Remittance Advice Provider Alerts
Follow this link for historical Provider Alerts.
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.
2009
December 10, 2009
The optimal quantity of units (Sildenafil 20, 25, 50, 100 mg tablets) should be used when compounding Sildenafil Suspension for pediatric pulmonary hypertension patients. For example, if a daily dose of 100 mg is required at 3000 mg per month, then 30 of the 100 mg tablets should be used in compounding the allotted monthly supply, rather than 150 of the 20 mg tablets.
November 19, 2009
Effective November 30, 2009, a maximum of four prescriptions of an opiate that is a Federal Controlled Substances, Schedules III-V (multiple drugs and multiple strengths) will be allowed per 30 days without a prior authorization. Claims over the maximum limit of four opiate prescriptions (multiple drugs & multiple strengths) per 30 days will deny for “Limit 4 duplicate prescriptions per 30 days.” The prior authorization process is available for those requests which exceed the monthly limit for opiate prescriptions.
This represents an enhancement to the programming logic that was implemented in August 2009.
August 11, 2009
Effective August 24, 2009, a maximum of four prescriptions of an opiate that is a Federal Controlled Substances, Schedules III-V, same drug & strength, will be allowed per 30 days without a prior authorization. Claims over the maximum limit of four opiate prescriptions (same drug & strength) per 30 days will deny for “Limit 4 duplicate prescriptions per 30 days.” The prior authorization process is available for those requests which exceed the monthly limit for opiate prescriptions.
May 11, 2009
Effective May 20, 2009, successful adjudication of a pharmacy claim will require the Medicaid recipient’s date of birth submitted in the date of birth (DOB) data field be accurate with regard to birth month and birth year. The submitted birth month and birth year must match the birth month and birth year that is on the Medicaid eligibility file. This date of birth edit will prevent claim adjudication until the correct (or matching) birth month and birth year is entered in the DOB data field. This will be a “hard edit” and overrides will not be possible.
For important details please review the following: Date of Birth Edit.
March 13, 2009
Pharmacy claims for compounds and Total Parental Nutritions (TPNs) must be submitted for reimbursement as compound claims. These claims can be submitted Point of Sale or manually using the Universal Claim Form. The ingredients in compounds and TPN claims can no longer be billed individually. Please refer to the Payer Specification Manual at http://ahca.myflorida.com/Medicaid/Prescribed_Drug/current_info.shtml. For additional instructions contact Medicaid Pharmacy Services at (850) 487-4441.
January 21, 2009
Notice to Broward, Duval, Nassau, Baker and Clay Counties:
Updated billing instructions for the Enhanced Benefits Reward$ Program (EBA) are now available on the Agency for Health Care Administration (AHCA) website: http://ahca.myflorida.com/Medicaid/medicaid_reform/enhab_ben/enhanced_benefits.shtml.
