Remittance Advice Provider Alerts
Follow this link for historical Provider Alerts.
2012
February 1, 2012 
Patanol Removal - Preferred Drug List Update
On January 13, 2012, the Medicaid Pharmacy and Therapeutics Committee voted to remove Patanol from the Medicaid Preferred Drug List. This change will be effective February 8, 2012. Pataday will remain on the Preferred Drug List.
February 1, 2012
Proton Pump Inhibitors - Preferred Drug List Update
On January 13, 2012, the Medicaid Pharmacy and Therapeutics Committee voted to remove lansoprazole capsules and solutabs from the Medicaid Preferred Drug List. Effective February 8, 2012, Proton Pump Inhibitors that will be included on the preferred drug list are pantoprazole, omeprazole, Protonix suspension and Prevacid Solutabs. A maximum age limit of 11 years will be applied to Protonix suspension and Prevacid Solutabs.
January 30, 2012
CII-CV Prescriptions Provider Alert
Effective February 1, 2012, the maximum number of narcotic prescriptions defined by Federal Controlled Substance, Schedule CII-CV (multiple drugs and multiple strengths), that will be allowed per month without a prior authorization will be as follows:
- Oncology and sickle cell patients can receive up to six (6) CII-CV prescriptions per month. The prior authorization process is available for recipients whose needs exceed the monthly limit of six (6) CII-CV narcotic prescriptions.
- All other patients can receive up to four (4) CII-CV prescriptions per month. The prior authorization process is available for recipients whose needs exceed the monthly limit of four (4) CII-CV narcotic prescriptions.
This enhancement includes all medications and combinations of medications listed in Federal Schedules CII-CV, including but not limited to:
- All narcotics on Federal Schedules CII-CV
- Narcotic containing cough preparations
- Benzodiazepines
- Sleep agents (Zolpidem and similar agents)
- Carisoprodol
- Lyrica
- Suboxone and Subutex
The prior authorization process is available for those requests which exceed the monthly limit of prescriptions per 30 days.
It is important to note that multiple strengths of the same medication will be applied individually toward the limit. Claims over the maximum limit of prescriptions per 30 days will deny for “Limit 4 CII-CV/30days; Prescribers call 877-553-7481” or “Limit 6 CII-CV/30 days; Prescribers call 877-553-7481”.
This represents an enhancement to programming logic that was initiated in August 2009.
Prior Authorization is also required for the following:
- When dose and/or dispense quantities of any of the above listed medications exceed Medicaid Fee-for-Service plan limitations.
- Carisoprodol, Suboxone, Subutex, and any other medications that are not on the Medicaid Preferred Drug List (PDL).
2011
September 22, 2011
HIV and Hep-B Diagnosis Verification
Effective September 22, 2011, all incoming fee-for-service pharmacy claims for HIV/AIDS-related anti-retroviral medications will require specific HIV/AIDS diagnosis codes in the medical claims history. Recipients who are being treated for Hepatitis B with a medication in this class will need to have the appropriate Hepatitis B diagnosis code in the medical claims history. An appropriate diagnosis code must be found within the past 365 days of the date of the pharmacy claim submission. However, patients and providers that verbally attest to an HIV or Hepatitis B diagnosis will be allowed a one month override to allow time for the verification form to be submitted to Medicaid. Claims will automatically pay for children younger than one year old. We have also developed a technology solution to identify and pay claims for assault victims.
HIV/AIDS-related anti-retroviral medications generally remain included on the Preferred Drug List (PDL) by statutory exemption. However, the Agency has an obligation to ensure appropriate utilization of medications. Therefore, pharmacy claims for recipients who lack the appropriate HIV/AIDS and/or Hepatitis B diagnosis code(s) in the medical claims file will deny at point-of-sale, except in the case of the child younger than one year and the assault victim. Providers are advised to update recipient diagnosis codes when billing for office visits or other related services.
A prior authorization (PA) submission will be required for these denied claims. Providers should fax PA requests on an HIV/HEP-B Diagnosis Verification PA Request form to (877) 614-1078, except for Fuzeon, Selzentry, and Serostim, which have their own unique forms. The request should be submitted with the requested official medical documentation (i.e. progress notes) and a copy of the prescription.
If the recipient does not have the specific diagnosis and the therapy is being requested for pre-exposure prophylaxis, then the provider must demonstrate implementation of comprehensive HIV prevention services, as per the CDC Interim Guidance (http://www.cdc.gov/nchhstp/newsroom/images/CDC-Interim-PrEP-Guidance.jpg).
Prior Authorization forms may be downloaded from:
http://ahca.myflorida.com/Medicaid/Prescribed_Drug/pharm_thera/paforms.shtml
September 20, 2011
Qualitest Oral Contraceptive Recall
"Qualitest Wants Pharmacists To Contact Patients Who Have Company's Oral Contraceptive"
Please click on the link below to read more about this recall.
http://www.ashp.org/menu/News/PharmacyNews/NewsArticle.aspx?id=3614
September 13, 2011
Prevacid
Effective September 12, 2011, both Prevacid (brand) and lansoprazole (generic) capsules and solutabs will be temporarily included on the FL Medicaid Preferred Drug List. The overlap in coverage is designed to allow pharmacies who have purchased large amounts of Prevacid for their Medicaid patients to use up existing stock, and switch patients to lansoprazole. Prevacid (brand) will be removed from the FL Medicaid Preferred Drug List on October28, 2011. After that, only lansoprazole (generic) capsules and solutabs will be covered. Lansoprazole solutabs will continue to have an age limit of 12 years old.
August 30, 2011
FDA Website Updates
This is a notice to providers introducing the option to receive routine notices of useful, up-to-date health related information from the United States Food and Drug Administration (FDA) by visiting their website at http://www.fda.gov. Providers may subscribe to e-mail updates and Really Simple Syndication (RSS) feeds by clicking on the icons provided in the upper right corner of the home page. In order to receive these automatic updates the user must select topics of interest. Some pharmaceutic related topics include drug updates, recalls, safety alerts, research, and shortages.
August 26, 2011
Coordination of Benefits / Third Party Liability Claims
Effective August 26, 2011 the OCC codes for COB claims will be updated to ensure proper use.
OCC 0: POS claims will deny if there is a primary payer. The rejection is NCPDP EC 41 – Submit bill to other processor or primary payer.
