ModifiedNevada Health AuthorityPolicy N/A

Medicaid Services Manual Chapter 1200 — Prescribed Drugs

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Governs coverage, limitations, prior authorization, dispensing, reimbursement, and refill requirements for prescription and non-prescription pharmaceuticals provided to eligible Nevada Medicaid recipients and generally Nevada Check Up recipients.

Policy Summary

PayerNevada Health Authority

PolicyMedicaid Services Manual Chapter 1200 — Prescribed Drugs

Policy CodePolicy N/A

Change TypeModified — Wegovy exception criteria added

Effective DateMay 29, 2024

Next Review DateN/A

Key ActionSubmit prior authorization and quantity-limit documentation when required for the prescribed drug.

SourceLink

POLICY UPDATE CHANGES

Wegovy exception criteria were added to Appendix A, Section KK, Incretin Mimetics.

The chapter was revised for grammar, punctuation, capitalization, acronym standardization, duplication removal, rewording, renumbering, and section rearrangement.

34 daysStandard monthly supply

100 daysMaintenance supply

80% / 90%Early refill thresholds

12 months

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ModifiedNevada Health AuthorityPolicy N/A

Medicaid Services Manual Chapter 1200 — Prescribed Drugs

Customize your policy alerts

Sign up for all Nevada Health Authority policy alerts

Know when Nevada Health Authority releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerNevada Health Authority

PolicyMedicaid Services Manual Chapter 1200 — Prescribed Drugs

Policy CodePolicy N/A

Change TypeModified — Wegovy exception criteria added

Effective DateMay 29, 2024

Next Review DateN/A

Key ActionSubmit prior authorization and quantity-limit documentation when required for the prescribed drug.

SourceLink

POLICY UPDATE CHANGES

Wegovy exception criteria were added to Appendix A, Section KK, Incretin Mimetics.

The chapter was revised for grammar, punctuation, capitalization, acronym standardization, duplication removal, rewording, renumbering, and section rearrangement.

34 daysStandard monthly supply

100 daysMaintenance supply

80% / 90%Early refill thresholds

12 months

Contraceptive supply

96 hoursEmergency supply

Coverage Criteria

General outpatient drug coverage

Covered when all applicable general drug requirements are met.

General coverage requirements: The drug is prescribed for a medically accepted indication; the manufacturer participates in the Federal Medicaid Drug Rebate Program; and applicable prior authorization, Preferred Drug List, step therapy, and quantity-limit requirements are satisfied.

Written prescriptions must meet applicable tamper-resistant prescription requirements; this does not apply to electronic, faxed, or telephone prescriptions.

Standard PDL exception

A non-preferred drug may be covered when at least one applicable exception criterion is met.

Standard PDL exception criteria: The recipient has an allergy to all preferred drugs in the class; a contraindication or drug interaction with all preferred drugs; unacceptable or toxic side effects from all preferred drugs; therapeutic failure of two preferred drugs, or the only preferred drug when fewer than two exist; a unique indication supported by peer-reviewed literature or an FDA-approved indication; qualifying continuity of care for non-preferred psychotropic or antidepressant therapy after institutional discharge; or therapeutic failure of one preferred agent for specified antipsychotic, anticonvulsant, and antidiabetic medications.

PDL statutory and interim exceptions

The following statutory or policy exceptions apply to PDL restrictions.

PDL restriction exceptions: The drug is for HIV/AIDS treatment, organ-transplant antirejection therapy, or antihemophilic treatment; the drug is essential for treating sickle cell disease or its variants; the drug prevents acquisition of HIV/AIDS; the product is new and outside a reviewed PDL class; or the product is a new FDA-approved drug or has new clinical evidence supporting PDL inclusion and has an approved Standard PDL Exception.

New-product exceptions remain in effect until the Silver State Scripts Board reviews the relevant class, product, or evidence as described in the policy.

Excluded drugs and uses

The DHCFP does not reimburse the listed products or uses.

Excluded pharmaceuticals and uses: The agent is used for weight loss, fertility promotion, cosmetic purposes, hair growth, impotence or erectile dysfunction, or an experimental use; the product is yohimbine or is designated ineffective or less than effective under the DESI policy, including identical, related, or similar products; the manufacturer does not participate in the Federal Medicaid Drug Rebate Program unless the product is FDA-rated 1-A; or the product is a prescription dietary supplement, vitamin, or mineral without an FDA-approved indication, other than prescription prenatal vitamins or fluoride.

Refill and dispensing limits

Refills and quantities are covered only when the applicable timing and supply rules are met.

Refill and supply requirements: The refill follows the dosage schedule; the applicable 80% or 90% utilization threshold is met unless an emergency, disaster, or approved override applies; the monthly supply does not exceed 34 days unless the medication qualifies as maintenance; and maintenance medications are dispensed according to the applicable 100-day rule.34 days standard; 100 days for most maintenance medications

Contraceptives have separate supply rules, including coverage up to a 12-month supply when applicable.

Early refill coverage

Early refills are payable only when the applicable condition or exception is met.

Permitted early refill: The prescription has reached the applicable utilization threshold; an emergency or disaster exception applies to a non-controlled substance; the recipient will be out of town and the pharmacist enters the appropriate override; or another policy-authorized exception applies.80% used for non-controlled substances; 90% used for controlled substances; emergency/disaster non-controlled coverage up to 30 days after declaration or until the emergency or disaster ends, whichever is later

Early refills are not payable when gross negligence or failure to follow prescriber instructions is displayed.

Maintenance medication dispensing

Maintenance medication dispensing follows the stated supply rules and exceptions.

