2024 Medicaid Statewide Provider Training - Pharmacy Program Reminders

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Welcome to the Medicaid Pharmacy Statewide Provider Training! This event covers updates on hormone therapy for gender dysphoria, morphine milligram equivalent (MME) updates, telephonic MTM services billing, and more. Participants are encouraged to interact through chat and provide feedback post-training.

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2024 Medicaid Statewide Provider Training Medicaid Pharmacy Program

WELCOME! WELCOME! Thank you for attending the Medicaid Pharmacy Statewide Provider Training! Reminders for our meeting today: If you are dialing in via telephone, Google Meet has muted you. If you need to speak to the group, please press *6 on your phone to unmute and mute. We kindly ask that only those who are speaking to the group unmute their devices. Reserve questions until the end of presentation, submit via Meeting chat OR email medicaidpharmacy@utah.gov. Please provide feedback after the meeting to help us support our providers https://forms.gle/N9LTy9qH82cB5FdV7. Thank you!

Whats New Highlights Resources Q&A session Agenda Agenda

Whats new? What s new?

Prior Auth for Hormone Therapy for Gender Prior Auth for Hormone Therapy for Gender Dysphoria Dysphoria S.B.16 (Transgender Medical Treatments and Procedures) and Utah Code 58-1-603(3)- (5) Healthcare providers and mental health professionals who treat gender dysphoria in minors are required to complete at least 40 hours of education related to transgender healthcare Transgender Treatment Certification issued by the Utah Division of Professional Licensing (DOPL) Hormone Therapy for Gender Dysphoria Prior Authorization Form

Update on Morphine Milligram Equivalent (MME) at Update on Morphine Milligram Equivalent (MME) at the point of sale the point of sale Per the CDC Clinical Practice Guideline for Prescribing Opioids for Pain United States, 2022 | MMWR, effective December 1, 2023, the MME values for oral hydromorphone, methadone, and tramadol have been updated. Other policies regarding MME and quantity limits remain unchanged. Opioid Current MME Factor MME Factor effective 12/1/2023 Hydromorphone 4 5 Methadone 3 4.7 Tramadol 0.1 0.2

Telephonic MTM Services Billing Telephonic MTM Services Billing Fee for Service members may receive face to face Medication Therapy Management (MTM) services provided by a Medicaid-enrolled pharmacist in an outpatient setting. We have updated to include telephonic MTM services. Program information may be found on the Medication Therapy Management Services website: https://medicaid.utah.gov/pharmacy/medication-therapy- management-services/ Specific code information can be found by using the Coverage and Reimbursement Code Lookup. For point of sale billing information, please refer to the Utah Medicaid MTM Payer Sheet located within the Payer sheet folder on the Pharmacy Resource Library.

COVID Vaccine POS MA code COVID Vaccine POS MA code Claims for COVID vaccines processed through the pharmacy point of sale system, will be paid for the cost of the vaccine (lesser of logic) and the associated dispensing fee. The pharmacy must submit the code MA in the professional service code field to receive the COVID administration fee of $40. If MA is not submitted in the professional service code field, the pharmacy will only be paid for the cost of the vaccine and associated dispensing fee.

NDC pricing back to HCPCS in PRISM NDC pricing back to HCPCS in PRISM The PRISM system now adjudicates claims for physician-administered drugs using HCPCS codes and HCPCS units. This coding change is for all claims submitted in PRISM. Providers are encouraged to review the following guidelines which apply to claims submitted for physician-administered drugs: Review the PRISM Coverage and Reimbursement Code Lookup for current coverage status and the PRISM Coverage and Reimbursement Fee Schedule Download for current NDCs (National Drug Codes) crosswalked to specific HCPCS codes. A valid HCPCS (Healthcare Common Procedure Coding System) and HCPCS units for the drug being administered are required and The HCPCS unit submitted on the claim shall reflect the actual dosage administered, not the package size.

NDC pricing back to HCPCS in PRISM (continued) NDC pricing back to HCPCS in PRISM (continued) A valid NDC for the drug being administered is required. In order for a claim to be accepted, it must contain a valid HCPCS and NDC combination. Physician-administered drugs shall be administered by a qualified healthcare professional. Self-administered drugs shall not be billed as a provider-administered drug. Provider-administered drugs that do not require payment, such as samples or those previously billed at a pharmacy, should report the appropriate HCPCS and $0.00 or $0.10 charge.

NDC pricing back to HCPCS in PRISM (continued) NDC pricing back to HCPCS in PRISM (continued) NOC (Not Otherwise Classified) HCPCS codes should only be reported for drugs that do not have a drug-specific HCPCS code (e.g. J3490, J3590). Reimbursement shall be based on the submitted HCPCS code and units administered, using the lesser of logic as stated in the Utah Medicaid State Plan 4.19- B.