OCC 1: Where POS claims will deny NCPDP EC 41 – Submit bill to other processor or primary payer with supplemental message: “Contact AHCA TPL recovery unit (877) 357-3268.”
OCC 2: The logic will compare the remaining balance after primary has paid vs. the final calculated claim cost (Medicaid lesser of logic minus what the primary has paid). The claim will pay at the lesser of these 2 values. Pharmacy MUST submit the full amount paid by the primary payer in the “Other Payer Amount Paid” field (NCPDC field 431-DV). The patient’s responsibility, or co-pay, as returned on the claim from the primary payer, should be submitted in the “Patient Paid Amount Submitted” field (NCPDP field 433-DX).
OCC 3: Where POS claims will deny NCPDP EC 41 – Submit bill to other processor or primary payer with supplemental message. “Submit claim on paper with Documentation”
The dispensing pharmacy must determine the reason that the medication is not covered by the primary payer before billing the paper claim to Medicaid. If the primary payer requires a prior authorization, then the pharmacy must work with the prescriber to complete the necessary documentation to bill the claim to the primary payer. If the claim is for an injectable medication, the primary payer may require the beneficiary to use a specialty pharmacy mail-order program. In that case, the beneficiary must be referred to the specialty pharmacy program. Only medications that are not covered by the primary payer because of a benefit limitation and which are covered by Medicaid can be billed via paper claim to Medicaid. For instructions on how to complete a pharmacy claim with a sample of the Universal Claim Form (UCF) please refer to the Prescribed Drug Services Handbook, Chapter 3.
OCC 4: Where POS claims will deny NCPDP EC 41 – Submit bill to other processor or primary payer with a supplemental message, “Contact AHCA TPL recovery unit (877) 357-3268.”
OCC 5: Where POS claims will deny NCPDP EC 41 – “Submit bill to other processor or primary payer.”
OCC 6: Where POS claims will deny NCPDP EC 40 – “Pharmacy not contracted with plan on fill date.”
OCC 7: Where POS claims will deny NCPDP EC 41 – Submit bill to other processor or primary payer with supplemental message: “Contact AHCA TPL recovery unit (877) 357-3268.”
Prior to contacting the Helpdesk, the pharmacy should first remove any values originally submitted in the Other Coverage Code (OCC) field (NCPDP 308-C8) and attempt to reprocess the claim.
August 25, 2011
Synagis Coverage Period Update
On July 30, 2011, the Drug Utilization Review and Prescribing Pattern Review Boards voted to limit approved Synagis Prior Authorization coverage to a maximum of seven doses for the period including July 1 to April 30 only. The seven doses may be given at any time within the 10 month period. This limitation will be in effect for doses given since July of 2011.
All other qualifying risk factors, including age, disease, and exposures will remain the same on the form. There will now be one form for all regions. Weight forms will still be required for dosage adjustment requests.
NOTE: A new method of submitting claims for more than one vial of Synagis needed on the same day of service will go into effect on August 25, 2011. Pharmacies should not submit separate claims for different dosage strength vials needed on the same date of service. Only one compound claim submission will be necessary. For example, if the Synagis dosage is 150mg the pharmacy should submit a compound claim that lists the two different strength vials (100mg and 50mg).
Forms can be downloaded from:
http://ahca.myflorida.com/Medicaid/Prescribed_Drug/pharm_thera/paforms.shtmlProviders are advised to continue to educate parents of Respiratory Syncytial Virus (RSV) susceptible children to use good infection control practices such as frequent handwashing, avoiding contact and sharing of items with people having upper respiratory infections, especially children, and avoidance of exposure to tobacco smoke.
August 19, 2011
Informed Consent for Psychotherapeutic Medication Update
Pursuant to statute 409.912(51) The Agency may not pay for a psychotropic medication prescribed for a child in the Medicaid program without the express and informed consent of the child's parent or legal guardian. The physician shall document the consent in the child's medical record and provide the pharmacy with a signed attestation of this documentation with the prescription.
Florida Statute 394.492(3) “Child” means a person from birth until the person’s 13th birthday.
Psychotropic (Psychotherapeutic) Medications include antipsychotics, antidepressants, anti-anxiety medications, and mood stabilizers. Anticonvulsants and ADHD medications (stimulants and non-stimulants) are not included at this time. The generic names of those medications subject to the informed consent are listed below. Please note that chloral hydrate, diazepam, lorazepam, and midazolam have been removed from the list.
Alprazolam |
Droperidol |
Modafinil |
Temazepam
|
Effective September 1, 2011, the Bureau of Pharmacy Services will implement this legislative directive as follows:
- The prescriber must complete either the Medicaid “Informed Consent for Psychotherapeutic Medication” attestation form; the Department of Children and Families CF1630, or CF FSP 5339 form(page 8 only); the Department of Juvenile Justice Consent Form (page 3 only), or provide the court order for the medication. By accepting a variety of consent forms, the Medicaid Program is providing flexibility with respect to acceptable documentation. Dispensing pharmacists are encouraged to use good judgement, especially in the early phases of implementation, to work with families and prescribers to provide care to children AND obtain the necessary documentation to fulfill the legislative intent of the statute.
- The completed form must be presented to the pharmacy with every new prescription for a psychotherapeutic medication. Prescription refills where the original script was filled prior to September 1st will not be denied. However, pharmacies may not add refills to old prescriptions to circumvent the need for an updated informed consent form.
- In order for a prescription claim for a psychotherapeutic medication to pay, the pharmacy must enter the medical certification code “2” to certify that the consent form has been filed with the prescription. This process is similar to the pre-existing family planning “6” and dialysis “8” code requirements.
- The completed form must be filed with the prescription (hardcopy or imaged) in the pharmacy and held for audit purposes, for a minimum of five years.
- Every new prescription will require a new informed consent form. “NEW” means every time a new prescription number is assigned, and includes all new prescriptions including same drug / same dose prescriptions for continuing therapy.
- Prescriptions may be phoned in or emailed for these medications, when the child is less than 13. However, the pharmacist will need to obtain a completed consent form from the prescriber via fax, mail or from the guardian, prior to dispensing.
- If a prescription with remaining refills is transferred to another pharmacv, the consent form should be transferred to the new pharmacy, along with the prescription, to facilitate claim processing. Otherwise the receiving pharmacy should obtain a new consent form.
- The informed consent forms do not replace prior authorization requirements for non-PDL medications or prior authorized antipsychotics for children and adolescents from 0 through 17 years of age.