Maintenance medication supply: The medication is a maintenance medication subject to the 100-day supply rule, unless a stated exception applies.Three-month (100-day) supply

A one-time initial fill of less than three months is permitted to assess tolerability and compliance. Anticonvulsants and thyroid preparations are not required to be dispensed in 100-day supplies. Medications administered in a skilled nursing facility or physician's office are exempt. In long-term care, when therapy duration is not specified, dispense at least 30 days; for oral liquids, 16 fluid ounces satisfies the 30-day requirement.

Contraceptive coverage

Contraceptive coverage includes the listed services and supply limits.

Contraceptive coverage: The product or service is an FDA-approved contraceptive drug or therapeutic equivalent, contraceptive device insertion or removal as specified, contraception education or counseling, management of contraceptive side effects, or voluntary sterilization for women.Up to 12-month supply; up to 3 months initially and up to 9 months at the subsequent visit

For a refill after initial dispensing, the provider may dispense up to a 12-month supply or the amount covering the remainder of the rolling year. If the prescription is for less than one year, dispense according to the quantity specified in the prescription order.

Emergency supply criteria

Emergency supplies are covered only when all emergency dispensing requirements are satisfied.

Emergency medication supply: An emergency situation exists; the drug is a covered outpatient drug that requires prior authorization; the physician indicates the diagnosis on the prescription; and the provider follows up with the QIO-like vendor for a verbal verification number.Up to 96 hours

An approved prior authorization is required for additional medication when applicable.

Vaccine coverage

Vaccines are covered without prior authorization unless another provision of the chapter states otherwise.

Covered vaccine category: The vaccine is a covered childhood vaccine under the Healthy Kids Program; a covered adult vaccine such as tetanus, influenza, or pneumococcal vaccine; or a 9-valent HPV vaccine for an eligible Medicaid recipient within the stated age range and FDA-approved indications.HPV: ages 9 through 45

Childhood vaccines must be obtained through the Vaccines for Children Program when applicable; VFC-included vaccines are not reimbursed by DHCFP, Nevada Medicaid, or Nevada Check Up. Pharmacies may administer vaccines subject to Nevada Board of Pharmacy requirements. When a pharmacist administers the vaccine, an administration fee is paid instead of a dispensing fee.

Pharmacy lock-in eligibility

A recipient may be placed in pharmacy lock-in when all primary and secondary criteria are met.

Pharmacy lock-in criteria

Additional lock-in criterion: The recipient has used more than one pharmacy; used more than three physicians; used an emergency room to receive controlled substances; has a drug-dependency-related diagnosis; received clinically excessive quantities; or demonstrated other drug-seeking behavior.At least one
DHCFP conducts a comprehensive clinical review.

Brand exception coverage

A brand product may bypass upper-limit cost limitations only when the prescriber certifies medical necessity and the required authorization is obtained.

Medically necessary brand exception: The prescriber certifies that the specific brand is medically necessary for the patient; the certification is handwritten by the physician on the prescription blank or properly noted on an electronic prescription; the phrase 'Dispense as written' appears; and prior authorization is obtained.Prior authorization required

A printed checkbox or rubber-stamped statement is not acceptable. Certification is not required when a generic is not manufactured.

Generic substitution

Generic substitution is required when all listed conditions are met and the practitioner has not prohibited substitution.

Generic substitution conditions: The substituted drug is less expensive than the prescribed brand; biologically equivalent; has the same active ingredient or an ingredient of the same strength, quantity, and dosage form; and is the same generic type, with the least expensive available option selected.Least expensive available substitute

Applies unless the practitioner indicates that generic substitution is prohibited.

Medically necessary brand product

Upper-limit cost limitations may be bypassed when the prescriber establishes brand medical necessity and completes the required certification.

Brand certification requirements: The physician certifies that the specific brand is medically necessary; documents the need in the medical record; writes the certification in the physician's own handwriting directly on the prescription blank or electronically transmitted prescription; includes the phrase 'Dispense as written'; and obtains prior authorization to override generic substitution.Prior authorization required

Certification is not required when a generic is not manufactured. Fax or verbal certification requires an original printed copy to be obtained and retained by the pharmacy.

Setting-specific outpatient coverage

Separate reimbursement depends on the setting and whether the drug is included in another payment rate.

Drug reimbursement setting: Covered outpatient drugs may be separately reimbursed through point-of-sale or MMIS when billed according to the applicable setting requirements; drugs included in a facility, encounter, prospective payment system, or hospice payment are not separately reimbursed.Setting-specific billing

Drugs administered in physician offices, hospital-based outpatient clinics, and ESRD facilities require the appropriate NDC and quantity; administration is billed separately with the appropriate CPT code when applicable.

Coordination of benefits

Nevada Medicaid is the payer of last resort and claims must be processed according to available other coverage.

COB/TPL processing: When other coverage is identified, the claim is processed as a third-party liability claim, the returned carrier information is used in the override process, and the Nevada Medicaid allowed amount is used for payment calculation.Payer of last resort

Providers must submit the returned other-payer identifier in the OTHER PAYER ID (#340-7C) field. Payment may be zero when the other carrier pays more than the Medicaid allowable amount.

Nevada Medicaid does not reimburse pharmaceuticals used for weight loss, fertility promotion, cosmetic purposes, hair growth, impotence or erectile dysfunction, or experimental purposes.

Yohimbine, drugs designated ineffective or less than effective under the DESI policy and their identical, related, or similar products are excluded. Products manufactured by companies that do not participate in the Federal Medicaid Drug Rebate Program are also excluded unless the product is FDA-rated 1-A.

Prescription dietary supplements, vitamins, and minerals without an FDA-approved indication are excluded. The exception is for prescription prenatal vitamins and fluoride.

