Georgia Medicaid Fee-for-Service Pharmacy Program frequently asked questions

Georgia Medicaid Fee-for-Service Pharmacy Program Frequently Asked Questions
Below are answers to some of the most frequently asked questions regarding the Georgia Medicaid Fee-for-Service (FFS) Pharmacy Program.
General Questions
How many lives are in the Medicaid FFS Program? Approximately 446,000 individuals are enrolled in the Medicaid FFS program. This figure includes approximately 123,000 Medicare D dual eligible members. Total eligible Medicaid members including FFS and Care Management Organizations (CMOs) are approximately 1.5 million.
Who is the Medicaid FFS Pharmacy Benefit Manager (PBM)? SXC Health Solutions, Inc. 2441 Warrenville Road, Suite 610 Lisle, IL 60532-3642 www.sxc.com Technical Support: 1-866-525-5826 Clinical and Prior Authorization Support: 1-866-525-5827 For paper claims processing: Paper Claims Processing P.O. Box 3214 Lisle, IL 60532-8214
What services does SXC provide to the Georgia Department of Community Health (DCH)? SXC provides typical PBM services to DCH including but not limited to:
Claims processing Drug file maintenance Utilization reporting Technical and prior authorization call centers Provider relations
Additionally, SXC - through their contractor NorthStar Healthcare Consulting (NHC) - provides Therapeutic class reviews New drug evaluations Prior authorization criteria development and maintenance Retrospective drug utilization review Clinical benefit design consultation Drug Utilization Review Board (DURB) support Drug manufacturer point-of-contact on clinical issues Pharmacy audit
How can I contact NorthStar Healthcare Consulting (NHC)? NHC can be contacted via email at GAMedicaid@nhc-llc.com or by phone at: 1-(866) 356-9021.

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Georgia Medicaid Fee-for-Service Pharmacy Program Frequently Asked Questions
Manufacturer Focused Questions
How do I find out if the NDC for my drug is currently on the drug file the State is using? Manufacturers can contact our SXC Clinical Manager, Dr. Tami Sweat, to determine if NDCs for their products are currently on the drug file utilized by the Georgia FFS Medicaid Program. Dr. Sweat can be contacted at: Tami.Sweat@sxc.com
How often does the drug file that the State uses for on-line adjudication get updated? SXC utilizes Medispan as the drug reference file for Georgia Medicaid. New drugs are added to the Georgia Medicaid drug file twice monthly - on the first and fifteenth of each month. Pricing updates are added to the drug file weekly.
If I have new product information, who should I contact to discuss this information? NorthStar Healthcare Consulting (NHC) reviews all new drugs, new product information, and relevant clinical studies. In turn, NHC presents this information to the Department on a routine basis. If you have a new product or new product information you would like the Department to consider, please provide that information to NHC at: GAMedicaid@nhc-llc.com or contact them at 1-(866) 356-9021. Additionally, DCH would like to receive an electronic version of the product dossier in the AMCP format. These electronic versions may be mailed to:
DCH Pharmacy Department 2 Peachtree Street, NW 37th Floor Atlanta, GA 30303
What information would the State like to receive from the manufacturer in addition to new drugs and new indications? The Department would like to receive copies of new studies involving the manufacturers' product(s). Information regarding safety alerts as well as drug availability in the marketplace are also requested.
Where would I find a copy of the current Georgia Medicaid FFS Preferred Drug List (PDL)? The current FFS PDL can be found on the DCH web site at: www.dch.georgia.gov/pharmacy and the Georgia Medicaid Web Portal at: www.mmis.georgia.gov (Pharmacy>Other Documents). This document is refreshed on a monthly basis.
The PDL listed on the web includes designation of Preferred (P), Non-Preferred (NP), Prior Authorization (PA) and Quantity Level Limitations (QLL). What do these designations mean?
Preferred (P) This designation means the product is a preferred product and available at the lowest co-payment tier ($0.50) for populations that are subject to a co-payment. Preferred products are not necessarily exempt from prior authorization. If a prior authorization is associated with a preferred product, a designation of "PA" will appear on the PDL.

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Georgia Medicaid Fee-for-Service Pharmacy Program Frequently Asked Questions

Non-Preferred (NP) This designation means the product is not preferred. When clinically appropriate, the Department asks providers to use preferred alternatives. Non-preferred products may or may not be associated with a prior authorization. If a prior authorization is required, a designation of "PA" will also appear on the PDL. Non-preferred carries the designation of a non-preferred co-payment which is scaled based on the cost of the product. This nonpreferred copayment is determined by the following formula:

DCH Reimbursement Under $10.00 $10.01-$25.00 $25.01-$50.00 $50.01 or more

Co-Payment $0.50 $1.00 $2.00 $3.00

Quantity Level Limitation (QLL) This designation indicates the maximum quantity of a product that can be processed without requiring a prior authorization. If that maximum quantity is exceeded, a prior authorization is required. These established quantity level limitations are published in Appendix B of the Part II - Policies and Procedures for Pharmacy Services Manual.

