Hypertonic saline prior authorization for Kentucky Medicaid
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Establishes prior authorization requirements and coverage criteria for specified hypertonic saline NDCs for Kentucky Medicaid members (MCO and FFS); affects prescribers and pharmacies submitting PA requests to MedImpact for Kentucky Medicaid.
Prior authorization criteria will be implemented for the listed hypertonic saline NDCs effective March 15, 2026.
Members with at least one paid claim for hypertonic saline between October 1, 2025 and December 31, 2025 are grandfathered with an existing PA through May 1, 2026.
For listed NDCs, approval duration is specified (example: NEBUSAL 3% approval duration = 12 months).
Covered indications enumerated for listed hypertonic saline products include cystic fibrosis (E84), bronchiectasis (J47 and Q33.4), and acute bronchiolitis (J21).
Coverage criteria
Initial coverage criteria
Covered when ALL of the following are met
Approval duration example: NEBUSAL 3% = 12 months.
No other explicit exclusions are listed in this policy. For diagnoses that are not among the conditions enumerated for the listed hypertonic saline NDCs, prescribers are encouraged to request prior authorization and provide supporting clinical literature to demonstrate medical necessity.
The policy ties coverage to specific diagnoses; absence of a listed diagnosis may result in a non-approval unless the prescriber submits supporting clinical literature during the prior authorization process to justify medical necessity.
Coding and authorization details
| E84 | Cystic fibrosis (ICD-10 group E84) |
| J47 | Bronchiectasis (ICD-10 group J47) |
| Q33.4 | Congenital bronchiectasis |
| J21 | Acute bronchiolitis (ICD-10 group J21) |
| 50190014263 | NEBUSAL 3% VIAL (NDC) |
| 00378699789 | SODIUM CHLORIDE 3% VIAL (NDC) |
| 50190074060 | PULMOSAL 7% VIAL (NDC) |
| 50190014123 | SODIUM CHLORIDE 7% VIAL (NDC) |
| 83490030760 | SODIUM CHLORIDE 7% VIAL (NDC) |
Provider actions and prior authorization
Prior authorization required (effective Mar 15, 2026)
Prior authorization is required for the listed hypertonic saline NDCs effective March 15, 2026. Members with at least one paid claim for hypertonic saline between October 1, 2025 and December 31, 2025 are grandfathered and retain prior authorization coverage through May 1, 2026; after May 1, 2026 these members must obtain a new PA or transition therapy if appropriate.
How to submit prior authorization requests
Submit prior authorization requests through the MedImpact Kentucky pharmacy portal or by phone/fax as listed for MCO or FFS; include the patient’s prescribed NDC and confirmed diagnosis to support approval.
- MCO prior authorization phone: (844) 336-2676; fax: (858) 357-2612; portal: https://kyportal.medimpact.com/
- FFS prior authorization phone: (877) 403-6034; fax: (858) 357-2612; portal: https://kyportal.medimpact.com/
- For program questions: KYMCOPBM@MedImpact.com (MCO) or KYMFFS@MedImpact.com (FFS)
Provide supporting clinical literature for non‑listed diagnoses
For any diagnosis not listed in the approval criteria, prescribers are encouraged to obtain prior authorization and submit supporting clinical literature to demonstrate medical necessity when requesting coverage.
PA required for new starts — denials expected without PA
Beginning March 15, 2026, claims for members who are new starts or who did not fill hypertonic saline between October 1, 2025 and December 31, 2025 will be denied without an approved prior authorization.
Initial therapy prior authorization criteria
Initial therapy PA
Approval duration example provided for NEBUSAL 3% = 12 months.
Continuation and grandfathering
Grandfathered continuation
Grandfathering rule for existing users
After May 1, 2026 a new PA or transition to a different therapy is required.
Step therapy and utilization management
| Step | Requirement |
|---|---|
| 1 | No step therapy requirements specified in the document. |
Definitions
Background
Hypertonic saline inhalation solutions are used to aid airway clearance in respiratory conditions. This policy associates coverage of the listed hypertonic saline NDCs with specific diagnoses including cystic fibrosis (ICD-10 group E84), bronchiectasis (ICD-10 group J47) and congenital bronchiectasis (Q33.4), and acute bronchiolitis (ICD-10 group J21).
Site of care and submission contacts
Use MedImpact Kentucky portals/PA phone/fax for submissions (Kentucky Medicaid)
Contact the appropriate MedImpact Kentucky portal or prior authorization phone/fax listed for MCO or FFS to submit and process prior authorizations; Kentucky Medicaid benefits and PA rules apply to both MCO and FFS enrollees.
- MCO portal: https://kyportal.medimpact.com/; PA phone: (844) 336-2676; PA fax: (858) 357-2612
- FFS portal: https://kyportal.medimpact.com/; PA phone: (877) 403-6034; PA fax: (858) 357-2612
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