CurrentVermont Agency of Human Services – Department of Vermont Health AccessPolicy 4.207.1

Prescribed Drugs

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Defines Vermont Medicaid coverage, eligibility, provider, prescription, supply, and prior authorization requirements for prescribed drugs and certain related items, including rules for dual-eligible individuals.

Policy Summary

PayerVermont Agency of Human Services – Department of Vermont Health Access

PolicyPrescribed Drugs

Policy CodePolicy 4.207.1

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for bulk powders or active pharmaceutical ingredients used in extemporaneously compounded prescriptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30–102 daysMaintenance-drug dispensing range

90 daysSelect maintenance-drug minimum

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CurrentVermont Agency of Human Services – Department of Vermont Health AccessPolicy 4.207.1

Prescribed Drugs

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Policy Summary

PayerVermont Agency of Human Services – Department of Vermont Health Access

PolicyPrescribed Drugs

Policy CodePolicy 4.207.1

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for bulk powders or active pharmaceutical ingredients used in extemporaneously compounded prescriptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30–102 daysMaintenance-drug dispensing range

90 daysSelect maintenance-drug minimum

Up to 11Prescription refills

72 hoursEmergency supply

12 monthsContraceptive duration

Covered Drugs and Eligibility Requirements

Preferred Drug List coverage

Covered prescribed drugs and related items must meet the current Preferred Drug List requirements.

General PDL coverage: The prescribed drug or related item is covered under the current Preferred Drug List requirements.

Some preferred drugs and all non-preferred drugs may also require prior authorization.

Over-the-counter drugs

Covered over-the-counter drugs must meet all of the following conditions.

OTC drug coverage: The item is subject to the Preferred Drug List and is prescribed as part of the medical treatment of a specific disease.

Prescription vitamins and minerals

Covered prescription vitamins and minerals include either of the following categories.

ONE of: The item is a select prenatal vitamin for a pregnant or lactating woman.
OR: The item is a single vitamin or mineral prescribed to treat a specific vitamin deficiency or disease related to a vitamin deficiency.
The FDA must require a prescription for the vitamin or mineral.

Compounded drugs

Coverage of compounded-drug ingredients requires all applicable conditions.

Compounded ingredients: The ingredient or excipient is covered, the prescription is dispensed by a participating pharmacy, and the prescription is issued by a licensed prescriber in accordance with state and federal law.

Bulk powders, also known as active pharmaceutical ingredients, are subject to prior authorization. The list of covered APIs and excipients is available on the DVHA website.

Medicare coordination exception

Vermont Medicaid may cover a drug during a Medicare coverage operational problem when all conditions are met.

Medicare operational-problem exception: The beneficiary is eligible for and has applied for the Medicare prescription-drug benefit but has not received coverage because of an operational problem with Medicare, or otherwise has not received a needed drug; the drug is medically necessary; good cause and hardship exist; and the individual has made every reasonable effort under the circumstances to obtain Medicare coverage.

Coverage continues until the operational problem and good cause and hardship end.

Dual-eligible coverage

Dual-eligible beneficiaries may receive Medicaid prescribed-drug coverage only under limited circumstances.

Dual-eligible exceptions

ONE of: The drug is in a class for which Medicare drug coverage is unavailable, including a drug for anorexia or weight gain subject to the Preferred Drug List.
OR: The drug is a single vitamin or mineral meeting the applicable prescription-vitamin coverage conditions.
OR: The drug is an over-the-counter drug meeting the applicable Preferred Drug List and specific-disease treatment conditions.
OR: The beneficiary has exhausted the Medicare prescription-drug appeal process and requests coverage of the prescribed drug.

Dual-eligible individuals generally are not eligible for Vermont Medicaid prescribed-drug coverage when Medicare prescription-drug coverage is available. Exceptions include specified drug classes for which Medicare coverage is unavailable, including drugs for anorexia or weight gain subject to the Preferred Drug List, qualifying single vitamins or minerals, and qualifying over-the-counter drugs. Coverage may also be requested after the individual exhausts the Medicare prescription-drug appeal process.

Payment is limited to Vermont Medicaid-enrolled qualified providers operating within their scope of practice. Qualified providers include licensed Vermont pharmacies, appropriately licensed out-of-state pharmacies, and certain licensed rural physicians with prior special approval to bill prescribed-drug items directly when no pharmacy is available.

