from
coverage any products not excluded under the current Medicaid Pharmacy Program.
Products available under the Medicaid Pharmacy Program must be made available regardless of
whether or not the prescriber is in the health plan’s network, but health plans may require that prior
authorization be obtained for prescriptions generated by an out-of-plan prescriber except as
otherwise noted herein. Any drug prior authorization program implemented by a health plan must
meet the following criteria:
• Health plans must provide response by telephone or other telecommunication device within
24 hours of a request for prior authorization.
• Health plans must provide for the dispensing of at least a 72-hour supply of a drug product
that requires prior authorization in an emergency situation.
• Approvals must be granted for any medically accepted use. Medically accepted use is
defined as any use for a Federal Food and Drug Administration approved drug product,
which appears in peer-reviewed medical literature or which is accepted by one or more of
the following compendia: the American Hospital Formulary Service—Drug Information,
the American Medical Association Drug Evaluations, the United States Pharmacopoeia—
Drug Information and DRUGDEX.
13.12.A PRIOR AUTHORIZATION
In addition, health plans must have a mechanism whereby drugs can be prior authorized if a
member is out of the health plan’s service area and during the time lag between the date of a
member’s effective enrollment and that member’s assignment to a primary care provider.
13.12.B FAMILY PLANNING SERVICES
MC+ managed health care plan members have freedom of choice in obtaining family
planning services. These services may be obtained from any Medicaid enrolled provider. As
such, Depo Provera, when used for family planning purposes, need not be prescribed or
administered by the plan member’s primary care physician, nor can coverage be limited to
physician offices. Plans may not deny reimbursement to pharmacies dispensing Depo
Provera to MC+ managed health care plan enrollees for administration as family planning
services, nor can coverage be limited to the plan’s network pharmacies.
Prescriptions for family planning products for MC+ plan enrollees need not be prescribed by
the patient’s primary care physician in order to be covered by the plan. Family planning and
public health prescriptions written by an advanced practice nurse are covered by the plan.
Pharmacy providers should contact the respective plans for directions in billing/claims filing
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for these services. As a reminder, there is no participant dispensing fee requirement for
family planning drug products.
13.12.C BEHAVIORAL HEALTH SERVICES
Behavioral health services for MC+ managed health care plan enrollees included in Group 4
are reimbursable on a fee-for-service basis through the Missouri Medicaid Program.
Pharmaceutical products provided for these managed health care plan enrollees are the
responsibility of the participant’s health plan. Pharmaceutical products used as part of
behavioral health services for Group 4 need not be prescribed by a health plan provider in
order to be covered. Plans may, however, limit coverage to network pharmacies. Refer to
Section 1.5.C for a listing of Group 4 ME codes.
13.13 MANAGED CARE PLAN PROTEASE INHIBITOR CARVE-OUT
Coverage of protease inhibitors for Medicaid beneficiaries enrolled in the MC+ program is not the
responsibility of the MC+ managed care plans. These products are covered through the Missouri
Medicaid fee-for-service Pharmacy Program for all Medicaid beneficiaries.
13.14 DRUG USE REVIEW (DUR)
The Drug Use Review (DUR) process was established to fulfill a federal requirement established by
the Federal Omnibus Budget Reconciliation Act of 1990 (OBRA 90) and state law (208.175 and
208.176, RSMo, Cum. Supp. 1992). Missouri Medicaid has implemented both of the required DUR
types - Prospective DUR (when the review of patient drug therapy is done by the pharmacist at the
point of sale) and Retrospective DUR (when the review takes place after the point of sale).
