Information for Pharmaceutical Companies
According to the Centers for Medicare and Medicaid Services (CMS), “the Medicaid drug rebate program was created by the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) and requires a drug manufacturer to enter into and have in effect a national rebate agreement with the Secretary of the Department of Health and Human Services (HHS) for states to receive Federal funding for outpatient drugs dispensed to Medicaid patients”.
Please note that even though a product may be listed as covered by Medicaid (such as diapers or catheters), a particular manufacturer’s product may not be covered if the manufacturer has not submitted all product information to Medi-Span®. It is the manufacturer’s responsibility to submit their product information to Medi-Span®.
Legend Drug Exclusions
The Wyoming Medicaid Pharmacy Program will not cover:
• Anorexiant products
• Androgenic or Anabolic steroids used for weight gain
• Agents used to promote fertility
• Acne agents for clients who are 21 years of age or older
• Agents used for the stimulation of hair growth
• Erectile Dysfunction medications
• DESI, as well as similar, related or identical drugs considered to be less-than-effective by the Food and Drug Administration (FDA)
• Compound prescriptions, which include a DESI drug, will deny (refer to Compound Drugs section of the Medicaid Pharmacy Provider manual for instructions on billing non-DESI ingredients.)
• Promethazine for children 2 years of age and younger
• Orphan drugs
• Medications not approved by the FDA
Some medications require prior authorization. Additional information may be found by clicking on the Preferred Drug List/Prior Authorization (PDL/PA) menu tab on the Office of Pharmacy Services home page.
For additional information on product coverage, including over-the-counter products, please refer to our provider manual at http://wyequalitycare.org
Prior Authorization/Preferred Drug List
To review information for medications which are subject to prior authorization, please visit our prior authorization website at http://wyequalitycare.org
Following introduction to the market, new drugs and new formulations of existing drugs, and new indications that are covered through the pharmacy services program will require prior authorization until published literature is available through standard literature review processes. The drug will be considered at the next scheduled P&T Committee meeting, and its coverage status will be reviewed at that time. Exceptions to this rule will be handled on a case by case basis.
For information regarding therapeutic classes currently listed on our Preferred Drug List (PDL), a timeline for future review of therapeutic classes, and agendas for upcoming Pharmacy & Therapeutics (P&T) meetings, please click on the following link to visit our P&T website at http://www.uwyo.edu/DUR/pandtcommittee
The following reimbursement algorithm applies to all legend drugs, diabetic supplies, medical supplies and OTC medications for all Medicaid Plans:
Providers will be reimbursed the lesser of SMAC, FUL, AWP-11%, or Ingredient Cost Submitted + $5.00 dispensing fee, GAD, U&C, or Lowest Advertised Price, whichever is less.
Questions regarding reimbursements should be directed to the GHS POS Help Desk at:
Goold Health Systems
Provider Relations Unit
P.O. Box 21719
Cheyenne, WY 82003-7032