Pharmacy

Provider Representative:  Ann Bennett  Tel.(571) 895-6866
email   Ann.Bennett2@gainwelltechnologies.com

Please Note: Consumers with questions regarding prescriptions please contact your case manager.

Program Information

• Drug Utilization Review
• OTC Listing, May 2004
• Pharmacy Prior Authorization Program
• Pharmacy and Therapeutics Committee
• Preferred Drug List   January 10, 2023 
• Request for Out of State Pharmacy Services
• General Public Assistance (GPA) Drug Formulary

Reference Guide

• Pharmacy Provider Manual

News

• Internet Drug Outlet Identification Program Progress Report - February 2018 

Updates 

• At-Home COVID-19 Test Kits to Process at POS for RI FFS Medicaid
  RI EOHHS Fee-for-Service (FFS) Medicaid program allows enrolled pharmacy providers to process At-Home COVID Test Kits at point of service (POS).  As with any over-the-counter (OTC) product, coverage of the claim requires a prescription.  The beneficiary may request a prescription from their FFS Medicaid enrolled prescriber, or use the standing order issued by Dr. Suzanne Bornschein, Medical Director COVDI-19 Unit, RI Department of Health.  Dr. Bornschein is an enrolled FFS prescriber.  The standing order can be accessed here.
  
  There is a quantity limit of eight (8) At-Home COVID Tests per thirty (30) Days.
  Reimbursement is $12.00 per test. Packaging with multiple tests will be reimbursed at $12.00 per test.  For example, if the package contains two (2) tests, then the claim will be reimbursed at $24.00.
   
• Changes to the RI FFS Medicaid Payer Sheet
  Effective 2/23/2021 RI FFS Medicaid, in order to support the Comprehensive Addiction and Recovery Act (CARA) of 2016, is adding 2 additional field requirements to the payer sheet for submission of pharmacy claims.  The following fields have been added to the payer sheet.  These fields will be required on all CII drug Claims. 
• 460-ET Quantity Prescribed Quantity prescribed expressed in metric decimal units
  384-4X Patient Residence Identifies patient's place of residence
  The following values will be the only values accepted for Patient Residence for CII drug claims:
  1- Home
  2-  Skilled Nursing Facility
  3- Nursing Facility
  4-  Assisted Living Facility
  6- Group Home
  11- Hospice
  14- Homeless Shelter
  Any value listed on the payer sheet will be accepted for all non-CII drug claims.
  Please reference the new payer sheet below and also note this information will be in the March Provider update. RI FFS Medicaid expects to begin receiving these fields on February 23, 2021
• Covered Outpatient Drugs Rule Changes to Pharmacy Reimbursement
  As part of regulatory rules defined by the Covered Outpatient Drugs Rule, EOHHS is implementing changes to the reimbursement algorithm.  Medicaid Fee for Service (FFS) pharmacy claims reimbursement algorithm will include the CMS National Average Drug Cost (NADAC) price point and the pharmacy professional fee of $7.90 for recipients residing in a facility and $8.96 residing at home.  The EOHHS Drug Assistance Program claims will follow the FFS reimbursement algorithm.  These changes will take effect for claims with a date of service equal to or greater than, August 1, 2019.
• Policy for the Treatment of Hepatitis C (Updated January 1, 2022)
• RI State Maximum Allowable Cost (MAC) List

Frequently Asked Questions (FAQ's)

• Where can I find the list of J Codes that require an NDC?
• Where can I find information about the RI AIDS Drug Assistance Program (ADAP)?
• Billing Part B Medications
• DUR Alert Override Codes
• Lost or Stolen Prescription Form and Instructions 
• CMS List of Rebateable Drug Manufacturers
• Can pharmacies bill for administering vaccines?
  No.  Billing for administering vaccines is submitted by a medical provider in the Fee-for-Service Medicaid Program.  For more information on vaccines go to: October 2018 Provider Update
• How to bill NDCs on the CMS-1500 Form 
• NCPDP D.0 Payer Sheet (Effective February 23, 2021)
• DESI Drug List (January 2023)
• Do Smoking Cessation Products need a prior authorization?                              No, effective January 2014 no prior authorization is needed.
• Tamper Resistant Prescription Pads