For the Medicare operational-problem exception, the prescribed drug must be medically necessary. Vermont Medicaid must also find that good cause and hardship exist, and the individual must have made every reasonable effort under the circumstances to obtain Medicare coverage. Coverage continues only until the Medicare operational problem and the good-cause-and-hardship circumstances end.

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization for Compounded APIs

Bulk powders, also known as Active Pharmaceutical Ingredients (APIs), used in extemporaneously compounded prescriptions require prior authorization. Covered APIs and excipients must be dispensed by a participating pharmacy and prescribed by a Vermont-licensed prescriber in accordance with state and federal law.

A list of covered APIs and excipients is available on the DVHA website.

Prior Authorization

PDL-Based Prior Authorization

All drugs and non-drug items are subject to Vermont Medicaid’s Preferred Drug List (PDL). Prior authorization is required for some preferred drugs and all non-preferred drugs, as specified in the PDL.

The PDL is available on the DVHA website.
Non-drug items subject to the PDL include vaccines, diabetic supplies, spacers, and peak flow meters.
An emergency fill may be dispensed for a medical emergency for up to 72 hours when required prior authorization has not been secured; prior authorization is still required for further dispensing.

Policy Context

This rule governs outpatient prescribed-drug coverage under section 1927 of the Social Security Act and Vermont Medicaid's Preferred Drug List (PDL). Covered items may include prescribed drugs, selected non-drug items, over-the-counter products prescribed to treat a specific disease, selected prescription vitamins and minerals, and certain compounded-drug ingredients. Coverage is subject to applicable PDL requirements and prior authorization rules.

Key Terms

Good Cause and Hardship

DefinitionA situation where the lack of coverage cannot reasonably be considered the individual's fault.

Alternative coverageAlternative means of obtaining the coverage at issue are not reasonably available.

Potential harmThe lack of coverage will likely result in irreparable loss or serious harm to the individual.

Maintenance Drug

FDA use durationA drug approved by the federal Food and Drug Administration for use longer than 30 days.

Clinical useThe drug is prescribed to treat a chronic condition.

Preferred Drug List

Supply and Dispensing Limits

Maintenance Drugs

Minimum supplyMaintenance drugs must be prescribed and dispensed for not less than 30 days.

Maximum supplyMaintenance drugs must be prescribed and dispensed for not more than 102 days.

Permitted rangeThe permitted maintenance-drug dispensing range is 30 through 102 days.

Select Maintenance Drugs

ApplicabilityThe minimum supply requirement applies to select drugs used for maintenance treatment.

Required supplySelect maintenance drugs must be prescribed and dispensed for a minimum 90-day supply.

First two fills

Qualified Dispensing Providers

Billing Rule

Use an eligible dispensing provider

Dispense covered prescribed drugs through a Vermont Medicaid-enrolled qualified provider operating within the scope of practice. Qualifying sites include licensed Vermont pharmacies, appropriately licensed out-of-state pharmacies, and a licensed rural physician with the required special approval to bill these items directly.

Policy Summary

PayerVermont Agency of Human Services – Department of Vermont Health Access

PolicyPrescribed Drugs

Policy CodePolicy 4.207.1

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for bulk powders or active pharmaceutical ingredients used in extemporaneously compounded prescriptions.

SourceLink

On This Page

A 72-hour emergency fill does not qualify as “started and stabilized” on the Medicaid PDL.

Prior Authorization

90-Day Supply Waiver

Select maintenance drugs must be prescribed and dispensed for a minimum 90-day supply after the first two fills. When extenuating circumstances in an individual case, in the prescriber’s judgment, require a shorter prescribing period, the prescriber may file a prior authorization request to waive the 90-day supply requirement.

The list of select maintenance drugs subject to the minimum 90-day supply is available on the DVHA website.
Maintenance drugs generally must be supplied for at least 30 days and no more than 102 days.

Prior Authorization

Authorization for Excess Supply

Supply limits exceeding the limits in Rule 4.207.5(c) require prior authorization and approval by the DVHA Medical Director.

Excess-supply requests include quantities above the applicable maintenance-drug limits or other limits described in the rule.