- Medicaid HMOs have been directed to implement the policy, but may choose to operationalize it in a different manner from Medicaid fee-for-service. They may require something other than a medical certification code.
Link to the forms:
http://ahca.myflorida.com/Medicaid/Prescribed_Drug/med_resource.shtml
August 5, 2011
Informed Consent for Psychotherapeutic Medication Update
Pursuant to statute 409.912(51) The Agency may not pay for a psychotropic medication prescribed for a child in the Medicaid program without the express and informed consent of the child's parent or legal guardian. The physician shall document the consent in the child's medical record and provide the pharmacy with a signed attestation of this documentation with the prescription.
Florida Statute 394.492(3) “Child” means a person from birth until the person’s 13th birthday.
Psychotropic (Psychotherapeutic) Medications include antipsychotics, antidepressants, anti-anxiety medications, and mood stabilizers. Anticonvulsants and ADHD medications (stimulants and non-stimulants) are not included at this time. The generic names of those medications subject to the informed consent are listed below. Please note that diazepam and lorazepam have been removed from the list.
Alprazolam |
Dexmedetomidine
Doxepin |
Midazolam |
Selegiline
|
Effective September 1, 2011, the Bureau of Pharmacy Services will implement this legislative directive as follows:
- The prescriber must complete either the Medicaid “Informed Consent for Psychotherapeutic Medication” attestation form; the Department of Children and Families CF1630 form; or provide the court order for the medication.
- The completed form must be presented to the pharmacy with every new prescription for a psychotherapeutic medication. Prescription refills where the original prescription was filled prior to September 1st will not be denied. However, pharmacies may not add refills to old prescriptions to circumvent the need for an updated informed consent form.
- In order for a prescription claim for a psychotherapeutic medication to pay, the pharmacy must enter the medical certification code “2” to certify that the consent form has been filed with the prescription. This process is similar to the pre-existing family planning “6” and dialysis “8” code requirements.
- The completed form must be filed with the prescription (hardcopy or imaged) in the pharmacy and held for audit purposes, for a minimum of five years.
- Every new prescription will require a new informed consent form.
- Prescriptions may be phoned in or emailed for these medications, when the child is less than 13. However, the pharmacist will need to obtain a completed consent form from the prescriber via fax, mail or from the guardian, prior to dispensing.
- The informed consent forms do not replace prior authorization requirements for non-PDL medications or prior authorized antipsychotics for children and adolescents from 0 through 17 years of age.
- Medicaid HMOs have been directed to implement the policy, but may chose to operationalize it in a different manner from Medicaid fee-for-service. They may require something other than a medical certification code.
Links to the forms:
http://www.dcf.state.fl.us/dcfforms/Search/DCFFormSearch.aspx
http://ahca.myflorida.com/Medicaid/Prescribed_Drug/med_resource.shtml
July 29, 2011
Flu Vaccine Alert for Pharmacies Only
Flu vaccine coverage for adults was expanded over the past couple of seasons because of the H1N1 epidemic. The Prescribed Drug Program is returning to the original pharmacy coverage policy as described below. Only pharmacies that provide service to long term care facilities may bill. Influenza vaccine is limited to one dose per year. Only single dose vials or pre-filled syringes will be reimbursed.
Prescribed Drug Services Handbook:
Immunizations and VaccinesMedicaid prescribed drug services does not reimburse for immunizations and vaccines, except for influenza vaccine limited to one per year per recipient and those specified under the topic, "Covered Services and Limitations for Institutionalized Recipients" in this chapter. Immunizations are available from primary care providers and county health departments.
Coverage and Limitations for Institutionalized Recipients:
Immunizations and VaccinesMedicaid reimburses for influenza and pneumococcus vaccines for institutionalized recipients who do not have Medicare benefits. Influenza vaccine is limited to one per year per recipient. Pneumococcus vaccine is limited to one per lifetime per recipient.
July 28, 2011
HIV/AIDS Diagnoses Verification
Effective August 12, 2011, all incoming pharmacy claims for HIV/AIDS related anti-retroviral medications will require specific HIV/AIDS diagnosis codes in the medical claims history. Recipients who are being treated for Hepatitis B with a medication in this class will need to have the appropriate Hep B diagnosis code in the medical claims history. An appropriate diagnosis code must be found within the past 365 days of the date of the pharmacy claim submission.
HIV/AIDS-related anti-retroviral medications generally remain included on the preferred drug list by statutory exemption. However, the Agency has an obligation to ensure appropriate utilization of medications. Therefore, pharmacy claims for recipients who lack the appropriate HIV/AIDS and/or Hepatitis B diagnosis code(s) in the medical claims file will deny at point-of-sale. Providers are advised to update recipient diagnoses codes when billing for office visits or other related services.
A prior authorization (PA) submission will be required for these denied claims. Providers should fax PA requests on a Miscellaneous PA Request form to (877) 614-1078, except for Fuzeon, Selzentry, and Serostim, which have their own unique forms. The request should be submitted with official medical documentation (i.e. progress notes and laboratory values) verifying the diagnosis. A copy of the prescription for the medication(s) must also be submitted with the PA request.
Forms may be downloaded from:
http://ahca.myflorida.com/Medicaid/Prescribed_Drug/pharm_thera/paforms.shtml
July 28, 2011
Flu Vaccine Reimbursement
Effective immediately, Florida Medicaid reimbursement for influenza vaccines is limited to Medicaid recipients who reside in long term care facilities. Reimbursement is not available for dually eligible (Medicare/Medicaid) recipients because Medicare is their primary payer. Only pharmacies that provide service to long term care facilities may bill. Influenza vaccine is limited to one dose per year. Only single dose vials or pre-filled syringes will be reimbursed.
July 18, 2011
Informed Consent for Psychotherapeutic Medication
Pursuant to statute 409.912(51) The Agency may not pay for a psychotropic medication prescribed for a child in the Medicaid program without the express and informed consent of the child's parent or legal guardian. The physician shall document the consent in the child's medical record and provide the pharmacy with a signed attestation of this documentation with the prescription.
Florida Statute 394.492(3) “Child” means a person from birth until the person’s 13th birthday.
Psychotropic (Psychotherapeutic) Medications include antipsychotics, antidepressants, anti-anxiety medications, and mood stabilizers. Anticonvulsants and ADHD medications (stimulants and non-stimulants) are not included at this time. The generic names of those medications subject to the informed consent are listed below.
