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Frequently Asked Questions
Pharmacy FAQ's  

1. Mandatory PDL FAQs
2.  Does the pharmacy program ever reimburse for a non-covered drug for children?
     While there are many services not covered under the Division of Medicaid's state plan for pharmacy, there are circumstances that may allow coverage through EPSDT (refer to Policy Manual Section 73.09).  Pharmacy providers are encouraged to contact the Bureau of Pharmacy at 601-359-5253.

3.  Do children have monthly prescription limits?
     In cases of medically necessity, requests for more than the monthly benefit limits i.e. more than 5 prescriptions monthly or more than 2 brand name drugs for beneficiaries under the age of 21 are to be submitted via fax to Health Information Designs (HID) at 1-800-459-2135. There is no change in policy regarding drug benefits for children. Medically necessary prior authorization form for beneficiaries less than 21 may be found DOM's web site at, Pharmacy Services, and forms. Or call Health Information Designs at 1-800-355-0486.

4.  Is DAW 7 still active for Narrow Therapeutic Index (NTI) drugs? Do NTI drugs count against the 2 brand limit?
     DAW 7 is still active for NTI Drugs. All legend brand name drugs, including NIT drugs, count against the 2 brand monthly limit. Some Narrow Therapeutic Index drugs have been added to the 90 Day Maintenance list. Please refer to DOM's web site at, Pharmacy Services, for most current 90 Day Maintenance List.

5.  What pharmacy services are covered for beneficiaries who are in the Family Planning Waiver and have a `yellow Medicaid card¿?
     Beneficiaries enrolled in the Family Planning Waiver are eligible for Medicaid coverage of family planning services only and are not eligible for any other Medicaid services. The Family Planning Waiver program is a collaborative venture of the Mississippi Department of Health and the Division of Medicaid. Oral contraceptives are supplied by the Department of Health. The only pharmacy services reimbursed for this beneficiary population are contraceptive injections and patches.

6.  Do pharmacies qualify to receive oral contraceptives from the Health Department?
     No. These oral contraceptives are to be viewed similar to 'physician samples' which the prescriber physically hands to beneficiary. The Mississippi Department of Health shoulders costs for oral contraceptives.

7.  What are the advantages of using drugs on the Preferred Drug List?
     The Preferred Drug List is a medication list recommended to the Division of Medicaid by the Pharmacy and Therapeutics Committee and approved by the Executive Director of the Division of Medicaid. These drugs have been selected for their efficaciousness, clinical significance, safety, and cost effectiveness for Medicaid beneficiaries. Most generic agents are preferred, do not require prior authorization, and are not individually listed. The PDL is routinely updated. For a current copy of DOM's PDL, refer to our website at, select Pharmacy Services, and select Preferred Drug List.

8.  Do long term care Medicaid beneficiaries have co-payments and monthly pharmacy service limits?
     No. Medicaid only beneficiaries residing in LTC facilities do not have co-payments nor service limits. If a LTC Medicaid only beneficiary is being accessed co-pays or monthly pharmacy service limits, please report this to the Division of Medicaid's Provider and Beneficiary Relations at 601-359-4292, Bureau of Long Term Care of at 601-359-6141 or DOM's toll free number of 1-800-421-2408.

9.  Are insulin supplies, such as syringes, lancets or glucometers, Medicaid reimbursable?
     For beneficiaries with Medicaid only, Medicaid covers insulin syringes, lancets, glucometers, glucose test strips, and other diabetic-related supplies. These must be billed through the DME program on a CMS-1500 claim form using the appropriate HCPCS codes. Prior authorization is not required for most of these supplies. Refer to the Medicaid Provider Manual Section 10 for specific coverage information. Insulin is reimbursed through the pharmacy system and is subject to monthly limits. For beneficiaries who have Medicare, insulin and insulin-related supplies are covered under Medicare Part D and must be billed to Medicare. Other diabetic-related supplies are covered through Medicare Part B and must be billed to Medicare as the primary payer.

