Provider Memos

Provider Memo Number

Subject

Date

ACS M01-01

Fee-For-Service Program Only :

1.   Early Refill
2.   Toradol Limitations Effective November 1, 2001
3. Androgens/Estrogens Limitations Effective November 1, 2001
4.   Retin-A, Altinac Cream and Avita Limitations Effective November 1, 2001
5.   Mandatory Generic Program Effective October 1, 2001
6.   Third Party Liability (TPL) Billing Information
7.   Local ACS/Consultec Clinical Services Manager’s Phone Number

September 12, 2001

ACS M01-02

Prevention Of Serious Lower Respiratory Tract Infections Caused By Respiratory Syncytial Virus (RSV)

October 3, 2001

ACS M01-03

Prevention Of Serious Lower Respiratory Tract  Infections Caused By Respiratory Syncytial Virus (RSV)

October 9, 2001

ACS M01-04

Fee-For-Service Program Only :

1. Gleevec – Diagnosis Required Starting December 1, 2001
2. Zyvox – Days Supply Limitation and Diagnosis Code Required Starting December 1, 2001
3. Compounds – Billing Reminders
4. Paper Claims – Billing Reminders
5. Hypopigmentation Agents – No Longer Covered Starting December 1, 2001
6.  Claims for Injectable Medications
7. John Pang, Pharm. D., ACS/Consultec Clinical Services Manager
8.     Dispense as Written (DAW) 7 – Coumadin and Brand Oral Contraceptives
9.   Billing for Condoms

October 11, 2001

ACS M01-06

Fee-For-Service Program Only :

1. Paper Claim Submissions – Incomplete Forms Returned Effective November 30, 2001
2. Gemzar – New Indication Effective Immediately
3. Over-The-Counter Formulary Additions Effective Immediately
4. Early Refill Claims - Point-Of-Sale Effective December 1, 2001
5. ACS Help Desk - Ask for a Help Desk Supervisor

November 13, 2001

ACS M01-07

Fee-For-Service Program Only :

1.       Website for Hawaii Med-QUEST Fee-For-Service Pharmacy Program -- Available Now
2.       Clarification of Lupron and Viadur Prior Authorization Criteria
3.       Quantity Restriction:  100 Units Only for Medications Billed as “Eaches” -- Effective January 30, 2002
4.       Metric Decimal Units Required for Billing 
5.       Implementation of New Federal Upper Limit (FUL) Prices -- Effective January 22, 2002
6.       DAW 1 for Anti-Seizure Medications, Coumadin and Oral Contraceptives -- Expected Reactivation December 30, 2001
7.       Prior Authorization for Brand Products on the Federal Upper Limit Price List from August 1, 2001 through October 31, 2001
8.       Reminder: Generics and Brand Medically Necessary

December 14, 2001

ACS Pharmacy No. 8

Fee-For-Service Program Only :

1.       Clarification of the Generic Mandatory Program – Dispense As Written (DAW) 5 and Expedited Prior Authorization
2.       Diagnosis Code Listing
3.       Expansion of Medicare Coverage of Immunosuppressants
4.       New Prior Authorization/Diagnosis Code Restriction - Bextra ®

February 22, 2002

ACS Pharmacy No. 9

Fee-For-Service Program Only :

1. State Maximum Allowed Cost (SMAC) 
2.     Prescription Strength Ranitidine 
3.     Over The Counter (OTC) Pepcid Ò and Zantac Ò Brand and Generics 
4.    Days Supply Clarification 
5.    Home Infusion HCFA 1500 Claim Forms 
6.    New Drug Within Therapeutic Class 
7.    Drug-Drug Interactions At Severity Level One 
8.     Enbrel: New Indication and Rheumatologists Unrestricted For Prescribing 
9.    Prior Authorization Is Required For Compounds With No National Drug Code (NDC) Numbers 
10.   Paper Claims Requiring Prior Authorization (PA)

April 9, 2002

Shortages In Childhood Vaccines

April 12, 2002

ACS Pharmacy No. 10

Fee-For-Service Program Only :

1.    Quantity Restriction:  50gms and 50mls Will Be Effective on or After July 21, 2002

2.    Clarification of Dispense As Written (DAW) 5

3.     Incomplete Prior Authorization (PA) Requests For Drugs

4.     PA For Recipients With Coupons

5.     PA Number Required On Home Infusion Claims

6.    Drug Use Review of Atypical Antipsychotics and Narcotic Analgesics

7.    New Indication For Gleevec ®

June 10, 2002

ACS Pharmacy No.11

Fee-For-Service Program Only :