Alprazolam
Amitriptyline
Amobarbital
Amoxapine
Aripiprazole
Armodafinil
Asenapine
Bupropion
Buspirone
Butabarbital
Carbamazepine
Chloral hydrate
Chlordiazepoxide
Chlorpromazine
Citalopram
Clomipramine
Clorazepate
Clozapine
Desipramine
DesvenlafaxineDexmedetomidine Diazepam
Doxepin
Droperidol
Duloxetine
Escitalopram
Estazolam
Eszopiclone
Fluoxetine
Fluphenazine
Flurazepam
Fluvoxamine
Haloperidol
Iloperidone
Imipramine
Isocarboxazid
Lithium
Lorazepam
Loxapine
LurasidoneMaprotiline
Meprobamate
Midazolam
Mirtazapine
Modafinil
Molindone
Nefazodone
Nortriptyline
Olanzapine
Oxazepam
Paliperidone
Paroxetine
Pentobarbital
Perphenazine
Phenelzine
Pimozide
Protriptyline
Quazepam
Quetiapine
RamelteonRisperidone
Secobarbital
Selegiline
Sertraline
Sodium Oxybate
Temazepam
Thioridazine
Thiothixene
Tranylcypromine
Trazodone
Triazolam
Trifluoperazine
Trimipramine
Venlafaxine
Vilazodone Zaleplon
Ziprasidone
Zolpidem
Effective September 1, 2011, the Bureau of Pharmacy Services will implement this legislative directive as follows:
- The prescriber must complete either the Medicaid “Informed Consent for Psychotherapeutic Medication” attestation form; the Department of Children and Families CF1630 form; or provide the court order for the medication.
- The completed form must be presented to the pharmacy with every new prescription for a psychotherapeutic medication.
- The completed form must be filed with the hardcopy prescription in the pharmacy and held for audit purposes for a minimum of five years.
- In order for a prescription claim for a psychotherapeutic medication to pay, the pharmacy must enter the medical certification code “2” to certify that the consent form has been filed with the prescription. This process is similar to the pre-existing family planning “6” and dialysis “8” code requirements.
- Pharmacies may not add refills to old prescriptions to circumvent the need for an updated informed consent form.
- Every new prescription will require a new informed consent form.
- The informed consent forms do not replace prior authorization requirements for non-PDL medications or prior authorized antipsychotics for children and adolescents from 0 through 17 years of age.
Links to the forms:
Department of Children and Family Services (DCF) Consent Form
July 7, 2011
Coordination of Benefits / Third Party Liability Claims
Effective July 13, 2011, the OCC codes for COB claims will be updated to ensure proper use.
OCC 0: POS claims will deny if there is a primary payer. The rejection is NCPDP EC 41 – Submit bill to other processor or primary payer.
OCC 1: Where POS claims will deny NCPDP EC 41 – Submit bill to other processor or primary payer with supplemental message: “Contact AHCA TPL recovery unit (877) 357-3268.”
OCC 2: The logic will compare the remaining balance after primary has paid vs. the final calculated claim cost (Medicaid lesser of logic minus what the primary has paid). The claim will pay at the lesser of these 2 values. Pharmacy MUST submit the full amount paid by other payer.
OCC 3: Where POS claims will deny NCPDP EC 41 – Submit bill to other processor or primary payer with supplemental message. “Submit claim on paper with Documentation”
The dispensing pharmacy must determine the reason that the medication is not covered by the primary payer before billing the paper claim to Medicaid. If the primary payer requires a prior authorization, then the pharmacy must work with the prescriber to complete the necessary documentation to bill the claim to the primary payer. If the claim is for an injectable medication, the primary payer may require the beneficiary to use a specialty pharmacy mail-order program. In that case, the beneficiary must be referred to the specialty pharmacy program. Only medications that are not covered by the primary payer because of a benefit limitation and which are covered by Medicaid can be billed via paper claim to Medicaid. For instructions on how to complete a pharmacy claim with a sample of the Universal Claim Form (UCF) please refer to the Prescribed Drug Service s Handbook, Chapter 3.
OCC 4: Where POS claims will deny NCPDP EC 41 – Submit bill to other processor or primary payer with a supplemental message, “Contact AHCA TPL recovery unit (877) 357-3268.”
OCC 5: Where POS claims will deny NCPDP EC 41 – “Submit bill to other processor or primary payer.”
OCC 6: Where POS claims will deny NCPDP EC 40 – Pharmacy not contracted with plan on fill date.
OCC 7: where POS claims will deny NCPDP EC 41 – Submit bill to other processor or primary payer with supplemental message:“Contact AHCA TPL recovery unit (877) 357-3268.”
May 12, 2011
J0641: Levoleucovorin Calcium Injection, 0.5mg; Imported Levoleucovorin use due to Fusilev shortage
In order to manage the ongoing shortage of leucovorin and levoleucovorin, the United States Food and Drug Administration (FDA) has authorized Spectrum Pharmaceutical, Inc. to import and distribute Pfizer Levoleucovorin 100mg Powder for Injection from Italy. Be sure to note that the imported product is a 100mg powder. The product approved in the USA by the FDA is a 50mg powder. Please see the “Dear Healthcare Professional” letter, dated February 1, 2011, from Spectrum Pharmaceutical, Inc. for additional information.
Imported levoleucovorin has been assigned AIC #024659195. However, it has not been assigned an NDC number. Therefore Florida Medicaid has created an NDC number to be used for physician services billing purposes only. We combined the 5 digit labeler code for Spectrum Pharmaceuticals (68512) with the last 6 digits of the AIC number (659195) to create an 11 digit “NDC” number that the HP system can recognize.
When billing levoleucovorin, continue to use J0641. If you are billing for the 50mg vials use NDC 68152-101-00. This is the NDC that is on the vial. If you are billing for the 100mg vials, use NDC 68152659195. The HP system has been modified to accept both NDCs as valid NDCs for J0641.
May 2, 2011
Compounded Sildenafil Suspension
Effective immediately, Revatio will be the only sildenafil agent available for management of pulmonary hypertension.
Prior authorization (PA) requests for compounded Sildenafil suspension will be directed to Revatio (Sildenafil 20mg tabs) instead of Viagra (Sildenafil 100mg tabs). Revatio will still require a prior authorization review for the treatment of pulmonary hypertension. Providers should fax PA requests on a Miscellaneous PA Request form to (877)614-1078.
