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

Reference Guide

News

    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)