North Dakota Medicaid has posted the 2022 Preferred Drug List (PDL). The Preferred Diabetic Supply List (PDSL) and Medical Billing Drug Clinical Criteria (for HCPCS “J” codes requiring prior authorization) will now be included in the Preferred Drug List (PDL) document.
Here are some of the most notable changes to prior authorization policy:
Otezla, Xeljanz, and Kineret do not require prior authorization (PA) for all indications (Xeljanz XR still requires PA).
Colchicine capsules, including Mitigare, require prior authorization (brand tablets do not require PA)
Taltz requires PA with a TNF-inhibitor trial (e.g. Humira, Enbrel, Cimzia). Members currently receiving Taltz will be grandfathered.
ND Medicaid has expanded the list of HCPCS “J” codes for drugs requiring prior authorization, which are billed by a physician or clinic through 837p transactions. If a medical drug is not on the list of drugs requiring prior authorization, a FDA or compendia supported indication is still required.
Tablet Splitting:
Tablet splitting will be required for Rexulti. Splitting will be allowed immediately and required as of Feb 1, 2022. Rexulti is an immediate release, film-coated tablet, similar to the Latuda tab currently in the tablet splitting program.
4mg Split = 2mg dose
2mg Split = 1mg dose
1mg Split = 0.5mg dose
0.5mg Split = 0.25mg dose
Coverage policy updates:
Aspirin 81mg can be billed as a 120 days supply
ND Medicaid covers Continuous Glucose Monitor (CGM) start-up training through medical 837p transactions using CPT code 95251 and follow up CGM data interpretation using CPT code 95249. Pharmacists can also bill CPT code s 95251 and 95249 by enrolling in the Medication Therapy Management (MTM) program.
An updated version of the Medication Therapy Management (MTM) Program Manual will be posted in January 2022.
Therapeutic Duplication updates:
A form has been developed for requesting antipsychotic therapeutic duplication. Please submit the Concurrent Antipsychotics PA Form when receiving “88 – DUR Reject Error” for duplicate antipsychotics. It is posted under the PA Forms link at www.hidesigns.com/ndmedicaid.
Messages to pharmacy POS systems have been upgraded. Messages now indicate the duplicate drug and when the duplication will no longer result in a rejected claim as follows with the underlined information customized to the submitted claim:
“This claim has denied due to concurrent therapy omeprazole DR 20mg capsule filled on 2021-12-02. Next fill assuming the concurrent claim ends: 2022-01-01.”
