CurrentAmbetter NevadaPolicy NV.PHAR.04

Continuity of Care

Policy governing transitional medication authorizations for new Medicaid members and post-discharge recipients, including special rules for psychotropic medications and pediatric recipients; affects SilverSummit/Ambetter Nevada Medicaid pharmacy operations, prescribing providers, pharmacists, and Envolve Pharmacy Solutions.

Policy Summary

PayerAmbetter Nevada

PolicyContinuity of Care

Policy CodePolicy NV.PHAR.04

Change TypeNo material change

Effective DateJul 1, 2017

Next Review Date

Key ActionProvider should submit an authorization request to Envolve Pharmacy Solutions to continue non-PDL medications beyond the continuity period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

68max continuity (days)

6 monthspsychotropic continuity

Medicaidproduct type

3reviews listed

Coverage Criteria — Continuity of Care

New member continuity

Covered when ALL of the following are met:

New member FFS to MCO continuity: Member transitions from Fee-For-Service (FFS) to the MCO and has an approved medication authorization in place at transition

Automatic continuity applies up to 68 calendar days

Point-of-sale override: Point-of-sale (POS) system will allow up to a 68-day supply; if the POS does not allow the 68-day supply, the prescriber or pharmacist may contact Envolve Pharmacy Solutions for an override68 days

Pharmacy/prescriber verification required for override and member/provider notification will occur

Psychotropic continuity

Covered when ANY of the following are met:

Policy Summary

PayerAmbetter Nevada

PolicyContinuity of Care

Policy CodePolicy NV.PHAR.04

Change TypeNo material change

Effective DateJul 1, 2017

Next Review Date

Key ActionProvider should submit an authorization request to Envolve Pharmacy Solutions to continue non-PDL medications beyond the continuity period.

SourceLink

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Prior authorization verification rules

System entry rules when a current prior authorization exists:

Existing PA expiration known: If the pharmacy or prescriber can verify a current prior authorization on file, the current expiration date of that authorization will be entered into the system

Entering the current expiration overrides system continuity defaults

Existing PA expiration unknown: If the pharmacy or prescriber cannot verify the current expiration date: if the medication is on the PDL an authorization will be given for one year; if the medication is not on the PDL a 68-day authorization will be given1 year or 68 days

Duration depends on PDL status of the medication

Actions Required by Providers and Pharmacies

Denial Risk

Risk of denial without authorization

The POS system may not permit the automatic continuity supply at the time of fill. If the provider does not request or obtain an authorization or override when required, claims for the continuity supply may be denied or will not process for the extended supply.

Automatic POS 68-day supply may be blocked in some situations
An override or authorization from Envolve Pharmacy Solutions is required when POS does not allow automatic continuity

Prior Authorization

PDL switching recommendation

When a new member fills a prescription that is not on the Preferred Drug List (PDL), SilverSummit will notify both the prescribing provider and the member and recommend switching to a PDL agent. The provider may request an authorization to keep the member on the current non‑PDL medication; such requests are reviewed per EPS.PHARM.24 and P&T Committee criteria.

Members filling non‑PDL medications will be notified and switching to a PDL agent is recommended
Provider may submit an authorization request to Envolve Pharmacy Solutions to remain on a non‑PDL agent

Prior Authorization

Authorization request to Envolve

Provider should submit an authorization request to Envolve Pharmacy Solutions to continue non‑PDL medications beyond the continuity period when they wish the member to remain on the current agent. Requests will be reviewed based on P&T Committee criteria and any clinical information submitted by the prescriber.

Submit authorization requests to Envolve Pharmacy Solutions as outlined in EPS.PHARM.24
Clinical justification and supporting documentation may be required for review

Documentation Required

Verification and override requirements

Pharmacy or prescriber must verify member medication history or existing prior authorization when requesting an override. If verification shows prior use, a 68‑day authorization will be given; if a current prior authorization exists, the existing expiration will be entered. For medications on the PDL without a known PA expiration, an authorization may be given for one year; for non‑PDL medications the authorization will be 68 days. For non‑preferred psychotropic drugs after institutional discharge or for recipients under age 18, contact Envolve for a 6‑month override.

If member verification confirms prior use → 68‑day authorization
If current PA exists → enter PA expiration date into system
If medication is on PDL and PA expiration unknown → authorize for one year
If medication is not on PDL and PA expiration unknown → authorize for 68 days
Psychotropic after discharge or members <18 → 6‑month override

Continuation Therapy Rules

Continuation therapy rules

Automatic temporary continuation of existing medication therapy during transition periods.

Temporary continuation (non-PDL): For new members currently on a non-PDL medication, the POS system will allow up to a 68-day supply at point of sale68 days

Provider and member will be notified and provider may submit an authorization request to Envolve Pharmacy Solutions to continue therapy beyond this period

Temporary continuation (psychotropic post-discharge): Non-preferred psychotropic medications are honored up to six months following institutional discharge or for recipients under 18 when started and stabilized6 months

Override for six months can be entered by Envolve Pharmacy Solutions upon prescriber or pharmacist request

Quantity Limit Details

non-PDL medications — maximum automatic continuity supply (days)

Maximum automatic continuity supplyUp to a 68-day supply at point of sale for new members on non-PDL medications

Override when POS does not allowPrescriber or pharmacist may contact Envolve Pharmacy Solutions for an override to provide the continuity supply

Verification requirement for overridePharmacy or prescriber must verify the member has been on the medication to receive the 68-day authorization

Provider notificationSilverSummit will notify the prescribing provider and member when a non-PDL prescription is filled and recommend switching to a PDL agent

Authorization beyond continuity periodIf provider wishes to keep member on non-PDL medication beyond the continuity supply, submit an authorization request to Envolve Pharmacy Solutions per EPS.PHARM.24

OpenPayer

Continuity of Care

Coverage Criteria — Continuity of Care

Actions Required by Providers and Pharmacies

Continuation Therapy Rules

Quantity Limit Details

Background and Scope Notes