An early refill is not payable when the recipient has demonstrated gross negligence or failed to follow the prescriber's prescription instructions. Early refills must otherwise meet the applicable utilization threshold or an authorized exception.

Vaccines included in the Vaccines for Children (VFC) Program are not reimbursed by DHCFP, Nevada Medicaid, or Nevada Check Up. Covered vaccinations not included in the VFC Program may be reimbursed under the applicable pharmacy manual requirements.

When a pharmacist administers a vaccination, the dispensing fee is not reimbursed; an administration fee is paid instead. Pharmacies must comply with Nevada State Board of Pharmacy vaccine-administration requirements.

While a recipient is in pharmacy lock-in, the point-of-sale system will not allow another pharmacy to bill Medicaid for the recipient's controlled-substance prescriptions, except when a permitted lock-in override applies. Noncontrolled-substance prescriptions may be filled at any pharmacy.

Non-legend, over-the-counter pharmaceuticals are not separately reimbursable by DHCFP for nursing facilities. Legend pharmaceuticals are billed separately by a licensed pharmacy through the point-of-sale system.

In nursing-facility hospice services, drugs related to the documented terminal illness and to palliative or symptom relief are covered by the hospice and are not reimbursed separately by DHCFP.

Covered outpatient drugs included in an ambulatory surgical center facility rate or in an outpatient facility, clinic, or FQHC encounter rate may not be billed or reimbursed separately.

Outpatient hospice drugs related to the documented terminal illness and palliative or symptom relief are covered by the hospice and are not reimbursed separately by DHCFP.

For long-term-care recipients, standard IV hydration fluids without additives and supplies associated with IV therapy, enteral nutrition, and TPN administration are included in the LTC/NF rate and may not be billed separately. IV drugs and TPN may be separately billable when otherwise allowed.

An outpatient drug must be prescribed for a medically accepted indication: an FDA-approved use or a use supported by the American Hospital Formulary Service Drug Information, United States Pharmacopeia, DRUGDEX Information System, or peer-reviewed medical literature.

Maintenance medications generally must be dispensed in a three-month (100-day) supply. Dispensing less than a 30-day supply without reasonable medical justification may result in disallowance of the dispensing fee.

Coding, Billing, and Limits

Diagnosis coding referenced for emergency suppliesICD-10

ICD	International Classification of Disease code, preferably used to indicate the diagnosis supporting an emergency medication supply

Dispensing practitioner provider typemixed

PT 28

Nevada Medicaid provider type for dispensing practitioners

Pharmacy claim submission formatmixed

NCPDP

National Council for Prescription Drug Programs format required for dispensing practitioner claims submitted through the Medicaid point-of-sale system

Outpatient drug and administration billingmixed

NDC	National Drug Code; used with the drug quantity for covered outpatient drugs and other separately billed drugs.
CPT	Current Procedural Terminology code used to bill administration of an outpatient drug.
33	Provider Type number used to bill disposable supplies through MMIS.

COB and TPL override fieldsModifier

OTHER PAYER ID (#340-7C)	NCPDP field containing the client-identified other-carrier code required as part of the COB/TPL override process.
5	PA/MC CODE value used to exempt a claim from prescription limits or drug prior-authorization edits when permitted for coordination of benefits and the primary insurer has no PA requirement.

NCPDP standard billing unitsNDC

each	NCPDP billing unit for tablets, capsules, suppositories, patches, packets, powdered injectable vials, kits, and other products billed per item.
ml	NCPDP billing unit for liquids, oral liquids, suspensions, solutions, ophthalmic or otic products, liquid injectables, reconstituted products, and intravenous solutions.
g	NCPDP billing unit for ointments, bulk powders, and products labeled for gram-based billing, including certain inhalers and topical products.

Reimbursement limitationmixed

SMAC	State Maximum Allowable Cost reimbursement limit for multi-source outpatient pharmaceuticals.

Supply limits

Standard monthly supplyUp to 34 days

Maintenance exceptionUp to 100 days for maintenance medications

Refill paymentRequires the applicable utilization threshold to be met

Maintenance medication supply

Maintenance supply100 days

Standard interval

Provider Actions and Authorization

Prior Authorization

PDL and Quantity-Limit Authorization

Covered drugs may be subject to prior authorization and/or quantity limits. Drugs outside the Preferred Drug List (PDL), but within drug classes reviewed by the Silver State Scripts Board, require prior authorization unless exempt under Nevada or federal law or otherwise excluded.

PDL restrictions do not apply to prescribed HIV/AIDS treatment drugs, organ-transplant antirejection medications, or antihemophilic medications.
Sickle-cell-disease prescriptions and drugs preventing acquisition of HIV/AIDS must be covered and preferred.
New products outside reviewed PDL classes are covered without a Standard PDL Exception until the class and product or evidence are reviewed.

Prior Authorization

Standard PDL Exception

A Standard PDL Exception prior authorization may support coverage of a non-preferred drug when the recipient meets an approved exception basis. Submit the appropriate prior authorization form through the Nevada Medicaid Pharmacy Portal.

Policy Background

Nevada Medicaid pharmacy coverage is limited to medically necessary prescription services provided under the care of a licensed prescribing practitioner. Coverage is managed through medically accepted indications, preferred-drug requirements, prior authorization, step therapy, quantity limits, refill controls, and special dispensing rules, including a standard 34-day supply and generally a 100-day supply for maintenance medications.