How do I get my drug reviewed for PDL status? Manufacturers may use the Manufacturers' Forum to present clinical information to NorthStar Healthcare Consulting (NHC), SXC's contracted clinical vendor. Presentations by manufacturers at these forums should be related to drugs being discussed at the next Drug Utilization Review Board meeting. Information regarding the next scheduled Manufacturers' Forum and how to schedule an appointment can be located on our web site at www.dch.georgia.gov/pharmacy under the "Drug Utilization Review Board" link. Also, NHC can be contacted via email at GAMedicaid@nhc-llc.com or by phone at 1-866-356-9021. Please contact NHC for meeting parameters and protocols.

What is the default coverage status for new drugs? New drugs on the market are typically given a non-preferred status with or without a prior authorization until reviewed by the DUR Board. There are five exception categories that typically receive preferred status immediately upon release to the market and they are as followed: HIV/AIDs agents; antineoplastics; agents which had expedited review by the FDA; seizure medications; and immunosuppressants. The Board reviews new drugs after a six month period of availability of the medication to the public. This six month waiting period is measured starting from the date the drug is first shipped from wholesalers.
Note: While this is the default position for new drugs, the Department may position drugs differently prior to the expiration of the six month waiting period as necessary to appropriately manage the benefit.

What is the default coverage for new strengths or formulations of existing drugs? New strengths of existing drugs typically default to the status of the existing drug. New formulations of the existing drug are typically reviewed by DCH and not brought before the DUR Board. DCH will evaluate the clinical merits and costeffectiveness of new formulations of existing drugs and make a PDL determination for those products.

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Georgia Medicaid Fee-for-Service Pharmacy Program Frequently Asked Questions
What is the role of the DUR Board? The Georgia Drug Utilization Review Board (DURB) was established under the authority of Section 1903(3) A of the Omnibus Budget Reconciliation Act of 1990 (OBRA). The Board promotes patient safety through an increased review and awareness of outpatient prescribed drugs. The Board recommends medical criteria, standards and educational intervention methods and advises DCH about products considered to be the most clinically effective. The Board reviews drug therapy, drug studies and utilization information, thus enabling the Department to identify the most cost-effective policies for its members. The DURB serves as a Pharmacy and Therapeutics Committee. The DURB is an advisory body to DCH. DCH makes all final decisions regarding matters discussed at the DURB meeting.
Is there a separate Pharmacy and Therapeutics (P&T) Committee? No. DCH utilizes its DUR Board as the body that recommends preferred drug list status for medications.
Where can I find out about upcoming DUR Board meetings? Information about upcoming DUR Board meetings can be obtained on the DCH web site at: www.dch.georgia.gov/pharmacy. The DUR Board typically meets on a quarterly basis in March, June, September, and December. However, check the website for exact dates, times, location, and frequency.
Is there a schedule showing which drugs will be reviewed at each DUR Board meeting? At least 30 days prior to each DURB meeting, a list of drugs to be discussed at that meeting will be posted on the DURB page of our web site at: www.dch.georgia.gov/pharmacy. The drugs in the Supplemental Rebate Program scheduled for review are also located at this website under "Drug Utilization Review Board" > "Meeting Information", "Drugs Under Review".
Do you allow public comment at the DUR Board meetings? Yes. Public comment from recipients, advocates, and Medicaid providers is allowed at the DUR Board meeting. Comments from industry representative are not allowed during the DUR Board meeting. Speakers must disclose any and all conflicts of interest.
What is the current policy on a manufacturer's relationship/role with DUR Board members? The Department respectfully requests that contact with DUR Board members remains limited to the normal contact the manufacturer would have with that individual as it relates to that members normal practice responsibilities. DCH request that manufacturers refrain from discussions with Board members on DUR Board specific issues.
Does the DCH Division of Medical Assistance (DMA) Pharmacy Unit routinely meet with manufacturers? The Pharmacy Unit attempts to make sure all meetings are productive. "Meet and greet" or "introduction of transitioning staff" are preferred to be handled by e-mail or a quick phone call. The pharmacy unit does allow 30-minute meetings with manufacturers within 10 business days after the manufacturer's drug has been discussed at the Drug Utilization Review Board Meeting. Those meetings can be coordinated with Rose Duncan at 404-657-7247. Meetings requested outside of this schedule should include a proposed agenda, and they are subject to the review and discretion of the Pharmacy Director.

