Payer Sheets - Version D.0
Specifications for online claims processing/NCPDP:
Instructions for 340b pharmacies are within the payer sheet. 340b contract pharmacies must carve out ND Medicaid. For Medicaid Managed Care, providers are not allowed to use 340b products. Pharmacy services are carved out of managed care starting January 1, 2020.
Pharmacy Prior Authorization Info and Forms
Acentra Health is North Dakota Medicaid's Prior Authorization Vendor. Per federal law, state Medicaid programs may require, as a condition of coverage or payment for a covered outpatient drug, the prior approval of the drug before it is dispensed for any medically accepted indication.
The 2003 Legislative Assembly passed House Bill 1430. This restructured the existing Drug Use Review (DUR) Board and required the Board to advise the Department of Health & Human Services in developing a Prior Authorization (PA) process to help assure that beneficiaries receive appropriate medications in the most cost-effective manner, thus conserving state expenditures for drugs whenever possible.
Questions? Contact Brendan Joyce, PharmD, Administrator, Pharmacy & Clinical Services at bjoyce@nd.gov .
Naloxone Standing Order
This Standing Order, issued pursuant to North Dakota Century Code § 23-01-42, authorizes North Dakota Medicaid enrolled pharmacies to dispense any over-the-counter naloxone product covered by North Dakota Medicaid to eligible North Dakota Medicaid members.
Pharmacy Industry / Drug Rebate Program
Contact Information
Mailing/Physical Address:
ND Dept of Health & Human Services
Attn: Fiscal – Drug Rebate Program
600 E Blvd Ave Dept 325
Bismarck, ND 58505-0261
Contact Information:
- Questions on usernames and passwords for ND’s RebateWeb and for dispute issues – rebatewebnd@nd.gov
- For invoice and payment questions – ndrebates@nd.gov
Please note, payments can only be for 1 program per check. ROSIs and PQASs must be mailed/emailed to ndrebates@nd.gov with each payment.
We now (April 2021) accept payments through EFT/ACH. Please send an email to ndrebates@nd.gov – subject line: ACH Payment Process to receive instructions regarding setting up your company.
To view/download CLD or invoices, please visit our ND RebateWeb site (state specific) https://drugrebate.nd.gov. Invoices are mailed and delivered electronically if labeler requested electronic through the ND RebateWeb site.
*New program starting 1q22. ND Medicaid Expansion FFS Medical (EXPFFSJ & EXPFFSJSU). Currently just 19-20 year old Expansion members (carved out of MCO).
Drug Coverage and Clinical Updates
ND Medicaid covers products by default as they appear in the First DataBank database files that are loaded weekly into our system. Please use the NDC Drug Lookup tool which is also populated by the First DataBank drug database files for coverage and reimbursement information.
New Labeler: When a labeler newly enters into a National Drug Rebate Agreement (NDRA) to participate in the Medicaid Drug Rebate Program (MDRP), our system will be updated with the next quarterly CMS file. Coverage will begin by the mandatory coverage date.
Drugs that cost over $3000 for a month's supply: Drugs be covered according to the package insert. If it is part of an already existing PDL category, it’ll be added to that category. An update will be provided to the DUR board the following meeting in the PDL update. General utilization management measures, such as quantity limits, therapeutic duplication, and diagnosis requirements will be implemented as applicable.
Oncology Medications: Oncology medications will simply be covered with a quantity limit and to FDA and compendia diagnoses, with no step therapy. Clinical presentations are generally not necessary, due to the lack of impact on management.
Clinical Presentations: The best timing for a clinical presentation to the ND team is shortly after FDA approval or launch. The ND team applies utilization management and strategizes for PDL placement and criteria after drugs are launched so the presentation is highly relevant during this time and is less likely to have the important clinical information lost in the shuffle.
- Please fill out the Pharmacy Industry Meeting Application and email to medicaidpharmacy@nd.gov or fax to 701-328-1544.
- Things we find especially informative during presentations:
- Place in therapy
- Highlighting the differences between your drug and the current drugs in the marketplace
- Unique mechanisms of action and how the mechanism affects the disease state vs other drugs on the market
- Relevant clinical guidelines
- Real world data
- Distribution plans.
- Clinical presentations are generally not needed for classes that are not managed. Most commonly these would be oncology medications. North Dakota will always reach out for more information when needed so a simple greeting and informative drug launch email to medicaidrx@nd.gov is often the best strategy for oncology medications.
Reimbursement: ND Medicaid uses the methodology of lesser of NADAC or MAC if NADAC is available, or lesser of WAC and MAC if NADAC is not available. Please use the NDC Drug Lookup tool to lookup reimbursement information.
DUR Board Review:
- Agenda: The DUR Board Agenda will be posted on the DUR Board vendor’s website 30 days prior to the meeting. Chemotherapy, HIV/AIDs, antidepressants, antipsychotics, seizure, and immunosuppressants for prophylaxis of organ transplant rejection classes are currently excluded from prior authorization so will not be reviewed for prior authorization or step therapy criteria at the DUR meeting.
- Public Comment: Please email Julie McKee at julie.mckee@acentra.com and provide any materials to be distributed to the board members. This is not a requirement to be allowed to speak at the DUR Meeting but is appreciated for an orderly meeting and record keeping. Public comments must be related to agenda item. Public comments will be allowed for first and second reviews and annual prior authorization reviews. For more information regarding public comments, please see the ND Medicaid DUR Board Procedures
- Annual Prior Authorization Review: The annual review for all classes subject to prior authorization occurs in the December meeting.
Supplemental Rebates: ND Medicaid participates in the Sovereign States Drug Consortium (SSDC) supplemental rebate pool. Please visit the SSDC website to view information on the consortium and how to submit a rebate offer. ND Medicaid has been approved by CMS to participate in value-based agreements as a state. Please contact medicaidrx@nd.gov or SSDC if you are interested in pursuing a value based agreement.
Additional Links
- Visit: website ND Board of Pharmacy
- Visit website: Centers for Medicare and Medicaid Services: Medicaid Prescription Drug
Questions? Contact Us
If you have pharmacy questions, you may ask by e-mail to medicaidpharmacy@nd.gov or by telephone (701) 328-4086.