Effective February 1, 2010, the ODJFS is implementing changes for prescription drug coverage for members of Medicaid managed care plans (MCPs) and to coverage of certain medical supplies for all Ohio Medicaid consumers, including MCP members.

Previously, Ohio’s MCPs, including Buckeye Community Health Plan, were responsible for providing all pharmacy benefits to their members. The ODJFS paid MCPs a capitation payment that included a fixed amount of funds to provide the pharmacy benefit, and MCPs were at full risk for the drug costs of their members. Now that the pharmacy is carved out of the benefit provided by MCPs, ODJFS has assumed responsibility for medications administered in the home. Capitation payments to MCPs have been adjusted accordingly to reflect the change in policy.

Currently, each of the seven Medicaid MCPs are responsible for pharmacy claims processing and prior authorization activities related to drugs dispensed by pharmacy providers to their members. Under the carve-out, managed care members will use the Ohio Medicaid fee-for-service (FFS) pharmacy benefit. All drug coverage policies will be the same for members enrolled in each of the seven MCPs, as well as the FFS program. 

What drugs are part of the carve-out? Will any drugs be covered by the MCPs?

The carve-out is limited to “take-home” drugs, meaning those drugs that are prescribed by a physician to be self-administered by the patient in their residence. Drugs administered by the physician or another professional in the course of an office or hospital visit are under the medical benefit and will still be part of the managed care benefit. Drugs administered via home health services or in a long-term care facility are carved out and under the FFS program.

Are any medical supplies part of the carve-out?

Some medical supplies that are usually obtained at the pharmacy, such as diabetic testing supplies, supplies for injection of insulin and other drugs, inhaler spacers, and peak flow meters, will only be able to be billed by pharmacies (including hospital pharmacies) and will no longer be covered when billed by any other provider type, including durable medical equipment (DME) dealers, clinics, or individual physician offices.

How will ODJFS ensure MCP members can continue to fill their prescriptions?

Prescription drug coverage for Medicaid MCP members will be the same as coverage for Medicaid FFS consumers. A transition period for MCP members will be in effect from February 1 through April 30, 2010. For claims within these dates of service, MCP members will be able to continue to receive medications that were filled under the MCP within the previous six months. If the drug claim for a MCP member requires prior authorization (PA) through FFS, the claim will be authorized during February, March, and April 2010 if the MCP member had a claim for the same drug during the previous six months that was covered by the MCP. The MCP member will be notified that the drug that was filled requires PA, but that they may continue to receive that drug through April 30, 2010. Beginning May 1, 2010, claims will deny at the pharmacy and the prescriber should either change to a drug that does not require PA or request PA.

Will MCP members have a different ID card for prescriptions?

No, MCP members will continue to use their MCP ID card to receive prescriptions. The MCPs have changed the ID card to include information about billing prescriptions through FFS.

What is the policy regarding coverage for newborns?

The ODJFS has implemented a policy change that will allow prescription drug coverage for newborns who have not been assigned a Medicaid identification (ID) number. This policy applies for prescriptions that should be billed through the ODJFS pharmacy vendor, ACS. Pharmacies should make every attempt to determine whether a child born to a mother who has Medicaid has been assigned a Medicaid ID. If the consumer does not have an ID card showing the newborn’s MMIS billing ID, call ACS at 1-877-518-1545 to determine if an ID number has been assigned.

Beginning February 1, 2010, if a Medicaid ID has not been assigned for the baby, newborns will be covered for prescriptions under their mother’s Medicaid billing ID until the newborn reaches age one. The pharmacy should submit the claim for the newborn using the mother’s Medicaid ID and the baby’s date of birth. Pharmacies should encourage consumers to immediately report newborns to the CDJFS caseworker so the newborn can be added to the mother’s case and the newborn can be assigned a separate Medicaid ID.