PA Compounds
What LOB gets sent to secondary review if the compound contains a Non-Formulary IV Antibiotic?
IL Medicaid - Youth Care & IL Medicaid – YouthCare HealthChoice DCFS consent
Name some instances when we would NOT expand Uptravi for all strengths?
When it is a continuation request and member is already stable on a certain dose AND/OR no titration being requested by the provider
- We have previously approved the titration pack so only UPTRAVI Tablet (200MCG/400MCG/600MCG/800MCG/1000MCG/12000MCG/14000MCG/16000MCG) is needed (or vice versa)
If you are working a compound with missing information and the missing information was NOT obtained and the provider information is NOT available, what is the Status and Status Reason that needs to be selected?
Closed, Misc
If you are working a Non-PDL drug for Texas Medicaid how would you place your auth?
You would NOT place an override as Non-Formulary medications are not to be overridden for TX (or IA) Medicaid plans.
What year did VHS start?
2020
You are approving a Meropenem (NF MR) and Sodium Chloride (Formulary) compound for Ambetter how would you place the override that exceeds the cost ceiling? (Hint use ESI Override Guide tab 2 and 8)
Place override for Meropenem GCN No expansion, Compound Coverage Indicator YES, Per Claim Ingredient Max Override YES, Flip Formulary to YES
No override needed for Sodium Chloride if the medication pays in ESI on its own, if it does not pay in ESI, we will place an override matching the rejection and using GCN No expansion
For a Medicare case, the patient meets PA criteria, and the pharmacist advises we can approve over the QL for Uptravi 200MCG Tablets how would we place the override?
Auth type: B & flip the clinical flag to YES
If you are working a compound that contains at least ONE ingredient that requires B vs D review & one of the compound ingredients is determined to be covered under part B how would you deny for PDG? What would you do if it was a CCP-MADP LOB?
Deny the case for Part B (PDG) Follow B vs D step action to review under OD (CCP-MADP)
If you receive a case for a Non-PDL IVIG/SCIG med for an Exchange LOB that leads to approval, how should you place your auth?
Highest strength needs to have Auth Type: B; all other strengths need to have Auth Type: L; Formulary Flag needs to be flipped to yes, Retail/Mail Quantity Limit needs to be completed as well as Retail/Mail History Days Backup Quantity. (GCN needs to be set to Expand_Across_All_Dosages_And_Strengths)
What does PDAC and VHS stand for?
precision drug action committee
Very high spend
Which LOB can NOT be partially approved/denied?
Washington Medicaid
What denial template would we use if the member meets the PA criteria, but we are denying for over the ql?
Deny QL; Drug Approved Ongoing/Other Strength
The amount requested is over the limit allowed by your plan. You have met the drug criteria. However, we cannot approve your request of #&DER.DrugQuantity# <<tablets>> for a #&DER.Duration# day supply.
Therefore, this drug has been approved with a quantity limit of <<60 tablets>> per <<30>> days from <<00/00/0000 until further notice>>.
This drug also comes in <<Uptravi Oral Tablets Dose Pack 200 Mcg (140)- 800 Mcg (60)>>. You can use this strength to stay within the quantity limits. We may be able to make an exception to the quantity limit.
Your prescriber will need to send us a statement that explains why you need this amount. The notes can be the number of doses available under the limit does not work to treat your condition or there is sound clinical, medical, or scientific evidence that is likely to not work or cause adverse effect or cause you to not comply with taking the drug.
**We want to push the provider to utilize the Starter Pack over using the 200MCG tablets for titrations, but we will let the pharmacist make the final decision.
If you are working a compound that contains all formulary ingredients and the claim is not paying, what should you do?
Review the Route of Administration
If you are approving a Compound for a Medicaid LOB that exceeds Cost Ceiling and the primary ingredient rejects 75, how would you place your auth?
Auth Type: A: Prior_Authorization; Compound Coverage Indicator: Yes; Per Claim Ingredient Max Override: Yes; Claim Dollar Limit: Leave Blank; Use appropriate Brand/Generic Indicator & Flip the Clinical Flag to Yes.
Where can you locate the list of VHS medications we work?
Blue banner, NE Sharepoint
What steps should you take before sending a compound to the possible duplicate queue?
Ensure the same NDC’s for the compound ingredients are being requested for the same dates of service, ensure claim is payable on date of service being requested, then run a test claim for the compound in the PBM system and attach a screenshot of the test claim to your case proving it is payable. Route the case to the Possible Duplicates queue for review.
If we are working the starter pack and maintenance dosing in 1 case, what would we put for the NDC/Drug Name field, qty field, and day supply field according to the Medicare step action?
1. NDC/Drug Name field: Enter the maintenance drug
2. QTY field: Enter the quantity for the maintenance regimen
3. Day Supply field: Enter the day supply for the maintenance regimen
If you are working a compound that contains an ingredient that NDC is not found in the Formulary Search Tool (FST) and a Coverable NDC is found, what do you need to do?
Call the pharmacy to see if they can change to an NDC that was found in the ESI CSP system.
If you are partially denying a case, what do you need to verify is not set to N/A?
Auth Type, as partial denials will always default to status of N/A.
What is the New NDC for Misc requests? And how do you route to TR if in VHS cluster in error.
33333-3333-33.
Copy drug name
change NDC
paste drug name
hit submit and release the case
How can you determine if a medication is a true OTC Medication or not?
OTC medication (Click on the hyperlink for the drug name to view the drug detail. Under Coverage Notes note if the drug is indicated as an OTC or a Legend Drug)
When approving Uptravi, when are multiple overrides required?
None! Per the ESI Override Guide we always expand for all dosages and strengths so only 1 override should ever be needed
If you are working a compound that contains Excluded and Formulary ingredients ONLY what are the steps you need to take?
1. Check claims to see if the pharmacy is processing as a compound; 2. Call the pharmacy if they are not submitting the claim correctly with SCC8 (making sure to document the call); Complete the case by setting up as a partial denial.
If you are approving an Excluded Medication for Medicaid/Exchange, what flags need to be flipped to yes?
Coverage, Formulary, Clinical
Where can you nominate a member of the NE region for NE employee of the month? What does the winner get?