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Coverage of Anticonvulsant Medications
The purpose of this provider alert is to clarify Florida Medicaid’s coverage requirements for anticonvulsant medications.Florida Medicaid reimburses for generic, brand name, and non-preferred brand name anticonvulsant medications as follows:
For more detailed information about the specific anticonvulsant medications that are listed on the Florida Medicaid Preferred Drug List (PDL), please visit: http://ahca.myflorida.com/medicaid/Prescribed_Drug/pharm_thera/pdf/PDL.pdf. (Pages 86-94 lists the anticonvulsant medications.)
Medicaid health plans must cover non-preferred brand name medications when medically necessary. The provision of services to recipients enrolled in a Medicaid health plan must not be subject to more stringent service coverage limits than specified in Florida Medicaid policies. For additional information, please contact the health plan directly.
Announcement of New Pharmacy Reimbursement Methodology Implementation
The Centers for Medicare and Medicaid Services final rule (CMS-2345-FC) pertaining to Medicaid reimbursement for covered outpatient drugs in the fee-for-service delivery system required states to submit a State Plan Amendment (SPA) with an effective date of no later than April 1, 2017. The SPA relates to the reimbursement methodology and a new pharmacy professional dispensing fee.
Once the SPA was approved, a new reimbursement methodology was promulgated into rule to meet this federal requirement. Rule 59G-4.251, Florida Administrative Code can be found in this link: https://www.flrules.org/gateway/ruleno.asp?id=59G-4.251.
Florida Medicaid will begin reimbursing pharmacy providers using the new methodology on June 15, 2018. A subsequent provider alert will outline the plan for scheduling the reprocessing of pharmacy claims retroactive to April 1, 2017 in order to comply with the approved SPA.
Florida Medicaid Pharmacy Providers Billing of 340B Purchased Drugs
Florida Medicaid pharmacy providers who dispense drugs purchased under the 340B program are reminded to do the following:FEE-FOR-SERVICE (FFS) PROVIDERS
For assistance, FFS providers may call the Florida Medicaid Pharmacy Technical Help Support Line at 1-877-603-1714.HEALTH PLANS / PHARMACY NETWORK PROVIDERS / ENCOUNTER CLAIMS
This Submission Clarification Code is in addition to the mandatory value of “9” currently required on pharmacy encounter claims.
Health plans’ pharmacy network providers, may contact the plans directly for assistance.
Codeine and Hydrocodone Cough & Cold Containing Products
The U.S. Food and Drug Administration (FDA) is requiring labeling changes for codeine and hydrocodone containing prescription cough and cold medicines to limit their use to recipients 18 years of age and older due to their risks outweighing their benefits in recipients younger than18 years of age. Additionally, the FDA is also requiring safety information about the risks of misuse, abuse, addiction, overdose, death, and slowed or difficult breathing be added to the boxed warning of these products.
Florida Medicaid, in response to the FDA safety guideline recommendations, will adopt the minimum age limitation of 18 years of age on codeine and hydrocodone containing prescription cough and cold medicines, effective May 14, 2018. The list of FDA recommended products are included as a reference below.List of Prescription Cough and Cold Medicines Containing Codeine:
Source: U.S. Food & Drug Administration
Substance Use Disorder Treatment Options and Prevention
Governor Rick Scott has declared the opioid epidemic a state of emergency in Florida (see Executive Order 17-146). In response to the opioid crisis, the Agency for Health Care Administration (Agency) is implementing provisions under the Florida Medicaid program to assist in the prevention and treatment of substance use disorders.
Medication-assisted treatment combines behavioral health therapy and medications to treat substance use disorders. Florida Medicaid covers an array of behavioral health therapies and prescribed drugs (e.g., Naltrexone, Buprenorphine, Methadone, etc.) to treat substance use disorders and does not limit the length of time recipients may receive treatment.
Additional Changes Related to Prescribed Drugs:
Florida Medicaid has or will implement the following additional changes to prescribed drugs benefit:
For recipients enrolled in a Medicaid health plan, services are reimbursed by the plan in accordance with their established agreements/contracts with network providers. In no instance may the health plan impose limitations or exclusions more stringent than those specified in Florida Medicaid coverage policies. In any instance when compliance with provisions in the Florida Medicaid promulgated rules in Chapter 59G, F.A.C. conflicts with the terms of the health plan contract, the contract prevails. For additional information, please contact the plan directly.
