For three-month supply drugs, the following apply:
Dispensing a three-month supply of drugs streamlines the prescription filling process for pharmacy providers, encourages the use of generic, maintenance drugs when medically appropriate for a member, and results in savings to ForwardHealth programs.
ForwardHealth has identified a list of drugs for which pharmacy providers will be required to dispense a three-month supply.
Claims for drugs required to be dispensed in a three-month supply will be denied with an EOB text and an NCPDP reject code.
Pharmacy providers will be required to call the DAPO Center to request a policy override to dispense less than a three-month supply. ForwardHealth may authorize dispensing of less than a three-month supply for up to one year. Pharmacy providers may request an override to dispense less than a three-month supply for members enrolled in BadgerCare Plus, Medicaid, and SeniorCare.
Examples of when a request for a policy override to dispense less than a three-month supply may be approved include, but are not limited to, the following:
Pharmacy providers may dispense up to a 96-hour supply of a drug to a member when the DAPO Center is closed and a policy override to dispense less than a three-month supply must be obtained. If the DAPO Center grants a policy override for less than a three-month supply, the policy override will be retroactive and the pharmacy provider may submit a claim for the drug. If the claim for a 96-hour supply is submitted on paper, the pharmacy provider will be required to complete and submit a Pharmacy Special Handling Request. Providers should check Element 4 (Policy Review Request) and provide this statement in the space provided: 96-hour policy override for a three-month supply.
If the DAPO Center denies the policy override, ForwardHealth will reimburse the provider for the 96-hour supply. A claim must be submitted on paper with the Pharmacy Special Handling Request. Providers should check Element 4 (Policy Review Request) and provide an explanation of the review needed (e.g., 96-hour policy override for early refill) in the space provided.
The 14-day emergency medication dispensing policy does not apply to the three-month supply initiative.
For drugs that are allowed to be dispensed in a three-month supply, but are not required to be, pharmacy providers should work with the member and the prescriber to determine whether or not it is clinically appropriate to dispense a three-month supply. Claims for these drugs will no longer be denied as policy regarding the prospective DUR alert for insufficient quantity "NS" is changed to make it an information claim message. Providers will receive the informational claim message "Three Month Supply Opportunity" on claims for these drugs.
If a claim is submitted for an unbreakable prepackaged item with directions for use that are greater than the allowable maximum of a 34-day supply and the drug is not listed on the Three Month Supply of Drugs data table, use the smallest available package size and indicate a 34-day supply.
For drugs that are required to be dispensed in a three-month supply, prescribers must indicate a three-month supply (e.g., a quantity of 90 or 100) on the prescription to allow the pharmacy provider to dispense maintenance drugs in quantities up to a three-month supply. For example, if the prescription is written for "Hydrochlorothiazide 25 mg, take one tablet daily," the prescriber is required to indicate a quantity of 90 or 100 tablets on the prescription so the pharmacy provider can dispense a three month supply.
For drugs required to be dispensed in a three-month supply, once a member has been stabilized on a drug as evidenced by use of the same drug strength and dosage form for 90 days of the past 120 days, refills of the same drug strength and dosage form must be dispensed in a three-month supply. If the member previously has been dispensed a three-month supply of a drug of the same strength and dosage form, a three-month supply must be dispensed.
If a member has not previously been dispensed a three-month supply of a drug of the same strength and dosage form, but has been stabilized on that drug, the prescriber must write a prescription so the pharmacy provider can dispense a three-month supply of the drug.
According to DHS 107.10(3)(e), Wis. Admin. Code, providers are required to dispense all legend drugs in the full quantity prescribed, not to exceed a 34-day supply, except for drugs that may be dispensed in a three-month supply and those required to be dispensed in a three-month supply.
If a prescription is written for a drug that is required to be dispensed in a three-month supply, the pharmacy provider should determine if the member has been stabilized on the drug.
If the member has not been stabilized on the drug, a quantity not to exceed a 34-day supply should be dispensed. If the member has been stabilized on the drug, the pharmacy provider must work with the prescriber to obtain a prescription for a three-month supply or obtain a policy override to dispense less than a three-month supply.
A prescriber must indicate a sufficient quantity on prescription orders to allow pharmacy providers to dispense a three-month supply of drugs that are required to be dispensed in a three-month supply.
Pharmacy providers must work with prescribers to make certain the total quantity of a drug dispensed per a prescription order does not exceed the total quantity of the drug authorized by the prescriber on the prescription order.
ForwardHealth will not audit or recoup three-month supply claims if a pharmacy provider changes a prescription written as a one-month supply with refills as long as the total quantity dispensed per prescription does not exceed the total quantity authorized by the prescriber.
A three-month supply of a drug may benefit a member in the following ways:
Intervention-based services are voluntary face-to-face member assessments and interventions performed by a pharmacist. Three-month supply intervention is one type of intervention-based service. Dispensing a three-month supply of drugs streamlines the prescription filling process for pharmacy providers and members, encourages the use of generic maintenance drugs when medically appropriate for a member, and results in savings to ForwardHealth programs. If the pharmacy contacts the prescriber to amend the prescription, pharmacies are eligible to receive the reimbursement for this service. If the prescription is already prescribed for a three-month supply, pharmacies will not be eligible to receive the reimbursement.
If an override of a service limitation, such as a three-month supply policy override, is requested and the request does not meet service limitation override criteria, the policy override will be denied and the service will be a noncovered service.
In addition, if one of the following circumstances is met, a three-month supply of a drug is a noncovered service:
Pharmacy providers enrolled in BadgerCare Plus, Medicaid, and SeniorCare may collect payment from members in the previously listed circumstances.
With the exception of previously described policies, pharmacies cannot collect payment from members for a three-month supply of a drug if the pharmacy provider does not follow the policies described above.
Members do not have appeal rights for noncovered drugs or service.
If a member is in a nursing facility, providers should indicate the appropriate place of service code on the claim. This will exempt the member from the three-month supply of drugs policy. When serving a member in a nursing facility, pharmacy providers are not required to contact the DAPO Center to obtain an override to dispense less than a three-month supply of drugs.