The purpose of this bulletin is to advise providers of changes made by the Department of Human Services (Department) to Medical Assistance (MA) pharmacy services to ensure MA beneficiaries maintain access to needed services during the COVID-19 public health emergency. 

This bulletin applies to all licensed pharmacies and prescribers enrolled in the MA program, including the Fee-for-Service (FFS) delivery system and the MA managed care organizations (MCOs) in Physical Health HealthChoices and Community HealthChoices. 

Background

On March 6, 2020, Governor Tom Wolf issued a public health emergency declaration in response to the presence of COVID-19 in Pennsylvania. On March 13, 2020, COVID-19 was declared a nationwide emergency under the Stafford Act, retroactive to March 1, 2020.

*01-20-07      09-20-07     27-20-04     33-20-04     02-20-02      11-20-01      30-20-01      
03-20-02     14-20-03      31-20-07        08-20-10      24-20-03     32-20-01

Discussion

The Department suspended copayments effective with dates of service on and after March 1, 2020, for testing services (including in vitro diagnostic products), testing-related services, and treatments for COVID-19, including vaccines, specialized equipment and therapies (including drugs). 

MA copayments are also suspended for the following drugs/drug categories, as they may be used in the treatment of COVID-19:

• Acetaminophen
• Antidiarrheals
• Antiemetics
• Antihistamines (Second Generation)
• Anti-infectives • Asthma/COPD
• Ophthalmic Antihistamines/Decongestants
• Ophthalmic Lubricants
• Oral NSAIDs 
  

Copayment exemptions for COVID-19 treatment-related outpatient drugs/drug classes listed above were added to the FFS (ACCESS) online claims system on April 22, 2020.

Cough and Cold Medications for Adults Over the Age of 21 Years 

The Department will pay for prescriptions for cough and cold medications for MA beneficiaries 21 years of age and older beginning with dates of service on and after March 1, 2020. Prior to the public health emergency, the Department was already paying for prescribed cough and cold medications for MA beneficiaries under 21 years of age. The allowance of payment for cough and cold medications for MA beneficiaries over the age of 21 will remain in effect for the duration of the public health emergency declaration authorized by the president related to the COVID-19 virus. 

Hydroxychloroquine Limits 

On March 28, 2020, the United States Food and Drug Administration issued an Emergency Use Authorization that allows individuals with COVID-19 to be treated with hydroxychloroquine. In an effort to prevent potential shortages and stockpiling of hydroxychloroquine, thresholds for prior authorization apply for hydroxychloroquine:

• Prescriptions with a quantity greater than 4 tablets per day require prior authorization.
• Prescriptions for a supply greater than 10 days require prior authorization. 

NOTE: In an effort to prevent gaps in care for non-COVID-19 patients prescribed hydroxychloroquine, approvals will be automated at the pharmacy point-of-sale for medically accepted non-COVID-19 diagnoses. Prior authorization overrides will be issued for current users of hydroxychloroquine for non-COVID-19 related diagnoses. These beneficiaries will be able to obtain their usual day supply at the pharmacy. Prior authorization requests for longer durations of treatment for COVID-19 will be reviewed for medical necessity and approved based on current medical literature and specialist/prescriber input. Prior authorization approvals will not be issued for COVID-19 prophylaxis. 

The above limits align with the dosing found in current medical literature for both COVID-19 and non-COVID-19 indications. The Department will continue to monitor emerging medical literature and treatment guidelines and will adjust the above limits as necessary. 

Changes to Statewide Preferred Drug List (PDL) for Albuterol Metered Dose Inhalers 

Albuterol HFA is the preferred short-acting beta agonist metered dose inhaler (MDI) on the Pennsylvania MA Statewide PDL. The Department is aware of ongoing supply issues with albuterol HFA MDIs. Effective April 1, 2020, additional short-acting beta agonist MDIs are preferred on the Statewide PDL, as set forth below, and will remain preferred until an adequate supply of albuterol HFA is available in the marketplace. 

Bronchodilators, Beta Agonist

Sublocade Prior Authorization 

Sublocade (buprenorphine extended-release) injection is a once-monthly injection indicated for the treatment of opioid use disorder. It is a preferred medication in the Opioid Dependence Treatments class on the Pennsylvania MA Statewide PDL. The prior authorization guidelines for Opioid Dependence Treatments have been revised to indicate that prescriptions for Sublocade injection that do not exceed the quantity limit no longer require prior authorization. 

Procedure

Claims for medications for FFS beneficiaries should be billed as pharmacy claims using the standard NCPDP, 837 Professional, or internet formats. 

For the duration of the public health emergency declaration authorized by the president related to the COVID-19 virus, the following apply:  

• Dispensing providers and pharmacies may dispense a 90-day supply of a medication pursuant to a valid prescription that is written for at least a 90-day supply.
• Claims billed to Fee-for-Service on or after April 22, 2020 for COVID-19 treatment-related outpatient drugs/drug classes listed above will return a copayment of $0 at the point-of-sale. MA providers may not collect a copayment for these medications and the amount of the copayment will not be deducted from the amount paid to the provider. For claims billed to FFS from March 1, 2020, through April 21, 2020, for COVID-19 treatment-related outpatient drugs/drug classes listed above pharmacies should refund copayments paid by the beneficiary and resubmit the claims to receive the full payment amount from the Department.
• Claims for cough and cold medications pursuant to a valid prescription for adults over the age of 21 years will pay at the point-of-sale.
• If a pharmacy is unable to obtain a generic albuterol HFA product due to a product shortage, a corresponding brand name product may be dispensed with a DAW code of 1. Claims submitted for ProAir HFA, Proventil HFA, and Ventolin HFA that are within the quantity limits will pay at the point-of-sale. Claims submitted for levalbuterol HFA that are within the quantity limits will pay at the point-of-sale.
• Claims submitted for Sublocade that are within the quantity limits will pay at the point-of-sale. 

Providers can contact the Department’s Pharmacy Call Center for assistance at 1-800­ 537-8862 option 2, then option 2.

The procedures for prescribers to request prior authorization of prescriptions that exceed the quantity and/or duration limits are located in SECTION I of the Prior Authorization of Pharmaceutical Services Handbook. 

The Physical Health HealthChoices and Community HealthChoices MCOs are required to implement the same changes implemented in the FFS delivery system for the duration of the public health emergency declaration authorized by the president related to the COVID-19 virus. The procedures to submit claims or request prior authorization for beneficiaries in the MCOs may differ from those for beneficiaries in the FFS delivery system and are specific to each MCO. Providers should contact the MCOs for MCO-specific information. 

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