13.14.A PROSPECTIVE DUR
State Regulation 13 CSR 70-20.310 requires that Missouri pharmacy providers screen for
potential drug therapy problems before each prescription is dispensed to any non-nursing
home Medicaid participant. Federal Prospective DUR requirements mandate that the
pharmacist’s review include screening to identify potential drug therapy problems of the
following types:
• Incorrect drug dosage—the dosage lies outside the daily dosage range specified in
predetermined standards as necessary to achieve therapeutic benefit;
• Adverse drug-drug interaction—the potential for, or occurrence of, an adverse medical
effect as a result of the participant using two or more drugs together;
• Drug-disease contraindication—the potential for, or occurrence of:
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• an undesirable alteration of the therapeutic effect of a given prescription
because of the presence, in the patient for whom it is prescribed, of a disease
condition; or
• an adverse effect of the drug on the patient’s disease condition;
• Therapeutic duplication—the prescribing and dispensing of two or more drugs from
the same therapeutic class such that the combined daily dose puts the participant at
risk of an adverse medical result or incurs additional program costs without additional
therapeutic benefit;
• Incorrect duration of drug treatment—the number of days of prescribed therapy
exceeds or falls short of the recommendations contained in the predetermined
standards;
• Drug-allergy interactions—the significant potential for, or the occurrence of, an
allergic reaction as a result of drug therapy; and
• Clinical abuse-misuse—the occurrence of situations referred to in the definitions of
abuse, gross overuse, overutilization and underutilization, and incorrect dosage and
incorrect duration, as defined in the dot points above.
The goal of Prospective DUR is to identify potential drug therapy concerns to allow the
pharmacist to use professional judgment regarding the need for intervention, such as whether
or not to contact the prescribing physician.
13.14.A(1) Prospective Drug Use Review (DUR) Through the Electronic
Claims Management (ECM) or Point of Service (POS) System
Prospective DUR alerts transmitted through the electronic claims management
(ECM) or point of service (POS) system are generated on the basis of
predetermined standards which have been approved by the Missouri DUR Board.
These predetermined standards utilize data from claims history files which include
physician, outpatient, inpatient, long term care facility and other claims that report
patient diagnoses, in addition to drug claim data. Reference Section 17.11 for a
description of alert responses transmitted via POS.
Providers that do not choose to utilize this service must develop and document their
own predetermined standards for evaluating drug therapy.
13.14.A(2) Patient Counseling
As a component of Prospective DUR, federal law requires Medicaid participating
pharmacies to offer patient counseling to each participant upon dispensing each
prescription. In Missouri, the Board of Pharmacy has required the offer of
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counseling for all patients through State Regulation (4 CSR 220-2.190). As stated
in the regulation, “the elements of counseling shall include matters that the
pharmacist deems significant in the exercise of professional judgment and are
consistent with applicable state laws.”
13.14.A(3) Documentation of Offer to Counsel
As specified in 13 CSR 70-20/310, the pharmacist must document for each
Medicaid patient’s prescription in a uniform fashion, whether the offer to counsel
was accepted or refused by the patient or her/his agent or caregiver.
Although no standard has been established for such documentation, the information
must be easily retrievable by the pharmacy upon request by the Department of
Social Services.
13.14.A(4) Patient Profiles
Regulations promulgated by the Board of Pharmacy do not specify what
information is required to be maintained in patient profiles. However, due to the
federal mandate found at 42 CFR Part 456.705(d), the Division of Medical
Services requires in 13 CSR 70-20/310, effective December 10, 1993, that for
Medicaid patients, participating pharmacies must make a reasonable effort* to
obtain, record and maintain patient profiles containing, at a minimum:
• the name, address, telephone number, date of birth (or age) and gender of
the patient;
• individual medical history, if significant, including disease states, known
allergies and drug reactions, and a comprehensive list of medications and
relevant devices; and
• pharmacist’s comments relevant to the individual’s drug therapy.
* “Reasonable effort” is defined in the rule to mean that each time a Medicaid patient or his/her agent or caregiver
presents a prescription, the pharmacist or pharmacist’s designee should request profile information verbally or in
writing. For example, if the patient presents the prescription in person, the request should be made verbally; and if the
prescription is mailed, the request should be made in writing. This does not imply that the service should be denied
solely on the basis of the patient’s refusal to supply profile information.
