Pharmacy Services

IMPORTANT CLAIMS INFORMATION

May 23, 2024

Dear Pharmacy Provider,

            Please be advised that OptumRx/Change Healthcare will be reinstating some of Wyoming Medicaid’s prescription limits effective May 29, 2024, specific to NCPDP Reject 76 (Plan Limitations Exceeded) and Reject 79 (Refill too Soon). See below for a list of rejections that will no longer be accepted without contacting the Pharmacy Help Desk for an appropriate override:

POLICY AND DOCUMENTATION REMINDERS

Additionally, please review and make every attempt to adhere to the limits and dispensing policies that can be found on the Preferred Drug List (PDL) and in the Wyoming Provider Manual found at https://health.wyo.gov/healthcarefin/medicaid/pharmacy-services

• Within specific plan limitations, prescriptions should be dispensed in the maximum quantity that the prescriber’s order allows. For non-maintenance medications, the maximum days supply allowed is thirty-four (34) days.

• Wyoming Medicaid requires medications with manufacturer “original container” language on the packaging or within the package insert to be dispensed in the original container. Claims that do not meet this requirement will be subject to recovery and further audit proceedings, even if the claims pays successfully at the point-of-sale (POS) while prior authorizations are suspended.
• If plan limitations and the prescriber’s orders allow, prescriptions for oral contraceptives and maintenance drugs should be dispensed in a ninety (90) day supply. When a client has been stabilized on a dosage of a maintenance medication for 90 days total supply, as evidenced by previous fills, the prescriber may choose to prescribe the medication for a 90-day supply. When all other criteria and conditions have been met, Medicaid will reimburse for a maintenance supply. For more information regarding this policy and list of applicable drug classes, please refer to pages 11-12 of the Wyoming Provider Manual which can currently be found at https://health.wyo.gov/healthcarefin/medicaid/pharmacy-services.
• Please make every effort to adhere to the preferred medications and limits on the Preferred Drug List and Dose Limitation Chart. Both can be found at https://health.wyo.gov/healthcarefin/medicaid/pharmacy-services. If you would like copies of either document sent via fax, please contact the Pharmacy Helpdesk at 877-209-1264 and we will be happy to assist you.
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REMITTANCE ADVICE/835 INFORMATION

At this time, OptumRx and Change Healthcare are continuing to work through restoration of services impacted by the cyberattack in February 2024. EDI documentation and the corresponding Pharmacy Portal are not available at this time, but notification will be provided when these services are restored. We apologize for any inconvenience that this causes. For specific questions regarding claims and/or payments, please contact the Pharmacy Helpdesk at 877-209-1264.

May 7, 2024

Dear Pharmacy Provider,

Please be advised that OptumRx/Change Healthcare will be reinstating some of Wyoming Medicaid’s prescription limits effective May 8, 2024 specific to NCPDP Reject 76 (Plan Limitations Exceeded) and Reject 79 (Refill too Soon). See below for a list of rejections that will no longer be accepted without contacting the Pharmacy Help Desk for an appropriate override:

Please note that the conditions specific to the refill too soon logic can be found on page 18-19 of the provider manual currently published at the link below: https://health.wyo.gov/healthcarefin/medicaid/pharmacy-services/

• Scheduled drugs II-V require 90% of the days supply to be used before a refill or new claim for the same medication will be allowed. For each claim that is filled, the number of days that the claim is filled early will be added to the day supply submitted on all subsequent claims, and the 90% refill tolerance will be calculated on that accumulated total.
• All other medications require 80% of the days supply be used before a refill or new claim for the same medication will be allowed. For each claim that is filled, the number of days that the claim is filled early will be added to the day supply submitted on all subsequent claims, and the 80% refill tolerance will be calculated on that accumulated total.

Pharmacies with denied claims for Refill Too Soon (RTS) (NCPDP reject code 79) may use a Submission Clarification Code (SCC) = 5 to override an increase in dose from the previous fill on non-controlled medications or will need to call the POS help desk at 877-209-1264 to obtain an override for controlled substances.

Pharmacies trying to fill a prescription that was previously lost or stolen should call the helpdesk.  If the criteria are met for an early fill under the lost or stolen prescription policy, Change Healthcare/OptumRx will enter the override and inform the pharmacy that the override has been entered. The pharmacy can then resubmit the denied claim. A maximum of one (1) Refill Too Soon override is allowed for a lost, stolen, or vacation, per client per year (365-day lookback period).

Claims submitted with dates of service between 2/21/2024 and 5/8/2024 will not be subject to these reinstated limits. For these or any other overrides that may be required, please contact the Pharmacy Help Desk at 877-209-1264.