Influenza Antiviral Treatment
Florida Medicaid covers brand name Tamiflu capsules for all ages and Tamiflu suspension for recipients 12 years of age and under. Due to the increased influenza activity levels across the state and to allow greater access to antiviral treatment for eligible Florida Medicaid recipients who are experiencing onset of illness from the influenza virus, Florida Medicaid has added coverage of the generic formulation of Tamiflu which is Oseltamivir. Oseltamivir capsules for all ages and Oseltamivir suspension for recipients ages 12 and under, will now be covered through May 1, 2018.
The Centers for Disease Control and Prevention recommends antiviral treatment be administered as early as possible after influenza illness onset. Ideally, treatment should be initiated within 48 hours of symptom onset. However, antiviral treatment initiated later than 48 hours after illness onset can still be beneficial for some patients.
For recipients enrolled in a Medicaid health plan, prescribed drug services are reimbursed by the plan in accordance with their established agreements/contracts with network providers. In no instance may the health plan impose limitations or exclusions more stringent than those specified in Florida Medicaid Coverage Policies. For additional information, please contact the plan directly.
New Requirement for Billing Immunizations Codes
Effective October 1, 2017, Florida Medicaid providers who administer vaccines to Florida Medicaid recipients ages 0 through 20 years, will be required to submit both, the vaccine product Current Procedural Terminology (CPT) code as well as the vaccine administration CPT code on the claim in order to receive reimbursement from Florida Medicaid through the fee-for-service delivery system. If more than one vaccine is administered during the same visit, each vaccine code and an administration code for each vaccine must be submitted on the claim form.
Florida Medicaid providers who receive vaccine products through the Vaccine For Children program for recipients ages 0 through 18 years are eligible to receive reimbursement for the administration of the vaccine from Florida Medicaid. The vaccine product code will be reimbursed at $0.00, and the vaccine administration code will be reimbursed in accordance with Rule 59G-4.002, Florida Administrative Code (F.A.C.).
Florida Medicaid providers who administer vaccines to recipients ages 19 and 20 years, must also include both CPT codes on the claim. Florida Medicaid providers will receive reimbursement for the vaccine product plus the administration fee for each vaccine in accordance with Rule 59G-4.002, F.A.C.
The following vaccine administration CPT codes (for ages 0 through 20 years) have been added to the 2017 Immunization Fee Schedule for billing purposes in the Florida Medicaid Management Information System:
For recipients enrolled in a health plan, Medicaid services are billed directly to the health plan using their established policies. For additional information, please contact the plan directly.
Proton Pump Inhibitors Prolonged Use
In 2011, the Food and Drug Administration (FDA) stated that available data showed that patients at highest risk for fractures were those who received high doses of prescription proton pump inhibitors (PPIs) or used a PPI for one year or longer. The FDA also communicated through a drug safety bulletin that patients treated with PPIs for longer than five months were at higher risk of infections and that long-term use of PPIs could be associated with lower magnesium levels. The Agency for Health Care Administration (Agency) published a Medicaid health care alert on April 1, 2011 with this information, along with revised coverage guidelines based upon the FDA recommendations.
The purpose of this alert is to notify prescribers and pharmacies of an exception to the daily dosing limits of PPIs that has been recommended by the Agency’s Drug Utilization Review (DUR) Board. The DUR Board recommended that patients with a history of Barrett’s esophagus, bariatric surgery, gastric or esophageal malignancy, or hypersecretory condition (such as Zollinger/Ellison), be automatically approved for chronic therapy (longer than six months). An automatic prior authorization is in place to override the 6-month limit for patients who meet the above criteria.
Providers prescribing PPIs in excess of the limits, and for other diagnoses specified above, will be required to submit a prior authorization request to the Agency’s pharmacy benefits manager if the recipient is receiving services through the fee-for-service delivery system. Please refer to the clinical criteria posted on the Agency’s website: http://ahca.myflorida.com/Medicaid/Prescribed_Drug/drug_criteria.shtml.
