Amerigroup pharmacy benefit manager companies

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Respiratory Therapy Equipment. Apnea Monitoring. Chinstrap used with CPAP. Headgear used with CPAP. Oxygen And Related Respiratory Equipment. Oxygen Concentrator. Oxygen Concentrator, Portable. Portable Gaseous Oxygen System. Respiratory Suction Pumps.

Respiratory Suction Pumps - Supplies. Volume Ventilators And Supplies. Respiratory Therapy Supplies. Nebulizer Compressors and Supplies. Aerosol Mask, used with Nebulizer. Nebulizer, with Compressor. Aerosol Compressor, Battery Powered, Nebulizer. Peak Flow Meter. Steam Inhalers. Tracheostomy Care. Tracheostomy Tubes. Tracheostomy Care Supplies. Tracheostomy Care Kit. Tracheostomy Cleaning Brush. Tracheostomy Mask. Tracheostomy Shower Protector. Tracheostomy Tubes - Misc. Urological Supplies.

Catheters - Miscellaneous. Catheter Kits. Catheters with Syringe. Foley Catheters, 2-way. Foley Catheters, 2-Way Coude. Foley Catheters, 3-way. Insertion Trays with Drainage Bag but without Catheter.

Intermittent Catheters, Coude Tip. Intermittent Catheters, Straight Tip. Male External Catheter, Reusable. Male External Catheters. Pessary Devices, Pessaries. Vaginal Urinary Collection. Irrigation Supplies. Asepto Bulb Syringes. Catheter Syringes. Irrigation Bulb Syringe. Karaya Gum Ostomy. Adhesive Bandages. Adhesive Tape. Compression Bandages. Conforming Bandages, Non-Sterile. Conforming Bandages, Sterile. Foam Dressing, Wound Cover. Gauze Bandages Rolls.

Gauze Eye Pads. Transparent Dressings. Topical Products. Becaplermin Regranex Gel. Bismuth Tribromophenate-Petrolatum Xeroform. Calcium Alginate. Collagen Matrix Fenestrated Porcine.

Collagen Matrix Meshed Porcine. Control Gel Formula Dressing Duoderm. Cultured Skin Substitute. Hydroactive Dressings. Silver-Carboxymethylcellulose Sodium. Wound Care Drainage Supplies. Wound Cleansers. Wound Dressing Adhesive. Wound Dressings. Zinc Impregnated Bandage Unna Boot. Home Medical Equipment. Ambulatory Walking Aids. Bath and Toilet Aids. Canes and Crutches. Decubitis Care Equipment. Patient Room Equipment and Accessories.

Physical Therapy. Power Wheelchairs and Scooters. Wheelchairs and Accessories. Bath And Toilet Aids. Shower Accessories. Canes, Fixed And Adjustable. Crutches Underarm, Other Than Wood. Crutches Underarm, Wood. Forearm Crutches. Pressure Reducing Support Surfaces - Group 1. Pressure Reducing Support Surfaces - Group 2. Wheel Chair Cushions.

Hospital Beds. Hospital Bed Accessories. Lift Chairs and Patient Lifts. Phototherapy Equipment and Accessories. Home Ultraviolet Light Therapy Panel 6 sq ft. Traction Therapy. Power Scooters. Power Scooters Accessories. Power Wheelchairs. Power Wheelchairs Accessories.

Power Wheelchairs Batteries and Chargers. Transport Chairs. Wheelchairs Accessories. Inotuzumab ozogamicin Besponsa procedure code J is a benefit of Texas Medicaid for clients who are 18 years of age and older with prior authorization. Besponsa is indicated for the treatment of relapsed or refractory precursor B-cell acute lymphoblastic leukemia ALL. Prior authorization approval for Besponsa intravenous injection procedure code J will be considered when all of the following criteria are met:.

Besponsa is not a benefit for patients who have hepatic veno-occlusive disease. Interferons are a family of naturally-occurring proteins that are produced by cells of the immune system. Three classes of interferons have been identified: alfa, beta, and gamma. Each class has different effects, though their activities overlap. Once interferons have detected and attacked a foreign substance, they alter it by slowing, blocking, or changing its growth or function.

The following interferon procedure codes are benefits of Texas Medicaid:. Interferon Alfa-2B procedure code J may be indicated for, but is not limited to, treatment of the conditions listed below:. Interferon Gamma-1B procedure code J may be indicated for, but is not limited to, treatment of the following:. Interferon Beta-1A procedure codes J, Q, and Q , and Interferon Beta-1B procedure code J may be indicated for, but are not limited to, treatment of relapsing forms of multiple sclerosis.

Iron is a hematinic, essential to the synthesis of hemoglobin to maintain oxygen transport and to the function and formation of other physiologically important heme and non-heme compounds. Ferric derisomaltose procedure code J may be indicated for, but is not limited to, treatment of iron deficiency anemia for adult clients with:. Ferric carboxymaltose procedure code J may be indicated for, but is not limited to, treatment of iron deficiency anemia for the following:. Iron Dextran injection procedure code J may be indicated for, but is not limited to treatment of Iron deficiency anemia when oral administration is unsatisfactory or impossible.

Iron Sucrose injection procedure code J may be indicated for, but is not limited to treatment of iron deficiency anemia for the following conditions:. Sodium Ferric Gluconate Complex injection procedure code J may be indicated for, but is not limited to treatment of Iron deficiency anemia in clients who are six years of age or older who are undergoing long term hemodialysis treatments and who are receiving supplemental epoetin therapy.

Ferumoxytol injection procedure code Q may be indicated for, but is not limited to treatment of Iron deficiency anemia in adults who have chronic kidney disease CKD. Authorization is not required for iron injections. Retrospective review may be performed to ensure documentation supports the medical necessity for the service being billed.

The following procedure codes must be used to submit claims for injections into joints:. Procedure Codes for Joint Injections. The following procedure codes must be used to submit claims for trigger point injections:. Procedure Codes for Trigger Point Injections. These procedures are valid only in the treatment of acute problems. Procedures billed for reimbursement with chronic diagnosis codes are denied.

The provider must use the AT modifier to indicate an acute condition. The cost of the injection does not include the drugs used. The drug can be reimbursed separately. Multiple joint injections may be reimbursed when billed with the same date of service if the claim indicates the specific site of each injection.