Definitions

DefinitionA use for a covered outpatient drug approved under the Federal Food, Drug and Cosmetic Act

Compendia supportSupport may come from AHFS Drug Information, United States Pharmacopeia, or DRUGDEX Information System

Literature supportPeer-reviewed medical literature may support the use

Definitions

DefinitionA list of preferred outpatient drugs

Established bySilver State Scripts Board

Non-preferred drugsCovered benefits when applicable coverage criteria are met

Initial Therapy Criteria

Initial maintenance medication fill

A one-time introductory dispensing exception is available for maintenance medications.

Initial maintenance fill: The prescription is the first fill of a maintenance medication and a shorter supply is needed to assess tolerability and compliance.Less than three months permitted once

Subsequent fills generally must follow the applicable 100-day supply requirement.

Step Therapy

Step	Preferred-drug trial	Requirement before non-preferred coverage
1	Trial preferred medications before coverage of a non-preferred medication.	Document therapeutic failure of two preferred medications in the same class. If only one preferred medication exists, document failure of that medication. For typical or atypical antipsychotics, anticonvulsants, and antidiabetic medications, document therapeutic failure of one preferred agent. A Standard PDL Exception may apply when another exception criterion is met.

Quantity Limits

Quantity limits

Applies toAll medications

Monthly limitUp to 34-day supply each month

ExceptionMaintenance medications generally qualify for a 100-day supply

Quantity limits

Medication typeMaintenance medications

Supply limitThree-month supply

Equivalent amount100 days

Site-of-Care Rules

Billing Rule

Apply the maintenance-supply exemption

Medications administered in a skilled nursing facility or physician’s office are exempt from the three-month (100-day) maintenance supply requirement.

Billing Rule

Follow pharmacy vaccine rules

Pharmacies may administer childhood and adult vaccines or immunizations, subject to Nevada State Board of Pharmacy requirements and applicable Vaccines for Children rules.

Obtain childhood vaccinations through the VFC Program when applicable.
Bill an administration fee, rather than a dispensing fee, when the pharmacist administers the vaccine.

Revision History

2024-05-29Added coverage criteriaLatest

Added Wegovy exception criteria to Appendix A, Section KK, Incretin Mimetics, because of a new FDA-approved indication for use.

Policy Summary

PayerNevada Health Authority

PolicyMedicaid Services Manual Chapter 1200 — Prescribed Drugs

Policy CodePolicy N/A

Change TypeModified — Wegovy exception criteria added

Effective DateMay 29, 2024

Next Review DateN/A

Key ActionSubmit prior authorization and quantity-limit documentation when required for the prescribed drug.

SourceLink

On This Page

Initial-fill exceptionA one-time initial fill of less than three months is allowed

Early refill threshold

Medication typeNon-controlled substance

Threshold80% of the prescription must be used

BasisUse must comply with the prescriber’s orders and medication label

Early refill threshold

Medication typeControlled substance

Threshold90% of the prescription must be used

BasisUse must comply with the prescriber’s orders and medication label

Emergency or disaster refill

Emergency or disaster windowUp to 30 days after the declaration

End conditionCoverage continues until the emergency or disaster ends if that is later

Affected prescriptionsNon-controlled substances

Contraceptive supply

Maximum supplyUp to 12 months

Initial dispensingUp to 3 months

Subsequent visitUp to 9 additional months

Medication supply

Standard medication supplyUp to 34 days per month

Maintenance exceptionMaintenance medications may be dispensed for 100 days

Refill conditionThe applicable used-medication threshold must be met

Maintenance medication supply

Maintenance medication supply100 days per month

Equivalent intervalThree-month supply

Initial-fill exceptionA one-time initial fill of less than three months is permitted

Early refill

Medication typeNon-controlled prescription

Refill threshold80% must be used before refill payment

Emergency exceptionThe 80% requirement is waived for qualifying emergency or disaster situations

Early refill

Medication typeControlled-substance prescription

Refill threshold90% must be used before refill payment

Additional requirementUse must be consistent with the prescriber’s orders and medication label

Emergency or disaster refill

Medication typeNon-controlled prescription

Coverage windowUp to 30 days after the declaration

End conditionCoverage continues until the emergency or disaster ends if that is later

Initial maintenance fill

Applies toFirst fill of a maintenance medication

ExceptionA one-time initial fill of less than three months is permitted

PurposeTo assure tolerability and compliance

Contraceptive dispensing

Total annual supplyUp to 12 months

Initial dispensingUp to 3 months

Subsequent visitUp to 9 additional months

Long-term care supply

When duration is unspecifiedProvide at least a 30-day supply

Oral liquids16 fluid ounces fulfill the 30-day supply requirement

SettingLong-term care facility

Emergency supply

Maximum emergency supplyUp to 96 hours

Drug typeCovered outpatient drug requiring prior authorization

Follow-upAdditional medication requires approved prior authorization when applicable

Pharmacy lock-in review

Prescription threshold10 or more controlled-substance prescriptions

Review periodPast 60 days

Additional criterionAt least one risk criterion, such as multiple pharmacies, multiple physicians, or drug-seeking behavior

Initial lock-in period

Initial lock-in duration36 months

Review timingClinical review occurs not less than one month before the 36-month mark

RestrictionControlled-substance prescriptions must be filled at the assigned pharmacy

Second lock-in period

Second lock-in duration108 months

BasisContinued excessive or inappropriate controlled-substance use or need for additional monitoring

Review cycleRecipients are reevaluated at each 108-month period

Fair hearing

Request deadlineWithin 90 days of the Notice of Decision

Notice timingWritten notice is issued 15 days before implementation or continuation

Review subjectThe recipient may challenge the pharmacy restriction

Pharmacy quantity conversion

Volume conversion1 ounce = 30 ml

Billing unitLiquids are billed in milliliters

ApplicationConvert ounces to milliliters before submitting quantity

Pharmacy quantity conversion

Full ounce1 ounce = 30 g

Half ounce1/2 ounce = 15 g

ApplicationOintments and bulk powders must be billed by grams

Pharmacy quantity conversion

Liter conversion1 liter = 1,000 ml

Billing unitLiters must be converted to milliliters

ApplicationUse milliliters for applicable liquid quantities

Unit-dose repackaging

Incentive amount$0.43 per claim

Eligible activityRepackaging eligible non-unit-dose pharmaceuticals for unit-dose dispensing

Eligible providersPharmacies supplying long-term-care inpatients

LTC IV dispensing fee

Daily fee$10.17 per day of therapy

SettingLong-term care

CalculationThe fee is multiplied by the number of therapy days

Qualifying bases include allergy, contraindication or interaction, unacceptable toxic effects, or therapeutic failure involving preferred medications.

