Catalog of Nonregulatory Documents
Under Governor Ridge's Executive Order 1996-1, agencies under the jurisdiction of the Governor must catalog and publish non-regulatory documents such as policy statements, guidance manuals, decisions, rules and other written materials that provide compliance related information. The following compilation is the sixth list of the Administration's non-regulatory documents. This list will be updated and published annually on the first Saturday in August.
This catalog is being provided to ensure that the public has complete access to the information necessary to understand and comply with state regulations. We have made every effort to ensure that the catalog includes all documents in effect as of August 1, 2001; however, due to the breadth and changing nature of these documents, we cannot guarantee absolute accuracy. Facilitating access to information is a critical component of the Ridge Administration's initiative to enhance the partnership between the regulated community and the state.
THOMAS J. RIDGE
Editor's Note: The Index of Issuances, Manual M210.3, issued by the Governor's Office of Administration, Directives Management System, includes Executive Orders, Management Directives and Manuals. New or revised documents to the Index are published monthly in the PA Bulletin and the entire index is revised yearly in the PA Code.
Office of Chief Counsel
Contact: Jacqueline Welby, Assistant Counsel (717) 783-2529
* Reynolds vs. Department of Aging, 570 A.2d 1373 (Pa. Commw. 1990).
* Pennsylvania Department of Aging v Lindbergh, 469 A.2d 1012 (Pa.1983).
* Suburban/Bustleton v Department of Aging, 579 A.2d 426 (Pa. Commw. 1990).
* McGuire v Department of Aging, 592 A.2d 830 (Pa. Commw. 1991).
* Dickey v Department of Aging, 615 A.2d 990 (Pa. Commw. 1992).
* In the Interest of M.B., 686 A.2d 87 (Pa. Commw. 1996).
* Calabro v Department of Aging, 689 A.2d 34 (Pa Commw. 1997).
* Calabro v Department of Aging, 698 A.2d 596 (Pa. 1997).
* Schaffren v Philadelphia Corporation for Aging, 1997 U.S. Dist. Lexis 17493 (Middle Dist. Pa., 1997).
* Scanlon v. Department of Aging, 739 A.2d 635 (Pa. Commw. 1999)).
* Pharmaceutical Program (PACE)
Contact: Gretchen Beard, Chief of Compliance Division (717)-787-7313
PACE PROVIDER BULLETINS: 2001
* January 26, 2001--Prescription Records: Notified Providers that the Department of Aging will accept the ''daily hardcopy record'' identified in Section 22.62, (c),(3) of Chapter 22, Pharmaceutical Assistance Contract for the Elderly, as being a certification statement which will contain verbiage clearly identifying the prescriptions and stating that the pharmacist, identified by his or her signature, attests to the identified prescriptions' validity, accuracy and completeness. Reminder that Section 22.62 (c) and (d) state that ''hardcopy prescriptions'' and ''other records necessary to disclose the full nature and extent of prescription drugs . . . dispensed by a provider shall be retained for 4 years. . .''.
* February 23, 2001--Sarafem®: Effective February 26, 2001, the PACE Program will deny all claims for Sarafem®. This action is being taken based on the manufacturer's package insert which states, ''Sarafem® is indicated for treatment of premenstrual dysphoric disorder (PMDD).''
* March 9, 2001--Immunosuppressants: Notified Providers that effective April 1, 2001, Medicare has eliminated the time limitation for Medicare recipients receiving immunosuppressant drug benefits. This change re-establishes coverage for disabled Medicare recipients as well as Medicare recipients over age 65 who had previously exceeded the Medicare time limit for immunosuppressant drug coverage. Effective April 1, 2001, all medical exceptions for immunosuppressants will calculate the PACE reimbursement based on the percentage NOT reimbursable by Medicare, which is currently 20%.
* March 16, 2001--Mandatory Substitution Coumadin®: Notified Providers that effective April 16, 2001, the PACE Program will mandate substitution for all new claims for Coumadin®.
* March 16, 2001--Ketoprofen Reminder: Notified Providers that as stated on page V.20 of your PACE Provider Manual, section m, ''Ketoprofen being compounded for off-label use to treat arthritis will be disallowed when identified in utilization review reports.''
* March 23, 2001--PACE--CRDP Cardholders Reminder: Notified Providers that PACE is payor of last resort.
* March 30, 2001--Renagel®: Notified Providers that effective Monday, April 9, 2001, PACE will deny all claims for Renagel®. No additional medical exceptions will be approved prior to the receipt of supporting diagnostic and treatment information.
* April 20, 2001--Non-Participating Manufacturers: Notified Providers of manufacturers not participating in the PACE Program.
* April 20, 2001--Mandatory Substitution for Coumadin® Clarification: Notified Providers that Cardholders whose prescription history contains Coumadin® usage and therefore received a Medical Exception should submit the Coumadin® claim to PACE with a DAW code of ''1''. PACE will not disallow Coumadin® claims on future audits in those instances in which a medical exception was granted to continue Coumadin® therapy even in the absence of Brand Medically Necessary documentation. Cardholders with no history of Coumadin® usage are subject to the Program's mandatory substitution regulations unless a Medical Exception is authorized.