The first injection or aspiration is reimbursed at the full profile allowance and any subsequent injections are reimbursed at half allowance. Lefamulin procedure code J is a benefit of Texas Medicaid for clients who are 18 years of age or older. Procedure codes J, J, or J may be reimbursed for leuprolide acetate injections with the following limitations:. Procedure code J may be reimbursed in monthly, three-month, four-month, and six-month doses as follows:.

Billed with a quantity of 3 Reimbursed once every three months. Lumasiran procedure code J is a benefit of Texas Medicaid for clients when billed with diagnosis code E Belimumab Benlysta is indicated to treat the following:. Initial therapy for anifrolumab-fnia Saphnelo may be approved for a month duration if all the following criteria are met:. Initial therapy for belimumab Benlysta may be approved for a month duration if all the following criteria are met:.

For renewal or continuation therapy for anifrolumab-fnia Saphnelo , the client must meet the following criteria:. For renewal or continuation therapy for belimumab Benlysta , the client must meet the following criteria:. Luspatercept-aamt Reblozyl procedure code J is a benefit of Texas Medicaid with prior authorization. Luspatercept-aamt Reblozyl is restricted to clients who are 18 years of age or older, and may be approved for treatment of the following:.

For initial prior authorization requests for Luspatercept-aamt Reblozyl , the client must be 18 years of age or older and meet the following criteria:. For renewal or continuation of therapy, the client must meet the initial age and diagnosis criteria, in addition to the following requirements:.

Meloxicam procedure code J is a benefit of Texas Medicaid for clients who are 18 years of age or older. Vestronidase alfa-vjbk Mepsevii procedure code J is a benefit of Texas Medicaid for pediatric and adult clients with prior authorization.

Vestronidase alfa-vjbk Mepsevii may be approved for a duration of every 12 months per prior authorization request. For initial therapy, the following criteria must be met:. For renewal or continuation of therapy, the following criteria must be met:. Mogamulizumab-kpkc Poteligeo procedure code J is a benefit of Texas Medicaid. Mogamulizumab-kpkc Poteligeo procedure code J may be approved for a duration of every 12 months.

Prior authorization for initial therapy using mogamulizumab-kpkc Poteligeo infusion will be considered when all of the following criteria are met:. One of the following diagnosis codes must be submitted with procedure code J if the diagnosis is mycosis fungoides:. Diagnosis Codes for Mycosis Fungoides.

For renewal or continuation of therapy, the client must meet all the following requirements:. Omalizumab may be a benefit of Texas Medicaid when medically necessary with prior authorization. Omalizumab procedure code J is an injectable drug that is FDA-approved for the following treatments:. Benralizumab procedure code J is a benefit of Texas Medicaid for clients who are 12 years of age and older with prior authorization.

Benralizumab is an injectable drug that is FDA-approved and indicated for the treatment of clients who are 12 years of age and older and have severe asthma with an eosinophilic phenotype. Mepolizumab procedure code J is a benefit of Texas Medicaid when medically necessary with prior authorization. Mepolizumab is an injectable drug that is approved by the FDA and indicated for the following treatments:.

Reslizumab procedure code J is a benefit of Texas Medicaid when medically necessary with prior authorization. Tezepelumab-ekko procedure code J is a benefit of Texas Medicaid when medically necessary with prior authorization. Tezepelumab-ekko is an injection drug that is FDA-approved and indicated as an add-on maintenance treatment of adult and pediatric clients who are 12 years of age and older with severe asthma.

When requesting prior authorization, the exact dosage must be included with the request using omalizumab procedure code J , benralizumab procedure code J , mepolizumab procedure code J , reslizumab procedure code J , or tezepelumab-ekko procedure code J Prior authorization for omalizumab Xolair will be considered for the following:.

Prior authorization for mepolizumab Nucala will be considered for the following:. Prior authorization for tezepelumab-ekko Tezspire will be considered for the following:. Tezepelumab-ekko is not to be used as a single or primary therapy. Documentation supporting medical necessity for treatment of asthma with omalizumab, benralizumab, mepolizumab, reslizumab, or tezepelumab-ekko must be submitted with the request and must indicate the following:.

Consideration for these exceptions will be reviewed by the TMHP medical director. Prior authorization approvals for omalizumab, benralizumab, mepolizumab, reslizumab, or tezepelumab-ekko are for intervals of six months at a time. Clients must be compliant with their omalizumab, benralizumab, mepolizumab, reslizumab, tezepelumab-ekko regimen in order to qualify for additional prior authorizations.

The provider must submit a statement documenting compliance with the requests for each renewal. Treatment of benralizumab, mepolizumab, or reslizumab may not be used concurrently with omalizumab or any other interleukin-5 antagonist. The following additional documentation for treatment with mepolizumab must also be submitted:.

The following additional documentation for treatment with omalizumab also must be submitted:. The following additional documentation for treatment with benralizumab must also be submitted with the initial prior authorization request:.

The following additional documentation for treatment with reslizumab must also be submitted:. After lapses in treatment of 3 months or greater, prior authorization requests submitted with documentation will be reviewed by the TMHP medical director. Requests for clients who do not meet the above criteria will be reviewed for medical necessity by the TMHP medical director. Client continues to meet the initial authorization approval for tezepelumab-ekko and has not had any hypersensitivity reactions or unacceptable adverse events, such as helminth infection, due to the therapy.

Client experienced positive clinical response to therapy as demonstrated by no increase in asthma exacerbations or improvement in asthma symptoms. Procedure codes J, J, J, J, and J may not be billed in any combination for the same date of service by any provider. Providers may not bill for an office visit if the only reason for the visit is an omalizumab, benralizumab, mepolizumab, reslizumab, or tezepelumab-ekko injection.

Moxetumomab pasudotox-tdfk Lumoxiti procedure code J is a benefit of Texas Medicaid when indicated for the treatment of relapsed or refractory hairy cell leukemia in adults who have received at least two prior systemic therapies, including treatment with a purine nucleoside analog PNA. Prior authorization is required for moxetumomab pasudotox-tdfk Lumoxiti procedure code J Prior authorization may be granted for a duration of 6 months 6 cycles. Prior authorization approval for moxetumomab pasudotox-tdfk Lumoxiti infusion will be considered if all the following criteria are met:.