Therapeutic failure of two preferred medications is generally required; if only one preferred medication exists, failure of that medication is sufficient.

A unique indication supported by peer-reviewed literature or an FDA-approved indication may qualify.

Continuity of care may apply for non-preferred psychotropic or antidepressant therapy after institutional discharge, for up to six months.

For specified antipsychotic, anticonvulsant, and antidiabetic medications, therapeutic failure of one preferred agent may qualify.

Prior Authorization

Interim Authorization for New Products or Evidence

New FDA-approved drugs, or existing products with new clinical evidence supporting PDL inclusion, may be covered with an approved Standard PDL Exception prior authorization until the Silver State Scripts Board reviews the drug or evidence.

The product must not be excluded under the state plan or Nevada law.
Products outside reviewed PDL classes and not otherwise excluded may be covered without a Standard PDL Exception until review.

Unsupported block type: prior_auth03?

Prior Authorization

Pharmacist-Submitted Prior Authorization

Pharmacists may submit a prior authorization request when the requesting pharmacist has access to the recipient’s medical records.

Confirm medical-record access before submitting the request.

Billing Rule

Dispensing Practitioner Claim Controls

A dispensing practitioner claim remains subject to all applicable prior authorization criteria and quantity limitations.

Claims must be submitted in NCPDP format through the Medicaid Point-of-Sale system.
Dispensing practitioners must meet Nevada Board of Pharmacy and Medicaid enrollment requirements.

Prior Authorization

Brand Exception Prior Authorization

To obtain a brand product when generic substitution is overridden, prior authorization is required and the prescriber must certify that the brand is medically necessary.

The physician should document the need for the brand product in the patient’s medical record.
The certification must be handwritten by the physician on the prescription blank and include “Dispense as written.”

Prior Authorization

Brand Substitution Override

A brand product may be authorized when the prescriber certifies medical necessity, but the required certification and prior authorization must be completed before overriding generic substitution.

For electronic prescriptions, “Dispense as written” must be noted electronically.
A printed checkbox or a handwritten statement transferred by rubber stamp is not acceptable.

Prior Authorization

Submit Pharmacy Prior Authorization Request

Submit pharmacy prior authorization requests by phone, fax, or internet using the appropriate Prior Authorization Request form. A facsimile signature stamp is acceptable on faxed requests.

Pharmacy forms are available at https://nevadamedicaid.magellanrx.com/provider/forms.
Long-term-care drug claims are also subject to prior authorization requirements.

Prior Authorization

PA Processing and POS Entry

The QIO-like vendor processes prior authorization requests within 24 hours of receipt and advises the requesting practitioner of approval, denial, or pending status within that period. An approved authorization must be entered in the POS system before dispensing, except where after-the-fact review is permitted, such as retroactive eligibility.

If further information is requested, the practitioner must respond within three working days or the request will deny.
Refer to the Nevada Medicaid and Check Up Pharmacy Billing Manual for additional procedures.

Prior Authorization

Prior Authorization or Quantity Limitations May Apply: A–Alzheimer’s Agents

The indexed drug list identifies products and categories for which prior authorization and/or quantity limitations may apply. Providers should verify current requirements before dispensing.

ABSTRAL® (fentanyl citrate sublingual tablet).
ACTIQ® (fentanyl citrate transmucosal lozenge).
ACTEMRA® (tocilizumab).
ADUHELM® (aducanumab-avwa).
Agents used for ADD/ADHD.
ALBUTEROL NEBULIZER.
Alzheimer’s disease agents.

Prior Authorization

Prior Authorization or Quantity Limitations May Apply: Selected Categories

Additional indexed categories and products may require prior authorization and/or be subject to quantity limitations.

AMONDYS 45® (casimersen) and AMVUTTRA® (vutrisiran).
Antifungal agents; anti-hepatitis agents; anti-insomnia agents; anti-lipidemic agents—PCSK9 inhibitors; anti-migraine medications; and anti-Parkinson’s agents.
Antibiotics; anticonvulsants; antiemetics; and antihemophilic agents.
ARCALYST® (rilonacept).

Prior Authorization

Prior Authorization or Quantity Limitations: A–B Products

The indexed list continues with additional products and categories subject to prior authorization and/or quantity limitations.

AUSTEDO® (deutetrabenazine), AUVI-Q® (epinephrine injection device), and AVSOLA® (infliximab-axxq).
BENLYSTA® (belimumab) and BERINERT® (C1 esterase inhibitor).
BOTULINUM TOXIN.

Prior Authorization

Prior Authorization and Quantity Limitation List: B Products

The index includes further B products for which prior authorization and/or quantity limitations may apply.

BREXAFEMME® (ibrexafungerp).
BRILINTA® (ticagrelor).
The listed products and categories should be checked against the current Medicaid drug criteria and quantity limits.