Preferred Drug List updates Preferred Drug List updates Effective March 1, 2024, the Oral Acne Products class on the Preferred Drug List was updated to include preferred medications which were historically non- preferred. Effective June 1, 2024, Utah Medicaid will cover chewable fluoride supplements for members age 6 to 16 years old. For more information, please refer to the Preferred Drug List and Resource Document and R414-60-5.

Medications to promote fertility Medications to promote fertility Effective May 1, 2024, drugs to promote fertility are covered for some members. The Centers for Medicare and Medicaid Services (CMS) approved two 1115 Waivers allowing Utah Medicaid to cover certain fertility preservation or in vitro fertilization procedures and medications for certain members, including: Members and their partner who are a carrier for or have been diagnosed with certain genetic conditions. Members who have been diagnosed with a form of cancer that requires treatment that may cause a substantial risk of sterility or iatrogenic infertility, including surgery, radiation, and chemotherapy. Please refer to the Physician Services Manual Chapter 8-22 Genetic Carrier Screening and In Vitro Fertilization and Chapter 8-23 Fertility Preservation for specific eligibility information.

SL modifier removal SL modifier removal Providers no longer need to use the SL modifier on vaccine claim lines to indicate that they are for administration codes for Vaccine For Children products. Claims will continue to adjudicate correctly with or without the SL modifier.

Dispensing fee Dispensing fee Effective July 15, 2024, dispensing fees were updated for pharmacy point of sale claims as follows: $11.57 for prescriptions eligible for a dispensing fee except hemophilia clotting factor. $97.53 for hemophilia clotting factor. Per R414-60-7(7), Medicaid pays a pharmacy one dispensing fee every 24 days for each covered outpatient drug. For more information on professional dispensing fees, please refer to the Utah State Plan ATTACHMENT 4.19-B.

Highlights Highlights

Folic acid for women Folic acid for women Folic acid is covered for all women. Prenatal vitamins are covered for pregnant women with a valid prescription. The Centers for Disease Control and Prevention recommends all women of reproductive age receive 400 micrograms (mcg) of folic acid every day from supplements, in addition to consuming folate from their diet to prevent neural tube defects (NTDs). For women who have already had an NTD-affected pregnancy, the recommendations are 4,000 mcg of folic acid daily beginning one month before becoming pregnant and through the first three months of pregnancy. Refer to Utah Medicaid Preferred Drug List for covered products.

Medical claims 340B modifiers Medical claims 340B modifiers All claims submitted to Utah Medicaid, including Medicare crossover claims, from a 340B covered entity for medications that were purchased through the 340B program shall be submitted with the provider s 340B actual acquisition cost as the billed charges. Providers shall also report the TB or JG modifier for each 340B medication on the claim. Claims submitted without the 340B modifier indicate the covered entity purchased the medication outside the 340B program. Utah Medicaid will pursue the federal Medicaid drug rebate on those claims.

Pharmacy POS 340B review Pharmacy POS 340B review 340B claims must be submitted with the provider s 340B actual acquisition cost in the Ingredient Cost Field Basis of Cost field = 8 Submission Clarification Code field = 20 Claims submitted without the 340B modifier indicate the covered entity purchased the medication outside the 340B program. Utah Medicaid will pursue the federal Medicaid drug rebate on those claims.

Compounds billed through the POS Compounds billed through the POS Claims for compounds billed through the pharmacy point of sale system shall: Contain two (2) or more ingredients AND Submitted as a compound claim using submission clarification code (SCC) 8

Compounds billed through the POS Compounds billed through the POS Medicaid may only reimburse pharmacies for the ingredient that meets the definition of a covered outpatient drug, except for those listed as non-covered drugs in Section R414-60-5.(2). Medicaid does not cover bulk powders. Please refer to the Compound Billing Alert Fax Blast for examples of correct and incorrect billing.

Resources Resources

Pharmacy policy resources: Pharmacy policy resources: Medicaid Information Bulletins (MIB) and Provider Manuals: https://medicaid.utah.gov/utah-medicaid-official-publications/ Administrative Rule: https://adminrules.utah.gov/public/home DUR and P&T Committee, as well as other specific information related to the Pharmacy Program is located on the Utah Medicaid Pharmacy website: https://medicaid.utah.gov/pharmacy/pharmacy-program/ State Plan: https://medicaid.utah.gov/stplan/ Preferred Drug List: https://medicaid.utah.gov/pharmacy/preferred-drug-list/ Prior Authorization: https://medicaid.utah.gov/pharmacy/prior-authorization/