1.    PA Criteria For Botulinum Toxin (Type A And B)
2.    PA Criteria For Elidel ® Cream
3.    PA Criteria For Kineret ®
4.    PA Criteria For Intrathecal Baclofen ®
5.    PA Criteria For Rebif ®
6.   Third Party Liability
7.   Multiples Of Package Size For Billing
8.   Vaccines For Children’s Program Stock

August 7, 2002

ACS Pharmacy No. 12

Oxycodone HCL (Oxycontin ®)

October 11, 2002

ACS Pharmacy No. 13

Modified Prior Authorization For Use Of Atypical Antipsychotics In The Elderly With Specific Behavioral Symptoms

October 18, 2002

P02-14

Fee-For-Service Program Only :

1.    Recovery Of Pharmacy Payment If The Physicians' Orders are Not Countersigned Withinithe 72-Hour Period
2.    New Forms For Request For Medical Authorization For Drugs (1144B)
3.    New Forms For Manual Billing of Drugs (Form 204)
4.    Availability Of Records

November 1, 2002

P02-15

Fee-For-Service Program Only :

1.       Pharmacy Audit Contractor
2.       Recovery of Pharmacy Payment if The Prescribers’ Telephone Orders are not Countersigned Within the Appropriate Time Period

December 6, 2002

P02-16

Hospice Recipients and Payment for Drugs not Related to the Terminal Illness

December 19, 2002

P03-01

Fee-For-Service Program Only :

1.     All OxyContin ® Claims
2.     Maximum Standard Doses
3.     Plan Summary Descriptions on the Website
4.     Prior Authorization for Eloxatin ®
5.     Prior Authorization for Lotronex ®
6.     Prior Authorization for Zelnorm ®
7.     Modified Prior Authorization for Low Dose Atypical Antipsychotics - CORRECTIONS
8.     Prior Authorization for Low Dose Atypical Antipsychotics (Abbreviated Format)
9. Prior Authorization for OxyContin ® (Abbreviated Format)

January 10, 2003

P03-02

Fee-For-Service Program Only :

1.    HMSA 204 forms ~ Clarification
2.     Home Infusion Rate Code Change

January 17, 2003

P03-03

Fee-For-Service Program Only :

1. Prior Authorization (PA) for Abilify ® (Aripiprazole)
2.   Prior Authorization for Humira ®(Adalimumab)
3.    Prior Authorization for Isoniazid for Nursing Facility Residents 
4.   Prior Authorization for Oxycontin ® - CLARIFICATION
5.   Prior Authorization for Xyrem ® (Sodium Oxybate)
6.   Prior Authorization for Zetia ® (Ezetimibe)
7.   Billing for Zevalin ® (Ibritumomab tiuxetan)
8.   Restriction Criteria for Kineret ® (Anakinra)
9.    Federal Upper Limits (FUL) Update
10.   Brand Medically Necessary - CLARIFICATION
11.   Maximum Standard Doses - Updates

April 11, 2003

P03-04

Fee-For-Service Program Only :

1. New Indication for Gleevec ® (Imatinib Mesylate) Added 
2.    New Indication for Taxotere ® (Docetacel) Added 
3.    Prior Authorization (PA) for Vicon Forte ® and Vicon Plus ®
4.    Billing of Synvisc ® (Hylan polymers A & B) 
5.    Hawaii Medicaid Pharmacy Compliance Audit 
6.   Maximum Standard Doses – Updates

May 16, 2003

P03-05

Fee-For-Service Program Only :

1. Billing Process When Expiration and Termination Dates Conflict
2.    Affiliated Computer Services Pharmacy Benefits Management (ACS PBM) Transition to New Drug Claim System – Effective July 13, 2003

June 20, 2003

S03-01

Forms:

 1.       DHS 1144B, Request for Medical Authorization form and instructions; 
 2.       DHS 1162, Use of Clozapine, Olanzapine, Risperidone, Questiapine and Ziprasidone form and instructions; and 
 3.       BPRS (Brief Psychiatric Rating Scale).

