Increased Reimbursement of Medications for the Treatment of Opioid Use Disorder
Download PDF
The purpose of this memo is to notify Medicaid enrolled pharmacy providers that DMAS fee-for-service (FFS) and the Medicaid Managed Care Organizations will provide up to five professional dispense fees per month (defined as a rolling 30 day period) for buprenorphine-based opioid use disorder (OUD) products, effective December 1, 2022.
Currently, FFS reimbursement for pharmacy services includes only one professional dispensing fee per member per month for each specific drug. However, as defined in 12VAC30-80-40, “Exceptions to the monthly dispensing fees shall be allowed for drugs determined by the department to have unique dispensing requirements.” The Department has determined that buprenorphine-based SUD products meet the standard of unique dispensing requirements as standard of care includes multiple prescriptions per month of these medications, especially during the induction and dose-finding phases of treatment.
The Medicaid MCOs are required to follow the FFS schedule for these products (see the March 17, 2022 Bulletin Coverage of Medications for the Treatment of Opioid Use Disorder) therefore this change in reimbursement applies.
|
PROVIDER CONTACT INFORMATION & RESOURCES |
|
|
Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. |
|
|
Medicall (Audio Response System) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. |
1-800-884-9730 or 1-800-772-9996 |
|
KEPRO Service authorization information for fee-for-service members.
|
|
|
Provider Appeals DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal. |
|
|
Managed Care Programs Medallion 4.0, Commonwealth Coordinated Care Plus (CCC Plus), and Program of All-Inclusive Care for the Elderly (PACE). In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider. The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals. |
|
|
Medallion 4.0 |
|
|
CCC Plus |
|
|
PACE |
|
|
Magellan Behavioral Health Behavioral Health Services Administrator, check eligibility, claim status, service limits, and service authorizations for fee-for-service members. |
www.MagellanHealth.com/Provider For credentialing and behavioral health service information, visit: www.magellanofvirginia.com, email: VAProviderQuestions@MagellanHealth.com,or Call: 1-800-424-4046 |
|
Provider HELPLINE Monday–Friday 8:00 a.m.-5:00 p.m. For provider use only, have Medicaid Provider ID Number available. |
1-804-786-6273 1-800-552-8627 |
|
Aetna Better Health of Virginia |
www.aetnabetterhealth.com/Virginia 1-855-270-2365 1-866-386-7882 (CCC+) |
|
Anthem HealthKeepers Plus |
1-833-207-3120 1-833-235-2027 (CCC+) |
|
Molina Complete Care
|
1-800-424-4524 (CCC+) 1-800-424-4518 (M4) |
|
Optima Family Care |
1-800-643-2273 1-844-374-9159 (CCC+) |
|
United Healthcare |
1-844-284-0149 1-855-873-3493 (CCC+) |
|
Virginia Premier |
1-800-727-7536 (TTY: 711), www.virginiapremier.com |