April 16, 2019 Revised: 4.17.2019
Medicaid single preferred drug list implementation on schedule for May 1, 2019
Work continues on the single preferred drug list (PDL) for all managed care organizations (MCO) and Medicaid fee-for-service (FFS). Medicaid is on schedule for a May 1, 2019 implementation date.
Staff continues to work on state rulemaking and amendments to the State Plan with the Centers for Medicare & Medicaid Services (CMS). Proposed changes include:
- An increase in the professional dispensing fee from $10.41 to $10.99 for FFS prescriptions, upon CMS approval.
- A change in the ingredient cost methodology from Average Acquisition Cost (AAC) to the National Average Drug Acquisition Cost (NADAC), upon CMS approval.
Although the dispensing fee and NADAC changes are only applicable to FFS Medicaid, MCOs are mandated through legislation to reimburse local pharmacies at the FFS rate.
The provider fee requirement will remain unchanged. The provider fee ($0.10) will continue to be reimbursed separately from the professional dispensing fee, per legislative mandate, in NCPDP field 558-AW (flat sales tax paid). Pharmacy providers should continue to submit the provider fee ($0.10) in NCPDP field 481-HA (flat sales tax submitted) on all pharmacy claims.
The single PDL that will become effective on May 1, 2019 will be posted through a static link on April 29, 2019 on the Louisiana Medicaid and Louisiana Department of Health websites. The current FFS PDL is the same PDL that will become effective on May 1, 2019. Links to criteria are embedded in the current posted FFS PDL, and some criteria will be updated to become effective on May 1, 2019.
Additional clarifications are forthcoming and will be shared in future editions of Pharmacy Facts. More background on the single PDL can be found in previous editions of Pharmacy Facts.
Billing changes with MCOs
Healthy Blue is changing its pharmacy benefit manager (PBM) from Express Scripts to IngenioRx. The BIN, PCN and Group will change effective May 1, 2019. See below:
- RXBIN: 020107
- RXPCN: FG
- RXGRP: WKLA
AmeriHealth Caritas Louisiana will change their BIN ONLY effective May 1, 2019. See below:
- RXBIN: 019595