CT – Billing Clarification for Brand Name Medications on the PDL

June 2017 ~

The Pharmaceutical & Therapeutics (P&T) Committee has made changes to the list of preferred prescription products. As an aid to providers, Connecticut’s Medical Assistance Program has released clarification on billing requirements for a pharmacy when a brand name medication is dispensed.

Effective July 1, 2017, the following modifications (additions or removals) have been made to select drug classes:

CT Medicaid Preferred Drug List (PDL):

  • A new brand or generic entry into an existing PDL class will only appear if it is preferred.
    • Preferred brand name products with a non-preferred generic equivalent will be designated in bold print;
  • Prior Authorization (PA) is required when any new or when a refill prescription is filled for a non-preferred product for the first time;
    • Prescribers may submit their PA requests via the Pharmacy Web PA feature via the secure Web portal;
  • Providers are urged to be proactive in switching clients to a preferred medication, or in obtaining PA, when appropriate;
    • If a claim for a non-preferred medication is submitted and no PA is on file, the pharmacy will receive a message that they should contact the physician to explain that a PA is required;
  • Pharmacists will have the opportunity to dispense a one-time, 14 day supply of medication by entering all 9’s in the Prior Authorization Number Submitted field, NCPDP 462-EV, and a numeric value of “1” in the Prior Authorization Type field, NCPDP 461-EU;
    • Each time a 14 day supply of medication is dispensed, the pharmacist should provide the client with a Department of Social Services (DSS) authorized flier;

Five Day Emergency Supply:

  • The Department also allows for a 5 day emergency supply of a medication that requires PA for non-PDL or Brand Medically Necessary (BMN);
  • If the pharmacist or prescriber is unable to obtain a PA and the client requires the medication after the one-time 14 day override has been used, the pharmacist may call the Pharmacy Prior Authorization Assistance Call Center;

Brand Name Medications on the PDL:

  • If the brand name medication for a multi-source product (a medication that is available as both the brand name and the generic) is identified as the preferred drug on the PDL, and the brand medication is dispensed, the claim does not need to be submitted with a Dispense As Written (DAW) code of ‘1’ for the pharmacy to receive brand reimbursement;
    • If the prescriber has not indicated the brand product is medically necessary, the pharmacy may submit the claim with a DAW code of ‘5’ to signify that the pharmacy dispensed the brand as the generic, or ‘9’ to signify that although substitution is allowed by the prescriber, the Connecticut Medical Assistance Program requests the brand and will receive brand reimbursement as long as the brand name product remains preferred on the PDL;
  • Any pharmacy claim submitted with a DAW of ‘1’ to signify the prescriber specified the brand product is medically necessary is subject to audit;
    • Unless a prescription is transmitted electronically, such as through SureScripts, the pharmacy must have a prescription with the words ‘Brand Medically Necessary’ written in the prescriber’s handwriting on file;
    • Failure to provide written documentation in the event of an audit will result in the recoupment of the claim;
    • A verbal prescription would need to be followed up by a hard copy prescription sent to the pharmacy with the appropriate documentation;
    • Should the pharmacy choose to dispense the generic equivalent when the brand is the preferred product, a non-preferred PA would be required for the claim to process.

The full list of PDL changes as well as the Alphabetized Preferred Drug List can be accessed at www.ctdssmap.com. For more information on Pharmacy Web Prior Authorization, refer to PB 14-55.


Source(s): Connecticut Department of Social Services Medical Assistance Program;