IDAHO MEDICAID PHARMACY PROGRAM AND HOSPICE
Effective December 2, 2013, the Pharmacy Program has implemented a new procedure related to Medicaid participants receiving hospice care. Any prescription medication that hospice does not provide under the routine home care prospective (per diem) rate must undergo prior authorization evaluation by a pharmacist. Please see the fax which was sent to statewide pharmacies posted to the right under “Important Information”. There has been no change in IDAPA Rule, but this is a payment methodology change in the Pharmacy Program. Idaho Medicaid does not reimburse for drugs prescribed for participants enrolled in hospice services when the drugs are related to the participant’s terminal illness and related conditions. Coverage for drugs outside of the hospice payment responsibility requires the submission of a prior authorization request to the Pharmacy Department. Only drugs approved through the prior authorization process will be paid for by Medicaid. The hospice participant or caregiver/family member, pharmacy, or hospice agency can contact the prescribing physician’s office to inform the physician that non-hospice covered medications must have a prior authorization.
How prior authorization for non-hospice related medication is requested: There are two options available to access authorization. One option is to use the Universal Pharmacy Prior Authorization Form which can be accessed at www.medicaidpharmacy.idaho.gov. There will soon be a “Hospice Prior Authorization Form” posted on the website. The prescribing physician or the physician’s nurse will need to complete the form and fax it to the Idaho Medicaid Pharmacy Unit Call Center at 1(800)327-5541. The second option is for the physician or his/her nurse to call 1(866)827-9967 or 1(208)364-1829 and the determination of “approval” or “denial” may be obtained over the phone. The Call Center is open 8am-5pm Mon.-Fri. MST and is closed on state holidays. The hospice diagnosis and justification as to why hospice is not responsible for paying for the medication must be provided. It would be helpful if the prescribing physician is made aware of the exact primary ICD Diagnosis Code under which the participant was enrolled to hospice care. Authorizations will be approved for a six month period of time. Medicaid does pay for a 72-hour emergency supply of medication that requires PA if the request has been submitted, but has not been processed. If a voice mail is left it will be answered in a timely way. There will be no retro-active authorizations.
How to learn if a medication has been approved or denied: If a request has been approved, the prescribing physician and pharmacy receive a fax notification. The participant does not receive a notice of decision, but knows a medication has been approved because it is billed to Idaho Medicaid by the pharmacy. If a request has been denied, the prescribing physician and pharmacy receive a fax notification. The participant receives a mailed notice of decision (NOD). The NOD contains information on how to appeal the decision. Also, Megellan Medicaid Administration can be contacted at 1(800)922-3987 to learn the outcome of a PA Request. A hospice agency may contact the pharmacy, the prescribing physician’s office, the participant/family, or Megellan to learn if a specific medication has been approved or denied.
Additional questions: Please contact the Idaho Medicaid Pharmacy Program at 1(866)827-9967 or 1(208)364-1829 during the hours listed previously.