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News & Updates

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Provider/Physician Notice

View the COVID-19 Telehealth and Telemedicine Policy for coding guidelines and claims submission procedures. We have also reduced our Prior Authorization Requirements.

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2020 News

05-22-2020 Texas Health Steps Computer-Based Training Now Available

Click here.

Continuing Education Credit: Immunization

Click here.

Drug Shortages of Nitrofurantoin Oral Suspension and Azithromycin Products

RightCare has identified drug shortages of nitrofurantoin oral suspension and azithromycin products on the Medicaid and CHIP formularies. There are many other antibiotic choices available on the formulary and prescribers may choose an appropriate alternative based on patient diagnosis and indication for use. Prescribers are encouraged to use the VDP Formulary Search, click here to identify other antibiotic options to avoid delays in people receiving medication.


Corrected Claim and Redetermination Memo - May 1, 2020

Details on where to submit any corrected claims and redeterminations with a date of service prior to 11/01/2019. For more information please click here.


Temporary Change in Status for the Stimulants Drug Class Effective April 22, 2020

HHSC has been informed of a drug shortage for Methylphenidate ER in the Stimulants drug class. RightCare temporarily removed the non-preferred status from the brand formulations of the NDCs below on April 22, 2020. These changes will allow providers to prescribe for these drugs without requiring a PDL prior authorization and allow continued access to necessary medication for clients. This is a temporary change until the preferred products are sufficiently available in the market. RightCare will announce any further PDL status changes of these NDCs.

NDC Label Name
50458058501 CONCERTA ER 18 MG TABLET
50458058601 CONCERTA ER 36 MG TABLET
50458058701 CONCERTA ER 54 MG TABLET
50458058801 CONCERTA ER 27 MG TABLET


PCSK9 Clinical Prior Authorization Criteria Changes To Begin May 22, 2020

RightCare will revise the clinical prior authorization criteria for protein convertase subtilisin/kexin type 9 (PCSK9) inhibitors on May 22, 2020. All clinical edit criteria can be found here.

Revisions include:
  • The LDL1 requirement for initiation of PCSK9 therapy was changed from greater than or equal to 130 mg/dL to greater than or equal to 70mg/dL
  • Diagnosis of Heterozygous Familial Hypercholesterolemia) (HeFH) was replaced with the diagnosis of Primary Hyperlipidemia which includes HeFH diagnosis
  • The list of generic code numbers for atorvastatin and rosuvastatin was updated (Table 5)
  • References

For more information please click here.


Temporary Change in Status for Oral Immunosuppressives Drug Class Effective April 17, 2020

The Food and Drug Administration announced a drug shortage for Tacrolimus, part of the in the Oral Immunosuppressives drug class. In response RightCare has temporarily removed the non-preferred status from the generic formulations of the NDCs below effective April 17. These changes will allow providers to prescribe for these drugs without requiring a PDL prior authorization and allow continued access to necessary medication for clients. This is a temporary change until the preferred products are sufficiently available in the market. RightCare will announce any further PDL status changes of these NDCs.

NDC Label Name
00469060773 PROGRAF 0.5 MG CAPSULE
00469061773 PROGRAF 1 MG CAPSULE
00469065773 PROGRAF 5 MG CAPSULE
00469123050 PROGRAF 0.2 MG GRANULE PACKET
00469133050 PROGRAF 1 MG GRANULE PACKET


RSV Season and Synagis Prior Authorization Ends April 14, 2020

The 2019-20 respiratory syncytial virus season ends for all counties on April 14, 2020 and prior authorization requests for Synagis are no longer be accepted or reviewed.


Temporary Change in Status for Topical Nonsteroidal Anti-inflammatory Drugs Class effective April 13, 2020

RightCare has implemented the temporarily revised preferred drug list on April 13,2020, to address reported possible drug shortages of products in the Topical Nonsteroidal Anti-inflammatory drug class. The change allows providers to prescribe these drugs without requiring a non-preferred prior authorization and people enrolled in Medicaid continued access to necessary medication. For a list of affected drugs click here. This is a temporary change until the preferred products are sufficiently available in the market.


Ranitidine Products Removed from Formulary April 4, 2020

The Food and Drug Administration requested manufacturers withdraw all ranitidine products (commonly known by the brand name Zantac) from the market because of consumer exposure to unacceptable levels of impurities. RightCare removed all ranitidine products from the Medicaid and CHIP formularies on April 4, 2020. Formulary alternatives available include famotidine (10mg, 20mg and 40mg), cimetidine (200mg, 300mg, 400mg, and 800mg), and nizatidine (150mg and 300mg). For more information click here.


Temporary Change in Status for Inhaled Glucocorticoid, Insulin Hypoglycemics Drug Classes on April 2, 2020

RightCare has implemented the temporarily revised preferred drug list on April 2,2020 to address reported possible drug shortages of products in the inhaled glucocorticoid and hypoglycemic insulin drug classes. The change allows providers to prescribe these drugs without requiring a non-preferred prior authorization and people enrolled in Medicaid continued access to necessary medication. For the list of the affected drugs click here. This is a temporary change until the preferred products are sufficiently available in the market.