13.14.B RETROSPECTIVE DUR
The Retrospective DUR system applies to all Medicaid participants (both fee-for-service and
MC+) and focuses on drug regimen reviews after the patient has received a prescription. It
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targets potential therapy problems that result after a period of time, possibly characterized by
an exacerbated medical condition or the appearance of a drug side effect.
The Division of Medical Services has entered into an outside contract for production of
computerized patient reports or “patient profiles.” These patient profiles are generated by
applying therapeutic criteria to paid Medicaid claims data. Therapeutic criteria is reviewed
and approved by the DUR Board. Rather than using a single statewide committee to review
all patient profiles, Missouri has instituted a regional approach, dividing the state into 6
different regions (St Louis, Kansas City, Columbia, Kirksville, Springfield and Cape
Girardeau) with a separate review committee in each region.
These committees, composed of pharmacists and physicians actively practicing in their
region, are responsible for reviewing the profiles for patients of their colleagues practicing in
their specific region.
The purpose of the profile reviews is to detect potential drug therapy problems and to bring
the information to the attention of the treating physician and dispensing pharmacist. The
information is presented in an informational manner and is not intended to be punitive in any
way. Reimbursement of claims are not affected by DUR interventions, nor are provider
sanctions employed. Letters contain a summary of the potential problem, along with a copy
of the patient profile and a response form for the provider’s return.
13.15 EMERGENCY SERVICES
Emergency services are services required when there is a sudden or unforeseen situation or
occurrence or a sudden onset of a medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) that the absence of immediate medical attention could
reasonably be expected to result in:
1.
Placing the patient’s health in serious jeopardy; or
2.
Serious impairment to bodily functions; or
3.
Serious dysfunction of any bodily organ or part.
13.16 OUT-OF-STATE, NONEMERGENCY SERVICES
All nonemergency, Medicaid covered services that are to be performed or furnished out-of-state for
eligible Missouri Medicaid participants and for which Missouri Medicaid is to be billed, must be
prior authorized before the services are provided. Services that are not covered by the Missouri
Medicaid Program are not approved.
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Out-of-state is defined as not within the physical boundaries of the State of Missouri nor within the
boundaries of any state that physically borders on the Missouri boundaries. Border-state providers of
services (those providers located in Arkansas, Illinois, Iowa, Kansas, Kentucky, Nebraska,
Oklahoma and Tennessee) are considered as being on the same Medicaid participation basis as
providers of services located within the State of Missouri.
A Prior Authorization Request form is not required for out-of-state nonemergency services. To
obtain prior authorization for out-of-state, nonemergency services, a written request must be
submitted by a physician to:
Division of Medical Services
Participant Services Unit
P.O. Box 6500
Jefferson City, MO 65102
The request may be faxed to (573) 526-2471.
The written request must include:
1.
A brief past medical history.
2.
Services attempted in Missouri.
3.
Where the services are being requested and who will provide them.
4.
Why services can’t be done in Missouri.
NOTE: The out-of-state medical provider must agree to complete an enrollment application and
accept Missouri Medicaid reimbursement. Prior authorization for out-of-state services expires 180
days from the date the specific service was approved by the state.
13.16.A EXCEPTIONS TO OUT-OF-STATE PRIOR AUTHORIZATION (PA)
REQUESTS
The following are exempt from the out-of-state prior authorization requirement:
1. All Medicare/Medicaid crossover claims.
2. All Foster Care children living outside the State of Missouri. However,
nonemergency services that routinely require prior authorization continue to require
prior authorization by out-of-state providers even though the service was provided to
a Foster Care child.
3. Emergency ambulance services.
4. Independent laboratory services.
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13.17 HOSPICE
Refer to Section 1.5.E for a full description of hospice beneficiaries. The Medicaid hospice benefit
includes covered services provided according to a written plan of care. All drugs (prescription and
over the counter) and biologicals used primarily for pain or symptom control of the terminal illness
are the responsibility of the hospice provider. Any service or treatment that is not directly related to
pain control or palliation of the participant’s terminal illness is not the responsibility of the hospice
and can be reimbursed on a fee-for-service basis.