Nivolumab and relatlimab-rmbw procedure code J is a benefit of Texas Medicaid for clients who are 12 years of age or older. Onasemnogene abeparvovec-xioi Zolgensma is a benefit of Texas Medicaid, with prior authorization.

Claims for onasemnogene abeparvovec-xioi Zolgensma must be submitted with unlisted procedure code J Onasemnogene abeparvovec-xioi Zolgensma procedure code J is limited to one treatment per lifetime, per client. Onasemnogene abeparvovec-xioi Zolgensma is a one-time infusion therapy indicated for the treatment of a client who meets all of the following requirements:.

Onasemnogene abeparvovec-xioi Zolgensma is not a benefit for clients with a tracheostomy or invasive ventilator support. Onasemnogene abeparvovec-xioi Zolgensma must be prescribed by, or in consultation with, a board-certified neurologist or pediatric neurologist who is familiar with the diagnosis and management of spinal muscular atrophy.

To be considered for the approval of a one-time intravenous infusion, prior authorization requests for onasemnogene abeparvovec-xioi Zolgensma unlisted procedure code J must be submitted with a Special Medical Prior Authorization SMPA Request Form. The prior authorization request for an onasemnogene abeparvovec-xioi Zolgensma single-dose intravenous infusion must include documentation of all of the following:.

Providers must also complete the following to administer the drug:. However, it is not a prerequisite of therapy and should not delay treatment.

If nusinersen Spinraza procedure code J or risdiplam Evrysdi have been previously prescribed, the prescriber must provide documentation of one of the following before switching to onasemnogene abeparvovec-xioi Zolgensma therapy:.

Panhematin procedure code J is a benefit of Texas Medicaid and is limited to diagnosis code E Patisiran Onpattro is a benefit of Texas Medicaid with prior authorization for the treatment of the polyneuropathy of hereditary transthyretin-mediated hATTR amyloidosis in adults.

Prior authorization requests for patisiran Onpattro procedure code J must be submitted with a Special Medical Prior Authorization SMPA Request Form and may be approved for 12 months per prior authorization request. Plasminogen human-tvmh Ryplazim procedure code J is a benefit of Texas Medicaid and is limited to diagnosis code E Plazomicin procedure code J is a benefit of Texas Medicaid for clients who are 18 years of age or older.

Rilonacept procedure code J is a benefit of Texas Medicaid for clients who are 12 years of age or older. Risperidone procedure code J is a benefit of Texas Medicaid for clients who are 18 years of age or older. Rituximab-abbs Truxima procedure code Q is a benefit of Texas Medicaid for clients who are 18 years of age or older. Romosozumab procedure code J is a benefit of Texas Medicaid for clients who are 18 years of age or older.

Sirolimus protein-bound particles Fyarro procedure code J is a benefit of Texas Medicaid for clients who are 18 years of age or older. Sutimlimab-jome Enjaymo procedure code J is a benefit of Texas Medicaid for clients who are 18 years of age or older.

Tagraxofusp-erzs Elzonris procedure code J is a CD directed cytotoxin indicated for the treatment of blastic plasmacytoid dendritic cell neoplasm BPDCN in adults and pediatric clients who are 2 years of age and older.

Tagraxofusp-erzs Elzonris procedure code J is a benefit of Texas Medicaid with prior authorization. Prior authorization is required for tagraxofusp-erzs Elzonris procedure code J and may be approved for a duration of every 12 months.

Prior authorization approval for tagraxofusp-erzs Elzonris infusion will be considered once all of the following criteria are met for initial therapy:. Tebentafusp-tebn Kimmtrak procedure code J is a benefit of Texas Medicaid for clients who are 18 years of age or older. Teprotumumab-trbw Tepezza procedure code J is a benefit of Texas Medicaid and prior authorization is required. Teprotumumab-trbw Tepezza is indicated for the treatment of thyroid eye disease TED.

The client must meet all of the following requirements for approval of Teprotumumab-trbw Tepezza :. Teprotumumab-trbw Tepezza should not be used in pregnancy as it may potentially lead to fetal loss. Females of reproductive potential should use effective contraception prior to initiation, during treatment with Teprotumumab-trbw Tepezza and for 6 months after the last dose of Teprotumumab-trbw Tepezza.

Thyrotropin alpha for injection Thyrogen procedure code J is a benefit of Texas Medicaid and is limited to the following diagnosis codes:. Tildrakizumab procedure code J is a benefit of Texas Medicaid for clients who are 18 years of age or older, and is limited to diagnosis code L Procedure code J is a benefit of Texas Medicaid.

Reimbursement for this drug is considered when it is used as a single agent for the treatment of clients who have metastatic breast cancer whose tumors overexpress the Her-2 protein and who have received one or more chemotherapy regimens for their metastatic disease. Trastuzumab may also be reimbursed when:.

Trastuzumab is a benefit for clients whose tumors have Her-2 protein overexpression. When billing for the test used to determine whether a client overexpresses the Her-2 protein, use procedure code Diagnosis of overexpression of the Her-2 protein must be made before Texas Medicaid will consider reimbursement for trastuzumab.

An additional test by the same provider requires documentation to support the medical necessity. Procedure code J is a benefit of Texas Medicaid and is restricted to the following diagnosis codes:. Trilaciclib procedure code J is a benefit of Texas Medicaid for clients who are 18 years of age or older.

Procedure code J valrubicin sterile solution for intravesical instillation Valstar , is a benefit for clients with the diagnosis of bladder cancer in situ who have been treated unsuccessfully with BCG therapy and have an unacceptable morbidity or mortality risk if immediate cystectomy should be performed.

Documentation of diagnosis and treatment must be submitted with the claim. Vitamin B12 injections are a benefit of Texas Medicaid. Vitamin B12 injections should only be considered for clients with conditions that are refractory to, or have a contraindication to, oral therapy. Vitamin B12 injections may be considered for the following indications:. Procedure code J must be used when billing for Vitamin B12 cyanocobalamin injections. Vitamin B12 cyanocobalamin injections are limited to the following diagnosis codes:.

