2020 News
Epinephrine Injection Drug Shortage Impacts Medicaid Non-Preferred Status
Mylan issued an alert regarding the manufacturing challenges in the production of EpiPen (epinephrine injection, USP) 0.3 mg and EpiPen Jr (epinephrine injection, USP) 0.15 mg auto-injectors and the authorized generic versions of these strengths. These challenges resulted in the reduced availability of these products.
RightCare temporarily removed the non-preferred status from the following:
| NDC | Name |
| 00093598627 | Epinephrine 0.3 mg auto-injector |
This change will allow providers to prescribe these product NDCs without requiring non-preferred prior authorization and will allow continued access to medication. The current preferred NDCs are:
| NDC | Name |
| 00093598527 | Epinephrine 0.15 mg auto-injector |
| 00115169449 | Epinephrine 0.3 mg auto-injector |
| 00115169549 | Epinephrine 0.15 mg auto-injector |
| 49502010101 | Epinephrine 0.15 mg auto-injector |
| 49502010102 | Epinephrine 0.15 mg auto-injector |
| 49502010201 | Epinephrine 0.3 mg auto-injector |
| 49502010202 | Epinephrine 0.3 mg auto-injector |
This is a temporary change until the preferred products are sufficiently available again in the market. There may be outages varying between pharmacies despite Mylan products no longer identified as a shortage according to FDA and ASHP. Further announcements regarding future PDL status changes of these NDCs will be sent out.
Resources
January 2020 Preferred Drug List Published
The semi-annual update of the Medicaid preferred drug list is now available. The update is based on changes presented and recommended at the July and October 2019 Texas Drug Utilization Review Board meetings.
Drugs on the Texas Medicaid formulary are designated as preferred, non-preferred, or have neither designation. The preferred drug list includes only drugs identified as preferred or non-preferred and can be found here.
Rinvoq Clinical Prior Authorization begins March 3
RightCare will implement the Rinvoq (upadacitinib) clinical prior authorization criteria on March 3, 2020. All clinical edit criteria can be found here. New Rinvoq criteria will be included within the existing Cytokine and CAM Antagonists criteria guide.
Rinvoq is a Janus Kinase inhibitor for treatment of adults with moderate-to-severe active rheumatoid arthritis who have not responded adequately, or are intolerant, to methotrexate. The Texas DUR Board approved the criteria at the Oct. 2019 meeting.
Austedo Clinical Prior Authorization Criteria Revision Coming March 3
RightCare will modify the Austedo prior authorization criteria on March 3, 2020. The criteria are included within the existing Vesicular Monoamine Transporter 2 (VMAT2) inhibitors criteria guide. All clinical edit criteria can be found here. The Texas Drug Utilization Review Board approved the criteria in January 2014. The class includes Austedo, Xenazine and Ingrezza.
Austedo is approved for treatment of Huntington-Induced Chorea and Tardive Dyskinesia (TD). RightCare will modify the prior authorization criteria to address the Austedo boxed warning about increased risk of depression in patients with only Huntington-Induced Chorea, and prevent unnecessary prior authorization denials for patients with TD.
Allergen Extract Clinical Prior Authorization Revision Coming February 24
RightCare will revise the Allergen Extracts clinical prior authorization criteria on February 24, 2020. This change reflects the Food and Drug Administration guidance expanding the indication for Oralair for people 5 years of age and older. The previous indication was for 10 years of age and older. Additionally, RightCare will change the contraindication diagnosis to include only severe, uncontrolled asthma diagnoses.
Oralair is part of the Allergen Extract clinical prior authorization criteria. All clinical edit criteria can be found here. 2019 News
Semi-annual Medicaid Preferred Drug List Update Coming in January Texas Medicaid will publish the semi-annual update of the Medicaid preferred drug list on January 27, with changes effective January 30. The update is based on changes presented and recommended at recent Texas Drug Utilization Review Board meetings. Visit the Vendor Drug Program website for a list of noteworthy changes in this update. Nov. 4: RightCare Update Fall 2019
Nov. 1: RightCare—Authorization Requirement for Therapies Effective November 1, 2019, we encourage all of our providers to utilize the RightCare Self-Service Provider Portal — rightcare.firstcare.com — to submit new authorization requests, view authorization status, and view prior authorization requirements. This online authorization process provides an immediate decision when clinical criteria meet for medical necessity. Read the notice here.
DSHS Laboratory Web Portal On Oct. 25, the Texas Department of State Health Services (DSHS) Laboratory reported that the Laboratory Web Portal application for public health microbiology and clinical chemistry results experienced unexpected technical difficulties and is currently shutdown. Read the notice here.
Announcement: Congenital Syphilis Health Advisory New state legislation was enacted on Sept. 1, 2019 to increase syphilis testing in pregnant women. Testing is now mandated at first prenatal care examination, during third trimester (no earlier than 28 weeks gestation) and at delivery.Read the notice here.