* May 11, 2001--Imitrex®: Notified Providers that effective May 14, 2001, PACE Will Deny Claims for all forms of sumatriptan (Imitrex®). No medical exceptions will be approved prior to the receipt of a cardiovascular evaluation stating the patient is free of cardiovascular disease.
PACE Provider Bulletins: 2000
* February 4, 2000--Medical Exception Authorization. Notified Providers that requests for Medical Exceptions for medications routinely prepared during non-processing hours will not be considered. Requests for Emergency Medical Exceptions for medications dispensed under exceptional circumstances during non-processing hours may be reviewed.
* February 4, 2000--Other Prescription Coverage. Notified Providers that effective February 14, 2000, PACE will edit claims for PACE cardholders identified by the following insurance carriers: Healthguard; Highmark; Qualmed; Health America; and KHP Central/Senior Blue. Claims submitted to PACE for cardholders identified by these companies will deny if the provider submits the claim with an incorrect Other Coverage value of ''0''--''Not Specified'' or ''1''--''No Other Coverage Identified.''
* February 11, 2000--Alupent® Billing. Notified Providers that to assist providers in maintaining billing consistency, PACE is changing its reimbursement calculation for Alupent® 14 gm-10ml, NDC 00597007017 from price per ml to price per gram, effective with dates of service of February 19, 2000 and thereafter. Providers submitting a claim for 1 inhaler of Alupent® 14 gm-10 ml, NDC 00597007017 should submit a quantity of 14 in the metric decimal quantity field.
* February 11, 2000--Medicare Billable Pharmaceuticals Additions. Notified Providers effective February 14, 2000, PACE will reject the following medications at the point-of-service: Synvisc®; Hyalgan®; Polygam®; Imovax®; Leukine®; and Aredia® because PACE has been advised that, with the proper diagnosis, physicians may submit these claims to Medicare.
* March 3, 2000--Duplicate Therapy Edit. Notified Providers that effective March 13, 2000 and thereafter, PACE is implementing a Duplicate Therapy Edit for benzodiazepines and miscellaneous sedative hypnotics.
* March 24, 2000--Non-Participating Manufacturers. Notified Providers of manufacturers not participating in the PACE Program.
* March 24, 2000--Propulsid® Boxed Warning Revision. Notified Providers that Janssen Pharmaceutica has notified physicians of important changes to its Boxed Warnings, Drug Interactions and Dosage and Administration sections. Highlights of the changes included: 1) A 12-lead ECG should be obtained before Propulsid® is administered; 2) Propulsid® should not be initiated if the QTs value exceeds 450 milliseconds; and 3) Propulsid® is contraindicated in patients with electrolyte disorders (hypokalemia, hypocalcemia and hypomagnesemia). Serum electrolytes should be assessed in diuretic-treated patients before initiating Propulsid® and periodically thereafter.
* March 24, 2000--Dentist Prescribers. Notified Providers that effective April 3, 2000, and thereafter, claims containing a dentist's license number in the prescriber license number field and submitted for pharmaceuticals other than antibiotics, analgesics, non-steroidal or fluoride preparations will reject with NCPDP Error 88, accompanied by the DUR response ''CH''.
* March 24, 2000--Duplicate Therapy Edit. Notified Providers effective April 17, 2000 and thereafter, PACE is augmenting its Duplicate Therapy Edit for Benzodiazepines and Miscellaneous Sedative Hypnotics with the inclusion of Ambien® and Sonata®.
* March 31, 2000--Oral Antidiabetic Agents. Notified Providers effective June 5, 2000 and thereafter PACE will review claims submitted for oral antidiabetic agents for maximum daily dose.
* March 31, 2000--Antirheumatic Drug Therapy. Notified Providers that effective June 5, 2000 and thereafter, PACE will review claims submitted for the antirheumatic drug etanercept (Enbrel®).
* March 31, 2000--COX-2 Inhibitors. Notified Providers that effective June 5, 2000 and thereafter, PACE will review claims submitted for the COX-2 inhibitors (Celebrex®) and rofecoxib (Vioxx®) for maximum daily dose.
* March 31, 2000--Antiplatelet Agent PLETAL®. Notified Providers effective June 5, 2000 and thereafter, PACE will review claims submitted for the antiplatelet agent cilostazol (Pletal®) for maximum daily dose of 200 mg.
* March 31, 2000--Skeletal Muscle Relaxants. Notified Providers effective June 5, 2000 and thereafter, PACE will review claims submitted for skeletal muscle relaxants for both maximum daily dose and duration of therapy.
* March 31, 2000--Rezulin®. Notified Providers that effective March 22, 2000 PACE no longer reimburses for Rezulin®. This action is in response to the Warner Lambert Company's voluntary withdrawal of Rezulin® from the marketplace on Tuesday, March 21, 2000.