13.17.A PHARMACY REIMBURSEMENT
The plan of care must indicate all medication the patient uses and whether the medication is
related to the terminal illness. Missouri Medicaid reimburses Medicaid pharmacy providers
for pharmacy claims that are not related to the hospice patient’s terminal diagnosis. It is the
responsibility of the hospice to provide documentation that verifies that specific medication
is not related to the terminal diagnosis. The hospice should provide a letter or statement to
the pharmacy that includes the following information:
Patient name;
Patient Medicaid ID Number (DCN);
Service dates;
Drug name(s);
Statements that the named drugs are not the responsibility of the hospice.
13.18 DIABETES SELF-MANAGEMENT TRAINING
Diabetes self-management training services are used in the management and treatment of type 1,
type 2 and gestational diabetes. These services are covered when prescribed by a physician or a
health care professional with prescribing authority and may be provided by a Certified Diabetes
Educator (CDE), Registered Dietician (RD) or Registered Pharmacist (RPh).
13.18.A DIABETES SELF-MANAGEMENT TRAINING ENROLLMENT
CRITERIA
To provide and bill for diabetes self-management training, a provider must be approved and
enrolled as a diabetes self-management provider with Missouri Medicaid. Missouri Medicaid
has established a new provider type—35–Diabetes Management Training—with three new
provider specialties: F1–Certified Diabetes Educator (CDE), F2–Registered Dietician (RD)
and F3–Registered Pharmacist (RPh). Following are the requirements to enroll as a F3–
Registered Pharmacist (RPh) under the Diabetes Self Management Training program:
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Registered Pharmacist (RPh): Must hold a permanent Missouri license as licensed
pharmacist and must have completed the National Community Pharmacists
Association (NCPA) "Diabetes Care Certification Program" OR completed the
American Pharmaceutical Association (APhA)/AADE certification program
"Pharmaceutical Care for Patients with Diabetes."
Diabetes education providers employed/contracted with federally qualified health
centers (FQHCs) or rural health clinics (RHCs) bill with their individual diabetes
self-management training provider number with payment designated to the FQHC or
RHC.
Diabetes education services provided on an inpatient basis by hospital staff are
included in the hospital per diem rate.
When diabetes education services are provided in an outpatient setting by hospital
staff, the CDE, RD or RPh enrolls as a diabetes self-management training provider
with payment designated to the hospital on the provider enrollment forms.
13.18.B DIABETES SELF-MANAGEMENT TRAINING SERVICE LIMITATIONS
Diabetes self-management training services are limited to any of the following circumstances
with documentation of the need for services maintained in the provider's file:
• Initial diagnosis of diabetes;
• Any significant change in the patient's symptoms, condition or treatment.
Diabetes self-management training must be prescribed by a physician or health care provider
with prescribing authority to the CDE, RD or RPh.
An initial assessment is reimbursed once per lifetime. The initial assessment must be
performed by a physician or a CDE.
The initial assessment should include but not be limited to information from the patient on
the following:
• Health and medical history;
• Use of medications;
• Diet history;
• Current mental health status;
• Use of health care delivery systems;
• Life-style practices;
• Physical and psychological factors;
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• Barriers to learning; family and social supports; and
• Previous diabetes education, actual knowledge and skills.
Two subsequent visits are reimbursed per rolling year. The two subsequent visits may be
individual, group or a combination of individual and group.
Any additional visits require a Certificate of Medical Necessity form from a physician or
health care provider with prescribing authority documenting the need for any additional
visits. The Certificate of Medical Necessity form must be submitted with the claim.
The diabetes self-management training services for patients enrolled in MC+ are the
responsibility of the health plan.