Claims that are denied for indications or other diagnosis codes may be considered on appeal with documentation of medical necessity. For the list of diagnosis codes above, documentation in the medical record must include rationale as to why the client was unable to be treated with oral therapy.

Voretigene neparvovec-rzyl Luxturna is an adeno-associated virus vector-based gene therapy indicated for the treatment of patients with confirmed biallelic RPE65 mutation-associated retinal dystrophy, who have viable retinal cells in each eye as determined by the treating physician. Luxturna procedure code J is a benefit of Texas Medicaid for clients who are 1 year through 65 years of age with prior authorization.

Voretigene neparvovec-rzyl Luxturna must be prescribed and administered by a retinal surgeon at an ocular gene therapy treatment center with experience performing intraocular surgery. Prior authorization is not required for the physician services associated with administration of Luxturna. Physician services include the procedural costs and the associated supplies for administration of the medication.

Prior authorization is required for voretigene neparvovec-rzyl Luxturna procedure code J For situations in which voretigene neparvovec-rzyl Luxturna is being dispensed by a pharmacy via white bagging, the prescribing provider must provide the dispensing DME pharmacy the authorization approval number. The dispensing DME pharmacy may not request prior authorization. The DME Pharmacy provider billing for voretigene neparvovec-rzyl Luxturna will be responsible for coordinating with the rendering provider to obtain the prior authorization request approval number.

The requesting provider physician or hospital may coordinate with the DME Pharmacy provider for the initial request for voretigene neparvovec-rzyl Luxturna. DME Pharmacy providers may assist in providing necessary information, such as their NPI number, fax number, and business address, to the requesting provider.

Reimbursement for dispensing of the drug by the pharmacy may not occur unless an approved prior authorization for voretigene neparvovec-rzyl Luxturna is in place. Prior authorization request for Luxturna injections will be considered when all of the following criteria are met:. Verification of viable retinal cells must be documented and evident by one of the following:.

Luxturna is not a benefit for patients who have previously received RPE65 gene therapy and who do not have viable retinal cells in each eye as determined by the treating physician. Claims for clinician-administered drugs must be submitted to TMHP in an approved electronic format or on the CMS paper claim form. Providers may purchase CMS paper claim forms from the vendor of their choice. TMHP does not supply them.

When completing a CMS paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills and itemized statements are not accepted as claim supplements. Subsection 6. Blocks that are not referenced are not required for processing by TMHP and may be left blank. Providers must not use the JW modifier for medications manufactured in a multi-dose vial format. Providers must choose the most appropriate vial size s required to prepare a dose to minimize the discarded portion of the vial payable.

Claims considered for reimbursement must not exceed the package size of the vial used for preparation of the dose. Providers must not bill for vial contents overfill. Providers must not use the JW modifier when the actual dose of the drug or biological administered is less than the billing unit. A 7mg dose is administered to a client while 3mg of the remaining drug is discarded. The 7mg dose is billed using one billing unit that represents 10mg on a single line item. The single line item of 1 unit would process for payment of the total 10mg of drug administered and discarded.

Billing another unit on a separate line item with the JW modifier for the discarded 3mg of drug is not permitted because it would result in overpayment. Therefore, when the billing unit is equal to or greater than the total actual dose and the amount discarded, the use of the JW modifier is not permitted.

Reimbursement for JW modifier claims is only available for drugs covered in an outpatient setting. Inpatient and diagnostic radiopharmaceuticals claims are not eligible for reimbursement, and may not include the JW modifier. Specialty pharmacies billing through the medical benefit must not submit claims with a JW modifier because they are unaware of how much the provider administered or discarded.

Critical Access Hospitals CAH are eligible to bill with the JW modifier because these providers bill for the coverage of drugs or biologicals separately. An example of a batch processing method is when a hospital or repackaging facility produces multiple non-patient specific doses of medications in advance of anticipated use. These preparations are labeled and distributed with client specific information only when orders are received.

Because these doses may be recycled for other client use, they are not eligible. Providers may utilize automatic systems to calculate dose and discard amounts. Providers must enter the dose administered used portion line item detail of the CAD and also enter the dose discarded unused portion line item detail of the CAD on the same claim.

The dose discarded unused portion line item detail must include the JW modifier to be considered for reimbursement. The Texas Drug Code Index, or formulary or list of available drugs , includes non-legend over-the counter drugs. Additionally, certain supplies and select vitamin and mineral products are also available as a pharmacy benefit. Some drugs are subject to one or both types of prior authorization, clinical and non-preferred.

VDP does not reimburse claims for nutritional products enteral or parenteral , medical supplies, or equipment other than a limited set of home health supplies. The PDL is arranged by drug therapeutic class, and contains a subset of many, but not all, drugs that are on the Medicaid formulary.

Most drugs are identified as preferred or non-preferred. Drugs listed on the PDL as preferred or not listed at all are available without prior authorization unless there is a clinical prior authorization associated with that drug.

The VDP Formulary Search is an online tool available to health-care providers to help clients get access to medications. Epocrates epocrates. Once registered, providers can utilize Epocrates Rx, the free drug reference, and search for brand, generic, or over-the-counter medicines. Epocrates does not mirror the HHSC designations differentiated by dosage form. In these situations, the designation includes an explanatory message. Pharmacies enrolled with VDP can dispense a limited set of home health supplies that are commonly found in a pharmacy to clients enrolled in traditional Medicaid.

The list of supplies that can be dispensed at a pharmacy and information about the provisions of these supplies for clients enrolled in traditional Medicaid can be found on the VDP Product Search website at www. Providers should contact the appropriate health plan or pharmacy benefit manager for more information about providing these supplies to clients enrolled in managed care.

Providers can obtain LARC products with no upfront cost by submitting a completed and signed prescription request form to certain specialty pharmacies. The specialty pharmacy will dispense the LARC product by shipping it to the practice address in care of the client and bill Medicaid or HTW for the product. Providers can only bill for product administration at the time of service. LARC products obtained by providers from specialty pharmacies must be returned if unused and unopened.