Forms may be downloaded from: http://ahca.myflorida.com/Medicaid/Prescribed_Drug/pharm_thera/paforms.shtml.
April 8, 2011
HIGH DOSE Antipsychotic Prior Authorization Expansion
Effective April 13, 2011, the “HIGH DOSE Antipsychotic Prior Authorization” initiated for children 6 through 12 years of age on November 23, 2010 will be expanded to include adolescents through 17 years of age.
The high dose limits were determined by an expert panel of child and adolescent psychiatrists in July 2008, and are updated regularly to reflect the most current standard of care. The high dose table is available for review at this Web link: http://medicaidmentalhealth.org/files/Guidelines/high_dosing_table_guide_children2010101502436982.pdf
The following situation is excluded and will continue to be reimbursed without requiring a prior authorization review:
- Antipsychotics that appear on the high dose table linked above,
- AND are currently included on the Preferred Drug List (PDL),
- AND are prescribed at or below the limit found on the high dose table.
Non-PDL antipsychotics and some of the PDL antipsychotics that are not on the high dose table will still require a prior authorization review for children age 6 through 17 years.
IMPORTANT: Early refills may result in false HIGH DOSE (HD) denials. To prevent false HD denials, claims must be submitted on or after the 27th day following the previous paid claim.
Note: All prescriptions for antipsychotics, at all doses, for children less than 6 years will continue to require a prior authorization review by a child psychiatrist.
March 17, 2011
BenzodiazepineTherapy in the Elderly
Benzodiazepines are commonly prescribed to older adults as a sedative and as an anxiolytic agent. With advancing age, elderly persons are more sensitive to the potential side effects of benzodiazepines because of altered pharmacokinetics and pharmacodynamics. Benzodiazepine kinetics have shown that alterations in the distribution and elimination of these agents occur in older patients, leading to the potential for accumulation and prolonged sedation.(1) Numerous studies have shown that benzodiazepines are associated with a variety of adverse outcomes including an increased risk of falls and fractures, motor vehicle accidents and cognitive impairment.(2,3)
It is currently recommended that long-acting agents (diazepam, flurazepam, chlordiazepoxide, and chlorazepate) be avoided in older adults.(4) In addition, daily doses of short-acting benzodiazepines greater than lorazepam 3 mg, alprazolam 2 mg, and temazepam 15 mg should be avoided in older adults.(4) And though their use should be limited to short-term (2 weeks) therapy, many are prescribed on a long-term or chronic basis, leading to an increased risk of dependency. This risk increases with age and is more common among patients diagnosed with depression or alcohol dependency.
Lastly, benzodiazepine dependence is a serious problem among elderly persons. Gradual tapering of these drugs has shown to be effective in reducing withdrawal symptoms that may occur with a “cold turkey” approach to quitting. A review of the literature leads the Agency to conclude that benzodiazepines should be prescribed with caution, at low doses and for short periods of time.
__________________________________
- Greenblatt DJ, Harmatz JS, Shader RI. Clinical pharmacokinetics of anxiolytics and hypnotics in the elderly. Therapeutic considerations (Part I). Clin Pharmacokinet. 1991 Sep;21(3):165-77.
- Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009;169:1952-60.
- Nicholas JG, Pimlott JE, Hux LM, et al: Educating physicians to reduce benzodiazepine use by elderly patients: a randomized controlled trial. Canadian Medical Association Journal 168:835-839, 2003.
- Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003 Dec 8-22;163(22):2716-24.
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Aging Out Notice
Many of Florida’s Medicaid non-disabled recipients “age-out” of the program every year. From 2003 to 2007, national studies showed 4 in 10 (40%) of 19 year olds previously covered by Medicaid programs were uninsured. Although as many as 64% of them were working, they may not have had access to employee-sponsored coverage or may not have been able to afford the premiums.(1) Florida’s economic outlook for 2011 suggests possibly fewer jobs and decreasing state revenues. And like most states, Florida is also facing an increase in Medicaid enrollments for 2011.(2) We encourage providers to speak with recipients who may “age-out” of the program soon regarding resources available to them, including assistance via www.needymeds.com.
_____________________________(1) Kaiser Commission on Medicaid and the Uninsured Publication Number:8057 Publish Date: 2010-03-19.
(2) Excerpts from CBS News (AP) 9/30/2010 online edition “Medicaid Enrollment Spikes to 48 million”.-----------------------------------------------------------------------------------------------------------------------------------------------------
Bisphosphonate Therapy Alert
The FDA is alerting the public to new safety information concerning atypical fractures of the femur occurring in patients using bisphosphonate therapy for osteoporosis. This information suggests a relationship with long-term use (3 to 5 years) of these agents. Subsequently, the FDA is recommending healthcare professionals discuss the known benefits and potential risks of using bisphosphonates with patients, as well as consider periodic reevaluation of the need for continued therapy, particularly in patients who have been treated for over 5 years.(1) Symptoms of hypocalcemia ,serum calcium and serum creatinine should be monitored during therapy with a biphosphonate.(2)
The FDA is also asking providers to report any adverse events attributed to the use of bisphosphonates via FDA’s Medwatch program.
______________________________________
- WWW.FDA.gov: FDA Drug Safety Communication: Safety update for osteoporosis drugs, bisphosphonates and atypical fractures;10-13-2010
- http://www.clinicalpharmacology.com.
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Clonidine Abuse
There have been reports that some patients abuse clonidine to “boost” the effects of opioids, benzodiazepines and cocaine.(1) The risks associated with these drug combinations include extreme alterations in blood pressure, as well as enhanced and prolonged CNS effects. One study indicates some of those patients could be receiving Medicaid services in our state.(2) The Agency for Healthcare Administration encourages providers to discuss the dangers of these drug combinations with their at-risk patients, particularly those prone to substance abuse. It is also important to discuss the possibility of clonidine withdrawal, such as agitation, headaches, sweating and nausea, if the medication is ceased abruptly.(3)
_______________________________(1) Pharmacist’s Letter 2010;vol.26, no. 3.
(2) Anderson F, Paluzzi P, Lee J, et al. Illicit use of clonidine in opiate-abusing pregnant women. Obstet Gynecol 1997;90:790-4.