13.18.B(1) Procedure Codes for Diabetes Self-Management Training
PROC
CODE
(Prior to
10/16/2003 date
of service)
PROC
CODE
(On or after
10/16/2003 date
of service)
DESCRIPTION
W0037..................99205 U9..............Initial Assessment–Comprehensive Diabetes
Education–Minimum 1 hour
W0038..................G0108...................Diabetes Education–Subsequent Visit–Minimum 30
minutes
W0039..................G0109...................Diabetes Education–Group Subsequent (No more than
8 persons)–Minimum 30 minutes
13.18.B(2) Diabetes Self-Management Training Billing Procedures
The diabetes self-management training services must be billed on the CMS-1500
claim form using type of service (TOS) code "1", with the appropriate procedure
code.
The place of service (POS) code must be one of the following: 11 (Office); 12
(Home); 97 (Private/Parochial School); 98 (Schools); 21 (Inpatient Hospital); or 22
(Outpatient Hospital).
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Electronic billing of claims is permitted unless claims require an attachment of a
Certificate of Medical Necessity form or any other attachment. Those claims
requiring an attachment must be billed on a paper CMS-1500 claim form.
Training provided by a CDE, RD or RPh not employed by the hospital, must be
billed using POS 21 (Inpatient Hospital) or 22 (Outpatient Hospital) using their
own diabetes self-management training provider number.
13.19 DIABETIC SUPPLIES
All diabetic supplies are reimbursed through the Pharmacy Program, via point of service, Internet or
on a paper Pharmacy Claim form. Durable medical equipment only providers may also continue to
bill for diabetic supplies, but are now required to bill an Internet claim or on a paper Pharmacy
Claim form. These supplies are not reimbursed through the Durable Medical Equipment Program.
Reference Diabetic Supplies for detailed information regarding the supplies and billing information.
Effective March 6, 2004, Precision Xtra Advanced Diabetes Management System, Precision Xtra
blood glucose test strips, Precision Xtra blood ketone test strips, and Precision Sure-Dose Insulin
Syringe are the only brands Missouri Medicaid fee-for-service covers without prior authorization. To
obtain a non-reference product, prior authorization for other brands are reviewed on an individual
patient basis and evaluated for medical necessity.
Insulin pumps continue to be available only through the prior authorization process. The authorized
prescriber may request the prior authorization by faxing the Diabetic Supplies Prior Authorization
form to (573) 636-6470.
Insulin pump supplies do not require prior authorization. For claims processing of insulin pump
supplies, the provider must code the claim with a UB service modifier. When a claim is submitted
with the UB modifier, it will suspend for claim review. Providers billing for these suplies must have
and maintain documentation that the patient has been seen and evaluated by the treating physician
every 3 months. In addition, the external insulin infusion pump therapy must be ordered and followup care rendered by a physician who manages multiple patients on continuous subcutaneous insulin
infusion therapy and who works closely with a team including nurses, diabetic educators and
dieticians who are knowledgeable in the use of continuous subcutaneous insulin infusion therapy.
Diabetic supplies for Medicare eligible patients, except for insulin syringes, are reimbursed by
Medicare. Providers are to bill Medicare according to Medicare established policies for diabetic
supplies.
13.20 MISSOURI MEDICAID DISEASE STATE MANAGEMENT PROGRAM
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The Missouri Medicaid Disease State Management Program was designed to improve the healthcare
of patients who suffer from chronic conditions such as asthma, diabetes, heart failure and depression.
Physicians and pharmacists work as a team to achieve these primary goals:
• Improve patient care
• Improve health outcomes
• Reduce inpatient hospitalization
• Reduce emergency room visits
• Lower total costs
• Better educate patients and providers
Specific and up-to-date information on the Missouri Medicaid Disease State Management Program
including provider and patient enrollment information, provider education and training, patient
education, care plan guidelines, assessment/care plan forms, and billing instructions may be accessed
at Disease Management.
END OF SECTION
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