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HomeMy WebLinkAboutMH-207 Reimbursement for Psychiatric Medications1 FRANKLIN/FULTON COUNTY MENTAL HEALTH/INTELLECTUAL & DEVELOPMENTAL DISABILITIES/EARLY INTERVENTION 425 Franklin Farm Lane Chambersburg, PA 17202 (717) 264-5387 MH/IDD/EI PROCEDURE STATEMENT PROCEDURE SUBJECT: Reimbursement for Psychiatric Medications PROCEDURE NUMBER: MH-207 Effective Date: December 1, 2003 Date Revised: January 24, 2022 Reference: 55 PA Code Chapter 4220, Reimbursement for Medication, August 1985 PURPOSE: To establish policies and procedures for prescribing, dispensing and payment of medications used solely for the treatment of diagnosed mental illness, for individuals funded by the MH/IDD/EI Program. PROCEDURE: Requirements:  A medication must be prescribed by a Practitioner licensed by the State to prescribe medications; be specifically for the mental health diagnosis under treatment; and, be on the MH/IDD/EI Medication Formulary for it to be reimbursed by the MH/IDD/EI Program. The MH/IDD/EI Administrator can approve exceptions with a clear clinical rationale from the prescriber. Requests for exceptions are to be submitted in writing to the MH/IDD/EI Administrator to include justification as to why this medication is needed over a medication that is on the formulary.  All third party revenues must be exhausted before MH/IDD/EI funds can be used for medication reimbursement; this includes the pharmaceutical manufacturers’ indigent programs and patient assistance programs (PAPs). If a Patient Assistance Program is available, MH/IDD/EI will pay for no more than two (2) months of that medication, prior to the person being approved for the PAP.  All pharmacies must be licensed by the State Board of Pharmacy to receive reimbursement.  Individuals must be open for services with a Base Service Unit (BSU) [Service Access & Management, Inc. (SAM) or TrueNorth Wellness Services] at the time of requesting medications and for the duration of receiving medication coverage. (If an individual is closed by either BSU, they will be closed in Express Scripts). 2 Limitations: A listing of MH/IDD/EI approved reimbursable medications is attached. This Medication Formulary includes available generic medications approved by the Federal Government. This list is reviewed and revised at least two (2) times per year to address any changes in PAP coverage or generic medications. Individuals Eligible to Receive MH/IDD Prescriptions:  Individuals must not be eligible for any other insurance or prescription plan/reimbursement, full or partial, or available patient assistance program (PAP).  Any individual who has a liability abatement and/or diagnostic abatement by the MH/IDD/EI Administrator. (A diagnostic liability abatement may be requested by a clinician/ psychiatrist/ physician in writing to the MH/IDD/EI Administrator, if it is determined that the individual should not be held responsible for his/her liability prior to getting prescriptions filled. See MHIDD-302 Individual Financial Liability, for more information.)  Eligible individuals will have an Express Scripts card or receive a 30 day medication letter. A prescription written for someone without a card will not be reimbursed without a prior authorization letter. Base Service Unit Responsibilities:  It is the responsibility of Service Access & Management, Inc. (SAM) or True North Wellness Services Case Manager to see that: o All third party payees have been exhausted and proof is in the individual’s case file, in the form of a letter from his/her insurance company or other proof before authorizing for MH/IDD/EI paid prescriptions. o The individual has a MA denial on file or has applied for Medical Assistance. (In the event that the individual does not have a MA denial, but has submitted a MA application, the individual will only be authorized for medications for 60 days until a MA denial is received). o They follow the Express Scripts/30 Day Med Letter process that is sent to them by the Administrative Officer. This process provides further detail regarding the expectations and process of medication requests. For the Prescribing Psychiatrist or Physician:  For any individual eligible for MH/IDD/EI payment of medications, the physician may prescribe any medication, but only those on the formulary will be reimbursed unless an exception is made as stated above under “purchase of medications”. If there are any questions regarding an individual’s eligibility, the provider should contact the MH/IDD/EI office prior to prescribing a medication.  All medications must be prescribed in generic form, if available. If an individual is unable to tolerate the generic form of the medication, that information must be included on the prescription in order for the name brand to be dispensed. Name brands require a 3 prior authorization. To save the individual time at the pharmacy, a physician’s office may notify the MH/IDD/EI office that a prescription for a name brand has been written. For the Dispensing Pharmacist/Pharmacy:  The pharmacist must fill the prescriptions with only the medications listed on the Medication Formulary. MH/IDD/EI will not reimburse for any medication that is not written according to the formulary guidelines. There are exceptions that can be made with approval from the MH/IDD/EI Administrator.  