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PRN Updates for Pharmacy Providers – Nov. 15, 2022

Nov. 15, 2022

Use of DAW ‘7’ for Narrow Therapeutic Index (NTI) Brand Name Drugs-Pharmacist must call Gainwell Pharmacy Call Center

Medicaid allows the generic mandate requirement to be overridden for brand name narrow therapeutic index (NTI) drugs to include Coumadin, Dilantin, Lanoxin, Synthroid, and Tegretol.

Pharmacists were previously able to override the generic mandate for NTI drugs by submitting a DAW of  ‘7’ for prescriptions on which the prescriber specifies, ‘Do Not Substitute’. However, DOM has learned this function is not operational in the Gainwell system.

Pharmacists should call the Gainwell pharmacy provider help desk at 1-833-660-2402 to request prior authorization (PA) for this purpose. A PA form is not required.


Oct. 19, 2022

Directions for waiving $3 copay on COVID-19-related prescriptions

Effective 10/1/2022 and through the end of the Public Health Emergency, the directions for waiving the $3 copay on COVID-19-related prescriptions when:

  • The prescriber has indicated a diagnosis of COVID-19 on the prescription,
  • The prescriber notates the beneficiary may have COVID-19 illness on the prescription, or
  • The beneficiary states that they may have COVID-19 or are being treated for COVID-19,

The V suffix on the member ID will no longer be accepted.

In Field # 461-EU (Prior Authorization Type Code) enter a value of “4” (exempt from copay and/or coinsurance)

In Field # 462-EV (Prior Authorization Number) enter a value of “19


Oct. 3, 2022

Please read the following updates regarding pharmacy provider billing and the MESA system

Medicaid Beneficiary ID number length – Medicaid cards issued to beneficiaries display a 12- digit ID number. However, providers must continue to submit only the first nine (9) digits of the ID number on NCPDP claims. Claims will deny when 12-digit ID numbers are submitted.

Short-Acting (SA) Narcotics and chronic/routine users in electronic PA criteria – Clinical criteria logic for approximately 100 Smart PA (prior authorization) rules was converted from the Conduent to Gainwell claims system. DOM created Smart PAs for the purpose of easing provider burden by issuing ‘behind-the-scenes’ electronic PAs when clinical criteria is met for nonpreferred drugs or other drugs requiring PA. Smart PAs are now known as DUR+ or Drug Utilization Review Plus PAs. On October 1st, it was discovered that there is a slight difference in the way the former system identified a chronic user of short-acting narcotics vs. the new system. Providers may notice a higher number of rejections for products such as hydrocodone/acetaminophen. Prescribers are advised to submit prior authorization requests for routine users of short-acting narcotics who require monthly quantities greater than the DOM quantity limits listed on the PDL. For example, prescribers should submit PA requests for beneficiaries requiring routine monthly quantities of 90 hydrocodone combination products. This will prevent the practice of pharmacists split billing quantities of 90 by billing one claim to Medicaid for 62 tabs and the other remaining 28 tablets to the beneficiary for cash.

Vaccines – The ‘generic mandatory’ edit is incorrectly causing vaccine claims to deny. Vaccines are not classified as covered outpatient drugs and, therefore, the generic mandate is not applicable. Gainwell is working to correct this error. In the meantime, pharmacists may administer the vaccines they have on hand and call the Pharmacy Prior Authorization (PA) Unit at 1-833-660-2402 to request PA overrides to allow these claims to pay.

Compounds – Medicaid does not cover compound claims. However, compounds may be covered if deemed medically necessary for children who are EPSDT-eligible. Prior authorization will be required in these situations. Providers may now submit compounds electronically as a single claim by entering each ingredient on multiple lines following the NCPDP Payer Sheet billing guidelines for compounds or by submitting via the claim via Provider Portal.

Total Parenteral Nutrition (TPN) – TPN claims which providers had been submitting via the Envision Web Portal can now be submitted via pharmacy claims as compounds or via the Provider Portal. PA requests submitted for TPNs should also include the prescription or prescriber’s order for the TPN.

K-Baby Billing – To bill a prescription for a newborn who doesn’t have a Medicaid ID#, please use the mother’s Medicaid ID# the baby’s real first and last name, the baby’s date of birth and gender and the patient relationship code of ‘3’ for child. The ‘K’ no longer needs to be entered behind the mother’s Medicaid ID#.