Documentation Required

Prescription and Provider Documentation

Payment is limited to covered items prescribed by a medical professional who is licensed by Vermont to prescribe within the scope of practice, enrolled in Vermont Medicaid, and issuing a valid prescription. The item must be dispensed by a qualified provider in accordance with applicable federal and state statutes and regulations and must be for the Medicaid member only.

Confirm the prescriber’s Vermont licensure, Medicaid enrollment, and scope of practice.
Confirm dispensing by a qualified provider and compliance with applicable federal and state requirements.

Documentation Required

Documenting a Supply-Limit Waiver

A request to waive the minimum 90-day supply for a select maintenance drug must document the individual-case extenuating circumstances that, in the prescriber’s judgment, require a shorter prescribing period.

Submit the prior authorization request for the 90-day supply waiver with supporting documentation of the extenuating circumstances.
The waiver does not eliminate other applicable supply limits or prior authorization requirements.

Unsupported block type: documentation

Denial Risk

PDL or Prior Authorization Failure

Drugs and non-drug items that do not meet applicable PDL requirements, or that require prior authorization without the required authorization, are not eligible for payment unless an applicable exception or emergency-fill process is satisfied.

Coverage is subject to the PDL for all drugs and specified non-drug items.
Some preferred drugs and all non-preferred drugs require prior authorization under the PDL.
Further dispensing after a qualifying emergency fill requires prior authorization.

Denial Risk

Prescription or Provider Eligibility Failure

Payment may be denied when the item is not supported by a valid prescription from a Vermont-licensed prescriber acting within the scope of practice, when the prescriber is not enrolled in Vermont Medicaid, or when dispensing is not performed by a qualified provider in compliance with applicable law.

The prescription must be for the Medicaid member only.
Verify Vermont licensure, prescribing authority, Medicaid enrollment, qualified-provider dispensing, and applicable federal and state compliance.

Billing Rule

Quantity Must Not Exceed the Prescription

A pharmacist may not fill a prescription in a quantity greater than the quantity prescribed. An exception applies only when the prescription quantity is changed in consultation with the prescriber.

The prescription must be changed before dispensing the greater quantity.
Document consultation with the prescriber supporting the revised quantity.

Denial Risk

Dual-Eligible Coverage Limitation

Individuals eligible for both a Medicare prescription drug benefit and Medicaid generally are not eligible for Medicaid prescribed-drug coverage under this rule, except for specified drug classes for which Medicare drug coverage is unavailable.

Exceptions include drugs for anorexia or weight gain, subject to the PDL; single vitamins or minerals meeting the applicable deficiency criteria; and OTC drugs meeting the applicable disease-treatment and PDL requirements.
A dual-eligible individual may request coverage after exhausting the appeal process under the Medicare prescription drug benefit.

Coverage is subject to the Preferred Drug List.

Maintenance-drug listCoverage is limited to the current list of drugs designated by Medicaid as maintenance drugs.

Emergency Fill

When availableA required prior authorization has not been secured and the need to fill the prescription is determined to be a medical emergency.

Prescriber unavailableThe prescriber or covering prescriber cannot be reached to obtain the required prior authorization.

Maximum supplyThe pharmacist may dispense an emergency supply lasting up to 72 hours.

Further dispensingA prior authorization is still required for further dispensing.

Compounded Drug

Prescription typeAn extemporaneously compounded prescription prepared using ingredients and excipients.

Dispensing requirementCovered ingredients and excipients must be dispensed by a participating pharmacy.

Prescriber requirementThe prescription must be issued by a licensed prescriber.

Legal complianceThe prescription must comply with applicable state and federal laws.

The 90-day minimum does not apply to the first two prescription fills.

Contraceptives

Maximum durationContraceptives may be dispensed in an amount intended to last up to a 12-month duration.

Prescriber discretionThe duration is permitted at the discretion of the prescriber.

Dispensing professionalA pharmacist may dispense the contraceptive supply.

Any Prescribed Drug or Non-Drug Item

Eligible itemsThe emergency-fill limit applies to any prescribed drug or non-drug item when applicable.

Maximum emergency supplyA pharmacist may dispense up to a 72-hour supply.

Applicable circumstanceThe limit applies when required prior authorization has not been secured, the prescription need is a medical emergency, and the prescriber or covering prescriber cannot be reached.