LETTER TO PHARMACISTS


September 20, 2007

Dear Pharmacy Provider:

RE:  PDL # 07-02

Attached is the complete, most current listing of drugs on the Medicaid Prior Authorization (PA) Process' Preferred Drug List (PDL) "07-02."  The listing includes preferred drugs and those drugs requiring prior authorization.  This list will be effective October 1, 2007. 

The PA process, in accordance with the program's "Continuity of Care" policy, does not impact original prescriptions (or refills) issued by a prescribing practitioner prior to effective PA dates of drugs as they are added to the PA process as long as they are within the 5 refills and 6-month program limits. An educational alert will notify the pharmacist that prescriptions (and their refills) will require a new prescription and prior authorization, if the prescription life exceeds six months or the refill exceeds the 5 refill limit. The educational alert will state, "NEW RX WILL REQUIRE PA AFTER (DATE)."

This issuance of the PDL includes the COX-2 selective agent, Celebrex®. Please be reminded that several years ago, the FDA issued a Public Health Advisory, which stated that use of a COX-2 selective agent may be associated with an increased risk of serious cardiovascular events, especially when they are used for long periods of time or in very high-risk settings.

As a result of this Public Health Advisory and to help ensure the safety and well being of Medicaid patients, our current policy requires the prescribing practitioner to include:

  • The condition being treated with the COX-2 selective agent by indicating the ICD-9-CM diagnosis code of the treated condition (e.g. Osteoarthritis - 715.0) on all new prescriptions written for a COX-2 selective agent; and
  • The reason a COX-2 selective agent is used rather than a non-selective NSAID (e.g. treatment failure or history of a GI bleed).

The ICD-9 diagnosis code and the rationale for the choice of a COX-2 selective agent must be noted in the prescriber's handwriting. A rubber stamp notation is not acceptable. The ICD-9 diagnosis code and the rationale may be submitted as an attachment to the original prescription via facsimile.

Medicaid's Drug Utilization Review Board recommended a review of patients' Medicaid medication histories and ages to indicate patients' risk factors for gastrointestinal complications when non-selective NSAIDs are used.  All prescriptions for COX-2 agents shall include a diagnosis, and when patients appear to be at greater risk for gastrointestinal complications from non-selective NSAIDs, Medicaid will process COX-2 selective agent claims without an override.

  • Pharmacy claims for new prescriptions for a COX-2 selective agent shall be submitted with an ICD-9 treatment diagnosis code in NCPDP field 424-DO (Diagnosis code).
  • Claims submitted without a diagnosis code will deny with NCPDP rejection code 39 (Missing or invalid ICD-9 diagnosis code) mapped to EOB code 575 (Missing or invalid diagnosis code).

A prescription written for a COX-2 selective agent for a Medicaid patient will only process without an override when the following conditions are met:

An ICD-9 diagnosis code indicating the reason for treatment  is documented and submitted and when one of the following conditions exists:

  • Patient has current prescription for H2 receptor antagonist or
  • Patient has current prescription for proton pump inhibitor or
  • Patient has current prescription for warfarin or
  • Patient has current prescriptions indicating chronic use of oral steroids or
  • Patient is sixty years old or greater.

When a diagnosis code is submitted and one of the above conditions does not exist, the claim will deny with NCPDP rejection code 88 (DUR Reject Error) mapped to EOB code 531 (Drug use not warranted - COX 2).

If in the professional judgment of the prescriber, a determination is made which necessitates therapy with a COX-2 selective agent, the pharmacist may override above edit. The pharmacy provider must supply the conflict code, intervention code and outcome code, as listed below, with the Point of Sale submission of the claim and have the information recorded on the hardcopy.

  • NCPDP 439-E4 (Reason for Service - Conflict Code)
    • NN - Unnecessary Drug
  • NCPDP 440-E5 (Professional Service Code - Intervention Code) 
    • MØ - Prescriber Consulted
  • NCPDP 441-E6 (Result of Service - Outcome Code)  
    • 1G - Filled with Prescriber Approval

The goal is to assure appropriate use of this COX-2 selective agent and allow a pharmacy claim to process when gastrointestinal risks appear likely with use of a non-selective non-steroidal anti-inflammatory drug. A prescription for a COX-2 selective agent will deny, if the claim does not include an ICD-9 diagnosis code and one of the above stated criteria is not met.

Information on the Prior Authorization process, including the PDL and Prior Authorization Request Form (copy is attached, Form RXPA01), is also available on the Louisiana Medicaid website (www.lamedicaid.com). This website will be updated when changes (additions or deletions) are made to the PDL. The program may also utilize the provider remittance advices to notify providers of PDL changes that must be implemented in short time frames.

The Department has received inquiries that drug products requiring PA are not reimbursable by Medicaid. Medicaid does reimburse for drug products requiring prior authorization when the prior authorization process is followed.   Additionally, should a claim deny because a PA is required, you may want to 1) verify that the PA was actually obtained and the dates of service for the PA; 2) verify that the filling date on the claim is subsequent to the start date of the PA.  (Remember:  PAs are not retroactive); and 3) call the POS help desk at 1-800-648-0790 for further assistance.

Thank you for your continued cooperation. We appreciate your participation in the Medicaid Program.

Sincerely,

Jerry Phillips

Medicaid Director

MJT/alp

The above letter and the Preferred Drug List are also available in PDF format on the Downloadable Forms and Files page.