July 23, 2003

S03-02

Fee-For-Service Program Only : Enteral Supplies - Emergency Foley Catheter

August 18, 2003

P03-06

Fee-For-Service Program Only - National Council For Prescription Drug Programs (Ncpdp) Version 5.1 Implementation

September 5, 2003

S03-03

Fee-For-Service Program Only : Home Infusion Supply Claims

December 19, 2003

P04-01

Fee-For-Service Program Only:

·       New Drug Prior Authorization Requirements

·       Clarification of Proton Pump Inhibitor Drug Availability

·       Nonpreferred Drug List Claims With Date Of Service Prior to January 17, 2004

·       New Features

June 1, 2004

P04-02

Medicaid Fee-For-Service (FFS) Pharmacy Program Only Preferred Drug List-Phase 2 Implementation

June 29, 2004

P04-03

First Health: Development And Implementation Of The “National Medicaid Pooling Initiative” (NMPI) Preferred Drug List (PDL)

July 27, 2004

P04-04

Fee-For-Service Program Only:

·       Actiq ® (Oral Transmucosal Fentanyl Citrate) Prior Authorization (PA) Criteria

·       Diagnosis Requirement for Neurontin ® (Gabapentin)

·       Prior Authorization Form Completion (1144b)

August 18, 2004

P04-05

Prevention Of Serious Lower Respiratory Tract Infections Caused By Respiratory Syncytial Virus (RSV)

October 14, 2004

P04-06

State Medicaid Fee-For-Service (FFS) Preferred Drug List (PDL) Update – Effective: January 5, 2005

November 5, 2004

P04-07

State Medicaid Fee-For-Service (FFS) Preferred Drug List (PDL) Update – Effective: February 2, 2005

November 24, 2004

P04-08

Fee-For-Service Program Only:

·       Refill Grace Period For C-II Controlled Drugs – Effective February 15, 2005

·       Oxycontin ® Including Generics Prior Authorization (PA) Changes And Clarification – Effective January 12, 2005

·       Oxycontin ® Including Generics Diagnoses Restrictions – Effective January 12, 2005

·       Clarification of Brand Medically Necessary Notation – Effective Immediately

·       Vioxx ® Recall and COX II Inhibitors – Effective September 30, 2004

·       PA Criteria For Subutex ® and Suboxone ® - Effective January 10, 2005

December 6, 2004

P04-09

State Medicaid Fee-For-Service (FFS) Preferred Drug List (PDL) Update – Effective: March 2, 2005

December 27, 2004

P05-01

State Medicaid Fee-For-Service (FFS) Preferred Drug List (PDL) Consolidation Of Phase I, II and III

January 24, 2005

Terminated Products

February 10, 2005

P05-02

Fee-For-Service Program Only:

·       Emergency Dispensing Of Drugs Which Require Prior Authorization – Effective Immediately

·       Processing Of Claims For Non-Rebate Drugs – Effective Immediately

·       Telephone Orders For Medications – Clarification

·       General Prior Authorization Clarification – Effective Immediately

·       Amendment Of The Refill Grace Period for C-II Controlled Drugs – Effective February 15, 2005

February 18, 2005

P05-03

State Medicaid Fee-For-Service (FFS) Preferred Drug List (PDL) – Expanded Exception Criteria

March 7, 2005

PDL Quick Reference List

P05-04

Fee-For-Service Program Only:

1.         Mandatory Generic Program: Brand or Branded Generic Limit Increased – Effective Immediately

2.         Maximum Dose for Oxandrin ® Prior Authorization Criteria – Effective April 27, 2005

3.         Paid Claims Recovery and Gender Edits

4.         Herceptin ® Billing Units – Clarification

March 18, 2005

P05-05

Fee-For-Service Program Only:

Prior Authorization (PA) Criteria

Enbrel ® (etanercept) 
Gemzar ® (gemciabine)
Vantas ® (histrelin)
Pravachol ®(pravastatin)
Xyrem ® (oxybate)
Combunox ® (ibuprofen/oxycodone)
Plenazis ® (abareliz)
Iressa ® (gefitinib)
Tarceva ® (erlotinib)
Velcade ® (bortezomib)
Spiriva ® (tiotropium)
Zelnorm ® (tegaserod)
Bextra ® (valdecoxib)

May 2, 2005

P05-06

Fee-For-Service Program Only:

Pharmacist Emergency Contraception Consultation Services

May 13, 2005

P05-07

Fee-For-Service Program Only:

·       Prior Authorization (PA) Criteria

·       Maximum Standard Doses

June 3, 2005

P06-01

State Medicaid Fee-For-Service (FFS) Preferred Drug List (PDL) Update

August 12, 2005

P05-10

Fee-For-Service Program Only:

·       ACS-PBM Mailing Address Change For Manual/Billing Paper Claims Effective April 8, 2005

·       ACS-PBM Hawaii Clinical Pharmacist Contact Information

·       Spiriva Ò (Tiotropium Bromide) Available for Adults With Chronic Obstructive Pulmonary Disease (COPD) Effective August 9, 2005