March 15, 2024

Dear Pharmacy Provider,

Please be advised that the Change Healthcare Provider Helpdesk personnel are available to assist pharmacies with Medicaid eligibility questions and other questions pharmacies may have. As of today, March 15, 2024, please contact them using their previous pharmacy helpdesk number at 1-877-209-1264.
We anticipate that claims will start processing per normal processes as of today, March 15, 2024, so please consider the following when attempting to submit claims that were dispensed during the outage:
• Make every attempt to submit claims from earliest date of service to most recent in order to avoid incorrect processing due to sequencing of submissions.
• No copays should be collected on any prescription dispensed during the outage, and will be turned off in the system when it becomes active.
• Prior authorizations will be removed, with the following condition codes being soft rejects which can be bypassed by resubmitting the claim:
o Reject Code 75 – PA Required
o Reject Code 76 – Plan Limitations Exceeded
o Reject Code 79 – Refill Too Soon.
• Please expect higher than average call volume to our Helpdesk, as well as potential congestion with switch vendors (i.e. RelayHealth) during resubmission.
• If you would like to set up an appointment to work directly with your pharmacy on submission of claims and troubleshooting, please call and let us know so that we can dedicate resources accordingly.
As this situation continues, we deeply appreciate your patience, understanding, and continued care of our Wyoming Medicaid clients.

March 6, 2024

Dear Pharmacy Provider,

We would like to genuinely thank you for your diligent efforts to serve Wyoming Medicaid clients during the ongoing Change Healthcare outage.  In response to reports from clients and pharmacies regarding copay issues, Wyoming Medicaid is lifting prescription client copays for all clients for the duration of the outage.

A $0.00 copay will be programmed on claims process for dates of service within the dates of the outage (2/21/2024-end of the outage).  Wyoming Medicaid will then pay the entire claim amount, including any copay amount usually collected from the client.  Please be assured, we do not intend for pharmacies to lose reimbursement for the copay amount.

If your pharmacy has charged copays on prescriptions already filled since February 21, 2024, please consider voluntarily refunding those to Medicaid clients.

As a reminder, the Department will adjudicate and pay all clean claims submitted once the Change Healthcare system is operational; therefore, as stipulated by Section 5.H. of the Wyoming Medicaid Provider Agreement, providers should not bill, demand, or otherwise seek reimbursement from a Medicaid client (or representative of the client) for any service for which reimbursement is available from the Department in accordance with the Wyoming Medicaid Pharmacy Provider Manual.

The PDL and Provider Manual have been placed on the Wyoming Department of Health pharmacy page at https://health.wyo.gov/healthcarefin/medicaid/pharmacy-services/.  Although PA requirements are being lifted, we urge you to examine the PDL to best navigate prior authorization criteria, especially with new prescriptions, to minimize the chance of a patient needing to switch to a preferred medication at their next fill.

For questions regarding a customer’s eligibility, you may utilize the Benefits Management System at 1-888-WYO-MCAD (1-888-996-6223), or call the Wyoming Medicaid office at 307-777-7531 to speak to someone in the pharmacy program.

Thank you for continuing to serve Medicaid clients and for your patience during this extremely challenging event.

Outage Response Information for Providers

The department will adjudicate and pay all clean claims submitted once the Change Healthcare system is operational; therefore, as stipulated by Section 5.H. of the Wyoming Medicaid Provider Agreement, providers should not bill, demand, or otherwise seek reimbursement from a Medicaid client (or representative of the client) for any service for which reimbursement is available from the department in accordance with the Wyoming Medicaid Pharmacy Provider Manual.

The PDL and Provider Manual have been placed on the Wyoming Department of Health pharmacy page at https://health.wyo.gov/healthcarefin/medicaid/pharmacy-services/.  Although PA requirements are being lifted, we urge you to examine the PDL to best navigate prior authorization criteria, especially with new prescriptions, to minimize the chance of a patient needing to switch to a preferred medication at their next fill.

For questions regarding a customer’s eligibility, you may use the Benefits Management System at 1-888-WYO-MCAD (1-888-996-6223), or call the Wyoming Medicaid office at 307-777-7531 to speak to someone in the pharmacy program.  For additional help, you may also call the normal pharmacy help desk number 1-877-209-1264, and you will be routed to an Optum Rx help desk.

Wyoming Medicaid Preferred Drug List 

Dosage Limitation Chart​

Additional Therapeutic Criteria Chart 

Wyoming Medicaid Pharmacy Provider Manual

New Provider Enrollment

Wyoming Medicaid would like to announce the transition of Medicaid provider enrollment and provider updates to our new vendor, HHS Technology Group. With this transition there will be a new provider portal specifically for providers to complete enrollments, re-enrollments, re-validations, make updates, and upload documents to their Medicaid provider file. Please click the link below to access the provider enrollment website.

FOR ANY QUESTIONS OR CONCERNS PLEASE EMAIL: WYProviderTraining@HHSTechGroup.com