Prior Authorization

Prior Authorization or Quantity Limitations Apply: Indexed Excerpt

The indexed excerpt lists products and categories subject to prior authorization and/or quantity limitations, including the following entries.

ARCALYST® (rilonacept).
AUSTEDO® (deutetrabenazine).
AUVI-Q® (epinephrine injection device).
AVSOLA® (infliximab-axxq).
BENLYSTA® (belimumab); BERINERT® (C1 esterase inhibitor); BOTULINUM TOXIN; BREXAFEMME® (ibrexafungerp); and BRILINTA® (ticagrelor).

Step Therapy

Step Therapy Requirement

Pharmaceuticals may require prior authorization because of step-therapy protocols regardless of whether they are included on the PDL.

Providers must follow the applicable step-therapy criteria before dispensing or billing.

Step Therapy

Preferred-Drug Trial Requirements

A non-preferred medication may require documented trials of preferred medications before authorization is approved.

Two preferred-medication failures are generally required; when only one preferred medication exists, failure of that medication is sufficient.
For specified antipsychotic, anticonvulsant, and antidiabetic medications, failure of one preferred agent may qualify.

Documentation Required

Standard PDL Exception Support

Support a Standard PDL Exception with documentation showing why preferred therapy is inappropriate or unsuccessful. The exception request should identify the applicable clinical basis and include supporting records or literature when required.

Document allergy, contraindication or interaction, toxic effects, therapeutic failure, or a unique FDA-approved or literature-supported indication.
Document continuity-of-care circumstances when relying on the psychotropic or antidepressant institutional-discharge exception.

Documentation Required

Medically Accepted Indication

Coverage may be restricted when a prescribed drug is not for a medically accepted indication. A medically accepted indication must be FDA-approved or supported by an authorized compendium or peer-reviewed medical literature.

Recognized sources include American Hospital Formulary Service Drug Information, United States Pharmacopeia, DRUGDEX Information System, and peer-reviewed medical literature.
Prescription dietary supplements, vitamins, and minerals generally require an FDA-approved indication, except prescription prenatal vitamins and fluoride.

Billing Rule

Prescription Compliance

Prescribers must be licensed healthcare practitioners acting within their scope of practice. Pharmaceuticals must be written, dispensed, and prescribed in accordance with Nevada State Board of Pharmacy regulations and enforcement requirements.

Non-electronic written prescriptions for Medicaid outpatient drugs generally must use tamper-resistant prescription pads.
The tamper-resistant requirement does not apply to e-prescriptions, faxed prescriptions, or prescriptions communicated by telephone.

Documentation Required

Emergency Diagnosis Documentation

For an emergency supply, the physician must document the diagnosis on the prescription, preferably with the applicable ICD code, to support use of the emergency policy.

Include sufficient diagnosis information with the emergency prescription.

Documentation Required

Prescription and Fiscal Records

Pharmaceutical providers must maintain prescription records for eligible recipients and provide access to those records when properly requested for fiscal, audit, or utilization review.

Maintain fiscal records for six years or for the period required by federal regulation.
Allow proper representatives access to records pertaining to Medicaid recipients.

Documentation Required

Brand Medical-Necessity Documentation

A physician seeking an exception to generic substitution must document in the patient’s medical record why the brand product is medically necessary.

The documentation should support the need for the brand product instead of the generic.

Documentation Required

Original Brand Certification Copy

The pharmacy must retain the original printed brand certification when a fax copy or verbal order is used to initiate the request.

Obtain and keep the original printed copy on file.

Documentation Required

Pharmacist Prior Authorization Records

A pharmacist may submit a prior authorization only when the pharmacist has access to the recipient’s medical records.

Maintain access to the records needed to support the request.

Documentation Required

Medical Record Documentation for Brand Necessity

Medical-record documentation from the physician should substantiate why the brand product is medically necessary for the particular patient.

Document the clinical need for the brand product in place of the generic form.

Documentation Required

Brand Certification Requirements

Brand certification must be handwritten by the physician directly on the prescription blank and must state “Dispense as written.”

For electronic prescriptions, note “Dispense as written” electronically.
A preprinted checkbox or rubber-stamped wording is not acceptable.
Certification is not required when a generic is not manufactured.

Documentation Required

Retention of Original Brand Certification

When a fax copy or verbal order is accepted from the physician, the pharmacy must obtain and retain the original printed certification.

Keep the original on file for documentation and audit purposes.

Billing Rule

SMAC Appeal Information

A provider appealing a State Maximum Allowable Cost (SMAC) must provide claim and pricing information sufficient for review.

Provide the NDC number, manufacturer, drug name, strength, and price paid.
A faxed copy of the actual invoice may be requested.
Appeals are responded to within three working days after referral to the SMAC Coordinator.

Billing Rule

Credit for Returned Unused Medication

Nursing facilities must credit Medicaid for unused prescription medicines returned when a prescription is discontinued or a beneficiary is transferred, discharged, or dies.

Follow Nevada State Board of Pharmacy requirements for repackaging.
The credit prevents double billing of the medication.

Denial Risk

Non-Medically Accepted Indication

Medicaid may restrict coverage for a drug prescribed for a use that is not medically accepted under federal law or the applicable compendia and literature standards.

Confirm the indication is FDA-approved or supported by an authorized compendium or peer-reviewed medical literature.

Step Therapy

Non-Preferred Drug or Step Therapy

Non-preferred drugs and drugs subject to step therapy may not be covered without prior authorization unless an applicable exception or exemption applies.

Submit a Standard PDL Exception when a preferred-drug trial or other exception basis is met.
Step-therapy requirements may apply regardless of PDL status.