Medicaid to Allow Expedited Pharmacy Enrollment Beginning April 1, 2020

Beginning April 1, Texas pharmacies, as well as any out of state pharmacy, can temporarily enroll with the Vendor Drug Program using our expedited enrollment application (HHS Form 1350). The expedited form and enrollment process allows pharmacies to quickly provide pharmaceutical services to people enrolled in Texas Medicaid during the COVID-19 pandemic. In addition, CMS has waived the collection of the enrollment application fee during the state of emergency. For more additional please visit the Vendor Drug Program Website: here.


Revised Growth Hormone Clinical Prior Authorization Begins April 1, 2020

RightCare will implement the Growth Hormone clinical prior authorization criteria on April 1, 2020. All clinical edit criteria can be found here. The implementation will include four diagnosis codes for approval as suggested by MCOs and approved by VDP:
  • Q87.11: Prader-Willi Syndrome
  • Q87.19: Noonan Syndrome
  • E34.3: SHOX deficiency with Dyschondrosteosis
  • Q78.8: SHOX deficiency with short stature


Medicaid to Allow Expedited Pharmacy Enrollment Beginning April 1, 2020

Beginning April 1, Texas pharmacies, as well as any out of state pharmacy, can temporarily enroll with the Vendor Drug Program using our expedited enrollment application (HHS Form 1350). The expedited form and enrollment process allows pharmacies to quickly provide pharmaceutical services to people enrolled in Texas Medicaid during the COVID-19 pandemic. In addition, CMS has waived the collection of the enrollment application fee during the state of emergency. For more additional please visit the Vendor Drug Program Website: here.


Albuterol Shortage Prompts Temporary Change in Preferred Status

On March 21, VDP temporarily changed the preferred drug list to address reported drug shortages for short-acting agents in the bronchodilators, beta agonist drug class. This change allows providers to prescribe these drugs without requiring a non-preferred prior authorization and allow people on Medicaid continued access to necessary medication. VDP will continue to update providers on the status these drugs. Additional information can be found here.


Sunosi Criteria Added to Central Nervous System Stimulants Clinical Prior Authorization Starting March, 9 2020

RightCare implemented the clinical prior authorization criteria for Sunosi (solriamfetol) on March, 9 2020. All clinical edit criteria can be found here.

The criteria is part of the Central Nervous System Stimulants clinical prior authorization. The drugs Provigil and Nuvigil are already part of this clinical prior authorization.


New PDL Criteria Check Stage-Four Advance Metastatic Cancer Diagnosis

RightCare added a new exception criteria to the Jan. 24 preferred drug list, to check for a diagnosis of stage-four advanced metastatic cancer, or for treatment of symptoms associated with the cancer diagnosis. Prescribers must contact the pharmacy prior authorization call center and attest the person meets the exception criteria for the non-preferred drug to be approved because diagnoses are not readily available in a person’s medical claims data. All clinical edit criteria can be found here.


HHS Seeking to Incresae LARC Utilization

In its ongoing efforts to promote women’s health, Texas Health and Human Services (HHS) is raising awareness of long-acting reversible contraception (LARC). The American College of Obstetricians and Gynecologists (ACOG) identifies LARCs, including intrauterine devices and subdermal contraceptive devices, as the most effective reversible contraceptive method. Requiring no action on the part of the person after the device is in place, LARCs have high rates of user satisfaction and method continuation. HHS has made improving access to LARCs a priority. More information can be found here.


Cystic Fibrosis Agents Clinical Prior Authorization to Include Trikafta Criteria Starting Feb 24, 2020

RightCare implemented the Trikafta criteria within the existing Cystic Fibrosis Agents clinical prior authorization on Feb 24, 2020. All clinical edit criteria can be found here.

The Texas Drug Utilization Board approved the criteria for Trikafta at the Jan 2020 meeting. Trikafta is a cystic fibrosis transmembrane conductance regulator (CFTR) modulating agent. As part of the criteria is a check for duplicative or concurrent therapies with another CTFR modulating agent. The board recommended the inclusion of this step to the criteria for all CFTR modulator agents.


2020 Provider Reference Guide

Refer to the Provider Reference Guide for information on claims, eligibility, and other RightCare services.

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:

NDCName
00093598627Epinephrine 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:

NDCName
00093598527Epinephrine 0.15 mg auto-injector
00115169449Epinephrine 0.3 mg auto-injector
00115169549Epinephrine 0.15 mg auto-injector
49502010101Epinephrine 0.15 mg auto-injector
49502010102Epinephrine 0.15 mg auto-injector
49502010201Epinephrine 0.3 mg auto-injector
49502010202Epinephrine 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.