* April 7, 2000--Propulsid® Reimbursement. Notified Providers effective April 10, 2000 PACE will deny all claims received for cisapride (Propulsid®). Physicians desiring their patients to continue taking cisapride (Propulsid®) have been advised they may request a Medical Exception. These exception requests will be considered only until the product is withdrawn from the market by Jansssen Pharmaceutica effective July 14, 2000.
* April 7, 2000--Dispensing Date. Reminded Providers that claims are to be submitted to PACE on the date they are dispensed. Advised PACE Providers enrolled as Nursing Home Providers as well as those providers servicing nursing homes that effective with dates of service of June 1, 2000 and thereafter, claims submitted with incorrect dates of service will have those claims disallowed.
* May 12, 2000--Mandatory Substitution Dilantin®. Notified Providers effective May 22, 2000, PACE is mandating substitution for Dilantin®,
* May 12, 2000--Generic Refills. Reminder to Providers that Section 22.55(e) of Title 28 (Health and Safety) of the Pennsylvania Code states: ''Prescription refills, where permitted by the practitioner, shall be completed using the identical product (same distributor and manufacturer) as dispensed on the original, unless the person presenting the prescription and the practitioner authorize, in advance, a different manufacturer's generic equivalent product. Advance authorization is not required in an emergency, but the physician shall be notified by the pharmacist as soon as possible thereafter.''
* May 19, 2000--LOTROXEX®. Notified Providers that in the package insert that accompanies Lotronex®, Glaxo Wellcome Inc. states that ''Lotronex® has NOT been shown to work in men with IBS.''(Irritable Bowel Syndrome). Effective June 12, 2000, all claims for Lotronex® will be denied with NCPDP Code 70, PACE Code 055 ''Drug not covered''. At a future date this edit will be converted to a DUR drug--gender denial. In the interim, providers should contact Provider Services to receive a Medical Exception for female cardholders.
* May 19, 2000--Zyvox®. Notified Providers effective June 5, 2000, PACE will deny all claims for Zyvox®. Medical Exceptions for the antibiotic linezoid (Zyvox®) will only be considered upon receipt of the appropriate documentation from the cardholder's physician. Providers should note that no evidence supports Zyvox® for use in the management of antibiotic associated colitis (AAC). No medical exceptions will be approved prior to the receipt of supporting diagnostic and treatment information.
* May 26, 2000--Dispensing Date Update. Notified Providers enrolled as Nursing Home Providers and those who service nursing homes affected by the PACE Provider Bulletin of April 7, 2000, that the implementation date cited in this notification has been delayed thirty days until July 1, 2000.
* June 9, 2000--Provider Update: Generic substitution for Dilantin®: Notified Providers as stated in the Provider Bulletin of May 12, 2000,PACE notified the physicians of all PACE cardholders currently receiving Dilantin® of the impending mandatory substitution and provided a Medical Exception Form if the prescriber did not wish the cardholder to receive the generic.
* July 14, 2000--PACENET Deductible Reminder: Notified Providers that any providers refusing to submit PACENET deductible claims through the on-line claims adjudication system at the time of presentation or prior to dispensing the prescription are in violation of their PACE/PACENET Provider Agreement. Failure to abide by the terms and conditions of the Provider Agreement could result in provider termination and/or suspension of payments by the Department of Aging until such non-compliance is corrected.
* August 4, 2000--Dispensing Date & Nursing Home Providers: Notified Providers our Bulletin of April 7, 2000, instructed that all claims for cardholders residing in nursing homes are to be submitted to PACE on the date that they are dispensed. Subsequently, the Department has reviewed issues raised by nursing home providers and providers who service nursing homes regarding this requirement. Although the Department recognizes that it cannot dictate a nursing home's medication dispensing policy, the Program does encourage the submission of claims for those chronic maintenance drugs to be on a monthly basis. The authorizations apply ONLY to those cardholders residing in nursing homes who are subject to the nursing home's controlled environment and internal drug utilization review policy.
* August 18, 2000--Vaniqa®: Notified Providers that PACE will NOT reimburse for Bristol-Myers Squibb and Gillette's Vaniqa® (eflornithine HCL) cream recently approved by the FDA for the treatment of unwanted facial hair in women.
* September 15, 2000--Other Prescription Coverage: Notified Providers that effective October 16, 2000, PACE will edit claims for PACE cardholders with dual coverage. Providers enrolled in other third party point-of-sale prescription plans must have the ability to ''dual bill.'' PACE is to be billed after the claim is adjudicated by the primary insurer but prior to dispensing.
* November 10, 2000--Reminder of Other Prescription Coverage: Notified Providers that PACE denies claims for cardholders identified as having other insurance if the provider submits the claim with an incorrect ''other coverage'' value.
* December 1, 2000--Manufacturers' Rebate: Notified Providers that Act 128-1992 amending the Lottery Fund Preservation Act, in part, requires all pharmaceutical manufacturers to have in effect a rebate agreement with the PACE Program if they wish to have their products covered. Sidmak Laboratories, Labeler Code 50111 is being added to PACE's non-participating list. Sidmak's products are no longer reimbursable effective December 18, 2000.