Announcement: Summary of smoking cessation benefits in Medicaid and CHIP As a reminder, screening and basic information about tobacco cessation is an expected part of any routine visit with a healthcare provider. Additional services or supports are available through Medicaid & CHIP. Read the notice here.
Announcement: Medication Assisted Treatment (MAT) benefits to change for Texas Medicaid Nov. 1, 2019. As part of the implementation of SB1564 (86R) Texas Medicaid is adding reimbursement for appropriately trained, advanced practice registered nurses who deliver Medication Assisted Treatment (MAT) in the office setting. Additionally, the public will be given the opportunity to provide comment regarding H2010 being directly replaced with H0033 for non-methadone MAT administration.Read the notice here.
Announcement: Tobacco Cessation Counseling Changes for Texas Medicaid Effective for dates of service on or after May 1, 2019, smoking and tobacco use cessation counseling benefits will change for Texas Medicaid. Read the notice here.
Announcement: Scott and White Health Plan Provider Relations Representative Contact Information To find the Provider Relations Representative for your county, please see the Provider Relations Representative Territory Map.
Oct. 1: New Prior Authorization update effective Nov. 1, 2019. Read the notice here.
Sports Physicals: RightCare covers sports physicals as a value-added service. If a sports physical is requested and the child is due for a Texas Health Steps checkup, the checkup including all the required Texas Health Steps components should be completed as well. Providers may be reimbursed for sports physicals performed at the same time as a Texas Health Steps checkup or during a separate medical visit. Span of Coverage Clarification: The purpose of this notice is to clarify the Span of Coverage policy for hospital transfers. Read the notice here.
June 1: New Prior Authorization update effective June 1, 2019. Click here for the announcement.
May 1: Revised Texas Medicaid Standing Order for Mosquito Repellent Benefit The Texas Medicaid Standing Order for Mosquito Repellent has been revised and is available for use with the mosquito repellent benefit for people enrolled in Medicaid (both traditional and managed care) and CHIP. Pharmacy staff must obtain a copy of the revised standing order, effective May 1, because of the change in prescribing authority of the standing order. The previous standing order expires Apr. 30. Pharmacies may request a copy of the standing order by emailing vdp-formulary@hhsc.state.tx.us.
- • Pharmacies or pharmacists not operating under the standing order will require a prescription from a valid healthcare provider prior to dispensing mosquito repellent to people enrolled in Medicaid or CHIP.
- • People enrolled in in the Children with Special Health Care Needs Services Program will always require a prescription for mosquito repellent from a health care provider.
- • People enrolled in the Healthy Texas Women program do not require a prescription.
Neonatal Emergency Billing Address Requirements In accordance with House Bill (HB) 15 (83R) and HB 3433 (84R), HHSC established rules for inpatient hospital designations for neonatal services and maternal services. Hospitals without designation will not be reimbursed for inpatient neonatal or maternal services except emergency services required to be provided or reimbursed under state or federal law. The level of care designation for each hospital will be reviewed by HHSC every three years and updated as appropriate.
Action: Providers who submit claims for inpatient newborn care must use the billing address that matches the facility address of the neonatal designation where neonatal services are rendered. To be considered for reimbursement of neonatal claims, providers must have their neonatal billing address. Business edits will set on encounters where the provider is billing incorrectly.
January 1: Peer Specialist Background: This policy is a result of House Bill (H.B.) 1486, 85th Legislature, Regular Session, 2017, which requires HHSC to establish a Medicaid reimbursable peer service benefit and adopt rules establishing training and certification requirements for peer specialists to provide Medicaid-reimbursable peer specialist "services to persons with mental illness or services to persons
The attached Peer Specialist notification outlines the new benefit, requirements for eligibility and service delivery, as well as claims filing/reimbursement details effective Jan. 1, 2019.
January 1: Morphine Equivalent Dose Limitations for RightCare to Decrease in January RightCare from Scott and White Health Plan will decrease the daily morphine equivalent dose limit for people enrolled in Medicaid Managed Care on January 1, 2019. The new limit will be set at 90, and apply to all opioid prescriptions with exceptions for those people diagnosed with cancer or those receiving palliative or hospice care. Prescribing providers and pharmacies should contact the Navitus Provider Hotline 1-877-908-6023 for dosage limitation override assistance.
SUD Policy Background: The attached SUD Policy notification outlines the finalized Substance Use Disorder Services policy update to be effective Jan. 1, 2019.
This policy update includes:
- Updated statement of benefits section
- Addressed Mental Health Parity and Addiction Equity Act requirements by allowing limits to be exceeded for adults with prior authorization
- Made Medication Assisted Treatment payable on same day as withdrawal management and treatment services
- Made Vivitrol payable to Chemical Dependency Treatment Facilities
- Made buprenorphine payable to Physician Assistants and Nurse Practitioners as allowed under the Comprehensive Addiction and Recovery Act of 2016
- Updated Prior Authorization forms for Fee for Service Medicaid recipients: Qualified Credentialed Counselor signature now permissible consistently across all forms, and supporting documentation now required with all forms consistently.