Providers may only bill for the LARC product if it was obtained through the buy-and-bill process. Providers do not need to enroll with specialty pharmacies to obtain LARC products. The participating pharmacies ship statewide. Prescribing providers should identify whether the patient is enrolled in traditional Medicaid or managed care.

Manufacturers offer abandoned unit return programs that allow a provider to return an abandoned LARC product. In order to be returnable, the LARC product should be in its original packaging. This form is available on the VDP website at www.

Advanced Practice Registered Nurses, Physician Assistants, and Nurse Practitioners should identify who their collaborative agreement is with to write prescriptions, if necessary. This is done to limit potentially abandoned IUD units. The pharmacy will not mail the IUD to the provider until confirmation from the patient is received.

Providers may return abandoned units. The box must be sealed and have been abandoned for at least 60 days 2 months from the dispensing date but no more than days 7 months past the fill date.

Only LARC products obtained through a specialty pharmacy can be returned through this program. Providers may return an abandoned unit. The Nexplanon box must be sealed and been abandoned for at least days 4 months from date of dispense but no more than days 6 months past the fill date.

A pre-paid shipping label and address will be provided by C3i. Upon receipt of your completed forms, Cooper Surgical will send you written confirmation by fax. The original Paragard box must be sealed and have been abandoned at least 90 days since it was shipped.

The following will occur ninety days following shipment:. You can reuse the original shipping box. If the client is no longer eligible for Medicaid or HTW, the provider may insert the LARC device, but reimbursement for all care and services provided must be resolved between the provider and the client.

If a provider accepts a client as a private pay client, the provider must advise the client she is accepted as a private pay client at the time the service is provided and is responsible for paying for all services received. In this situation, HHSC strongly encourages the provider to ensure the client signs written notification so there is no question how the client was accepted. Contact the specialty pharmacy for questions related to obtaining LARC products.

Makena is a once a week treatment administered by a health care provider. Makena requires clinical prior authorization for clients enrolled in traditional Medicaid. Health Plans may require prior authorization for Makena. Providers should refer to the appropriate health plan for specific requirements and forms. Makena and the compounded version of 17P are available as a Medicaid medical benefit.

For additional information about the medical benefit, providers can visit the TMHP website at www. HHSC covers mosquito repellent year-round for the prevention of the Zika virus. A list of products is available through the Formulary Product search. Clients that are eligible for the benefit include the following demographics:.

HHSC requires a prescription for all clients. This enables physicians to have palivizumab shipped directly to their office from a network pharmacy, and not purchase the drug. The administering provider may submit a claim to TMHP for an injection administration fee and any medically necessary office-based evaluation and management service provided at time of injection. The following sections provide information about the forms used for prior authorization requests.

Prescribing providers should contact the MCO for prior authorization requirements and forms. HHSC-enrolled pharmacies with VDP can dispense vitamin and mineral products to clients who are 20 years of age and younger and enrolled in traditional Medicaid. To expedite pharmacy claim processing for vitamin and mineral products, prescribing providers are encouraged to include the diagnosis on the prescription. The list of products that can be dispensed at a pharmacy and information about the provision of these products to clients enrolled in fee-for-service can be found on the VDP Product Search website at www.

Providers are required by federal law Public Law to use a tamper-resistant prescription pad when writing a prescription for any drug for Medicaid clients. Pharmacies are required to ensure that all written Medicaid prescriptions submitted for payment to the VDP were written on a compliant tamper resistant pad. These prescriptions may be printed on plain paper and will be fully compliant if they contain at least one feature from each of the following three categories:.

Two features that can be incorporated into computer-generated prescriptions printed on plain paper to prevent passing a copied prescription as an original prescription are as follows:. Medicaid prescriptions for non-controlled substances are valid for one year from the date written and up to 11 refills if authorized by prescriber. Medicaid prescriptions for controlled substances in Schedules III, IV, and V are valid for six months from the date written and up to five refills if authorized by prescriber provider.

Controlled substance prescriptions written by advanced practice registered nurses and physicians assistants are valid for 90 days. Medicaid prescriptions for Schedule II drugs cannot be refilled and must be dispensed within 21 days of the date on which the prescription was written. Prescriptions for Schedule II drugs may be written as multiples of three for a total of a 90 day supply subject to federal and state law.

Prescribers and pharmacies are required by statute to have a valid, active DEA numbers in order to possess, administer, prescribe or dispense controlled substances. A refill is considered too soon, or early, if the client has not used at least 75 percent of the previous fill of the medication. For clients enrolled in traditional Medicaid or the CSHCN Services Program, a refill for certain controlled substances is considered too soon if the client has not used at least 90 percent of the previous fill of the medication.

The returned results will include only those drugs that meet this requirement. Justifications for early refills include, but are not limited to, the following:. If a client requests an early refill of a drug, the pharmacy must contact VDP to request an override of the early refill restriction. Prescribing providers may be asked to verify the reason for the early refill by the dispensing pharmacy or VDP staff.

All Texas Medicaid providers must submit a rebate-eligible NDC for professional or outpatient claims submitted to TMHP with a clinician-administered drug procedure code.

Providers must enter identifier N4 before the NDC code. Clinician-administered drugs that do not have a rebate-eligible NDC will not be reimbursed by Texas Medicaid. Providers administering clinician-administered drugs in an outpatient setting for clients enrolled in Medicaid both traditional and managed care can send a prescription to a pharmacy and wait for the drug to be shipped or mailed to their office.

Providers should use the following steps for this delivery method:. The provider bills for an administration fee and any medically necessary service provided at time of administration.

The provider should not bill Medicaid for the drug. The pharmacy contacts the provider each month, prior to dispensing any refills, to ensure that the client received all previously dispensed medication. Auto-refills are not allowed. These medications cannot be used on any other client and cannot be returned to the pharmacy for credit.

For many people, substance use disorder starts after initially receiving opioid prescriptions for an episode of acute pain. To encourage the appropriate use of opioids and reduce the over-prescribing of opioids, Texas Medicaid has implemented the requirements in this section. The requirements in this section do not apply to clients who are:.

The requirements also do not apply to other clients that HHSC elects to exempt based on an objective, confirmable physical pathology known to cause severe chronic pain that is not ameliorated by other therapies and for which opioid treatment is appropriate e.