* December 15, 2000--Sidmak Laboratories Reinstatement: Notified Providers that the Department of Aging advises that Sidmak Laboratories, Labeler Code 50111 will continue to participate in the Manufacturers' Rebate Program. Providers should disregard the previous December 18, 2000 termination announcement.
PACE Provider Bulletins: 1999
* February 19, 1999--Optometrists's Prescribing Privileges: Provides PACE Providers with a list of medications permitted by Department of Health regulation to be prescribed by optometrists. Warns providers to not dispense and bill the Program for pharmaceuticals that are prohibited by regulation from being prescribed by optometrists.
* February 19, 1999--Optometrist's License Numbers: Notifies providers that Optometrists certified
* to prescribe and administer pharmaceutical agents for therapeutic purposes under section 4.1 of the Optometric
* Practice and Licensure Act are being issued a license with a suffix of ''T''.
* March 5, 1999--PACENET Deductible: Reminder to PACE Providers that the $500 PACENET deductible is accumulated based on each individual cardholder's enrollment year; not the calendar year.
* April 9, 1999--Notified PACE Providers that effective May 14, 1999, PACE will mandate substitution on the following medications: Lasix®, Depakene®, Mysoline®, Quinaglute Dura-tabs®, Mexitil®, Tegretol® and all sustained-release Theophylline preparations.
* April 9, 1999--Betoptic® Solution: Notified PACE Providers that Alcon Laboratories had informed PACE that it had discontinued production of Betoptic® solution in the 2.5 and 5 ml sizes.
* April 30, 1999--Propulsid® Drug to Drug Interactions: Notifies providers that effective May 10, 1999, PACE will review history across all providers and reject all prescriptions in the drug classes which are contraindicated for patients using Propulsid.
* May 7, 1999--Drug Utilization Review Program: Notified Providers that effective May 15, 1999, several new and revised maximum daily dose criteria, duration criteria and duplicate criteria will be added to the PACE ProDUR Program.
* July 2, 1999--Trovan®(Trovafloxacin/Alatrofloxacin Mesylate): Notified Providers that effective July 6, 1999, PACE will deny all claims for Trovan®. In accordance with FDA recommendations, PACE will reimburse for Trovan® only through the Medical Exception Process.
* July 2, 1999 Medicare Reimbursable Chemotherapeutics: Notified Providers that effective July 12, 1999, the following pharmaceuticals will be included with those products being reimbursed by the PACE/PACENET Program at 20%: Oaklide® and Neumega®
* July 16, 1999--HISMANAL®. Notified Providers that effective July 26, 1999, PACE will no longer reimburse for HISMANAL®. This action is in response to Janssen Pharmaceutica informing the U.S. Food and Drug Administration that it has voluntarily decided to discontinue the manufacturing and distribution of HISMANAL® 10 mg tablets.
* July 16, 1999--Cellcept® and Prograf®. Notified Providers that effective July 26, 1999, PACE claims for Cellcept® and Prograf® may be submitted to the Program using the PACE On-Line Claims Adjudication System (POCAS) Medical Exception process.
* July 16, 1999--Drug Utilization Review Program Anti-obesity Agents. Notified Providers that effective July 26, 1999, maximum dose and initial duration of therapy criteria will be added to the PACE ProDUR Program specifically for the anti-obesity class of medication.
* September 3, 1999--NEORAL® and SANDIMMUNE®. Notified Providers that effective September 13, 1999, PACE claims for Neoral® and Sandimmune® will be adjudicated by the Program using the PACE On-Line Cclaims Adjudication System (POCAS) Medical Exception process.
* October 20, 1999--Other Prescription Coverage. Notified Providers effective November 1, 1999, PACE cardholders identified by Highmark as possessing Security Blue prescription coverage, will have their claims denied by PACE IF the provider submits the claim with an incorrect Other Coverage value of: ''0''--''Not Specified'' or ''1''--''No Other Coverage Identified.''
* October 29, 1999--Multiple Point of Service Billing. Notified Providers whose software does not permit dual or multiple point-of-sale submissions may not bill cardholders for medications submitted to PACE after dispensing and experiencing a subsequent denial.
* November 5, 1999--RAXAR®. Notified Providers that Glaxo Wellcome has announced the voluntary withdrawal of RAXAR® tablets from the market. Any claims submitted for RAXAR® on or after November 3, 1999 will deny.
* November 19, 1999--PACENET Cardholders and Other Prescription Coverage. Reminded Providers that claims submitted to PACE during the PACENET cardholder's deductible period are to contain the dollar amount paid by the PACENET cardholder for the prescription. The out of pocket expense, borne by the cardholder, is the amount the Program accumulates toward the cardholder's $500 deductible.
* December 3, 1999--Medicare Reimbursable Agents. Notified Providers that effective December 13, 1999, PACE will deny claims submitted for all Medicare Reimbursable Agents. Providers attempting to bill for these products may contact Provider Services for a Medical Exception.