·       Lock-In Program Referrals

September 28, 2005

P05-09

Prevention Of Serious Lower Respiratory Tract Infections Caused By Respiratory Syncytial Virus (RSV)

October 7, 2005

P05-11

Fee-For-Service Program Only:

·       Legislative Initiatives – Senate Bill (SB) 1420 and House Bill (HB) 1051

·       Operational Guidelines and Implementation Dates

October 28, 2005

P05-12

1.         New Clinical Pharmacist/Account Manager for ACS/PBM in Hawaii

2.         Correction on Provider Memorandum P06-01

November 10, 2005

P05-13

Medicaid Fee-For-Service Coverage of Drugs Excluded By Medicare Part D

November 23, 2005

P05-14Medicaid Fee-For-Service Drug List - UpdateNovember 30, 2005M05-12Brief Summary of Medication CoverageDecember 23, 2005 State Pharmacy Assistance ProgramJanuary 6, 2006P06-01Medicaid fee-for-Service Preferred Drug List UpdateJanuary 19, 2006P06-2Coverage Clarification of Erectile Dysfunction DrugsJanuary 27, 2006P06-3

Assistance in Submitting Claims to Hawaii Medicaid for Persons Dually Eligible for Medicare Part D and Medicaid

January 30, 2006P06-04State Contigency Safety Plan ExtensionFebruary 24, 2006P06-05

1. Implementation of Edits for November 2005 - Revised2.  Proton Pump Inhibitors Flow Chart3.  Updated Quick Reference List    

 P06-06State Contigency Safety Plan ExtensionMarch 28, 2006P06-07State Contigency Safety Plan ExtensionApril 26, 2006P06-08P06-09State Contingency Safety Plan ExtensionMay 30, 2006 X2 ConversionJune 16, 2006 1. Pharmacy Claims Processing System Conversion
2. SmartPAJuly 6, 2006 Approved Provider Memo Change of DateAugust 7, 2006P06-10Medicaid fee-for-Service Preferred Drug List UpdateAugust 8, 2006 Pharmacy Claims Processing System ConversionAugust 22, 2006 Prevention of Serious Lower Respiratory Tract Infections Caused By RSVAugust 24, 2006 New PDL Denial MessageSeptember 5, 2005P06-12Medicaid fee-for-Service Preferred Drug List UpdateOctober 9, 2006P06-11Prior Authroization of Bexxar®October 26, 2006P06-13Medicare Part D and SPAP Updates for 2007December 12, 2006P06-14Legislation Regarding Psychotropic Medications – House Bill 3105December 29, 2006P06-15Centers for Medicare and Medicaid Services (CMS) Determined Non-Drug Items Effective January 1, 2007January 12, 2007P07-01Medicare Part D Information in the Department of Human Servers (DHS) Eligibility Verification SystemJanuary 10, 2007P07-02SPAP Claims for HMSAFebruary 1, 2007P07-03State Contingency Safety Plan ChangesFebruary 6, 2007P07-04PDL UpdateFebruary 26, 2007P07-051. NPI EFFECTIVE MAY 23, 2007 FOR BOTH PAPER AND ELECTRONIC DRUG CLAIMS
2. REVISED 204 FORM TO INCLUDE NPI
3. OXYCODONE LONG ACTING (OXYCONTIN®) ADDITIONAL INTERNATIONAL CLASSIFICATION OF DISEASES, 9TH REVISION RESTRICTION
4. SMOKING CESSATION PRODUCTS ACCESS AND PA CRITERIA
March 16, 2007P07-06State Pharmacy Assistance Program (SPAP) Claims For HMSA 65c Plus Basic Option SRX And HMSA 65c Plus High Option SRXFebruary 26, 2007P07-07State Contingency Plan & DHS Eligibility Verification SystemMarch 5, 2007P07-08NPI for Medication Claims effective May 23, 2007April 17, 2007P07-09

1.   SPAP Coverage of HMSA 65c Plus Basic and HMSA 65c Plus High Option
2.       Non drug deletions by CMS, effective July 1, 20073.       Status of new Nexium formulation”