If diagnoses are not available in the medical data, prescribers can request exemptions on a case-by-case basis through the pharmacy prior authorization process. Morphine milligram equivalents MME per day is used to compare the potency of one opioid to another. For clients who are opioid naive, providers must submit a one-time prior authorization request for:. The one-time requirement for prior authorization does not apply to subsequent claims because the member will no longer be opioid naive.

For those patients who may require a tapering plan, providers would determine the development and management of a patient specific course of therapy to help manage withdrawal symptoms.

A prescriber may request a tapering plan through the pharmacy prior authorization process on a case-by-case basis. Prior authorization approvals last for six-months. Opioid prescriptions for the treatment of acute pain are rarely required for more than ten days. Prescriptions for opioids to treat acute pain for clients who are 21 years of age and older are exempt from the three-prescription-per-month limit for members in fee-for-service.

Clients enrolled in traditional Medicaid are limited to three prescriptions per month with the following exceptions:. The following categories of drugs do not count against the three prescription per month limit:. Though TMHP reimburses family planning agencies and physicians for family planning drugs and supplies, the following family planning drugs and supplies are also available through the VDP and are not subject to the three-prescription limit:.

Cost avoidance coordination of benefits for pharmacy claims ensures compliance with CMS regulations. Under federal rules, Medicaid agencies must be the payer of last resort. Medically-necessary drugs and supplies that are not covered by the VDP may be available to children and adolescents birth through 20 years of age through the Medicaid Comprehensive Care Program CCP. Drugs and supplies not covered could include, as examples, some over-the-counter drugs, nutritional products, diapers, and disposable or expendable medical supplies.

The Prior Authorization fax number is Family planning services are excluded from lock-in limitation. Many Medicaid pharmacies offer free delivery of prescriptions to clients enrolled in Medicaid. To find out which pharmacies offer delivery services:. The returned results will include only those pharmacies that provide a delivery service. These HHSC-enrolled pharmacies have certified their delivery services meet the minimum conditions for the payment of the delivery fee. These certified delivery pharmacies are reimbursed a delivery fee that is included in the medication dispensing formula.

Each health plan develops its own participating pharmacy network for the delivery service. Delivery service is not applicable for mail-order prescriptions and not is available for over-the-counter drugs. Medication Synchronization establishes processes for early refills in order to align the filling or refilling of multiple medications for a client with chronic illnesses.

This process allows for clients to pick up all their medication on a single day each month versus requiring clients to make multiple pharmacy visits to obtain different prescription medications with different refill dates.

A drug is eligible for medication synchronization if it meets the following conditions:. This includes clinical prior authorizations, non-preferred prior authorizations, and drug utilization review edits. Having available refills is not required. A claim cannot be synchronized if it is a Schedule II controlled substance or a Schedule III controlled substance containing hydrocodone.

Medications eligible for synchronization must be used to treat chronic illnesses. A chronic illness is defined as an illness or physical condition that is:.

This includes drugs used to treat mental health conditions and substance use. A synchronized claim will count as one of the three prescriptions Medicaid will pay if a client is limited. In CHIP, cost sharing or co-payment amounts will be prorated. Dispensing fees will not be prorated. Some Medicaid drugs are subject to one or both types of prior authorization, clinical and non-preferred.

Clinical prior authorizations utilize evidence-based clinical criteria and nationally recognized peer-reviewed information. These prior authorizations may apply to an individual drug or a drug class on the formulary, including some preferred and non-preferred drugs. There are certain clinical prior authorizations that all health plans are required to perform. Usage of all other clinical prior authorizations will vary between health plans and at the discretion of each health plan.

It identifies the prior authorization each health plans uses and how those authorizations relate to the authorizations used for traditional Medicaid claim processing. The chart is updated quarterly. Subsection 8. The PDL is arranged by drug therapeutic class and contains a subset of many, but not all, drugs that are on the Medicaid formulary.

Drugs are identified as preferred or non-preferred on the PDL. Prior authorization for clients enrolled in traditional Medicaid is requested through the Texas Prior Authorization Call Center. Online submissions are only available for non-preferred prior authorization requests. The prescribing provider may request reconsideration if the prior authorization request is denied.

The Texas Prior Authorization Call Center will notify prescribing providers of their right to request a reconsideration of the decision rendered. Providers may also include supporting documentation with their form submission, including:. The Texas Prior Authorization Call Center will mail a copy of the reconsideration determinations to the requesting provider and client.

Federal and Texas law allows for a hour emergency supply of a prescribed drug to be provided when a medication is needed without delay and prior authorization is not available.

This rule applies to non-preferred drugs on the PDL and any drug that is affected by a clinical prior authorization. Drugs not on the PDL may also be subject to clinical prior authorization. Retrospective DUR provides for the ongoing periodic examination of claims data and other records to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care among prescribing providers, pharmacists, and people associated with specific drugs or groups of drugs.

The retrospective review also allows for active and ongoing educational outreach in the form of letters or face-to-face discussions to educate prescribing providers on common drug therapy problems with the aim of improving prescribing or dispensing practices. A fixed-number of interventions are performed each calendar year. MCOs are required to create and perform interventions and education of their population.

J 1, units One billing unit is equal to 5 units of medication. J 10, units One billing unit is equal to units of medication. J units One billing unit is equal to 1 unit of medication. Procedure Code Conditions J Multiple sclerosis MS : For treatment of relapsing forms of MS and should be reserved for clients who have had an inadequate response to two or more drugs indicated for the treatment of MS. J Alpha-1 proteinase inhibitor deficiency: For the treatment of clients who have a deficiency of the alpha-1 proteinase inhibitor enzyme also known as alpha-1 antitrypsin deficiency in the treatment of emphysema.

J Organ rejection: For the prophylaxis of acute organ rejection in patients receiving renal trans- plantation when used as part of an immunosuppressive regimen that includes cyclosporine and corticosteroids.

J Organ rejection: For the prophylaxis of organ rejection in adults receiving a kidney transplant, to be used in combination with basiliximab injection, mycophenolate mofetil, and corticosteroids. J Psoriatic arthritis, Rheumatoid arthritis, Ankylosing spondylitis J Renal homotransplantations: Adjunct for the prevention of rejection in renal homotransplantation.