PACE Provider Bulletins: 1998
* February 13, 1998--PACENET Deductible: Reminder to Providers that the PACENET $500 deductible is accumulated based on each individual's enrollment year, not the calendar year.
* February 13, 1998--PACE Required Documentation for ''Brand Medically Necessary'' (DAW Code 1) Prescriptions: Reminder to Providers who are being reimbursed for a Brand Name product having an A-rated generic because the Program has granted a cardholder medical exception or because the Program has elected not to require substitution must, by PACE regulation, have at the time of dispensing, a prescription on which the Prescriber has handwritten ''Brand Medically Necessary'' or ''Brand Necessary.''
* February 13, 1998--Clozapine (Clozaril): Notified Providers that Clozaril is subject to the PACE Program's mandatory substitution requirement. Generic clozapine is available from Zenith Goldline Pharmaceuticals.
* February 13, 1998--Use of NDC Codes and Calculation of Reimbursement: Reminder to PACE Providers that all claims submitted to the Program for reimbursement must accurately report the labeler code and product code of the drug dispensed. Reimbursement paid by the PACE Program will be based upon the package size as reported by the Provider.
* February 20, 1998--Other Prescription Coverage: Notified Providers that EOB Message ''041--Billable to Other Payor'' will soon be rejected with an Error Code 041.
* February 27, 1998--Bromfenac Sodium Capsules (DURACT): Reminder to Providers that DURACT is only intended for the short term (10 days or less) management of acute pain and is not indicated for long term use. Notified Providers effective March 2, 1998 PACE will reject all claims for DURACT at the point of sale. A one-time medical exception will be considered, upon request from the Provider, for a maximum 10-day supply at a maximum dose that does not exceed 150 mg per day. Written correspondence from the cardholder's physician will be necessary for reimbursement beyond ten days.
* February 27, 1998--Mibefradil Dihydrochloride (POSICOR): Notified Providers of advisory issued by Roche Laboratories Inc. of reported cases of interaction of POSICOR with certain HMG-CoA Reductase Inhibitors. PACE claims for POSICOR identified as being coadministered with either lovastatin or simvastatin will reject with the NCPDP Error ''88, DUR Reject''; PACE Error Code ''706,'' accompanied with the Conflict Code ''DD,'' the free text message of ''DRUG-DRUG,'' and the NDC of the drug in conflict.
* April 10, 1998--PACE Cardholders Enrolled in Medicare HMO's: Reminder to Providers that PACE Cardholders enrolled in Medicare certified HMO's are entitled to the same prescription medications under the Medicare certified HMO as those covered under Medicare Part ''B.'' This entitlement is not affected by a cardholder's decision not to subscribe to supplemental HMO offered prescription coverage.
* April 17, 1998--Drug Utilization Review Program: Notified Providers effective April 22, 1998, several new maximum daily dose criteria, duration criteria and duplicate therapy criteria will be added to the PACE ProDUR Program. The criteria is as follows: Mibefradil HCl (POSICOR) 100 mg maximum dose/duplicate therapy edit; Carvedilol (Coreg) 100 mg maximum dose/duplicate therapy edit; Losartan (Cozaar) 100 mg maximum dose/duplicate therapy edit with the ACE Inhibitors; Quetiapine (Seroquel) 400 mg maximum dose; Hydrocodone and Ibuprofen (Vicoprofen) 37.5 mg maximum dose/duration edit: 10 days out of every 30.
* April 25, 1998--Mandatory Substitution Diltiazem Extended Release Capsules: Notified Providers effective April 29, 1998, the PACE Program will begin mandating substitution of Dilacor XR and Cardizem SR. This is a result of information received from the FDA granting therapeutic equivalence to capsules manufactured by Mylan Pharmaceuticals, Watson Labs, Andrx and Teva Pharmaceuticals.
* May 8, 1998--Early Refill Edit: Notified Providers effective May 19, 1998, the additional classes will be added to the early refill edit: Intranasal Steroids; Topical Corticosteroids--Single Entity; Anti-diabetic Agents--Insulins; Bronchodilators; Conjugated Estrogens; Estrogens--Transdermal Patches; and Opiates. Reimbursement will not be made until 75% of the medication has been used.
* May 22, 1998--Drug Utilization Review Program: Notified Providers effective May 26, 1998 several new criteria will be added to the PACE ProDUR Program and applied to all claims submitted on or after this date for the medication Viagra. The criteria added are: maximum daily dose of 50 mg. Claims submitted for greater than 50 mg daily will require a diagnosis and approval through the PACE medical exception process. Duration of therapy will be thirty tablets per month. PACE will only reimburse claims submitted for male cardholders. Claims submitted for female cardholders will be reversed.
* June 1, 1998--Drug Utilization Review Program: Notified Providers that Pfizer, Inc. has recently reiterated that patients taking nitrates in any form, including nitroglycerin and long-acting nitrates commonly used for chest pain, should not take Viagra. PACE will reject prescriptions for Viagra and Nitroglycerin at the point-of-sale in order to comply with this guideline for appropriate use.
