South Carolina Pharmacy Services

Health Advisory - H1N1

South Carolina Department of Health and Environmental Control (SCDHEC) has issued a health advisory regarding the H1N1 virus. View details.

Web PA

South Carolina Medicaid offers Pharmacy Web Prior Authorization (Web PA), a web-based application developed by First Health Services (FHS) which allows prescribers to request PAs online and receive real-time approvals. Web PA is offered in addition to a telephone call or fax to request a PA. It offers a wide array of features including electronic submission of a prior authorization request, ability to view the status of a PA, an option to edit or delete incomplete requests, access to list of drugs that require a prior authorization, and a secure transaction of confidential information to comply with HIPAA guidelines.

Hepatitis C Program

To improve patient compliance and clinical outcomes, South Carolina Medicaid has implemented a specialty care management program for beneficiaries receiving certain specialty medications. The major focus of this program is to provide outreach to a population of South Carolina Medicaid beneficiaries who will receive high intensity intervention services to improve their care and outcomes. This program, administered by First Health Services Corporation, assists beneficiaries in an attempt to avoid duplication of existing services and serves as a “safety net” to identify any problems that may have occurred during the first level of services. With this initiative, beneficiaries are identified by the approval of a PA for a Hepatitis C treatment agent. Once enrolled in the program, beneficiaries will be contacted and educated on any medical or non-medical issues related to their disease or drug therapy, monitored for potential adverse reactions, reminded of refills to insure compliance with their drug therapy regime and assisted with transportation issues if necessary.

Prescription Limits

Effective January 1, 2009, adult beneficiaries can receive up to a total of 10 prescriptions in the Medicaid fee for service program. Adult beneficiaries qualify for 4 prescriptions per month unless they are enrolled in a qualifying waiver program which allows additional prescriptions. Once the initial 4 prescriptions have been reached for adults, an NCPDP 75 denial message "Prior Authorization Required" will be generated. At that point, pharmacists can override up to six additional prescriptions as long as the drug meets the criteria outlined in the Medicaid Pharmacy Policy Manual.

It is inappropriate for pharmacy providers to override drugs that do not meet the criteria in the Medicaid Pharmacy Policy Manual. Pharmacists must NOT use the override code for a given prescription until after the adult patient’s monthly prescription limit has been reached.

If the 10 prescription limit has been maximized a message will be returned as follows: NCPDP 76 -"Plan Limitations Exceeded". At this time, there are no exceptions allowed for beneficiaries to receive additional prescriptions.

Tamper Resistant Prescriptions

As a reminder, all written, non-faxed, non-electronic or non-verbal prescriptions must be written on a tamper resistant form for coverage by Medicaid fee for service programs. Effective 10/1/2008, all blanks must meet all three requirements for tamper resistant qualification. For full details, see Medicaid Bulletins dated August 30, 2007 and October 1, 2007. Answers to frequently asked questions regarding this requirement may be found at http://www.cms.hhs.gov. Please note that prescriptions reimbursed by a Medicaid Managed Care Organization (MCO) are exempt from this requirement.

Lock-In Program

SCDHHS began implementation for the Pharmacy Lock-In program effective December 1, 2008. We want to ensure that you are aware of the error messages associated with the denial in the event that a beneficiary attempts to obtain a prescription from a pharmacy other than their Lock-In pharmacy. The NCPDP message that will be provided is NCPDP 50 "Non matched pharmacy number" and the additional message is "Client locked into another pharmacy".