For recipients enrolled in a health plan, prescribers should contact the health plan directly for prior authorization requirements for PPIs.
New Oral Metoclopramide Safe Dosing Limitations
Metoclopramide carries a black box warning regarding the risk of tardive dyskinesia, which may be irreversible. The risk of developing tardive dyskinesia increases with duration of treatment and total cumulative dose. Treatment with metoclopramide for longer than 12 weeks should be avoided in all but rare cases where therapeutic benefit is thought to outweigh the risk of developing tardive dyskinesia.
Beginning October 2016, the Agency for Health Care Administration (Agency) will be implementing the following limitations for oral metoclopramide:
Providers prescribing oral metoclopramide in excess of the limits specified above will be required to submit a prior authorization request to Magellan Medicaid Administration, Inc. if the recipient is receiving services through the fee-for-service delivery system.
For recipients enrolled in a health plan, prescribers should contact the health plan directly for prior authorization requirements for this drug.
Codeine Restrictions for Recipients Under the Age of Six Years
During the June 27, 2015, Drug Utilization Review (DUR) Board meeting, the DUR members recommended that the Agency for Health Care Administration (Agency) consider updating the coverage of codeine-containing products for children under the age of 6 years by following the Food and Drug Administration (FDA) recommendations. The Agency accepted the DUR Board’s recommendation.
In February 2013, the FDA added a contraindication and boxed warning regarding the risk of codeine-containing products for pediatric post-operative pain management following tonsillectomy and/or adenoidectomy. (http://www.fda.gov/Drugs/DrugSafety/ucm339112.htm) In addition, both the American Academy of Pediatrics and the American College of Chest Physicians recommend against the use of codeine to treat cough in pediatric patients. The FDA is also investigating the possible risks of codeine-containing cough and cold preparations in children under the age of18 years. (http://www.fda.gov/Drugs/DrugSafety/ucm453125.htm) To address these safety concerns, products containing codeine will now be restricted for Florida Medicaid recipients who are under the age of six years.
Pharmaceutical & Therapeutics Board Committee Meeting Postponement
The Agency for Health Care Administration (Agency) has postponed the Pharmaceutical & Therapeutics Committee meeting scheduled for Friday, September 25, 2015 in Tampa, Florida. The Agency will post information when the meeting has been rescheduled.Thank you and we apologize for any inconvenience.
Epinephrine Auto-Injectors Preferred Drug Status Change
The Pharmaceutical and Therapeutics (P&T) Committee recommended at the June 26, 2015 meeting, to add Auvi-Q® 0.3mg and 0.15mg (epinephrine auto-injectors) to the Florida Medicaid Preferred Drug List (PDL) and to remove EpiPen® 0.3 mg 2-Pak and EpiPen® Jr. 0.15mg 2-Pak auto-injectors from the PDL. The Agency for Health Care Administration has accepted the P&T Committee’s recommendation. However, in order to facilitate this transition for prescribers, pharmacies, and patients, the Agency will continue to reimburse for EpiPen® and EpiPen Jr. ® without the need for prior authorization through September 22, 2015.
Here are available resources which may assist individuals in becoming more familiar with the Auvi-Q® auto injector delivery system:
J7302 for Liletta and Mirena Intra-Uterine Contraceptive Devices
Liletta, a new intra-uterine contraceptive device, is now covered by Florida Medicaid. This device contains the same main ingredient as Mirena, (levonorgestrel). Both products have been assigned the same HCPC code, J7302. For that reason, a modifier will be used to distinguish Liletta from Mirena.
When billing for Liletta, use J7302 and modifier SC.
When billing for Mirena, continue to use J7302.
Coverage Change for Palivizumab (Synagis®)
Effective July 1, 2015, the maximum number of palivizumab prophylaxis doses reimbursed for eligible recipients under the age of two will be five doses per respiratory syncytial virus (RSV) season.
This change aligns with the current American Academy of Pediatrics (AAP) updated guidance for palivizumab prophylaxis for RSV infection and was approved by the Florida Medicaid Drug Utilization Review Board at the June 27, 2015 meeting.