April 19, 2007P07-10Plan B Reimbursed Without a PrescriptionMay 23, 2007P07-11Advance Practice Registered Nurses with Prescriptive Authority to Prescribe Psychotropic Medications Effective July 1, 2007July 11, 2007M07-13Tamper-Resistant Paper Prescriptions are Required for Medicaid Reimbursement Effective October 1, 2007
August 30, 2007M07-13APrescribers Need Tamper-Resistant Prescription Paper and/or Pads (TRPP) To Use Effective October 1, 2007September 24, 2007M07-13BPrescribers Need Tamper-Resistant Prescription Paper and/or Pads (TRPP) To Use Effective April 1, 2008October 1, 2007P07-13State Pharmacy Assistance Program (SPAP) 1. Eligible Medicare Part D Plans for 2008 2. Co-Payment Update - Effective January 1, 2008
November 5, 2007P07-14Medicaid Fee-For-Service Preferred Drug List – Update and AttachmentsJanuary 18, 2008M07-13CTRPP Clarification of Population Covered and Recommended Features for Hawaii MedicaidFebruary 27, 2008M07-13E

Tamper Resistant Prescription Pad (TRPP) Clarificaiton Of Recommended Features For Hawaii Medicaid Effective October 1, 2008

August 22, 2008M08-11Prevention of Serious Lower Respiratory Tract Infections Caused by Respiratory Syncytial Virus (RSV)August 28, 2008M08-12

Attn: Dentists and Pharmacy ProvidersPharmacy Claims for Drugs Prescribed by Dentists for Quest Recipients are Processed by Medicaid FFSDentists need to be Medicaid FFS Providers for Specialty Identification

September 5, 2008M08-13

Fee for Service (FFS) Program only   1. Single-Ingredient Albuterol Chlorofluorocarbon (CFC) Inhalers for Asthma 
   2. Medicaid Drug Federal Upper Limits (FUL) Resume

September 5, 2008P08-01Pharmacy Claims Require Provider National Provider Identifier (NPI) Starting May 23, 2008May 12, 2008

Medicaid Fee-for-Service Preferred Drug List; Update

September 19, 2008M08-17State Pharmacy Assistance Program
   1. Eligible Medicare Part D Plans for 2009
   2. Copayment Update -- Effective Januaty 1, 2009November 21, 2008M08-19Fee-For-Service (FFS) Program Only
   1. Quest Expanded Access (QExA) Program for FFS Recipients - Effective February 1, 2009
   2. Medicaid Drug Federal Upper LImits (FUL) Updates - Effective November 6, 2008 and November 28, 2008November 21, 2008M08-23

Fee-For Service (FFS) Program Only
    1. Quest Expanded Access (QExA) Program for FFS recipients - Effective February 1, 2009
    2. Behavoiral Health Managed Care Plan, Communicate Care Services (CCS), Management Change - Effective January 1, 2009

January 2, 2009M09-05

QUEST EXPANDED ACCESS (QEXA) - Effective Feb 1, 2009
Specific Pharmacy and Prescription Informaiton

January 21, 2009M09-13

Fee-For-Service (FFS) Program Only
Change in Prior Authorization Requirements for Nicotine Replacement Therapy

June 26, 2009M09-14Drugs Prescribed by Dentists for Quest or Quest Expanded Access (QEXA) RecipientsJune 12, 2009M09-17CCS Clients and TPL Medicare Part B or D as Primary InsurersJuly 24, 2009M09-20Fee-For-service, Quest, and QEXA Programs, Prevention of Serious Lower Respiratory Tract Infections Caused by Respiratory Syncytial Virus (RSV)August 14, 2009M09-21

Fee-For-Service (FFS) Program
     1. Basic Health Hawaii, Quest-Net and Quest-Ace Formulary Effective September 1, 2009
     First Databank AWP Calculation Change Effective September 26, 2009

August 26, 2009M09-27State Pharmacy Assistance Program (SPAP)
    1. Eligible Medicare Part D Plans for 2010
    2. Copayment Update - Effective January 1, 2010
    3. New Contact Information for SPAP Questions Effective November 16, 2009November 10, 2009M10-14

State Pharmacy Assistance Program (SPAP)
    1. Eligible Medicare Part D Plans for 2011
    2. Copayment Update - Effective January 1, 2011
    3. Contact Information for SPAP Questions
    4. Billing Information

SPAP Eligible Plans and ID Numbers
November 12, 2010M11-09

Fee-For-Service, QUEST, and QEXA Programs
Prevention of Serious Lower Respiratory Tract Infections Caused by Respiratory Syncytial Virus (RSV)

September 8, 2011M12-04Medicaid Processing of 340B MedicationsMay 24, 2012M13-03Reporting Requirement of Non-340B Medications to Comply with the Affordable Care Act (ACA) Medicaid Medication Rebate ProgramMarch 14, 2013M13-04Medicaid Fee-For-Service Program Pharmacy Reimbursement Changes

April 25, 2013

M13-06Discontinuation of Automated Prior Authorization (PA) Process for FFS PrescriptionsJuly 31, 2013

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