Attention RI Medicaid Members: Update on Prescription Access Due to a cybersecurity issue, a contractor serving pharmacies and Medicaid programs across the US is unable to provide important online services at this time. In Rhode Island, this situation impacted pharmacies’ ability to fill prescriptions for members of the AIDS Drug Assistance Program (ADAP) and the Medicaid Program. In response, RI EOHHS has quickly brought online a new way for pharmacies to process claims. Rhode Island Medicaid has also told pharmacies that they can provide a 30-day supply of any prescriptions you are trying to fill, to help you get through this time. The pharmacy should not charge you for any prescription that is covered by Medicaid. Learn more.
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 January 2024 Pharmacy Prior Authorization Program Pharmacy and Therapeutics Committee Preferred Drug List January 25, 2024 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 EOHHS Fee-for-Service (FFS) Medicaid program allows enrolled pharmacy providers to process At-Home COVID Test Kits at point of service (i.e., at the pharmacy). As with any over-the-counter (OTC) product, coverage of the claim requires a prescription. As of February 24, 2023, the RI Department of Health (RIDOH) standing order for At-Home COVID-19 Test Kits is expired. Therefore, in order to obtain an At-Home COVID-19 Test Kit, the beneficiary must request a prescription from their FFS Medicaid enrolled prescriber. The process to prescribe an At-Home COVID-19 Test Kit is the same as the process for other OTC product. Coverage for At-Home COVID-19 Test Kits is unchanged; this update is solely regarding the need for a prescription from beneficiaries’ prescribers now that the RIDOH standing order is expired. 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 2024) Do Smoking Cessation Products need a prior authorization? No, effective January 2014 no prior authorization is needed. Tamper Resistant Prescription Pads