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PARS, OTC & BRAND NAME DRUGS - PUBLIC Trusting that you will find a nugget or two of wisdom that addresses your situation and gives you another resource, a piece of information, or hope to hang onto. An opinion by posters or references in this document to any specific product, service, therapy or company does not constitute a recommendation by Parent to Parent of Colorado. Information/advice in this document should not be substituted for professional consultation. Information on Medicaid and Prescription/Co-Pay Issues from Gina Robinson, Program Administrator Office of Client and Community Relations, Health Care Policy and Financing 1570 Grant St, 3rd Floor 303.866.6167 303.866.2573 - Fax Number 2/16/08: CO-PAYS APPLY TO MEDICAID CLIENTS UNDER 19 YEARS OLD 8.754 CLIENT CO-PAYMENT 1249710 8.754.1 CLIENT RESPONSIBILITY 1249711 Clients shall be responsible for the following co-payments: 1249712 8.754.1.A. Hospital outpatient, $3.00 per visit. 1249713 8.754.1.B. Physician (M.D. or D.O) office or home visit, $2.00 per visit. 1249714 8.754.1.C. Rural health clinic, $2.00 per visit. 1249715 8.754.1.D. Brief, individual, group and partial care community mental health center visits except services which fall under Home and Community Based Service programs, $2.00 per visit. 1249716 8.754.1.E. Pharmacy, $1.00 per prescription or refill for generic or multi-source drugs and $3.00 per prescription for single-source or brand name drugs. 1249717 8.754.1.F. Optometrist, $2.00 per visit. 2/16/08: OTC PRESCRIPTIONS FOR LONG-TERM USE DRUGS ARE COVERED FOR CHILDREN (ONLY) THROUGH MEDICAID After our phone conversation last week, I explored your concerns regarding your Over the Parent to Parent of Colorado - updated 04/2012 Counter (OTC) pharmacy requests for Miralax, Zyrtec and Claritin. Prescription Miralax is available in generic form and does not need Prior Authorization (PAR). We just need to be sure your physician doesn't check the box on the prescription pad which indicates "no generics." Zyrtec needs a PAR because it is an OTC. Brand name Claritin needs a PAR as well. PAR's for OTC's are actually easy for your provider to obtain for you. The staff in your provider's office can fill out the Pharmacy PAR listing the OTC as being medically necessary and send it to our reviewing agency. Another, quicker option would be for your provider to call the 1-800 number listed below and make a verbal request for coverage. I have heard from other Medicaid providers that this system is working well for them and they like having immediate access to PAR staff in order to quickly facilitate patient's needs. I have included the information below just in case your provider is not aware of the availability of the call in option: 800.365.4944. Fax is 888.772.9696 Both numbers are on all of the pharmacy forms, which can be located at: Please let me know immediately if you have any questions or encounter a roadblock. I have spoken to Pharmacy staff as well as EPSDT and Acute Care Benefits staff to assure that any time EPSDT is mentioned during a phone call that we stop and assess the situation. We want to be sure that every child is receiving all medically necessary care available to them. Please feel free to call me directly should you have any other issues or concerns. 2/17/08: INFORMATION ON CO-PAYS THAT GO INTO EFFECT WHEN OUR KIDS TURN 19 I have attached a copy of the rule which applies to Medicaid eligibles age 19 and over. This rule regarding the co-pays and the rates took affect about 4 years ago. Julie might be able to give you a better handle on the reasoning behind it since she has the Medical Services Board knowledge behind her and I was not yet here. I do have a request in to our IT section to post this rule as well as the rate information on the EPSDT Toolkit and link it to as many other sections on our new website as possible. Hopefully this web site information as well as the EPSDT brochures and letters will assist others in accessing the information easily. Parent to Parent of Colorado - updated 04/2012 When your daughter reaches the age of 21, she will no longer be eligible for EPSDT services or benefits. Things such as eyeglasses, orthodontia and dental care will no longer be available. She will continue to receive other services such as yearly physicals, sick care and prescriptions. 8.754 CLIENT CO-PAYMENT 1249710 8.754.1 CLIENT RESPONSIBILITY 1249711 Clients shall be responsible for the following co-payments: 1249712 8.754.1.A. Hospital outpatient, $3.00 per visit. 1249713 8.754.1.B. Physician (M.D. or D.O) office or home visit, $2.00 per visit. 1249714 8.754.1.C. Rural health clinic, $2.00 per visit. 1249715 8.754.1.D. Brief, individual, group and partial care community mental health center visits except services which fall under Home and Community Based Service programs, $2.00 per visit. 1249716 8.754.1.E. Pharmacy, $1.00 per prescription or refill for generic or multi-source drugs and $3.00 per prescription for single-source or brand name drugs. 1249717 8.754.1.F. Optometrist, $2.00 per visit. 3/18/08: OTC MEDS THAT ARE USED LONG-TERM CAN BE COVERED BY MEDICAID IN CERTAIN CIRCUMSTANCES As more of our kids' meds go Over-the-Counter, it can become difficult to obtain them through Medicaid. However, OTC meds that are used long-term can be covered by Medicaid in certain circumstances - if your child has been on the med for a long period of time, this is an indication that can be covered. In my case, my pharmacy has had difficulty figuring out how to bill my son's medications. At first, they simply said that they were not covered. Further investigation produced the following response from Gina Robinson at the State. a. All OTC medications, except for insulin and aspirin, require a prior authorization and always have. Anytime a prescriber writes a prescription for an OTC product, they will need to get a prior authorization. (OTC medications are one of the restricted categories that can be excluded from coverage completely per CMS. Colorado Medicaid has chosen to cover OTCs but monitors usage through prior authorization.) b. The Department posts the medications that need a prior authorization on the pharmacy web site at Parent to Parent of Colorado - updated 04/2012 Prescribers can and should check Appendix P to be aware of the medications that require a prior authorization. (Parents can also access this information at the same website address.) c. The pharmacy should have called the prescriber when the medication rejected for a prior authorization. It is common practice for pharmacies to notify prescribers about prior authorization rejections and this should have been done. (Although this was the weekend, the pharmacy staff should have called your physician's after hour's line for assistance. Instead, you steered them towards the 1-800 number, which was also an appropriate short-term solution.) The 1-800 number for emergent prior auths works as designed and Brady's medication was accessible. (Had the PAR been in place last month as requested, you wouldn't have had these issues for the Zyrtec.) 5/5/08: WHAT IF THE ONLY DRUG THAT WORKS HAS BEEN DENIED BY MEDICAID IN THE BRAND NAME FORM? The generic lacks the controlled release. Have the doc do a "PAR"; if that is denied have the doc ask for an "Exception" - see email below from Gina Robinson. If the parent needs further help, Gina is the person to call - Robin a. All OTC medications, except for insulin and aspirin, require a prior authorization and always have. Anytime a prescriber writes a prescription for an OTC product, they will need to get a prior authorization. (OTC medications are one of the restricted categories that can be excluded from coverage completely per CMS. Colorado Medicaid has chosen to cover OTCs but monitors usage through prior authorization.) b. The Department posts the medications that need a prior authorization on the pharmacy web site at Prescribers can and should check Appendix P to be aware of the medications that require a prior authorization. (Parents can also access this information at the same website address.) Parent to Parent of Colorado - updated 04/2012

Source: http://p2p-co.org/wisdom/pdf/MDCD%20Co-Pays,%20PARS,%20OTC%20&%20Brand%20Name%20Drugs+.pdf