* June 12, 1998 RECALL: Notified Providers that a Voluntary Class I recall has been initiated by Meridian Medical Technologies, manufacturer of both Epipen and Epipen Jr. Auto-Injectors. All PACE cardholders for whom reimbursement was made during this period have been instructed to return their product to their pharmacy for a lot number review.
* June 12, 1998--RECALL: POSICOR--Notified Providers that Roche Laboratories Inc. is withdrawing POSICOR from the market effective June 8, 1998. The PACE Program will deny reimbursement for claims submitted with dates of service of June 9, 1998 or thereafter will be denied.
* June 19, 1998--Cholinesterase Inhibitors: Notified Providers that effective June 22, 1998, several new maximum initial dose and maximum daily dose criteria will be added to the PACE ProDUR Program. The criteria added are for Tacrine (Cognex®), initial maximum dose 40 mg/6 weeks; 80 mg/6 weeks; 120 mg/6 weeks and a maximum dose of 160 mg; and Donepezil (Aricept®), initial maximum dose 5 mg and a maximum dose of 10 mg.
* June 26, 1998--DURACT®: Notified Providers that effective June 22, 1998, Wyeth-Ayerst Laboratories is withdrawing Duract® capsules from the market. Accordingly, any Duract® claim submitted to PACE after June 22, 1998 is being denied.
* June 26, 1998--Early Refill Edit Applied to Ophthalmics: Notified Providers that effective July 6, 1998, PACE is applying the early refill edit criteria to ophthalmic preparations requiring that at least 75% of the medication, based on the day's supply submitted on the previous claim, has been used before PACE will consider reimbursement for a prescription refill.
* December 11, 1998--Meridia® Drug to Drug Interactions: Notified Providers that in order to comply comply with the manufacturers' warnings that Meridia® should not be used concomitantly with MAOI's (at least a two week interval after stopping an MAOI before commencing with Meridia®), PACE will review history across providers and reject all prescriptions for Nardil, Eldepryl and Parnate at the point of sale.
* December 31, 1998--Drug Utilization Review Program: Notified Providers that effective January 4, 1999, revised criteria will be added to the PACE ProDUR Program and applied to all claims submitted on or after this date for the medication Viagra®. The criteria is as follows: Maximum Daily Dose--50 mg; Duration of Therapy decreased from thirty to eight tablets per month.
PACE Provider Bulletins: 1997
* February 7, 1997--Brand Medically Necessary Update: Notified Providers that effective immediately PACE is no longer mandating generic reimbursement on the following brand medications: Lasix, Depakene, Tegretol, Mysoline, Quinaglute Duratabs (Quinidine Gluconate), Pronestyl SR, Mexitil, and All Sustained -Release Theophylline Preparations.
* February 14, 1997--Mandatory Substitution Nitoglycerin Transdermal Patch: Notified Providers that effective February 21, 1997, the PACE Program will being mandating substitution on both Nitro-Dur and Transderm-Nitro.
* March 1, 1997--PACENET: Reminder to Providers to encourage their older customers to make application for the new PACENET Program. Bulletin include income requirements, information regarding the crediting of out-of-pocket expenses; use of 1997 PACE applications to apply for both PACE and PACENET and a reminder to discard the old 1996 enrollment applications.
* March 28, 1997--Drug Utilization Review Program: Notified Providers that effective April 14, 1997, PACE will be adding new criteria to our Prospective Drug Utilization Review Program for HMG Co-A Reductase Inhibitors.
* May 9, 1997--PACENET Claim Submission: Provides explanation to Providers regarding the $500 deductible and submission of out-of-pocket prescription expenses for PACENET cardholders.
* June 20, 1997--Claim Timeliness: Reminder to Providers that PACE claims are to be submitted on the date of dispensing.
* July 11, 1997--Fragmin: Notified Providers that on July 18, 1997, PACE would reimburse claims submitted for Fragmin only when being prescribed for the prevention of deep venous thrombosis, which may lead to a pulmonary embolism following abdominal surgery or hip replacement. Further, since Fragmin is indicated for short-term treatment (five to ten days), PACE would apply a duration of therapy edit of not greater than 14 days to all incoming claims.
* August 7, 1997--Generic Update: Ranitidine: Notified Providers that Ranitidine currently being manufactured by Novopharm and Geneva is now available as a therapeutically equivalent generic for Zantac and effective Friday, August 15, 1997, PACE would be mandating substitution on Ranitidine.
* August 7, 1997--1997 Pharmacy Licensure: Reminder to Pharmacies that current pharmacy licenses expire August 31, 1997 and that PACE Regulations mandate that, ''Only pharmacies and dispensing physicians that are currently licensed by the Commonwealth are eligible to participate as providers in the PACE Program.''
* August 15, 1997--PACENET Claims: Reminder to Providers that they must submit all PACENET Cardholder prescription claims on POCAS to permit the accurate recording of the amount accumulating toward the $500 deductible.
* August 15, 1997--Other Prescription Coverage: Reminder to Providers that, by statute, the PACE Program is the payor of last resort and will accept responsibility only for those costs not covered by the cardholder's other prescription drug benefit program.
