Supplies testing supplies.
All diabetic supply claims submitted to Medicaid will deny when recipients are Medicare Part B eligible. Medicare Part B covers diabetic supplies for all diabetic recipients regardless of insulin requirements. Pharmacy providers shall submit these claims to the Medicare DMERC. These claims will then
automatically cross-over to the Medicaid fiscal intermediary for payment of the coinsurance and deductible amounts, where applicable.
Diabetic supplies and glucometers for long term care recipients are not covered in the Medicaid Pharmacy Program or through prior authorization because they are covered in the nursing home per diem rate.
It is allowable for Medicare Part B to be billed if the long term care recipient is eligible for the benefit. Medicaid is not obligated to pay the coinsurance and deductible if the items are included in the Medicaid per diem. The Medicaid fiscal intermediary will automatically deny any crossover claims for diabetic supplies for long term care recipients.
Note: Refer to Section 37.7 Medicare Prescription Drug Coverage for detailed
information.
37.5.7 DRUGS WITH SPECIAL PAYMENT CRITERIA/LIMITATIONS,
continued
________________________________________________________________ Fertility Agents Fertility preparations, when they are used solely for the treatment of infertility,
are not reimbursable. The drugs include Clomiphene citrate tablets 50mg, Urofollitropin ampules 75IU, and Menotropins ampules 150IU and 75IU. If prescriptions for these products are prescribed for any indications other than infertility, the physician shall certify the indication, in his own handwriting, on the prescription. In order for the pharmacist to be reimbursed for the product, a hard copy claim along with a copy of the original prescription will have to be submitted to the fiscal intermediary for processing indicating a diagnosis other than infertility.
________________________________________________________________ Isotretinoin Isotretinoin capsules will be covered only if a handwritten prescription signed
by the prescribing practitioner, with no provisions for refills, is submitted. ________________________________________________________________ Ketorolac Pharmacy claims for oral forms of ketorolac will deny for a quantity greater than
twenty (20) or the days supply is greater than five (5) days as exceeding the program‘s maximum allowed. The pharmacist may override the denial after consultation with the prescriber. The prescriber must supply the ICD-9-CM diagnosis code and the rationale for using greater than a five days supply of ketorolac. The ICD-9-CM diagnosis code is required for the claim submission.
Note: Refer to Appendix D Point of Sale User Guide for detailed billing
information.
________________________________________________________________ Nicotine Transdermal Nicotine transdermal patches, nicotine polacrilix gum, and nicotine spray are Patches,Gum and Spray covered only with a handwritten prescription signed by the prescribing
practitioner. There are no provisions for refills. The physician will need to rewrite a prescription each time.
Also, physicians must certify, in their own handwriting, either directly on the prescription or on an attachment to the prescription that the recipient is enrolled
in a physician-supervised behavioral program in order for Medicaid to provide coverage for nicotine adhesive patches, gum and spray. Pharmacy providers should verify that the above noted documentation is written on or attached to the prescription when the prescription is dispensed.
This information must be retained by the pharmacy as evidence of compliance with program policy, and it must be readily retrievable when requested by audit staff.
SECTION: 37.5 COVERED SERVICES, LIMITATIONS AND EXCLUSIONS___
37.5.7 DRUGS WITH SPECIAL PAYMENT CRITERIA/LIMITATIONS,
continued
________________________________________________________________ Orlistat Medicaid will provide reimbursement to outpatient pharmacies for orlistat
prescriptions based on the following criteria:
An authorized prescriber has hand written the prescription - no facsimiles allowed;
Patient is twelve years of age or older;
Only original prescriptions—no refills are allowed;
Maximums of ninety (90) capsules and thirty (30) days supply;
Patient has a documented current body mass index (BMI) of twenty-seven (27) or greater and the prescriber had identified the BMI, in his/her handwriting, on the dated prescription or a dated and signed attachment to the prescription;
Patient has other risk factors warranting the use of Orlistat and the prescriber has identified an approved ICD-9-CM diagnosis code in his/her handwriting, on the dated prescription or a dated and signed attachment to the prescription; and
No provisions for override of the prospective drug utilization edits, i.e., early refill (ER) and duplicate drug (ID) editing.
The following risk factors, as identified by ICD-9-CM numeric codes only, are acceptable:
ICD-9-CM Code Description
250.00 through 250.93 Type II Diabetes
271.3 Impaired Glucose Tolerance
251.0 through 251.2 Hyperinsulinemia 272.0 through 272.4 Dyslipidemia 401.00 through 405.99 Hypertension
410.00 through 414.99 Ischemic Heart Disease
429.2 Cardiovascular Disease, unspecified
440.00 through 440.90 Atherosclerosis
443.00 through 443.90 Other peripheral vascular diseases 530.11 and 530.81 Gastric Reflux Disease
715.05 through 715.97 Osteoarthritis of Hips/Knees 780.51, 780.53 and 780.57 Sleep Apnea
430.00 through 438.99 Cerebrovascular Disease
348.2 Pseudotumor cerebri
454.2 Varicose Veins of the lower extremities
with ulcer and inflammation
451.0 Phlebitis & Thrombophlebitis of the superficial vessels of the lower extremities 451.11 Phlebitis & Thrombophlebitis of the femoral
37.5.7 DRUGS WITH SPECIAL PAYMENT CRITERIA/LIMITATIONS,
continued
________________________________________________________________ Orlistat, continued ICD-9-CM Code Description
451.19 Phlebitis & Thrombophlebitis of other deep vessels
451.2 Phlebitis & Thrombophlebitis of lower extremities, unspecified
454.0 Varicose veins of lower extremities, with ulcer
454.1 Varicose veins of lower extremities, with
inflammation
454.9 Varicose veins of lower extremities, without mention of ulcer & inflammation
The prescriber identified ICD-9-CM diagnosis code must be included in the claim submission. The required supporting documentation for coverage must be retained by the pharmacy as evidence of compliance with program policy, and it must be readily retrievable when requested by audit staff.