(3) Dennison, Sylvia. Clonidine abuse among opiate addicts. Psychiatry Quarterly 2001;vol 72:191-195.-----------------------------------------------------------------------------------------------------------------------------------------------------
Comprehensive Heart Failure Guidelines
The use of angiotensin-converting-enzyme (ACE) inhibitors, angiotension-receptor blockers (ARB’s) and beta blockers in patients with heart failure (HF) is supported by The Heart Failure Society of America’s 2010 Comprehensive Heart Failure Practice Guidelines.(1) A retrospective study of Medicare beneficiaries hospitalized with HF showed that outcomes from 2001 to 2005 continued to be poor and changed very little. And due in part to hospitalizations, the estimated cost of managing HF in the U.S. was $39 billion in last year.(2) The direction of pharmacotherapy targeting neurohormonal pathways over the past 2 decades, has lead to the annual mortality in subjects with New York Heart Association (NYHA) class IV HF to dramatically improve from 52% in the seminal consensus trial to less than 20% in more recent trials. Suppression of the renin-angiotensin system (RAS) with various angiotensin-converting enzyme (ACE) inhibitors has been proven to reduce mortality in several clinical trials of CHF.(3) The Agency for Healthcare Administration encourages providers to consider the established clinical guidelines when caring for HF patients, helping improve outcomes for the many Medicaid recipients affected.(4)
____________________________
- www.hfsa.org/hf_guidelines.asp
- Coons J, McGraw M, Murali S. Pharmacotherapy for Acute Heart Failure Syndromes. Amer Jour of Health-System Pharmacy 2011;68(1):21-35
- Jorde, UP. Suppression of the renin-angiotensin-aldosterone system in chronic heart failure: choice of agents and clinical impact. Cardiol Rev. 2006 Mar-Apr; 14(2): 81-7.
- http://guideline.gov/content.aspx?id=23909
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Short-Acting Beta-2 Agonists Limits
The increased utilization of short-acting beta-2 agonists (SABA’s) has been associated with worsening asthma symptoms and the increased risk of death.(1) The excessive, uncontrolled use of drugs in this class contribute to the increasing rates in asthma mortality seen in most countries. International consensus guidelines now generally recommend using short-acting beta-2 agonists only for the relief of symptoms, on an as needed basis.(2) Florida Medicaid has instituted limits on the number of SABA’s that a recipient may receive during one month. We encourage providers to speak with recipients regarding the proper use of short-acting beta-2 agonists for asthma. The Global Initiative for Asthma (GIA) provides guidelines and other resources for providers via www.ginasthma.com.
_________________________________
- Spitzer, WO, Suissa, S, Ernst, P. The Use if Beta-Agonists and the Risk of Death and Near Death from Asthma. N Engl J med 1992; 326:501
- www.nhlbi.nih.gov
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Sedative/Hypnotic and Benzodiazepine Age Limits
Effective March 21, 2011, age limits as approved by the Food and Drug Administration will be applied to the Sedative/Hypnotics and benzodiazepines listed below. Claims for recipients younger than the specified age limits will deny for “Product/Service Not Covered For Patient Age”.
- Ambien (Zolpidem), Halcion (triazolam), Restoril (temazepam), Rozerem (Ramelteon), Lunesta (Eszopiclone), Sonata (Zaleplon) – Age 18
- Dalmane (Flurazepam) - Age 15
- Librium (Chlordiazepoxide), Serax (Oxazepam) - Age 6
- Tranxene (Clorazepate) - Age 9
- Xanax (Alprazolam) - Age 7
- Xanax XR (Alprazolam XR) – Age 18
The prior authorization process is available for those requests for recipients who are younger than the age limits above. Prior Authorization is also required when dose and/or dispense quantities of any Sedative/Hypnotic or benzodiazepine exceed Medicaid Fee-for-Service plan dosage or quantity limitations.
For claims related to an age limit the medical provider may fax a prior authorization (PA) request on a Miscellaneous PA Request form to the Agency for Health Care Administration (AHCA) at (850) 922-0685. For claims related to plan dosage or quantity limitations the PA may be faxed to (877)614-1078.
Forms can be downloaded from http://ahca.myflorida.com/Medicaid/Prescribed_Drug/pharm_thera/paforms.shtml.
March 14, 2011
Studies show there may be risks associated with prolonged use of proton pump inhibitors (PPIs). Some patients on prolonged PPI therapy (at least one year) were reported to have a higher incidence of hip, wrist, or spine fractures.(1) The FDA has recently required this information be added to PPI prescription and OTC labeling.
Another safety concern with the prolonged use of PPIs is infection.(2) A study showed that there was about one case of community-acquired pneumonia for every 226 or more patients treated with a PPI for five months.(3)
PPIs have been proven to be very effective when used appropriately. Patients should be evaluated to determine the appropriateness of PPI therapy (i.e., indication, duration of therapy, etc). For patients who have been on these medications for months at a time, especially patients with gastroesophageal reflux (GERD), it is recommended to taper PPIs before discontinuing them. An antacid or histamine-2 (H2) blocker can be used for breakthrough symptoms if needed.(4)
_______________________________________
- FDA. FDA drug safety communication: possible increased risk of fractures of the hip, wrist, and spine with the use of proton pump inhibitors. May 25, 2010. http://www.fda.gov/Drugs/DrugSafety/
- Vakil N. Acid inhibition and infections outside the gastrointestinal tract. Am J Gastroenterol 2009;104(Suppl 2):S17-20.
- Laheij RJ, Sturkenboom MC, Hassing RJ, et al. Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. JAMA 2004;292:1955-60.
- Björnsson E, Abrahamsson H, Simrén M, Mattsson N, Jensen C, Agerforz P, Kilander A. Discontinuation of proton pump inhibitors in patients on long-term therapy: a double-blind, placebo-controlled trial. Aliment Pharmacol Ther. 2006 Sep 15;24(6):945-54. http://onlinelibrary.wiley.com/
February 8, 2011
Medicaid Pharmacy Services is pleased to announce the Florida Pediatric Psychiatry Consult Hotline. This valuable new service is administered by the Florida Medicaid Drug Therapy Management Program for Behavioral Health located at the Florida Mental Health Institute (FMHI) at the University of South Florida. The call line serves prescribing clinicians who have questions about the medical care of children and adolescents with psychiatric needs.