Denial Risk

Excluded Drug Use

Nevada Medicaid does not reimburse excluded pharmaceuticals, including agents used for weight loss, fertility promotion, cosmetic purposes or hair growth, impotence or erectile dysfunction, and certain ineffective, experimental, or non-MDRP products.

DESI drugs identified as ineffective or less than effective, and identical, related, or similar products, are excluded as described.
Prescription dietary supplements, vitamins, and minerals without an FDA-approved indication are excluded, except prescription prenatal vitamins and fluoride.

Denial Risk

Manufacturer or Product Eligibility

Pharmaceuticals must generally be manufactured by a company participating in the federal Medicaid Drug Rebate Program (MDRP).

A non-MDRP product may be eligible only when rated “1-A” by the FDA, as specified by policy.

Denial Risk

Early or Inconsistent Refill

Early or inconsistent refills may be denied when refill timing does not match the prescribed dosage schedule or when required utilization thresholds have not been met.

Nevada Medicaid pays up to a 34-day supply monthly, or a 100-day supply for maintenance medications.
Refills generally require use of 80% of a non-controlled prescription or 90% of a controlled prescription.
Early refills may be waived during declared emergencies or allowed for travel with the appropriate override.

Denial Risk

Replacement Medication

Nevada Medicaid does not pay to replace medication that is lost, stolen, or destroyed, even when a physician writes a replacement prescription.

The recipient is responsible for replacing the medication.
Prior authorization may be granted in life-threatening situations and for maintenance medications.

Denial Risk

Early Refill Restrictions

Refills are generally payable only after 80% of a non-controlled prescription or 90% of a controlled prescription has been used according to the prescriber’s instructions.

An emergency or disaster may waive the 80% requirement for non-controlled substances for up to 30 days after the declaration or until the emergency ends, whichever is later.
A pharmacist may use the appropriate override for a recipient who will be out of town; overrides are monitored.
Early refills may be denied when the recipient demonstrates gross negligence or fails to follow prescription instructions.

Billing Rule

Maintenance Supply Requirements

Maintenance medications generally must be dispensed in three-month, 100-day supplies, subject to the policy’s initial-fill and medical-justification rules.

A one-time initial fill of less than three months is permitted to establish tolerability and compliance.
Dispensing less than a 30-day supply without reasonable medical justification may result in disallowance of the dispensing fee.
Contraceptives may be covered up to a 12-month supply under the stated dispensing schedule.
Anticonvulsants and thyroid preparations are maintenance medications but are not required to be dispensed in 100-day supplies.

Prior Authorization

Emergency Supply Does Not Replace Prior Authorization

An emergency dispensing does not satisfy the prior authorization requirement for continued therapy. Additional medication requires an approved prior authorization when one is required.

After the emergency supply, obtain the QIO-like vendor’s verbal verification number as follow-up.
Secure the approved authorization before dispensing additional medication.

Billing Rule

Vaccine Reimbursement Limitations

Childhood vaccinations obtained through the Vaccines for Children (VFC) Program are not reimbursed by DHCFP, Nevada Medicaid, or Nevada Check Up.

Covered vaccinations not included in VFC may be reimbursed under the Pharmacy Manual.
When a pharmacist administers the vaccine, bill the administration fee instead of a dispensing fee.
Follow Nevada Board of Pharmacy vaccine-administration requirements.

Billing Rule

Quantity and Utilization Controls

All drugs are subject to quantity limitations, and prospective drug-utilization-review edits apply to POS claims, including long-term-care claims.

Providers may submit NCPDP standard interactive DUR override codes on the initial claim.
No long-term override codes are issued; enter the applicable code each time an error occurs.
Refer to the Nevada Medicaid and Check Up Pharmacy Manual for current quantity limits and Pro-DUR procedures.

Billing Rule

Locked-In Pharmacy Billing Restriction

When a recipient is locked into one pharmacy, the POS system will not allow another pharmacy to bill controlled-substance prescriptions. Noncontrolled prescriptions may be filled at any pharmacy.

The initial lock-in period is 36 months; a second period may last 108 months when continued excessive or inappropriate use is identified.
A Notice of Decision is issued before implementation or continuation and includes fair-hearing rights.

Billing Rule

Generic Substitution and Brand Exception

When generic substitution has not been prohibited, the pharmacy must dispense an available, less expensive, biologically equivalent drug with the same active ingredient, strength, quantity, dosage form, and generic type.

The least expensive available substitutable drug must be selected.
A brand exception requires the prescriber’s medical-necessity certification and prior authorization.

Unsupported block type: denial_risk yang?

Billing Rule

Incorrect Outpatient or ESRD Drug Billing

For outpatient, hospital-based outpatient, and ESRD settings, bill covered outpatient drugs with the appropriate NDC and NDC quantity and bill administration with the appropriate CPT code when applicable.

Physician-office outpatient drugs are billed through MMIS using the NDC and NDC quantity.
Drugs included in the ESRD Prospective Payment System rate deny when billed separately.

Denial Risk

Drug Included in Facility, Encounter, or Hospice Payment

Covered outpatient drugs included in a facility, encounter, or hospice payment must not be billed separately.

Drugs are included in the ASC facility rate and cannot be billed separately.
Drugs included in an outpatient facility, clinic, or FQHC encounter rate cannot be separately reimbursed.
Hospice covers drugs related to the documented terminal illness and palliative or symptom relief.

Billing Rule

Other Coverage Not Processed Through COB

Nevada Medicaid is the payer of last resort. When other coverage is identified, providers must process the claim through third-party liability and coordination-of-benefits procedures.

Submit the returned OTHER PAYER ID (#340-7C) in the override process when required.
The claim may process as TPL even when the eligibility file indicates no other insurance if the pharmacy submits it as a TPL claim.
The Medicaid allowed amount is used to calculate payment and may result in a zero payment.

