DOH Medicaid Update November 2000 Vol.15, No.11

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Zyvox (linezolid) has received Federal Drug Administration approval for treatment of Vancomycin Resistant Enterococcus (VRE) infections, nosocomial pneumonia, community-acquired pneumonia, and various skin/skin structure infections.

Effective November 1, 2000, the New York State Medicaid Program implemented a prior authorization mechanism for prescribing and dispensing Zyvox in the outpatient setting. This process has been implemented to assure that bacterial resistance to this newly approved antibiotic does not occur due to mis-utilization. Prescribers and pharmacies were notified of this new requirement by letter in October. The Zyvox prior authorization prescriber overview, prescriber response format, pharmacy overview, and pharmacy response format are listed below.

Please contact the Pharmacy Policy and Operations Unit at (518) 486-3209 if you have questions or need technical assistance

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• All prescriptions for Zyvox must be prior authorized.
• The toll-free Zyvox prior authorization number is 1-877-309-9493.
• Access to the prior authorization system for Zyvox will be Monday-Friday, 9 a.m.- 8 p.m.; Saturday and Sunday, 9 a.m.-5 p.m. A voice interactive phone system (VIPS) for this program is under development that will make the prior authorization system available 24 hours a day, 7 days a week. Prescribers and pharmacies will be notified when the VIPS is operational.
• Prescribers will be required to call the toll free telephone number and respond to a series of questions that identify the prescriber, the patient and the reason for prescribing. An eight-digit prior authorization number will be issued following completion of the questions. The eight-digit prior authorization number must be entered on the face of the prescription.
• For orders written by an unlicensed intern or resident, the supervising physician's MMIS ID number or their license number must be entered. Hospital, clinic, or other health care facility MMIS ID numbers cannot be used when prescribing Zyvox.
• Prescriber response and issuance of the eight-digit prior authorization number is not expected to take more than a few minutes of telephone time.
• The completed prescription may be filled at any NYS Medicaid enrolled pharmacy that stocks the drug.
• Phone and fax orders for Zyvox will be allowed. The prescriber is required to provide the pharmacy with the original prescription including the prior authorization number within five business days.
• The dispensing pharmacist will call the same toll free telephone number and use the issued prior authorization number to complete the prescription information prior to dispensing.
• Prescriptions will be limited to a maximum of a 28 tablet, 900 ml of suspension, or 8400 ml of intravenous solution for a 14 day supply. Continuation beyond 14 days of therapy will require a new prescription and a new prior authorization number.
• If Zyvox is not dispensed by a pharmacy within 14 days of the order date, the prior authorization number will expire. The pharmacy will be given a message to contact the prescriber to determine if their patient has a current need for Zyvox.
• No refills for this agent will be allowed.
• Zyvox is not reimbursable to pharmacies on an outpatient basis for patients who have a Temporary Medicaid Authorization.
• The back of this page has a list of questions that will need response and the proper format for responding. Fill in the information and have that information in front of you before calling into the prior authorization system. You should reproduce the blank form for future Zyvox prescribing.
• The toll free Zyvox prior authorization number, 1-877-309-9493, can be used to cancel a prior authorization number that you obtained if the drug was not dispensed.

For technical assistance or policy questions, contact the NYS Department of Health, Pharmacy Policy and Operations Unit at (518) 486-3209.

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ZYVOX (linezolid) Indications*

1. Vancomycin resistant infections including concurrent bacteremia

• Susceptible microorganism - Vancomycin-resistant Enterococcus faceium
• Dosage/Duration - 600mg q12h for 14-28 days
• Clinical trials - high dose 600mg q12h cure rate 50% for Bacteremia, low dose 200mg q12h cure rate 29% for Bacteremia. Pneumonia 67% for high dose and 0% for low dose. Skin/ Skin Structure infections 69% for high dose and 100% for low dose

2. Nosocomial pneumonia

• Susceptible organism - MSSA, MRSA, pen-susceptible Strep. Pneumo
• Dosage/Duration - 600mg q12h for 10-14 days
• Clinical trials - cure rates Staph. aureus 61% (Vancomycin cure rate 61%), MRSA 59% (Vanco cure rate 70%), Strep. Pneumonia 100% (Vanco cure rate 90%)

3. Community acquired pneumonia

• Susceptible organism - MSSA, pen-susceptible Strep. Pneumoniae
• Dosage/Duration - 600mg q12h for 10-14 days