* August 15, 1997--Notified Providers effective August 18, 1997, several new maximum dose criteria will be added to the PACE ProDUR Program. These new additions are: 1) Maximum daily dose and duplicate therapy (with ACE inhibitors) edit for angiotensin II antagonist inhibitor: Valsartan (Diovan) 320 mg; 2) Maximum initial dose and maximum daily dose for antipsychotic agent Olanzapine (Zyprexa) 2.5 mg (initial) 10 mg (maximum); 3) Maximum daily dose and duplicate therapy for the HMG Co-A Reductase Inhibitor: Atorvastatin (Lipitor) 80 mg (maximum); 4) Maximum daily dose and duplicate therapy for the beta blocker: Cavedilol (Coreg) 100 mg (maximum); 5) Maximum initial dose and maximum daily dose for the antidepressant: Mirtazapine (Remeron) 15 mg (initial) 45 (maximum); 6) Maximum dose and duplicate therapy for the calcium channel blocker Nisoldipine (Sular) 60 mg (maximum); and 7) Maximum initial dose and maximum daily dose for the antipsychotic: Clozapine (Clozaril) 25 mg (initial) 100 mg (maximum).
* August 29, 1997--Updated listing of Non-Participating Manufacturers.
* September 12, 1997--Reinstatement of Common Package Size: Notified Providers effective September 15, 1997, PACE will reinstitute the Common Package Size pricing which was discontinued in November, 1996.
* September 19, 1997--Audit Issues: Reminder to Providers their responsibilities regarding voiding claims' payments for prescriptions that are not picked up by cardholders as well as maintaining an accurate, current signature log to identify the individuals who are receiving the PACE prescriptions dispensed by the Provider.
* September 19, 1997--DAW/Product Selection Code: Reminder to Providers of the five codes used by POCAS.
* October 3, 1997--Injectable Chemotherapy Antineoplastics: Reminder to Providers that Injectable chemotherapeutic antineoplasic claims are only reimbursed based on the 20% not covered by Medicare.
* October 3, 1997--Claim Submission Timeliness: Reminder to Providers that they are required by contract to submit claims prior to dispensing.
* October 17, 1997--Other Prescription Coverage: Notification to Providers effective November 3, 1997, PACE is implementing edit criteria to ensure compliance with the Program's requirement of billing other prescription plans prior to billing PACE. Providers entering a TPL indicator identifying ''no other coverage'' for a cardholder identified as having other prescription coverage will have the claim denied with the NCPDP Error Code 41 ''Submit Bill to Other Payor.''
* November 14, 1997--Drug Utilization Review Program: Notified Providers effective November 24, 1997, the following new maximum daily dose criteria will be added to the PACE ProDUR Program: Maximum daily dose edit for the centrally acting analgesic Tramadol (Ultram) 300 mg maximum for individuals 75 years of age or older and 400 mg for individuals younger than 75 years.
* November 14, 1997--Drug Utilization Review Program: Notified Providers effective November 24, 1997, the following new maximum daily dose criteria will be added to the PACE ProDUR Program: Edits for the miscellaneous sedative/hypnotics are as follows: Amobarbital (Amytal) 200 mg; Butabarbital (Butisol) 100 mg; Chloral Hydrate 1 gm; Pentobarbital (Nembutal) 100 mg; Ethchlorvynol (Placidyl) 500 mg; Secobarbital (Seconal) 100 mg; Amobarbital/Secobarbital (Tuinal) 50/50 mg.
* November 21, 1997--Reminder to PACE Providers to review their Remittance Advice and to pay particular attention to those claims with Message Codes 041 and 918, which address those claims for cardholders with other prescription coverage.
* November 21, 1997--Oral Anti-Nausea Medication: Notified Providers effective December 1, 1997, PACE will being reimbursing only 20% of the Average Wholesale Price of oral formulations of Kytril and Zofran. Remaining cost of the drug will have to be submitted to the regional Medicare carrier, United Health Care in Wilkes-Barre for reimbursement.
* December 26, 1997--Reminder to PACE Providers that claims submitted for brand name pharmaceuticals having an A-rated generic therapeutic equivalent will be denied unless a medical exception is granted or PACE does not mandate substitution for the product. PACE does not require substitution on these products with A-rated generics Warfarin Sodium (Coumadin); Carbamazepine (Tegretol); Phenytoin (Dilantin); or Furosemide (Lasix).
PACE Provider Bulletins: 1996
* January 8, 1996--Prilosec and Prevacid: Notified Providers these drugs would be edited for maximum duration for all claims dispensed on or after January 8, 1996.
* January 26, 1996--Non-Participating Manufacturer List.
* May 24, 1996--Biaxin Filmtabs (NDC: 00074248660): Notified providers of an error on the formulary file from 1/22/96 to 3/21/96.
* May 24, 1996--Solopak Pharmaceuticals: Notified providers that Labeler Codes 39769 and 59747 would be participating in the PACE Program.