J Allogeneic transplants: For prophylaxis of organ rejection in kidney, liver, and heart allogeneic transplants. J Organ rejection prophylaxis: For the prophylaxis of organ rejection in clients receiving allogeneic liver, kidney, or heart transplants.

Procedure Codes for Joint Injections Procedure Codes for Trigger Point Injections Modifier Use AT For acute conditions. Procedure Code Limitation s J Reimbursed once per month. Frequency Dosage Limitations Monthly 7. Dose Administered to Patient. One billing unit is equal to 1 unit of medication. One billing unit is equal to 5 units of medication. One billing unit is equal to units of medication.

Psoriatic arthritis, Rheumatoid arthritis, Ankylosing spondylitis. Billed with a quantity of 4 Reimbursed once every 4 months. Billed with a quantity of 6 Reimbursed once every 6 months.

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PBMs play an important role in contracting with employers, insurers, and pharmacies to manage drug pricing and prescription drug coverage for pharmacy patients in a more convenient way.

There are about 50 pharmacy benefit manager companies currently with Caremark CVS still making the lead. In , Pharmacy Benefit Managers took care of the benefits of pharmacy for about million Americans with their numbers fewer than 30 companies, which as of , the largest PBMs had higher revenue than the largest pharmaceutical manufacturers, indicating their increasingly large role in healthcare in the United States thus the motivation behind the increasing number of the pharmacy benefit managers companies.

Below is the list of pharmacy benefit manager companies we show as the best considering reviews relating to customer satisfaction and the range of coverage.

CVS Caremark is a leading pharmaceutical services company providing comprehensive drug benefit services to over 2, health plan sponsors and their plan participants throughout the U. They work with employers, health plans, unions, and state and local governments nationwide managing prescription plans that help control costs while ensuring access. It was founded in and provides innovative solutions for managing pharmacy-benefit costs and enhancing the quality of care.

Express Scripts Holding Company is a pharmacy benefit management organization. In it was the 22nd-largest company in the United States by total revenue as well as the largest pharmacy benefit management organization in the United States.

OptumRx was founded in was among the best pharmacy benefit management companies in the US. It has received recognition and accreditation from trade associations, regulatory agencies, and other governing bodies.

They manage your pharmacy and overall health care spend, help clients and over 66 million members achieve better health outcomes also lower overall costs through innovative management. The unique approach drives significant savings in both medical and pharmacy costs by incorporating powerful and proven health management programs for chronic and specialty conditions within their core pharmacy benefit offering.

This is also among the amazing pharmacy benefit manager companies driven by innovation, data analytics, and clinical excellence. It was founded in having a groundbreaking ABM solution that stands alone in the industry and the PBM solution is comprised of industry-unique tools and services providing unmatched value and results.

Kroger Prescription Plans is dedicated to providing pharmacy benefit management services and innovative clinical programs that focus on engagement, choice, and cost savings. Built on personalized care solutions that simplify health, wellness, and nutrition, the industry-leading programs are delivered by highly credentialed pharmacists, technicians, and health care providers. They bring together the full range of Kroger entities to optimize your experience, improve health and deliver savings.

For 30 years, MedImpact has been lowering costs, improving care, and delivering better solutions for our clients. Today, they are among the largest independent pharmacy benefit solutions companies and are investing millions of dollars in clinical programs, technology, operations, and analytics for better operation. PBM Plus was founded in and is among the best pharmacy benefit manager companies that differentiate itself from other PBMs by being completely independent of pharmaceutical manufacturers, insurance companies, and pharmacies.

As part of the Omnicare Specialty Care Group, they focus on creating cost-effective solutions for their clients by having the freedom to develop and implement solutions that are dedicated to meeting the needs of our clients and their individual members. For about 3 decades, WellDyne has leveraged clinical expertise to drive improved health outcomes for our clients and members. They are on a quest to fill the gap that exists today for Pharmacy Benefit Managers options serving the middle market and has grown to partner with more than 2, clients and serve more than 3 million members.

P rogressive Medica l, Inc. Their strong and steady growth has led to the establishment of strategically located nationwide distribution capabilities, and an expanding global supplier presence. By delivering a simple, mobile View Full Profile. Create Account to Unlock. Capital Rx is a next-generation pharmacy benefits manager, overseeing prescription benefit plans on behalf of employers, unions, and government entities. We specialize in solving complex pharmacy challenges for our customers. We believe in developing smart solutions that leverage our industry-leading experience and technology to exceed expectations Manage your pharmacy and overall health care spend.

We help clients and over 66 million members achieve better health outcomes and lower overall costs through innovative management services For more than 30 years, MedImpact has been lowering cost, improving care, and delivering better solutions for our clients. Today, we are the largest independent pharmacy benefit solutions company, investing millions of dollars in clinical programs, technology Where some see obstacles, we see possibilities.

Add in more criteria and see your match score for every vendor. It only takes a few minutes, just create free account to get started. CVS Health is a health care innovation company with a simple and clear purpose: Helping people on their path to better health. And that purpose goes beyond Plan sponsors can replace their PBM entirely and get the best of both Rightway is the leader in driving healthcare value for everyone, everywhere. Our Care Navigation solution offers a digital front door into healthcare and is delivered through an award-winning mobile app that pairs every member with a live, clinical guide.

Kroger Prescription Plans is dedicated to providing pharmacy benefit management services and innovative clinical programs that focus on engagement, choice, and cost savings. Built on personalized care solutions that simplify health, wellness and nutrition, MedOne is your key to the pharmacy benefit marketplace. We unlock the most appropriate prescription at the most affordable price for organizations and their health plan members nationwide.

Have a specialist help you narrow it down. Folks like Katie can help prioritize the criteria that matters most. We are a PBM focused on reducing our client and their members' costs through transparent and honest plan governance. We provide plan flexibility and superior member service to deliver the plan management desired by the employer We provide services to health plans who manage Medicare, Medicaid and commercial business. Known for our high-touch service, insightful analytics, and flexible benefit designs, At Phoenix, we are bringing a new approach to the complicated world of healthcare management.

Our job is Select -5 Vendors. The vendors you selected will be in touch to provide pricing info shortly. They may need more specific information about the program you're looking for, so that they can provide pricing on the most appropriate features and components.