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Georgia Medicaid Fee-for-Service Pharmacy Program Frequently Asked Questions
Who would a manufacturer contact regarding consideration of possible DUR opportunities? NorthStar Healthcare Consulting (NHC) conducts retrospective drug utilization reviews on behalf of the Department. Any manufacturer opportunities should be presented to NorthStar Healthcare Consulting for consideration. NorthStar will advise the Department on the opportunity, and DCH will make the final decision on whether to pursue or not. NHC can be contacted at GAMedicaid@nhc-llc.com or contact them at 1-866-356-9021.
Does Georgia Medicaid have a Supplemental Rebate program? Yes. Georgia Medicaid has a stand alone supplemental rebate program which is administered by Goold Health Systems (GHS).
Who handles drug rebates, disputes, and invoicing? Goold Health Systems handles all Centers for Medicare & Medicaid Services (CMS) and supplemental rebate issues. Inquiries on these matters can be directed to:
Rossi Rowe Goold Health Systems P.O. Box 1090 45 Commerce Drive, Suite 5 Augusta, Maine 04332-1090 Phone: 800-832-9672 Fax: 207- 430-4651 Email: garebate@ghsinc.com
I have submitted an enhanced rebate bid to Goold Health Systems. Will my drug be reviewed at the next DURB meeting? How will the Department be notified of my enhanced bid? Submission of an enhanced supplemental rebate bid does not qualify a drug for review outside of its normal review cycle by the DURB. Upon receiving any enhanced supplemental rebate bids, in accordance with the established guidelines, Goold Health Systems will notify DCH of the bid and notification will be sent to resubmit a bid during the next bidding cycle.
Does Georgia Medicaid make prior authorization or stepped therapy criteria available online? Yes. Conditions for coverage can be located on the DCH web site at: www.dch.georgia.gov/pharmacy. As criteria are updated during the year, this page is also updated. Please refer to this page regularly for any changes.
Where can I find the quantity level limits established for various drugs? The quantity level limit list is located at: www.mmis.georgia.gov, > "Provider Information" > "Provider Manuals" > "Pharmacy Services." The quantity level limits are in Appendix B of the document.
Who do I contact if I have concerns regarding the prior authorization criteria, quantity level limit, or other clinical benefit design parameters applied to my drug? Please contact NHC via email at: GAMedicaid@nhc-llc.com or by phone at 1-(866) 356-9021. NHC will research the issue and present the issue to DCH for consideration.

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Georgia Medicaid Fee-for-Service Pharmacy Program Frequently Asked Questions

Do the CMOs have to follow the FFS PDL and PA criteria? No. Each CMO has its own PDL and associated prior authorization criteria. The preferred drug list for each Medicaid CMO can be found as follows:

CMO AMERIGROUP Community Care Peach State Health PlanTM WellCare of Georgia

Website https://www1.amerigroupcorp.com/providers/_documents/2008 _pdl.pdf www.pshpgeorgia.com/pdf/en/PreferredDrugList.pdf
http://georgia.wellcare.com/Resources/Documents/Providers/P harmacyServices_GA_PreferredDrugList.pdf

Where would I find more information regarding the CMO effort and CMO contact information? Information on the three Medicaid CMO programs and their contact information can be located at: www.dch.georgia.gov > "Georgia Medicaid" > "Georgia Families".

What type of drug benefit does Georgia Medicaid provide for full-benefit dual eligible members? Members who are Medicare D eligible must get their prescriptions filled under their Medicare Part D plan. The Georgia Medicaid program does however cover some drugs excluded under the Medicare Part D legislation for these enrolled members if those drugs are included as covered under the Georgia Medicaid FFS program.

Does Georgia have a limit on the number of prescriptions or number of branded drugs patients can receive per month? No. Georgia does not have such a limit.

Does Georgia Medicaid have a disease management program? No.

What is the Physicians' Injectable Drug List (PIDL)? The PIDL is a listing of drugs that are covered through the Physicians' Program when administered in the physician's office. These drugs are not processed through the outpatient pharmacy program. The coverage of these drugs is through the Physicians' Program and not a function of DMA Pharmacy Unit. Inquiries regarding the PIDL and coverage should be submitted via email to: medicalpolicy@dch.ga.gov.