* July 12, 1996--PACE Cardholders with PEBTF Prescription Coverage: Notified Providers that PACE Cardholders with drug coverage through the Commonwealth's Retired Employees Health Plan had been notified they were being canceled from the PACE Program.
* August 2, 1996--Other Insurance Coverage: Reminder to Providers to exercise reasonable diligence in ascertaining the existence of other prescription benefits before billing the PACE Program.
* October 18, 1996--Injectable Chemotherapeutics: Reimbursement restrictions (20% of Average Wholesale Price) applied to injectable chemotherapy medications when administered through a home infusion pump or in a physician's office.
* October 18, 1996--Vaccine Reimbursement: Notified Providers of a change in the reimbursement of vaccines to be implemented on November 11, 1996 for claims with a date-of-service on or after that date. The change is as follows: Vaccines used to provide immunization against pneumococcal pneumonia and influenza will no longer be reimbursed by the PACE Program. Vaccines used to provide immunization against hepatitis B will be reimbursed at 20% of the Average Wholesale Price.
* October 18, 1996--Bronchodilator Drugs: Notified Providers that effective November 11, 1996, PACE will begin reimbursing only 20% of Average Wholesale Price for the following products: Acetylcysteine 10%; Acetylcysteine 20%; Albuterol Sulfate 0.083%; Albuterol Sulfate 0.5%; Cromolyn Sodium; Isoetharine HCI 0.1%; Isoetharine HCI 0.125%; Isoetharine HCI 0.167%; Isoetharine HCI 0.2%; Isoetharine HCI 0.25%; Isoetharine HCI 1.0%; Isoproternol HCI 0.5%; Isoproternol HCI 1.0%; Metaproternol Sulfate 0.4%; Metaproterenol Sulfate 0.6%; and Metaproterenol Sulfate 5.0%.
* November 21, 1996--PACE Legislative Changes: Notified Providers of increased income limits ($14,000 maximum for singles and $17,200 maximum for married); and Mandatory Substitution of A-Rated Multiple-source products.
* November 21, 1996--PACENET Requirements: Notified Providers of income limits for PACENET cardholders (Between $14,000 and $16,000 if single; Between $17,200 and $19,200 if married); Annual Deductible ($500 per person) which PACE Providers are expected to enter PACENET Enrollee's out-of-pocket prescription expenses in POCAS; Mandatory Copayments ($8 per prescription for non-innovator, multiple-source (generic) products; and $15 per prescription for single-source and innovator multiple-source products); Mandatory Substitution of A-Rated Multiple-source products after deductible is met; and the claims reimbursement formula for PACENET claims would be AWP--10% + $3.50 dispensing fee.
* November 22, 1996--Third Party Liability: Notified Providers that a PACE cardholder's I.D. card could currently contain two indicators that may affect coverage. The first indicator is a ''Y'' appearing in the lower right quadrant of the I.D. card meaning the cardholder has informed PACE that they have other third party insurance that is to be billed before PACE. The second indicator is an ''L'' appearing in the lower right quadrant of the I.D. card. This ''L'' means the cardholder has been restricted into receiving their PACE benefits at one specific provider.
* November 22, 1996--Lovenox: Notified Providers that effective December 9, 1996, PACE will reimburse claims submitted for Lovenox only when being prescribed for the prevention of deep venous thrombosis, which may lead to a pulmonary embolism following hip or knee replacement surgery or general surgery which includes abdominal, gynecologic, urologic or thoracic. Further, since Lovenox is indicated for short-term treatment (seven to ten days), the Program will apply a duration edit of not greater than 14 days to all incoming claims.
* November 22, 1996--Oral Vancomycin: Notified Providers that PACE would be applying a duration of therapy edit of not greater than 14 days for all incoming claims for oral Vancomycin.
* November 22, 1996--Bronchodilator Drug Update: Reminder for Providers that reimbursement for the bronchodilator solutions used in either IPPB machines or nebulizers is limited to 20% of the Average Wholesale Price by PACE and suggested that Providers who do not currently have a Medicare provider number contact the National Supplier Clearinghouse in North Carolina to request an application.
* November 22, 1996--Non-Participating Manufacturers effective November 27, 1996.
* December 1, 1996--Processing PACENET Claims: Provides information to assist pharmacies in the processing of claims for cardholders enrolled in PACENET.
* December 13, 1996--Imitrex Tablets: Notified Providers that effective December 30, 1996, all claims for Imitrex will not be reimbursed for a quantity greater than nine or a days' supply less than or equal to 25.
* December 13, 1996--Nimotop: Notified Providers that effective December 30, 1996, claims for Nimotop will be denied at the point-of-sale. After determining the diagnosis, providers can contact the POCAS operators and obtain a Medical Exception. Although this medication is approved only for use in subarachnoid hemorrhage, there are several other off-label uses for which reimbursement will be made.
* December 13, 1996--Revision: Non-Participating Manufacturer List.
* December 20, 1996--Mandatory Generic Substitution: Advises providers to direct cardholder questions about the new mandatory substitution policy to the Cardholder Services toll-free number (1-800-225-7223).
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