2018 News
October 31: Paper Claims Update Please note the RightCare mailroom has currently moved to 300 S. Riverside Plaza Suite 700, Chicago, IL 60606. All mail sent to P.O. Box 3757 Corpus Christi, Texas 78463 will be forwarded to Chicago. Providers whose mail cannot be forwarded will have mail returned. For more information, please contact RightCare customer service at 855 897-4448 (855-TX-Right). October 1: Ordering and Referring Providers NPI Requirements Implementation Date Background: As an update to the MCO notification sent June 18, 2018 about the ordering and referring provider’s (ORP) National Provider Identifier (NPI) requirement, the implementation date has been postponed. Previously set to be implemented on September 1, 2018, the new implementation date is October 1, 2018. Beginning October 1, 2018, HHSC will implement the requirement for the submission of the ORP NPI on all managed care encounters.
Additional Information: The edits to be implemented are: 1. Ordering Provider Number (NPI) cannot be identified for Encounter FDOS < 01/01/3999. This edit will set under the following conditions:
- No provider match found
- Detail Ordering Provider NPI is NOT NULL
- Detail Ordering Provider API is NOT Present OR present but first letter is not F/S/A
- Detail Ordering Provider API is present and first letter is F/S/A but is not equal to 10 characters
- OON Exception Code 3 or 4 is not submitted
- OON Exception Code 3 or 4 is submitted but the submitted ordering provider NPI is not found on the NPPES table for the submitted FDOS
2. Referring provider number (NPI) is missing when billing provider is a non-person entity for Encounter FDOS < 01/01/3999. This edit will set under the following conditions. - Submitted billing provider taxonomy requires a referring provider and the submitted referring NPI is not submitted.
September 19: Retroactive APR DRG Relative Weight Change and 2019 Relative Weight Table Background: HHSC has determined that an adjustment is needed for some All Patient Refined Diagnosis Related Group (APR DRG) relative weights and related factors. The relative weights that are being adjusted were for new APR DRGs in Grouper 35. The relative weights that were originally assigned were not proper for HHSCs reimbursement system. Key Details: The changes will require an adjustment in payment to some inpatient claims and encounters with discharge dates on or after October 1, 2017. See below for links to the following information: • Changes – a list of the impacted APR DRGs with revised and original details • 2018 Revised Grouper Table – effective 10/1/2017 • 2019 Grouper Table – effective for discharges occurring on or after 9/1/2018 Note: There are no changes in the weight tables from 2018 to 2019. Any potential changes will be made effective 10/1/2018 when 3M release their APR DRG grouper updates.
Provider Education: Lead Exposure Screening and Treatment RightCare would like you to be aware of the following course from Texas Health Steps. This short course covers what you need to know to screen, test, and retest children; properly collect blood specimens; use the mandatory reporting system; and protect Texas children from being exposed to lead in the first place.
Preventing Lead Exposure
September 7: Wraparound Training Webpage Update for MH TCM/Rehab Providers. Wraparound training is a requirement for mental health (MH) targeted case management (TCM) providers to provide intensive targeted case management. In response to concerns brought by providers and health plans about accessing information on Wraparound training, HHSC is sharing that the Texas Center of the National Wraparound Implementation Center has updated its website to include more detailed information about the training .
August 1: Anti-psychotics Clinic Prior Authorization Changes Begin September 1. RightCare from Scott and White Health Plan will revise the anti-psychotics clinical prior authorization for people enrolled in Managed Medicaid beginning 9/1/18. To learn more please review the antipsychotics clinical prior authorization guide (PDF).
July 12: HHSC recently released an Op-Ed piece that features resources for women experiencing postpartum depression. This information was published in The Daily News and the Tyler Morning Telegraph.
July 1: Mental Health Screenings to Change for Texas Health Steps Effective for dates of service on or after July 1, 2018, mental health screening benefits will change for Texas Health Steps. Mental health screening for behavioral, social and emotional development is required at each Texas Health Steps checkup birth through age 20. Major changes to this medical benefit policy include the following: Changes to limitation for initial health screening for clients 12 through 18 years of age; Update to mental health screening tools recognized by Texas Health Steps
View the changes to Mental Health Screenings for Texas Health Steps .
July 1: Postpartum Depression Screening During an Infant’s Texas Health Steps Checkup to Become a Benefit of Texas Medicaid Effective for dates of service on or after July 1, 2018, postpartum depression screening will be a benefit of Texas Medicaid.
See information on benefits, guidelines, documentation requirements, and submitting claims here.