4. Skin/skin structure infections both complicated and uncomplicated

• Susceptible organism - MSSA, MRSA, Strep. pyogenes and agalactiae
• Dosage - complicated is 600mg q12h for 10-14 days; uncomplicated is 400mg q12h for 10-14 days
• Cure rates - 90% for Zyvox (85% for oxacillin)

*(The above information excerpted from product information binder by Pharmacia Upjohn " New Zyvox linezolid injection, tablets, and for oral suspension " )

Examples of prescribing quantities for 10 or 14 day supply as follows:

Route	Strength	10 days	14 days
Tabs 600 mg bid	600mg/tab	20 tabs	28 tabs
Oral Suspension 600 mg bid	100mg/5ml	600 ml	840 ml
IV 400 mg bid	2mg/ml	4000 ml	6400 ml
IV 600 mg bid	2mg/ml	6000 ml	8400 ml

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• All prescriptions for Zyvox must be prior authorized.
• The toll free ZYVOX prior authorization number is 1-877-309-9493.
• Access to the prior authorization system for Zyvox will be Monday-Friday, 9 a.m.- 8 p.m.; Saturday and Sunday, 9 a.m.-5 p.m. A voice interactive phone system (VIPS) for this program is under development that will make the prior authorization system available 24 hours a day, 7 days a week. Prescribers and pharmacies will be notified when the VIPS is operational.
• Prescribers will be required to call a toll free telephone number and respond to a series of questions that identify the prescriber, the patient and the reason for prescribing. An eight-digit prior authorization number will be issued following completion of the questions. The eight-digit prior authorization number must be entered on the face of the prescription.
• The completed prescription may be filled at any NYS Medicaid enrolled pharmacy that stocks the drug.
• Phone and fax orders for Zyvox will be allowed. The prescriber is required to provide the pharmacy with the original prescription within five business days.
• Pharmacists should review the prescription for all information necessary to fill the prescription according to New York State Medicaid parameters and look for an eight-digit prior authorization number on the face of the prescription, fax, or telephone order.
• Pharmacists will be required to call the toll free telephone number and enter the issued prior authorization number. Pharmacists must respond to a series of questions that identify the pharmacy, their Medicaid category of service and drug. The pharmacy will get an error message that directs them to contact the prescriber if the pharmacy enters information that does not match the prescriber input.
• Pharmacy response to the prior authorization system is not expected to take more than a few minutes of telephone time.
• Dispensing must occur on or after the date the prior authorization number is issued and within 14 days of the order date otherwise the claim will not be paid.
• Fill the prescription on-line by placing the correct information into the prior authorization code field. The NCPDP format for this field uses the number " 1 " followed by the eight-digit prior authorization number and then three zeroes/co-pay exemption values. Please check with your software vendor prior to submitting a claim regarding your ability to submit for this drug. No more than two claims can be submitted in one transaction with different prior authorization numbers. Refer to the ProDUR/ECC Provider Manual for complete instructions. Systems questions regarding electronic claims capture should be directed to Deluxe Data at 1-800-343-9000.
• If the pharmacy is billing manually, only the eight-digit prior authorization number is required for the prior authorization field.
• The eight-digit prior authorization number must be entered on the claim to receive payment. Prior authorization does not guarantee payment. Payment is subject to patient eligibility and other Medicaid guidelines.
• Verify and transcribe all prior authorization numbers correctly. If a claim is submitted electronically and the prior authorization number is transcribed incorrectly, the claim will go through electronically but payment will be denied by Computer Sciences Corporation. These claims, if authenticated, can be resubmitted via paper using the correct prior authorization number.
• Prescriptions will be limited to a maximum of a 28 tablet or 900 ml of suspension or 8400 ml of IV solution for a 14 day supply. Continuation beyond 14 days of therapy will require a new prescription and a new prior authorization number.
• Payment for claims that exceed the 14 day/28 tablet/900 ml of suspension limit/8400 IV solution per single prior authorization number will be recouped.
• No refills for this agent will be allowed. If additional Zyvox is required, the prescriber must obtain a new prior authorization number and the pharmacy must be in receipt of a new prescription.
• Zyvox is not reimbursable to pharmacies on an outpatient basis for patients who have a Temporary Medicaid Authorization.
• The back of this page has a list of questions that will need response and the proper format for responding. Fill in the information and have this information in front of you before calling into the prior authorization system. You should reproduce the blank form for future Zyvox dispensing.

For technical assistance or policy questions, contact the NYS Department of Health, Pharmacy Policy and Operations Unit at (518) 486-3209.