The pharmacist must collect the individual’s co-pay of $4.00, established by MH/IDD/EI, for each filled prescription.  In addition, per Center for Medicare and Medicaid Services (CMS) regulation as documented in MA Bulletin 99-11-05, Provider Screening of Employees and Contractors for Exclusion from Participation in Federal Health Care Programs and the Effect of Exclusion on Participation, we are unable to make payment to any provider who has not followed the bulletin. Therefore, when a pharmacy submits a bill, they must also submit a statement verifying that all pharmacy employees have been checked on all three (3) exclusion and debarment websites for the month in which the medication was dispensed. If this statement is not included with the submitted bill, we will be unable to process payment. Pharmacy and Therapeutic Review Committee: In the event that the annual amount spent on pharmaceuticals meets the $50,000 threshold, a Pharmacy and Therapeutic Review Committee (PTRC) will be created. At this time, MH/IDD/EI does not meet that threshold. Instead, MH/IDD/EI contracts with a pharmaceutical consultant who reviews the formulary annually and as needed.  The goal of the consultant or the Pharmacy and Therapeutic Review Committee (if applicable) will be to ensure cost benefit and sound practice in the MH/IDD/EI Medication Program, as well as permit flexibility and accessibility by individuals to this program.  The following quality control/functions will be performed by the MH/IDD/EI staff, with the assistance of the consultant or PTRC as needed: › Periodic review of the Medication Program for patterns of over-utilization or medication abuse by individuals, inefficient and costly methods of dispensing medications and/or non-compliance with guidelines. › Review the Medication Formulary and generic/brand dispensing and prescribing. › Meetings will be held as needed. Any problems identified will be shared with all parties involved through letters or personal contacts. Any unresolved conflicts will be discussed with the consultant or PTRC at a special meeting that will be called. › If the consultant or PTRC is unable to meet, a survey will be sent requesting any suggestions, comments or difficulties associated with this procedure. The MH/IDD/EI Administrator will be responsible for coordinating this activity as well as making any changes to the current procedure. ATTACHMENT: MH/IDD/EI Medication Formulary 4 FRANKLIN/FULTON MH/IDD/EI MEDICATION FORMULARY The following medications will be covered in generic form only. The name brand is listed only for easy reference. A physician may request an exception to this by writing “Name Brand Only” on the prescription pad, but a name brand medication requires a prior authorization through Express Scripts (MH/IDD/EI must have a copy of the prescription written to provide a prior authorization). Name Brand Generic Name (required) Abilify Aripiprazole Adderall XR Amphetamine-Dextroamphetamine Ativan Lorazepam Concerta Methylphenidate HCI Depakote and ER Divalproex Sodium Effexor and XR Venlafaxine IR/ER Klonopin Clonazepam Lexapro Escitalopram Restoril Temazepam Thorazine Chlorpromazine Trileptal Oxcarbazepine Wellbutrin, SR & XL Bupropion HCI Xanax Alprazolam 5 FRANKLIN/FULTON MH/IDD/EI Medications covered by patient assistance programs (and, therefore, requiring a prior authorization) Brand Name Generic Name PAP Invega Paliperidone Johnson & Johnson Strattera Atomoxetine HCl Lilly Cares Vyvanse Lisdexamfetamine dimesylate Shire The above medications require a prior authorization by MH/IDD/EI. MH/IDD/EI will provide up to two (2) months of "bridge" payment while a person is applying for a Patient Assistance Program (PAP).  Many PAPs allow the discharging prescriber to complete the application. In those instances to qualify for "bridge" coverage, the discharging prescriber must provide the base service unit (BSU) a copy of the completed PAP application and submit the PAP accordingly.  In instances where the PAPs require that the medications be received by the prescriber who completed the PAP (i.e., mental health inpatient upon discharge cannot complete the PAP as the individual will be going to an outpatient clinic and the outpatient clinic must receive the medications), individuals can qualify for “bridge” coverage if the discharging provider begins the PAP application, sends the PAP application to the base service unit as verification that it was started, and sends the PAP application to the provider that will be utilized upon discharge. The provider receiving the PAP application will complete the remaining portion of the application and submit it accordingly.  A person denied for a Patient Assistance Program may request an exception to the formulary so that the generic version of the medication would be covered by MH/IDD/EI. In order to do this, MH/IDD/EI must receive a letter from the physician explaining why no other medication in the same category is acceptable for this person.