The remaining eligibility criteria for palivizumab prophylaxis of RSV will remain unchanged and may be viewed on the Agency for Health Care Administration’s website in the Synagis Criteria [238KB PDF].
The current AAP guidelines may be viewed at http://pediatrics.aappublications.org.
**Update to Inhaled Corticosteroids Age Limits Alert**
Beginning May 1, 2015, the Agency will adhere to the National Institutes of Health (NIH) minimum age limit guidelines on inhaled corticosteroids (ICS). Please view the chart below for the age limits of these ICS:
|Brand Name||Generic Name||Prescribing Information
- Minimum Age (years)
Please refer to http://ahca.myflorida.com/medicaid/Prescribed_Drug/preferred_drug.shtml for a list of the preferred ICS.
Spacer Devices for Inhalers
Effective immediately, all spacers will be reimbursed only through the Durable Medical Equipment (DME) Service. Pharmacies may bill Healthcare Common Procedure Coding System (HCPCS) code A4627 (“SPACER, BAG OR RESERVOIR, WITH OR WITHOUT MASK, FOR USE WITH METERED DOSE INHALER”) using their DME provider number. Medicaid reimburses for one spacer a year for all ages. For additional DME information, please call at 1-800-289-7799.
Principles of Long Acting Opioid Utilization
The Drug Utilization Review Board recently examined the use of opioid medications in Florida Medicaid recipients. If the use of chronic opioid therapy is deemed appropriate, guidelines recommend starting with a low dose, short acting, as needed opioid and individualizing the dosing.[i] The use of long acting opioids is generally reserved for chronic, persistent pain requiring around-the clock dosing in opioid tolerant patients. Inappropriate prescription practices have been shown to be a contributor to the rising prescription drug abuse problem in the United States.[ii] Overlapping use of more than one long acting opioid is a potentially inappropriate prescription practice that may be associated with adverse outcomes related to opioid usage.
[i] Nuckols TK, Anderson L, Popescu I, et al. Opioid Prescribing: A Systematic Review and Critical Appraisal of Guidelines for Chronic Pain Ann Intern Med 2014;160:38-47
[ii] Liu Y, Logan JE, Paulozzi LJ, et al. Potential Misuse and Inappropriate Prescription Practices Involving Opioid Analgesics Am J Manag Care 2013;19(8):648-658
Pharmacy System Retroactive Pricing
Drug manufacturers may increase their medications’ prices at any time throughout the year. In some instances, the effective date of the price change is loaded retroactively in the Florida Medicaid pharmacy system, which means that pharmacy providers could be underpaid for a claim after the price change is updated in the system. This is a reminder that pharmacies have one year from the date of service to reverse and rebill claims in order to receive the correct payment from Florida Medicaid. Please note this only applies to pharmacy claims for recipients not enrolled in a managed care plan.
Skeletal Muscle Relaxants
Skeletal muscle relaxants are a heterogeneous group of medications. Based on their mechanism of action, FDA labeled indications and clinical practice; they can be divided into two main categories.
Antispastics used to treat spasticity from upper motor neuron syndromes such as cerebral palsy and multiple sclerosis. Chronic therapy with these agents, including baclofen and tizanidine may be warranted in some patients with chronic spasticity. The other category is antispasmodics which are indicated for muscle spasm associated with acute painful musculoskeletal conditions unrelated to the central nervous system. The most commonly prescribed antispasmodic agents are carisoprodol, cyclobenzaprine, metaxolone, and methocarbamol. These agents do not act on motor neurons or on the muscle itself. Their mode of action is primarily in the brain and perhaps spinal reflexes to relax skeletal muscles by unknown mechanisms. Therapy with these agents should be utilized only for short periods (treatment beyond 2-3 weeks is not recommended) because adequate evidence of effectiveness for prolonged use has not been established. All skeletal muscle relaxants are associated with adverse effects including dizziness and drowsiness. In comparison trials, no single agent has been proven to be superior to another.