10.  What drugs are reimbursed by Hospice?
     Medicaid beneficiaries enrolled in Hospice Services are covered under a per diem rate which covers all services for that beneficiary. For those beneficiaries receiving Medicaid Hospice Services, all palliative therapy, or drugs used to treat beneficiary's terminal illness, is to be billed to the Hospice provider. Medicaid will only pay for drugs used for an indication not directly related to the beneficiary's terminal illness and are within the applicable Medicaid prescription service limits. Since plans of care are specific for beneficiaries, it is the responsibility of the dispensing pharmacy to bill the Hospice Provider or Medicaid appropriately. Medicaid's policies, prior authorizations, and limits are still applicable. The dispensing pharmacy must retain documentation regarding Hospice Services drug coverage for beneficiaries which is easily retrievable for auditing purposes. A listing of medications generally considered the responsibility of Hospice may be referenced on DOM's website at, select Pharmacy Services, and select Pharmacy Billing for Hospice Patients. Medicaid is always the payer of last resort.

11.  Why do some insulin products count as a brand and others count as a generic?
     All over the counter products, including OTC insulin, count toward the 5 prescription monthly limit but not toward the 2 brand monthly limit.

12.  Are drug prior authorization approvals assigned to a specific pharmacy?
     No. Drug prior authorization approvals are assigned to the beneficiary and not to a pharmacy.

13.  Where can I find a listing of generic drugs with federal upper limits (FUL) reimbursements? Where can I find the Centers for Medicare and Medicaid's web site?
     The Pharmacy Services section of Mississippi Medicaid web site, located at, has direct links for Federal Upper Limits (FUL) and Centers for Medicare and Medicaid (CMS) for your easy reference.

14.  What immunizations are reimbursed through POS?
     In the Pharmacy program, influenza and pneumonia immunizations are covered services for Medicaid beneficiaries aged 19 and above who are not residents of long-term care facilities. As with other pharmacy services, a hard copy prescription must be on file. Immunizations provided from a credentialed pharmacist will count against the service limits and co-payments are applicable. If a beneficiary has Medicare and Medicaid, Medicare is to be billed first. These are the only vaccines/immunizations available via the Pharmacy Program.

15.  I cannot reverse a POS claim, who do I call?
     Pharmacy claims are process by DOM's fiscal agent, or Conduent. Conduent may be reached at 1-800-884-3222 or fax at 1-888-495-8169. Contact Conduent for problems with reversal/backing out a POS claim, claim submission problems and questions regarding prescription billing.

16.  I have a question about prior authorizations, who do I call?
     The prior authorization process is administered by Change Health Care. Contact Change Health Care at 1-877-537-0722, fax at 1-877-537-0720, or their web site at Http:// Contact Change Health Care for error messages regarding prior authorizations, maximum dose exceeded, refill too soon, to verify if beneficiary has a PA for a medication and for assistance when filling out PA request forms.

17.  What about situations when a newborn baby needs medication, but has not been assigned a Medicaid number or card?
     To submit a pharmacy claim use the mother's identification number, followed immediately with the letter K, and place the baby's date of birth in the DOB field.

18.  How do I bill a pharmacy claim for a pregnant beneficiary?
     To submit a pharmacy claim for a pregnant beneficiary, place the letter P at the end of the beneficiary's identification number.

19.  What is happening when a new generic product is billed and the NCPDP short message returned is "54-non-matched product/serviceID" or "non-matched NDC not on drug file"?
     This message means that the new generic product is not found on Medicaid's master drug reference file. Medicaid's drug file is updated weekly. The drug file update includes new to the market drug information or price changes.

20.  Why does `other insurance¿ or 'other drug coverage' have to be billed first before Medicaid?
     Effective October 1, 2004, when beneficiaries are covered by both Medicaid and other third party insurance, pharmacy providers are required to bill prescription drug claims to private third party insurance carriers before billing Medicaid. All Medicaid policies and procedures such as prior authorization requirements and limits are still applicable. Medicaid is always the payer of last resort.

21.  What if my patient requests that I bill Medicaid first?
     The Centers for Medicare and Medicaid or CMS addresses this question: "The Medicaid program by law is intended to be the payer of last resort; that is, all other available third party resources must meet their legal obligation to pay claims before the Medicaid program pays for the care of an individual eligible for Medicaid."

22.  Cough and cold products are not covered by Medicare. What cough products are reimbursed by Mississippi Medicaid?
     The following cough products are reimbursed by DOM:

promethazine with codeine (compares to Phenergan with codeine)
guaifenesin(Compares to Robitussin)
guaifenesin with dextromethorphan (compares to Robitussin DM)
guaifenesin with codeine (compares to Robitussin AC)
guaifenesin, pseudoephrine, and codeine (compares to Robitussin DAC)

23.  Does Medicaid have access to Medicare Part D plan information for the dually eligible beneficiary?
     No. Medicaid does not have access to Medicare files and/or drug plan coverage. To determine a beneficiary's Medicare Part D plan, pharmacies may contact Medicare at 1-800-Medicare or submit an E1 query.