To find out more about this new program, click on the link provided below:
Florida Pediatric Psychiatric HotlineLinks to this and other behavioral health medication management resources are available on the main Medicaid Pharmacy Services Web page at:
http://ahca.myflorida.com/Medicaid/Prescribed_Drug/index.shtml
January 19, 2011
The Bureau of Pharmacy Services recently published an updated fee schedule for injectable medications administered in physician offices. The Bureau has received a number of requests related to the calculations used to create the fee schedule. The calculations are defined in Florida Statute 409.908(14).
Section 14: (14) A provider of prescribed drugs shall be reimbursed the least of the amount billed by the provider, the provider’s usual and customary charge, or the Medicaid maximum allowable fee established by the agency, plus a dispensing fee. The Medicaid maximum allowable fee for ingredient cost will be based on the lower of: average wholesale price (AWP) minus 16.4 percent, wholesaler acquisition cost (WAC) plus 4.75 percent, the federal upper limit (FUL), the state maximum allowable cost (SMAC), or the usual and customary (UAC) charge billed by the provider…
The Bureau of Pharmacy Services inserted the Medicare B reimbursement rate as the federal upper limit for these medications. At this time, the state maximum allowable program (SMAC) is applied only to prescriptions filled in pharmacies, not medications provided in physician’s offices.
Bureau staff will continue to review and update pricing in as timely a manner as possible.
January 12, 2011
An updated physician injectable medication fee schedule has been published to the Provider Fee Schedules Web page.
Fee schedule pricing and coverage policy for physician administered drugs has been assigned to the Bureau of Medicaid Pharmacy Services. Reimbursement rates for physician administered drugs have been calculated based upon mathematical formulas similar to those used to reimburse pharmacies. These formulas acknowledge the impact of generic competition when product patents expire.
Therefore, a number of reimbursement rates dropped significantly since the last fee schedule update; some reimbursement rates increased, some remained nearly the same, and some drug codes disappeared from the fee schedule because of product discontinuation from the marketplace.
Pharmacy Services looked to the Centers for Medicare and Medicaid Services (CMS) for approval to allow physician office settings to utilize C-codes for newly FDA approved medications. CMS indicated that utilizing C-Codes for physician office settings was at our discretion. As a result, effective immediately, we will begin using the C-codes to speed claims processing and reduce the number of claims in the J3490/J9999 manual claims review queue. If this doesn’t resolve the issues, we can return to the J3490/J9999 billing processes.
If you have any questions, please forward to:
Kiyoe Hebert, Govt Analyst II, Bureau of Pharmacy Services
Phone: 850-412-4150
Email: Kiyoe.Hebert@ahca.myflorida.comAnne C. Wells, Pharm.D. MS, Bureau Chief, Medicaid Pharmacy Services
Phone: 850-412-4146
Email: Anne.Wells@anca.myflorida.com
2010
November 8, 2010
Effective immediately, Medicaid Pharmacy Services requires the use of the most current Suboxone/Subutex prior authorization form with all Suboxone/Subutex requests. Instructions and standards for reviewing a prior authorization are included on the form, as well as contact information for submission.
To access the current Medicaid prior authorization form and instructions, click on the link below: http://ahca.myflorida.com/Medicaid/Prescribed_Drug/pharm_thera/paforms.shtml.
The current form reflects the Substance Abuse and Mental Health Services Administration (SAMHSA) consensus and evidence-based treatment improvement protocol (TIP 40); Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction.
To access this protocol click on: http://www.buprenorphine.samhsa.gov/Bup_Guidelines.pdf
October 22, 2010
Effective November 3, 2010, antipsychotic prescriptions for children age 6 through 12 years will require a prior authorization review when the dose exceeds high dose limits established by the Medicaid Drug Therapy Management Program for Behavioral Health. Doses exceeding those found on the high dose table will be reviewed by a child psychiatrist.
The high dose limits were determined by an expert panel of child and adolescent psychiatrists in July 2008, and are updated regularly to reflect the most current standard of care. The high dose table is available for review at this Web link: http://flmedicaidbh.fmhi.usf.edu/pdf/guidelines/child/high_dosing_table_guide_children.pdf
The following situation is excluded and will continue to be reimbursed without requiring a prior authorization review:
- Antipsychotics that appear on the high dose table linked above,
- AND are currently included on the Preferred Drug List (PDL),
- AND are prescribed at or below the limit found on the high dose table.
Non-PDL antipsychotics and some of the PDL antipsychotics that are not on the high dose table will still require a prior authorization review for children age 6 through 12 years.
Note: All prescriptions for antipsychotics, at all doses, for children less than 6 years will continue to require a prior authorization review by a child psychiatrist.
September 17, 2010
Coverage through physician services for the following HCPCS codes was recently updated as follows:
- Mirena J7302, $703.05, effective date 4/1/2010
- Implanon J7307, $627.04 effective date 7/1/2010
Effective 9/23/2010, neither Mirena nor Implanon will be billable to Medicaid through specialty pharmacies. Physician offices wishing to provide these contraceptive products for Medicaid recipients should plan to purchase the contraceptive products for office stock, and bill for the product and professional service fee through physician services.
If you have any questions, please contact your area office.
August 4, 2010
Interactive prior authorization forms are now available on the Medicaid Pharmacy Services website. The new user friendly forms are designed to be downloaded to your computer for the convenience of typing information into the form to be printed out, signed by the provider, and faxed to the fax number on the form. Please note that the PDF format does not allow the user to save information in the form or to email the completed form. To access the new forms click on the link below:
http://ahca.myflorida.com/Medicaid/Prescribed_Drug/pharm_thera/paforms.shtml
July 15, 2010
Effective August 3, 2010, a maximum of four prescriptions of medications defined by Federal Controlled Substances will be allowed per 30 days without a prior authorization. Claims over the maximum limit of four prescriptions (multiple drugs & multiple strengths) per 30 days will deny for “Limit 4 duplicate prescriptions per 30 days.”
This represents an enhancement to programming logic that was initiated in August 2009.
This enhancement includes all medications and combinations of medications listed in Federal Schedules CIII-CV, including but not limited to:
- All narcotics on Federal Schedules CIII-CV
- Narcotic containing cough preparations
- Benzodiazepines
- Sleep agents (Zolpidem and similar agents)
- Carisoprodol
- Lyrica
- Suboxone and Subutex
The prior authorization process is available for those requests which exceed the monthly limit of four (4) prescriptions per 30 days.
