Alaska Medicaid Pharmacy - Naloxone: point-of-sale edits and prior authorization
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Defines Alaska Medicaid pharmacy claims processing edits and prior authorization requirements for naloxone products, and pharmacist actions when multiple Narcan® Nasal Spray fills occur; applies to Alaska Medicaid-enrolled beneficiaries and dispensing pharmacists.
Prior authorization requirement for Narcan® Nasal Spray (NS) was removed except in specific circumstances.
A point-of-sale edit will reject claims for a patient's third Narcan® NS fill within a rolling 365-day period and requires pharmacist prescriber contact and documentation before override.
Evzio® Auto-Injector requires step therapy prior authorization before payment will be considered.
Naloxone Coverage and POS Rules
Coverage and point-of-sale operational rules for naloxone products
Covered when the following product-specific coverage and point-of-sale operational rules are met:
ALL of the following
Narcan coverage
- Narcan® Nasal Spray (NS) is designated the preferred agent for emergency treatment of opioid overdose and does not require prior authorization except in specific circumstances.
Evzio prior authorization
- Evzio® Auto-Injector requires step therapy prior authorization before payment will be considered; follow Alaska DHSS online clinical criteria and submit the product-specific form.
Point-of-sale edit for Narcan NS
- Claims for a patient’s third Narcan® NS fill within a rolling 365-day period will reject at point-of-sale with NCPDP reject 75 and the message: '>= 3 fills in 1 yr; contact MD, document on Rx, then override.'
- When the edit rejects, the pharmacist must contact the Narcan prescriber and the opioid prescriber (if different) to notify them that the patient has used Narcan NS two or more times in the previous year and is requesting another fill.
- The pharmacist must inquire what intervention the opioid prescriber intends, including any adjustments to the patient’s medication regimen to reduce overdose risk; the details of the conversation must be documented on the prescription (hard copy or electronic) including the prescriber’s office contacted, contact person, and date.
- If the prescriber is not immediately available, the pharmacist may fill the Narcan NS prescription but must follow up with the prescriber within 3 days; prescriber response may be by phone or fax.
- After documenting the intervention on the prescription, the pharmacist may override the point-of-sale denial using PATC = 5 (Prior Auth Type Code, NCPDP field 461-EU); documentation must be made available to Alaska Medicaid upon request.
Suggested prescriber interventions
- Possible options include use of a non-opioid analgesic; decreasing opioid potency per pill; decreasing frequency of opioid administration; tapering off opioids; discontinuing opioids; and decreasing or discontinuing concomitant CNS depressants (e.g., benzodiazepines, alcohol).
Point-of-Sale Edits and Billing Codes
| 75 | NCPDP reject code displayed at point-of-sale for >=3 fills in 1 year |
| PATC=5 | Prior Auth Type Code used to override after documented intervention |
Pharmacist and Prescriber Actions
Evzio step therapy prior authorization
Evzio® Auto-Injector requires step therapy prior authorization before payment will be considered. Providers should refer to the Alaska DHSS pharmacy prior authorization web page for the product-specific clinical criteria and the form to submit.
Narcan point-of-sale edit and required pharmacist actions
Alaska Medicaid has a point-of-sale edit that will reject a claim (NCPDP reject 75) when a patient requests a third Narcan® Nasal Spray (NS) fill within a rolling 365-day period; the pharmacist must contact prescribers, document the intervention on the prescription, and may override using PATC = 5 after documentation. If the prescriber is not immediately available, the pharmacist may fill the Narcan NS but must follow up with the prescriber within 3 days.
- POS reject: NCPDP reject 75 with message '>= 3 fills in 1 yr; contact MD, document on Rx, then override.'
- Pharmacist must contact the Narcan prescriber and the opioid prescriber (if different) and document the intervention on the prescription, including office contacted, contact person, and date.
- After documenting the intervention on the prescription, pharmacist may override the POS denial using PATC = 5 (Prior Auth Type Code, NCPDP field 461-EU).
- If prescriber not immediately available, pharmacist may dispense and must follow up within 3 days; documentation must be made available to Alaska Medicaid upon request.
Product Definitions
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