January 26, 2016 Progress Notes
Progress Reports 2016
Medicaid/ Bayou Health
FFS Edits on Xyrem® (Sodium Oxybate) for La. Medicaid Pharmacy Program
DATE: January 15, 2016
TO: All Louisiana Fee for Service (FFS) Med icaid Providers
FROM: Jen Steele, Interim Medicaid Dir
SUBJECT: FFS Edits on Xyrem® (Sodium Oxybate) for La. Medicaid Pharmacy Program
Effective January 22, 2016, the Louisiana Medicaid Pharmacy Program in collaboration with the Louisiana Medicaid Drug Utilization Review (DUR) Board has established clinical pre-authorization criteria and Point of Sale (POS) edits on Xyrem® (Sodium Oxybate).
Claims for Xyrem® (Sodium Oxybate) will be reimbursed at Point of Sale (POS) when the prescriber has obtained an approved clinical pre-authorization. Prescribers must complete the Pharmacy Clinical Pre-Authorization Form in full and fax to 1-866-797- 2329. See complete instructions below or refer to www.lamedicaid.com.
Pharmacy claims for these medications will deny with:
NCPDP reject code 88 (DUR Reject Error) mapped to EOB code 066 (Clinical Pre-Authorization Required)
Override provisions should be addressed through the Clinical Pre-Authorization process.
Pharmacy claims for Xyrem® (Sodium Oxybate) will deny when the recipient has an active claim on file for a CNS depressant (see attached list). Also claims for CNS depressants (see attached list) will deny when the recipient has an active claim on file for Xyrem® (Sodium Oxybate) with:
NCPDP reject code 88 (DUR Reject Error) mapped to EOB code 482 TD (Therapeutic Duplication)
There are no override provisions through the Point of Sale (POS) system usi ng NCPDP service codes.
Compliance associated with program policy will be verified through our Louisiana Medicaid Pharmacy Compliance Audit Program.
Your continued cooperation and support of the Louisiana Medicaid Program efforts to coordinate care and improve health are greatly appreciated.
If you have questions about the contents of this memo, you may contact the Pharmacy Help Desk at (800) 437-9101 or refer to www.lamedicaid.com.
Clinical Pre-Authorization Criteria and Point-of-Sale (POS) Edit for Xyremri (Sodium Oxybate) for Fee-For-Service Medicaid Recipients
Clinical Pre-Authorization Criteria
Requests for Xyrem() (sodium oxybate) will be considered for approval if all of the following criteria are met:
l . Recipient has a documented diagnosis of narcolepsy or cataplexy.
2. Prescribing provider is a Board Certified Neurologist or a Board Cetiified Sleep Medici ne Physician.
Point-of-Sale (POS) Edit
Incoming prescriptions for Xyrem@ (sodium oxybate) will deny at Point-of-Sale (POS) when there is at least one active prescription on the recipient’s file for any of the CNS depressant medications listed below. An active prescription is a prescription in which the days supply has not expired. Alternatively, incoming prescriptions for any of the CNS depressant medications listed below will deny at POS when there is an active prescription on the recipient’s file for Xyrem@ (sodium oxybate).
CNS depressant medications include the following agents, whether given as a single entity or as a component of a combination product:
Fax or Mail this form to: 1-866-797-2329
La Medicaid RxPA Operations ULM School of Pharmacy
1800 Bienville Drive
Monroe, LA 71201-3765
For more information, refer to www.lamedicaid.com and follow the “Pharmacy and Prescribing Providers” link.
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DHH and MCOs to Co-host Noon Provider Calls
Beginning Feb. 1, 2016, the noon provider calls will follow a new format. To continue to offer support to providers during the integration of mental health and substance use services into Bayou Health, the Department of Health and Hospitals (DHH) will co-host the calls with the Managed Care Organizations (MCO). The calls will take place Monday through Friday with a different MCO each day during the month of February. The calls will allow DHH to continue to keep providers up to date with announcements and will allow providers to make comments or ask the MCOs questions. If you email your questions or comments to firstname.lastname@example.org before the calls, Medicaid will forward your email to the appropriate MCO. This will allow the MCOs time to prepare a response. All provider types are welcome to participate on the calls. The call schedule will be as follows:
- Monday – Aetna
- Tuesday – Amerigroup
- Wednesday – AmeriHealth Caritas
- Thursday – Louisiana Healthcare Connections
- Friday – United Healthcare
All calls will take place from noon until 1 p.m. The call-in information is as follows:
- Call-in #: 1-888-636-3807
- Access Code: 1133472
DHH offers providers numerous avenues for reporting and resolving issues related to Bayou Health. Please refer to Information Bulletin 12-27 posted on www.makingmedicaidbetter.com. This bulletin also includes contact information for each of the MCOs.
For news specifically pertaining to the integration, you can click on the “Behavioral Health” tab onwww.makingmedicaidbetter.com. To automatically receive updates and releases from the Department regarding the integration, subscribe to the “Integrated Health Care” newsletter.
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Bayou Health Informational Bulletins for Providers
Informational Bulletins cover a variety of topics related to Bayou Health, and all are available here.
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Health Plan Advisories
Health Plan Advisories are available at http://new.dhh.louisiana.gov/index.cfm/page/1734
SUDIA Recipe: Easy Cheesy Chicken Enchiladas with Yogurt Sauce
These easy, mouth-watering enchiladas are stuffed with cheese, chicken and salsa and topped with yogurt, cilantro and cumin.
1 (3-ounce) package cream cheese
2 cups chopped cooked chicken breast
12 ounces chunky salsa
1 cup Mexican-blend cheese, shredded
8 (6-inch) flour tortillas
For the Yogurt sauce:
2 cups low-fat plain yogurt
1 cup chopped cilantro
1 teaspoon ground cumin
Heat cream cheese in large skillet over medium heat until soft. Stir in chicken and 1/2 cup of the salsa; mix well.
Add 1/2 cup shredded cheese; stir until melted. Spoon about 1/3 cup of the chicken mixture onto each tortilla; roll up.
Place seam side down in 12×8-inch baking dish. Top with remaining salsa and cheese.
Bake at 350 degrees Fahrenheit for about 15 minutes, or until heated through. Serve with yogurt sauce.*
*Combine yogurt, cilantro and cumin. Chill until needed.
For more information and recipes visit www.southeastdairy.org
Red River Potpourri
August 19-21, 2016
Shreveport Convention Center
Registration details will be forthcoming
Call us for more information 337.988.1816
Red River Potpourri is presented by The Louisiana Chapter of the American Academy of Pediatrics
For all the latest updates, go to: www.laaap.org/2016potpourri