Prior Authorization is also required for the following:
- When dose and/or dispense quantities of any of the above listed medications exceed Medicaid Fee-for-Service plan limitations.
- For Carisoprodol, Suboxone, Subutex, and any other medications that are not on the Medicaid Preferred Drug List (PDL).
May 19, 2010
Effective June 2, 2010, the maximum number of narcotic prescriptions defined by Federal Controlled Substance, Schedule II (multiple drugs and multiple strengths) that will be allowed per month without a prior authorization will be as follows:
- Oncology and sickle cell patients can receive up to six (6) CII prescriptions per month. The prior authorization process is available for recipients whose pain management needs exceed the monthly limit of six (6) CII narcotic prescriptions.
- All other pain management patients can receive up to four (4) CII prescriptions per month. The prior authorization process is available for recipients whose pain management needs exceed the monthly limit of four (4) CII narcotic prescriptions.
The edit includes all CII narcotic medications and all combinations of short-acting; long-acting and prior authorized CII narcotics.
April 26, 2010
The Medicaid pharmacy service recently implemented new programming at the fiscal agent (First Health) to automate prior authorization of brand name anticonvulsant medications for patients who are not seizure-free on generic anticonvulsants. The programming allows patients with seizure disorders to be maintained on brand anticonvulsants if the prescribing physician writes “Brand Medically Necessary” on the prescription. The programming also requires patients with other diagnoses, such as migraine headaches or bi-polar disorder, to be transitioned to generic medications.
One of the main technical requirements is for patients to have updated diagnosis codes (ICD9) in the medical claims file. The programming is able to query medical claims for the previous 365 days for a wide range of ICD9 codes consistent with seizure disorders. Medicaid pharmacy service is asking providers to be sure to submit ICD9 codes with medical claims to facilitate this new prior authorization program, as well as others that will be developed in the future.
The majority of anticonvulsants will be subject to prior authorization through the automated process. However, the following anticonvulsants are not on the preferred drug list, and will continue to be subject to a manual (paper-based) prior authorization. These include: Diastat; Lamictal XR; Lamictal ODT; Keppra XR; Vimpat; Banzel; Stavzor; and Sabril.
March 8, 2010
On January 13, 2009, the Medicaid P&T Committee voted to remove Xopenex nebulizer (Inhalation) for children less than the age of six years from the Medicaid Preferred Drug List. Xopenex for children older than six years of age and adults remains off the PDL, along with Xopenex HFA.
Levalbuterol is the R-isomer of racemic Albuterol (RS-albuterol). R-albuterol is primarily responsible for beta-2 adrenergic receptor mediated bronchodilation, while the S-albuterol appears to have no pharmacologic activity. When given in equimolar doses of R-albuterol (i.e., 2.5 mg of racemic albuterol or 1.25 mg of levalbuterol), levalbuterol produces bronchodilation and clinical activity similar to the parent drug (racemic albuterol). Additional studies further demonstrate that R-albuterol is not superior to racemic albuterol with respect to systemic effects. Systemic effects are a direct result of the amount of R-albuterol delivered. Therefore, the equivalent doses of racemic albuterol (instead of levalbuterol), a smaller amount of R-albuterol, or both should be administered, whichever delivers a lesser amount of R-albuterol with proper efficacy and minimal systemic effects. Therefore, Florida Medicaid is recommending that providers:
- Prescribe the correct, therapeutically equivalent dose of racemic albuterol as compared to the Xopenex dose:
- 2.5mg/3ml Albuterol = 1.25mg/3ml Xopenex
- 1.25mg/3ml Albuterol = 0.63mg/3ml Xopenex
- 0.63mg/3ml Albuterol = 0.31mg/3ml Xopenex
- Reduce the nebulization therapy time of Albuterol Sulfate to 5 minutes.
- Instruct on the use Albuterol HFA with a spacer - AND/OR -
- Ensure that there is combined maintenance therapy (eg. inhaled corticosteroid) in the existing medication regimen to obtain the desired therapeutic effects.
March 4, 2010
Effective March 15, 2010, pharmacists will no longer be allowed to use the codes listed below to override pharmacy claims that are rejected because of a high (excessive) dose warning (HD-88 DUR reject).
When the submitted dose per day is in excess of maximum dosing limits defined by First Data Bank, the pharmacy claim will reject, and the medical provider will have to fax a prior authorization (PA) request on a Miscellaneous PA Request form to the Agency for Health Care Administration (AHCA) at (850) 922-0685.
Forms: http://ahca.myflorida.com/Medicaid/Prescribed_Drug/pharm_thera/paforms.shtml
Miscellaneous PA Request: Most non-PDL medications and high dose requests Medication specific forms: Required for some medications (for example, Oxycontin, Vfend, Valcyte, and Procrit)
Providers must add sufficient medical documentation (progress notes, etc.) to justify all types of prior authorization requests.
| Intervention/Professional Service Code/Description | Outcome/Result of Service Code |
| 00/no intervention | 1A/filled as is, false positive |
| M0/prescriber consulted | 1B/filled prescription as is |
| P0/patient consulted | 1C/filled with different dose |
| R0/pharmacist consulted other source | 1D/filled with different directions |
| 1E/filled with different drugs | |
| 1F/filled with different quantity | |
| 1G/filled with prescriber approval | |
| 2A/prescription not filled | |
| 2B/not filled, directions clarified |
January 8, 2010
Effective February 24, 2010, Seroquel immediate release tablets will be removed from the Florida Medicaid Preferred Drug List (PDL) for Medicaid recipients 18yrs and older. This applies to adult recipients only. Seroquel immediate release tablets will remain on the PDL for recipients less than 18yo. Prior authorization will continue to be required when prescribing any antipsychotic medication for a child less than 6yo.
January 8, 2010
Effective February 1, 2010, a maximum of six (6) prescriptions of a narcotic that is a Federal Controlled Substance, Schedule II (multiple drugs and multiple strengths) will be allowed per 30 days without a prior authorization. Claims over the maximum limit of six CII narcotic prescriptions (multiple drugs & multiple strengths) per 30 days will deny for “Limit 6 duplicate prescriptions per 30 days.” The plan limitation includes all CII narcotic medications and all combinations of short-acting, long-acting, and prior authorized CII narcotics. The prior authorization process is available for those requests which exceed the monthly limit of six CII narcotic prescriptions.