24.  Why do some dual eligibles no longer have Medicaid drug coverage for Part D exclusions such as benzodiazepines, OTCs and barbiturates?
     Prior to January 1, 2006, all Medicaid beneficiaries who had Medicare and Medicaid were categorized as dually eligible. The Medicaid PLAD category of eligibility, which was an optional category of eligibility, ended on December 31, 2005. Beneficiaries previously classified as PLADs who have Medicare were converted to the Medicare Savings Program. These beneficiaries are no longer dual eligible and have no Medicaid outpatient drug benefit.

25.  Does Medicaid pay Part D drug co-pays?

26.  Can a prior authorization or override be issued by Medicaid for a Part D non-formulary drug?

27.  I am confused about new acronyms QMBs , SLMBs, or QI-1s. What do these terms mean? What does this mean regarding pharmacy and Medicaid services?
     (1) The acronym QMB, or Qualified Medicare Beneficiary, means that the person has Medicare and is in a certain income category. QMB beneficiaries have full Medicare cost sharing which means that Medicaid pays for Medicare premiums (for Part A and B), deductibles, and co-insurance. Medicare is the primary payer for services. QMB beneficiaries have no Medicaid drug coverage. QMBs do have crossover coverage for Part B drugs and DME supplies.
(2) The acronym SLMB, Specified Low-Income Medicare Beneficiary, means that the person has Medicare and is within a certain income category. Medicaid pays Part B premiums for SLMBs. SLMB beneficiaries have no Medicaid drug coverage nor crossover coverage for Part B drugs or DME supplies.
(3) The acronym QI-1, or Qualified Individual, means that the person has Medicare and is within a certain income category. Medicaid pays Part B premiums for QI-1beneficiaries and they have no Medicaid drug coverage, or Part B drug, or DME supplies crossover coverage.

28.  Are LTC beneficiaries charged copayments or deductibles with Part D?
     Full service dually eligible beneficiaries are not charged copayments or deductibles with Part D.

29.  What does the acronym LIS mean for Medicare Part D beneficiaries?
     LIS, or low income subsidy, represents cost sharing for low income Medicare beneficiaries. For pharmacies and beneficiaries, this means that cost sharing is applied at the pharmacy point of service when appropriate. LIS enrollees, eligible for a full subsidy such as Medicaid/Medicare dual eligibles, are set up for a benefit that would adjudicate at the pharmacy for no more than the minimal pharmacy copay and institutionalized dual eligible beneficiaries with no pharmacy copays.

30.  Does a dually eligible beneficiary have any pharmacy benefits with Medicaid?
     For beneficiaries who have Medicare, all pharmacy claims are to be billed to the beneficiary's Part D plan with the exception of the following:

(A)Benzodiazepines. Generic formulations are the only benzodiazepines covered by MS Medicaid for all beneficiaries effective January 1, 2006.

  1. Phenobarbital and natural are the only barbiturates only covered for all MS Medicaid beneficiaries effective January 1, 2006.
  2. Butabarbital combination analgesia products, such as Fioricet, are to be billed to Medicaid.
  3. Butabarbital combination analgesia products with codeine, such as Fioricet with codeine, are to be billed to beneficiary's Part D Plan.
(C) Certain over-the-counter (OTC) drugs as covered by the Division of Medicaid except OTC insulin products which are covered in the Medicare Part D plans.
A comprehensive listing of the OTC formulary is available on the DOM website at, Pharmacy Services, What's New and OTC Formulary. Note that this listing is subject to change.
 (D) These prescription vitamins only:
  1. Folic acid 1 mg
  2. Vitamin B12 injection
  3. Niacin
  4. Vitamin K (phytonadione)
  5. Vitamin D i.e. ergocalciferol and cholecalciferol are to be billed to Medicaid
Vitamin D analogs, such as Calcitrol, are to be billed to Part D Plans.

31.  Where can I find the Centers for Medicare and Medicaid's web site?
     This website and the Pharmacy Services section of the Mississippi Medicaid web site, located at, has Hotlinks to the CMS website.