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Georgia Medicaid Fee-for-Service Pharmacy Program Frequently Asked Questions
What is the process for getting my drug considered for inclusion on the Physicians' Injectable Drug List? Participating providers or manufacturers on the provider's behalf may submit written requests with supporting clinical documentation for consideration to add a non-covered injectable drug to the Physician Injectable Drug List (PIDL) directly to the Department at medicalpolicy@dch.ga.us or via US mail to:
Georgia Department of Community of Health ATTN: Physician Injectable Drug List
Medical Policy Unit 2 Peachtree Street, SW 37th Floor Atlanta, GA 30303
Note: To be considered for coverage, injectable drugs must be U. S. Food and Drug Administration (FDA) approved, administered by the provider (not self-administered by the patient), and have an active CMS rebate agreement unless exempted from rebate requirements in the Social Security Act. Also, PIDL claims are processed by the Medicaid Management Information System (MMIS) vendor, HP, and not SXC.
Where can I find the maximum allowable amounts for injectable drugs on the Physicians' Injectable Drug List (PIDL)? The list of maximum allowable amounts on the PIDL is located at: www.mmis.georgia.gov > "Provider Information" > "Provider Manuals"> "Physicians' Injectable Drug List." Please note that the Physicians' Injectable Drug List is not managed by the pharmacy department and further inquiries regarding this list can be directed to: medicalpolicy@dch.ga.gov.
Are there any physician-administered drugs or durable medical products which require a prior authorization through the medical or durable medical equipment programs? Yes. Please consult the policy manuals for the Durable Medical Equipment and Physician Injectable Drug List Programs. These manuals can be found at www.mmis.georgia.gov under the "Provider Information" tab then click on "Provider Manual". Both the Physician's Injectable Drug List and Durable Medical Equipment policy manuals provide this information.
How do I contact the Department regarding coverage of nutrition products and medical devices? Please contact the Medical Policy Unit at: medicalpolicy@dch.ga.gov.
How do I get on the Georgia Medicaid list serve or is there a way to receive any new Georgia Medicaid special bulletins/Newsletters/Policy and Procedure changes, etc.? Currently, there is no Georgia Medicaid pharmacy list serve for interested parties. News from the Department is best tracked via the following:
The main DCH Website at www.dch.georgia.gov The DCH pharmacy website at: www.dch.georgia.gov/pharmacy The Georgia Medicaid Web Portal which contains weekly notices to providers, policy manuals, forms, and a wealth of other information. This site is located at www.mmis.georgia.gov.

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Georgia Medicaid Fee-for-Service Pharmacy Program Frequently Asked Questions

Provider Focused Questions

What is your current provider reimbursement methodology? FFS Medicaid reimburses the lower of:
AWP 11% + $4.33 (non-profit providers) or $4.63 (for "for profit" providers); or Georgia Maximum Allowable Cost (GMAC) + $4.33 (non-profit providers) or $4.63 (for "for profit" providers); or Usual and customary charge; or Submitted ingredient cost plus submitted dispensing fee; or Provider's submitted Most Favored Nation (MFN) Rate. MFN is the lowest rate the provider has accepted from any other non-governmental payer.

What are the co-payments for FFS Medicaid recipients?

Drugs listed as "preferred" on the PDL carry a co-payment of $0.50 for patient populations subject to patient cost-

sharing requirements. Non-preferred products have a co-payment based upon DCH reimbursement to the pharmacy as

follows:

DCH Reimbursement Co-Payment

Under $10.00

$0.50

$10.01-$25.00

$1.00

$25.01-$50.00

$2.00

$50.01 or more

$3.00

What online services does the PBM have available to Medicaid providers? SXC in coordination with DCH has established an on-line service at the SXC web site to provide the following:
Weekly banner messages Remittance summaries Preferred drug list Prior authorization guide Part II policy and procedures manual Medicaid FFS member medication history
Providers must enroll on the SXC web site to gain access to this confidential service. Enrollment forms can be obtained at: https://ga.providerportal.sxc.com
How can I enroll as an in-state pharmacy provider? Applications can be obtained at: www.mmis.georgia.gov > "Provider Information".
How can I enroll as an out-of-state pharmacy provider? Providers located more than 50 miles outside the state of Georgia should complete an out-of-state provider application. Applications can be obtained at: www.mmis.georgia.gov > "Provider Information".

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Georgia Medicaid Fee-for-Service Pharmacy Program Frequently Asked Questions
How can I check the status of my Provider application? Go to: www.mmis.georgia.gov > "Provider Enrollment" > "Enrollment Application Status." Other Questions Does DCH oversee the Public Health Division programs? No. The Department of Public Health website is www.health.state.ga.us. What if I have a question that is not included in this FAQ? The DCH FFS Pharmacy staff can further assist you at (404) 656-4044.

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