Thank you! Examples of individuals that would not be granted access include, but are not limited to: vendors, students, practitioners, researchers, other non-employers or anyone that is unwilling to identify themselves will not pass our vetting criteria.

If you are a consultant, Shortlister offers a specialized product for consultants, called Shortlister Select. You can email Tom Ciccotti at tciccotti myshortlister. Get control of the vendor lifecycle.

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Amerigroup pharmacy benefit manager companies	Claims will only be not carefirst administrators ppo opinion for reimbursement if an HHSC review has determined that the medication has a weight-based, variable dosing schedule or that it requires dosing adjustments for pharmacokinetic or pharmacodynamic considerations. The single line item of 1 unit amerigrpup process for payment of the total 10mg of drug administered and discarded. Makena is a once a week here administered by a health care provider. Female Personal Products. Claim Form.

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OptumRx was founded in was among the best pharmacy benefit management companies in the US. It has received recognition and accreditation from trade associations, regulatory agencies, and other governing bodies. They manage your pharmacy and overall health care spend, help clients and over 66 million members achieve better health outcomes also lower overall costs through innovative management. The unique approach drives significant savings in both medical and pharmacy costs by incorporating powerful and proven health management programs for chronic and specialty conditions within their core pharmacy benefit offering.

This is also among the amazing pharmacy benefit manager companies driven by innovation, data analytics, and clinical excellence. It was founded in having a groundbreaking ABM solution that stands alone in the industry and the PBM solution is comprised of industry-unique tools and services providing unmatched value and results.

Kroger Prescription Plans is dedicated to providing pharmacy benefit management services and innovative clinical programs that focus on engagement, choice, and cost savings. Built on personalized care solutions that simplify health, wellness, and nutrition, the industry-leading programs are delivered by highly credentialed pharmacists, technicians, and health care providers.

They bring together the full range of Kroger entities to optimize your experience, improve health and deliver savings. For 30 years, MedImpact has been lowering costs, improving care, and delivering better solutions for our clients.

Today, they are among the largest independent pharmacy benefit solutions companies and are investing millions of dollars in clinical programs, technology, operations, and analytics for better operation.

PBM Plus was founded in and is among the best pharmacy benefit manager companies that differentiate itself from other PBMs by being completely independent of pharmaceutical manufacturers, insurance companies, and pharmacies. As part of the Omnicare Specialty Care Group, they focus on creating cost-effective solutions for their clients by having the freedom to develop and implement solutions that are dedicated to meeting the needs of our clients and their individual members.

For about 3 decades, WellDyne has leveraged clinical expertise to drive improved health outcomes for our clients and members. They are on a quest to fill the gap that exists today for Pharmacy Benefit Managers options serving the middle market and has grown to partner with more than 2, clients and serve more than 3 million members. P rogressive Medica l, Inc. Their strong and steady growth has led to the establishment of strategically located nationwide distribution capabilities, and an expanding global supplier presence.

To provide customers with the best value in health, dental, vision, and life insurance benefits, and administrative services. We are customer-focused and market-driven, using the strengths and opportunities created by Regence health plans. We are committed to keeping health care costs as low as possible for our customers by continually negotiating fair rates for health care services.

The pharmacy benefit manager companies in this article are in no order of ranking, therefore, we recommend you follow the individual links provided in each of the PBM companies for a wider view of their operations. Pharmacy benefit manager companies come with many pros however, their cons are not to be overruled.

Problems with pharmacy benefit managers. You must be logged in to post a comment. Skip to content. Leave a Reply Cancel reply You must be logged in to post a comment. Capital Rx is a next-generation pharmacy benefits manager, overseeing prescription benefit plans on behalf of employers, unions, and government entities. We specialize in solving complex pharmacy challenges for our customers.

We believe in developing smart solutions that leverage our industry-leading experience and technology to exceed expectations Manage your pharmacy and overall health care spend. We help clients and over 66 million members achieve better health outcomes and lower overall costs through innovative management services For more than 30 years, MedImpact has been lowering cost, improving care, and delivering better solutions for our clients.

Today, we are the largest independent pharmacy benefit solutions company, investing millions of dollars in clinical programs, technology Where some see obstacles, we see possibilities. Add in more criteria and see your match score for every vendor. It only takes a few minutes, just create free account to get started. CVS Health is a health care innovation company with a simple and clear purpose: Helping people on their path to better health. And that purpose goes beyond Plan sponsors can replace their PBM entirely and get the best of both Rightway is the leader in driving healthcare value for everyone, everywhere.

Our Care Navigation solution offers a digital front door into healthcare and is delivered through an award-winning mobile app that pairs every member with a live, clinical guide. Kroger Prescription Plans is dedicated to providing pharmacy benefit management services and innovative clinical programs that focus on engagement, choice, and cost savings. Built on personalized care solutions that simplify health, wellness and nutrition, MedOne is your key to the pharmacy benefit marketplace.

We unlock the most appropriate prescription at the most affordable price for organizations and their health plan members nationwide. Have a specialist help you narrow it down. Folks like Katie can help prioritize the criteria that matters most. We are a PBM focused on reducing our client and their members' costs through transparent and honest plan governance.

We provide plan flexibility and superior member service to deliver the plan management desired by the employer We provide services to health plans who manage Medicare, Medicaid and commercial business. Known for our high-touch service, insightful analytics, and flexible benefit designs, At Phoenix, we are bringing a new approach to the complicated world of healthcare management.

Our job is Select -5 Vendors. The vendors you selected will be in touch to provide pricing info shortly. They may need more specific information about the program you're looking for, so that they can provide pricing on the most appropriate features and components.

Thank you! Examples of individuals that would not be granted access include, but are not limited to: vendors, students, practitioners, researchers, other non-employers or anyone that is unwilling to identify themselves will not pass our vetting criteria.

If you are a consultant, Shortlister offers a specialized product for consultants, called Shortlister Select. You can email Tom Ciccotti at tciccotti myshortlister. Get control of the vendor lifecycle. Find, research and buy the services you need. Create a Free Account. Used by most of the top employee benefits consultants in the US, Shortlister is where you can find, research and select HR and benefits vendors for your clients.