Below is a table indicating the typical starting dosages as well as the FDA approved maximum dosage.
|Medication||Typical Starting Dose||FDA Maximum Dose|
|Baclofen||5 mg three times daily||80 mg|
|Parafon Forte(chlorzoxazone)||500 mg four times daily||3,000 mg|
|Flexeril (cyclobenzaprine)||5 mg three times daily||30 mg|
|Amrix (cyclobenzaprine ER)||15 mg once daily||30 mg|
|Skelaxin (metaxalone)||800 mg 3-4 times daily||3,200 mg|
|Robaxin (methocarbamol)||1,500 mg four times daily||8,000 mg|
|Zanaflex* (tizanidine)||4 mg three times daily||36 mg|
Statin Therapy in Diabetics - A look at recent guidelines
According to the 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults, a high level of evidence supports the use of moderate-intensity statin therapy in persons with diabetes 40 to 75 years of age.  The ACC/AHA expert panel found extensive and consistent evidence (Level I) supporting the use of statins for prevention of atherosclerotic cardiovascular disease (ASCVD) in individuals with diabetes aged 40-75 years with LDL-C 70 to 189 mg/dL and without clinical ASCVD (primary prevention). Diabetics between the ages of 40 and 75 with an LDL-C 70-189 mg/dL were one of four groups identified where the ASCVD risk reduction benefit achieved with statin therapy clearly exceeded the potential for adverse events. Recently published “Standards of Medical Care in Diabetes- 2014” by the American Diabetes Association state that statin therapy should be initiated, regardless of baseline lipid levels in diabetic patients with overt cardiovascular disease (CVD) (Grade A).  Furthermore, statin therapy should also be initiated in diabetic patients without CVD who are over the age of 40 years and have one or more other CVD risk factors including family history of CVD, hypertension, smoking, dyslipidemia or albuminuria (Grade A). These guidelines also suggest most adult patients with diabetes should have a fasting lipid profile measured at least annually. A recent review of Florida Medicaid recipient claims data revealed more than 60,000 diabetic patients between the ages of 40-75 were not receiving a statin and two thirds of all Florida Medicaid diabetes patients had not received a lipid profile in the last year. Prescribers are encouraged to discuss the risks and benefits of statin therapy in their diabetic patients between ages 40-75.
As always, lifestyle modifications (healthy eating, weight control, increased physical activity) remain a critical component of health promotion and ASCVD risk reduction, both prior to and in concert with the use of cholesterol-lowering drugs.
The ACC/AHA cholesterol guidelines are not intended to be a comprehensive approach to lipid management for purposes other than ASCVD risk reduction. Guidelines attempt to define practices that meet the needs of patients in most circumstances and are not a replacement for clinical judgment. The ultimate decision about care of a particular patient must be made by the healthcare provider and patient in light of the circumstances presented by that patient. As a result, situations might arise in which deviations from these guidelines may be appropriate. These considerations notwithstanding, in caring for most patients, clinicians can employ the recommendations of these guidelines confidently to reduce the risks of atherosclerotic cardiovascular disease events in their diabetic patients.
1 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Available at: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.citation Accessed August 28, 20142American Diabetes Association Position Statement Standards in Medical Care in Diabetes Diabetes Care 2014; 37:S14-S80; doi: 10.2337/dc14-S014 Available at: http://care.diabetesjournals.org/content/37/Supplement_1 Accessed August 28, 2014.
Antibiotic Utilization for Upper Respiratory Tract Infections
As we approach cold and flu season in Florida, prescribers are reminded of the importance of judicious use of antibiotics in the treatment of upper respiratory tract infections in both pediatric and adult patients. The Centers for Disease Control and Prevention (CDC) has developed a “Get Smart” campaign (http://www.cdc.gov/getsmart/index.html) to address sound utilization of antibiotics in order to curb the epidemic of antibiotic resistance. Specifically, one of the initial activities of the CDC’s Get Smart campaign was to collaborate with various medical societies to develop guidelines for appropriate antibiotic use in upper respiratory tract infections. The following links provide appropriate antibiotic treatment summaries for prescribers.
A recent publication in the journal “Pediatrics” defines three principles of judicious antibiotic principles for pediatric upper respiratory tract infections.[i] The first principle is to the determine the likelihood of a bacterial infection, the second principle is to weigh the benefits versus harms of antibiotics and the third principle is to implement judicious prescribing strategies, specifically noting the rates of pneumococcal resistance to macrolides and oral third-generation cephalosporins make these agents poor choices for treating most children with suspected bacterial URIs.
