New Requirements for Medicaid Reimbursement

Internal Medicine World Report, September 2007, Volume 0, Issue 0

Effective October 1, 2007, physicians must use tamper-resistant pads when writing prescriptions for outpatient drugs to be reimbursable by Medicaid. The requirement also applies to over-the-counter drugs in states in which such agents are reimbursable. The new requirements are in accordance with section 7002(b) of the US Troop Readiness, Veterans' Care, Katrina Recovery, and Iraq Accountability Appropriations Act of 2007.

The Centers for Medicare & Medicaid Services has already sent letters to all state Medicaid directors detailing 3 characteristics of tamper-resistant pads, namely, industry-recognized features designed to prevent the following:

  1. Unauthorized copying of a completed or blank prescription form
  2. Erasure or modification of information written on a prescription form
  3. The use of counterfeit prescription forms.

Starting in October, all states must require that at least 1 of these 3 features be used; the requirement(s) chosen may vary from state to state. By October 1, 2008, states must mandate the use of all 3 characteristics on prescription pads before they can be considered tamper resistant.

The new requirements do not apply to refills of written prescriptions presented to a pharmacy before October 1, 2007. After this date, the requirements do not apply to:

  • Prescriptions that are electronically transmitted, faxed, or communicated to the pharmacy over the phone
  • Prescriptions that are paid for by a managed-care entity
  • Drugs provided in certain institutional and clinical facilities, including nursing facilities and intermediate-care facilities for the mentally retarded.

A contingency is included that would allow Medicaid reimbursement for emergency fills, if the prescriber provides a verbal, faxed, electrotonic, or compliant prescription within 72 hours.

More information is available at www.cms.hhs.gov/smdl/downloads/smd081707.pdf.