New duration of use and dose limits for Proton Pump Inhibitors (PPI)
Beginning June 1, 2017, Washington Apple Health (Medicaid), administered by the Health Care Authority (Agency) will limit PPIs to one tablet/capsule per day for 2 months during any 12-month period. The Agency may authorize more than 2 months per year and/or more than one tablet/capsule per day for patients taking certain medications or who have one of the chronic medical conditions listed in the Washington Apple Health (Medicaid) Proton Pump Inhibitor Policy.
- New duration of use and dose limits for Proton Pump Inhibitors (PPIs)
- PPI coverage changes flyer for clients
Notice of Pharmacy Rates change in basis of Payment
As of April 1, 2017 Washington Apple Health (Medicaid) Fee-for-Service pharmacy claims will be using the National Average Drug Acquisition Cost (NADAC) in place of the AWP based rates as required by federal law.
Please visit Pharmacy reimbursement fee-for-service for information on Federal Upper Limit (FUL), National Average Drug Acquisition Cost (NADAC) and resources to assist in submitting pharmacy-related claims and requesting a change to reimbursement.
Apple Health has updated its Hepatitis C treatment policy for immune modulators and anti-viral medications to treat chronic active Hepatitis C virus (HCV) infection. Clients whose requests for authorization were initially denied may now qualify for treatment.
Medication Assisted Treatment (MAT)
- As of October 1, 2015 all medications prescribed as medication assisted treatment (MAT) to clients enrolled in an Apple Health Managed Care Organization (MCO) must be billed directly to the client's plan.
- Please visit Apple Health (Medicaid) Drug Coverage Criteria for current and updated treatment policy, guidelines and forms for all Medication Assisted Treatments (MAT).
Unintentional overdose deaths are associated with methadone and other opioids. The Pharmacy and Therapeutics Committee has asked the Health Care Authority (HCA) to distribute a special health advisory to pharmacists and prescribers.
Note: For information on billing and rates, the Apple Health preferred drug list, and expedited authorization codes, please visit the Prescription Drug Program on our provider billing guide and rates web page.
- Become an endorsing practitioner for the Washington Preferred Drug List
- Opioid dosing guidelines
- Apple Health (Medicaid) Drug Coverage Criteria
- Request a pharmacy prior authorization
- Emergency fill policy
- NCPDP D.O. payer specification sheet
- Participating drug rebate manufacturers
Supplemental rebate offers
- Electronic submission is required.
- Send offers to Contracts@hca.wa.gov with a subject line "WA Medicaid Supplemental Rebate Offers".
- Faxes or written submissions will not be accepted.
- No bids will be entertained until the drug class is evaluated per the Pharmacy and Therapeutics (P&T) Committee schedule.
- For questions about the supplemental rebate process, please email Julie Hartford or call 360-725-1846.