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Medicaid aims to increase access to physician-administered drugs

During the 2018 legislative session, lawmakers passed Senate Bill 2836, which includes provisions aimed at enhancing the Mississippi Division of Medicaid’s (DOM) coverage of certain pharmacy services and allowing for greater access to care. As a result, on July 1, 2018, DOM will allow certain physician-administered drugs to be billed and reimbursed as either a medical claim or a pharmacy point-of-sale (POS) claim. Currently, many physician-administered drugs may only be billed as a medical claim.

In order to implement this change, DOM has created a new category of drugs and drug-system devices, which may be billed as either medical or pharmacy POS claims. This new category is known as Clinician Administered Drug and Implantable Drug System Devices (CADD). The list of drugs included in the CADD category may be found on our fee schedules list.

To create the current list, DOM identified the drugs where reimbursing only by medical claims has caused the greatest access issues and targeted those for the CADD category. Additional drugs may be added to the category in the future.

Drugs classified as CADD drugs may now be billed as either a medical claim or a pharmacy POS claim. Furthermore, CADDs will not count toward the monthly prescription drug limit.

To take advantage of this new option, providers should be aware of the following steps:

  • Be familiar with the list of CADD-classified drugs available on DOM’s Pharmacy webpage. Physician-administered drugs not included on this list will be denied if billed on a pharmacy POS claim.
  • Prescribers should identify drugs to be billed to a beneficiary’s pharmacy benefit (via POS claim) by notating on the prescription that the drug will be administered in an outpatient setting, such as a physician’s office.
  • Pharmacists should enter a value of “11” (Office) in NCPDP Field 307-C7 (Place of Service) to identify that the CADD drug will be administered in a clinician setting and as the mechanism whereby the pharmacy claims processing system will not count the claim toward the prescription monthly limit. The pharmacist should ensure that the CADD drug is routed directly to the prescriber’s office.
  • The prescriber should not bill for the drug on the medical claim, but should only bill for the administration of the drug.

If providers experience any claims billing issues during the implementation of this new processing system, they are encouraged to contact DOM’s Office of Pharmacy at 601-359-5253, Option 4.