Denial Risk

Failure to Respond to PA Information Request

When the QIO-like vendor requests additional information on a prior authorization, the practitioner must respond within three working days.

Failure to respond within three working days causes the prior authorization request to deny.

Billing Rule

Ineligible Unit-Dose Repackaging Incentive

The unit-dose repackaging incentive does not apply to pharmaceuticals classified by First Data Bank as unit-dose products.

The $0.43-per-claim incentive is limited to pharmacies supplying long-term-care inpatients that enroll through the QIO-like Vendor Pharmacy Department.
Repackaging must comply with Nevada State Board of Pharmacy requirements.

Billing Rule

Non-Billable LTC IV Items

For long-term-care recipients, standard IV hydration fluids without additives and supplies associated with IV therapy, enteral nutrition, and TPN administration are included in the LTC/nursing-facility rate and may not be billed separately.

IV drugs and TPN may be billed separately for LTC recipients when otherwise allowable.
A daily IV-therapy dispensing fee applies as specified in the policy.

Definitions

DefinitionA prescription subject to the policy’s dispensing and timing limitations

ValidityAuthorized refills are valid only from the provider that dispensed the original prescription

TimingRefill intervals must be consistent with the prescribed dosage schedule

Definitions

DefinitionA medication category for which exceptions to the standard 34-day supply are allowed

Typical supplyGenerally filled in a three-month, 100-day supply

ExamplesIncludes antianginals, antiarrhythmics, antidiabetics, antihypertensives, cardiac glycosides, diuretics, estrogens, and progesterone

Definitions

DefinitionMedications intended for ongoing therapy

Required supplyGenerally dispensed in three-month, 100-day supplies

ExceptionsAnticonvulsants and thyroid preparations are not required to be dispensed in 100-day supplies

Definitions

DefinitionA restriction under which Medicaid pays for controlled-substance prescriptions only when filled at one assigned pharmacy

TriggerAt least 10 controlled-substance prescriptions in the past 60 days plus an additional risk criterion

Noncontrolled prescriptionsMay be filled at any pharmacy

Definitions

DefinitionA permitted dispensing of a covered outpatient drug requiring prior authorization during an emergency

Maximum amountUp to a 96-hour supply

Follow-upThe provider must obtain a verbal verification number from the QIO-like vendor

Definitions

MeaningProspective or concurrent drug utilization review

Processing pointPerformed through the point-of-sale system

ClaimsEdits apply to POS claims, including applicable long-term-care claims

Definitions

DefinitionThe upper reimbursement limit for multi-source outpatient pharmaceuticals

Established byDHCFP or its QIO-like vendor

UpdatesDrugs subject to SMAC are updated monthly

Definitions

DefinitionA reimbursement incentive for pharmacies supplying long-term-care inpatients

Eligible productsNon-unit-dose pharmaceuticals repackaged for unit-dose dispensing

PaymentAn additional $0.43 per claim

Definitions

DefinitionA product containing at least two different or discrete items in the same package

ExclusionsDiluents, applicators, and activation devices are excluded from the item count

BillingDispensed as one unit and billed as each kit dispensed

Definitions

MeaningCovered outpatient drugs administered in an outpatient setting

Drug billingBilled with the appropriate NDC and NDC quantity through MMIS

Administration billingThe administration service is billed with the appropriate CPT code

Quantity limits

Medication typeFDA-approved contraceptive drugs

Annual limitUp to a 12-month supply

Rolling yearThe amount may cover the remainder of the rolling year

Quantity limits

Medication typeStandard medications

Supply limitUp to 34-day supply

FrequencyPer month

Quantity limits

Medication typeMaintenance medications

Supply limit100-day supply

Standard equivalentThree-month supply

Quantity limits

Medication typeFDA-approved contraceptives

Initial supplyUp to 3 months

Subsequent supplyUp to 9 months at the subsequent visit, for up to 12 months total

Quantity limits

Medication typeCovered outpatient drugs requiring prior authorization in an emergency

Emergency limitUp to 96-hour supply

Additional medicationRequires approved prior authorization when applicable

Quantity limits

SettingLong-term care

Minimum supplyAt least 30 days when therapy duration is not specified

Oral liquids16 fluid ounces are considered sufficient for the 30-day requirement

Billing Rule

Bill hospital pharmacy services through the per diem

All pharmacy services for medical/surgical, specialty, and psychiatric hospitals and free-standing inpatient hospice facilities are included in the inpatient daily per diem and billed through MMIS.

Billing Rule

Bill eligible LTC pharmaceuticals separately

Legend pharmaceuticals, including compound prescriptions and TPN solution and additives, are excluded from the nursing-facility daily per diem and are billed separately by a licensed pharmacy through POS.

Billing Rule

Use direct pharmacy billing for ICF/IID drugs

Legend and non-legend pharmaceuticals for ICF/IID residents are excluded from the facility rate and are billed directly by a licensed pharmacy through POS.

Billing Rule

Bill retail and home-infusion drugs through POS

Covered outpatient drugs dispensed by retail pharmacies or home-infusion therapy or free-standing infusion clinics are reimbursed separately through POS.

Disposable supplies are billed separately through MMIS using Provider Type 33.

Billing Rule

Use NDC and CPT billing in office settings

Drugs administered in physician offices, hospital-based outpatient clinics, and ESRD facilities are billed with the appropriate NDC and quantity through MMIS; administration is billed with the appropriate CPT code.

Billing Rule

Submit IV therapy through POS

IV therapy is billed through the pharmacy POS system using multi-ingredient functionality. Drug coverage and prior-authorization edits are processed at the individual ingredient level.