Data specific to the southeastern United States show that Streptococcus pneumoniae susceptibility to azithromycin was 55.9 percent (based on 68 isolates) in 2006 and had fallen to 40.4 percent susceptibility (based on 94 isolates) in 2010. [ii]
iHersh AL, Jackson MA, Hicks LA, et al. Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics. Pediatrics 2013; 132: 1146-1154 DOI: 10.1542/peds.2013-3260
ii Antimicrobial Resistance Management Program University of Florida Available at: http://www.armprogram.com/TrendCrystalReport.aspx?Region=SouthEast&OrganismID=1 Accessed August 25, 2014
Lunesta Safety Alert - Next Day Impairment
On May 15, 2014, the U.S. Food and Drug Administration (FDA) issued a warning that the insomnia drug Lunesta (eszopiclone) can cause next-day impairment of driving and other activities that require alertness. As a result, the recommended starting dose of Lunesta is being decreased to 1 mg at bedtime.
A study of Lunesta found that the previously recommended dose of 3 mg may cause impairment to driving skills, memory, and coordination that can last more than 11 hours after receiving an evening dose. Patients were often unaware they were impaired.
Women and men are equally susceptible to impairment from Lunesta; therefore, the reduction in initial dosing is the same for both genders. If an increase in dosing is warranted to either 2 mg or 3 mg, there may be higher incidences in next-day impairment of driving and other activities that require full alertness. Patients should exercise extreme caution when taking a 3 mg dose. It is strongly advised against driving or engaging in other activities that require complete mental alertness the day after use.
Effective November 21, 2012, Chantix was added to the preferred drug list (PDL), with minimum age limitations of 18 years and quantity limits of two tablets per day. Ninety days (twelve weeks) of therapy are allowed without a prior authorization (PA). After ninety days of continuous therapy, a PA is required for an additional ninety days (twelve weeks) of therapy. A nicotine/cotinine lab test (blood or urine only) must be submitted with the prior authorization request, to verify that the patient is still abstinent from smoking. To prevent an interruption in therapy, the providers should submit prior authorization requests and the required test results prior to the completion of the initial 12-week treatment course.
Recipients are limited to one treatment cycle of 180 days every two years.
The recommended dose of Chantix is 1 mg twice daily following a 1-week titration, for twelve weeks. An additional 12-week treatment course is recommended to increase the likelihood of long-term abstinence from smoking.
Additional smoking cessation products covered by Florida Medicaid include nicotine patches, nicotine gum, and Zyban (bupropion) tablets. Reimbursement for these products are limited to twenty-four weeks duration per 365 days, or the manufacturer’s recommendation (whichever is less).
Smoking cessation information and resources are available at the following websites:
Update: Leukemia Drug Iclusig (ponatinib) Returns to Market
On October 31, 2013, at the request of the Food and Drug Administration (FDA), Ariad Pharmaceuticals suspended marketing and sales of the oral kinase inhibitor Iclusig (ponatinib) due to the risk of life-threatening blood clots and severe narrowing of blood vessels. The manufacturer of Iclusig has implemented new safety measures required by the FDA.
New safety measures for Iclusig include a risk evaluation and mitigation strategy (REMS), updated medication guide and revised label changes narrowing the indication for specific patient populations, updated dosage recommendations, and warnings about the potential risk of vascular occlusion and cardiac failure.
Biologics Inc., an integrated oncology service company has been selected by Ariad Pharmaceuticals to be the exclusive specialty pharmacy provider of Iclusig and the manager of its Patient Access and Support Services (PASS) Program. For information related to accessing the medication providers may contact Ariad PASS Program at 1-855-447-PASS (7277) or visit the website.
End of the Enhanced Benefits Program
Dear Pharmacies who participate with Enhanced Benefits (EB). The EB program will be ending in Baker, Clay, Duval and Nassau counties May 1, 2015 and in Broward county July 1, 2015. At those times beneficiary EB accounts will be brought to $0 and no OTC product purchases will be allowed. As we get closer to those times, AHCA will provide updates. For more information regarding this update please visit the Enhance Benefits Reward$ Program web page.