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March 1, 2006
TO:                 Prescribing Providers, Pharmacists, Pharmacies, and Long-Term Care Facilities
FROM:           Leslie M. Clement, Deputy Administrator
On July 1, 2006 Idaho Medicaid will initiate an edit that calculates a daily dosage limit for medications. The daily quantity limit set by Medicaid is based primarily on FDA approved guidelines.  This new edit will stop practices of “prescription splitting” that some pharmacies have developed.  This practice is considered fraudulent because the pharmacy receives duplicate dispensing fees and supersedes Idaho Medicaid quantity limits.
For example, Nexium® is indicated for once daily dosing for all FDA approved indications.  The Idaho Medicaid quantity limit is set at one dosage form per day.  When a pharmacy receives a prescription for twice daily dosing and attempts to bill 60 capsules as a 30 day supply, the claim denies. The correct action would be to initiate a prior authorization (PA) for a quantity over-ride if the quantity requested is justified.  To get around the need for prior authorization many pharmacies are splitting the prescribed 30 day supply and dispensing the monthly maximum allowed every 15 days (#30 dispensed as a 15 day supply).
The new edit blocks prescription splitting by calculating a daily dosage limit.  For instance, if 30 units are allowed every 30 days, then 1 unit is allowed per day.   Billing 30 units as a 15 day supply will no longer result in a paid claim.  If the pharmacy has a previously approved prior authorization (PA) for a quantity override, this edit will acknowledge that PA and approve the claim.
On July 1, 2006 we will also start editing for the unit of measure that is submitted on a pharmacy claim against the unit of measure in our drug files for the NDC.  The unit of measure (i.e. GM, ML, or EA) submitted on pharmacy claims are used by our system to validate that the quantity being billed is in the correct increments.  This is to ensure that the correct quantities are being submitted to Medicaid and proper payment is being made to our providers.  Please check with your software vendors to ensure that this information is being transmitted.
Quantity override forms are available at (PA Criteria & Forms).  Medication quantity limit values can be obtained by using MAVIS the automated phone information line at EDS 800-658-3757.  Questions regarding the Prior Authorization program may be referred to the Medicaid Pharmacy Unit at (208) 364-1829.