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ZYVOX (linezolid) Indications*

1. Vancomycin resistant infections including concurrent bacteremia

• Susceptible microorganism - Vancomycin-resistant Enterococcus faceium
• Dosage/Duration - 600mg q12h for 14-28 days
• Clinical trials - high dose 600mg q12h cure rate 50% for Bacteremia, low dose 200mg q12h cure rate 29% for Bacteremia. Pneumonia 67% for high dose and 0% for low dose. Skin/ Skin Structure infections 69% for high dose and 100% for low dose

2. Nosocomial pneumonia

• Susceptible organism - MSSA, MRSA, pen-susceptible Strep. Pneumo
• Dosage/Duration - 600mg q12h for 10-14 days
• Clinical trials - cure rates Staph. aureus 61% (Vancomycin cure rate 61%), MRSA 59% (Vanco cure rate 70%), Strep. Pneumonia 100% (Vanco cure rate 90%)

3. Community acquired pneumonia

• Susceptible organism - MSSA, pen-susceptible Strep. Pneumoniae
• Dosage/Duration - 600mg q12h for 10-14 days

4. Skin/skin structure infections both complicated and uncomplicated

• Susceptible organism - MSSA, MRSA, Strep. pyogenes and agalactiae
• Dosage - complicated is 600mg q12h for 10-14 days; uncomplicated is 400mg q12h for 10-14 days
• Cure rates - 90% for Zyvox (85% for oxacillin)

*(The above information excerpted from product information binder by Pharmacia Upjohn " New Zyvox linezolid injection, tablets, and for oral suspension " )

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Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid Management Information System (MMIS), announces the following schedule of Introductory Seminars. Topics will include:

• Overview of MMIS
• Explanation of MMIS Provider Manual
• Discussion of Medicaid Managed Care
• Overview of Billing Options
• Explanation of 90-day Regulation
• Explanation of Utilization Threshold Program

Please indicate the seminar(s) you wish to attend below:

January 23, 2001   10 AM
Computer Sciences Corporation
3rd Floor
800 North Pearl Street
Albany, NY

January 24, 2001   10 AM
Nassau County Department of Social Services
101 County Seat Drive
Mineola, NY

February 14, 2001   10 AM
Westchester County Department of Social Services
85 Court Street
White Plains NY

February 27, 2001   1 PM
Utica, NY (address to be announced

March 1, 2001   1 PM
Mexico, NY (address to be announced)

March 14, 2001   10 AM
Putnam County Department of Social Services
Old Route 6
Carmel, NY

Other seminars may be scheduled as new programs are implemented or changes to existing billing procedures are announced.

Please complete the following registration information:

Provider Name:__________________________________
Provider ID:__________________
Provider Category of Service:________________________________
Number Attending:__________
Contact Name:____________________________________
Phone Number:______________________

If the seminar address is not listed above, a CSC representative will contact you at least two weeks prior to the seminar date to confirm attendance and provide seminar address information. Each seminar will last approximately two hours. Providers who have questions about these seminars can call CSC at the following numbers:

Practitioner Services     (800) 522-5518   (518) 447-9860
Institutional Services     (800) 522-1892   (518) 447-9810
Professional Services     (800) 522-5535   (518) 447-9830

To register, please mail this completed page to:

Computer Sciences Corporation
Attn.: Provider Outreach
800 North Pearl Street
Albany, NY 12204

Or, you may fax a copy of the completed page to: 518-447-9240

Note: Please keep a copy of your seminar choice for your records. No written confirmations will be sent.

Thank you for participating in New York State's Medicaid program.

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As you are aware, Medicaid fees for certain procedures were increased effective October 1, 2000. For specific information on the fee changes, access the practitioner notification at http://www.health.state.ny.us/health_care/medicaid/fees/index.htm.

The answers to the most frequently asked questions on the fee increase are as follows:

1. Is the $30 office visit fee applicable to Article 28 (clinic) based physicians or to physicians treating patients in the nursing home?
   • No. The $30 office visit fees are payable only to physicians who treat the patient in their private office setting.
     Physicians working in Article 28 hospital-based and free standing clinics which do not have their services included in the clinic rate should continue to bill the appropriate " hospital evaluation and management " procedure codes (see pages 7-3 and 7-30 of the MMIS Physicians Provider Manual). Similarly, physicians who treat patients in a nursing home whose services are not included in the nursing home rate should continue to bill the appropriate nursing home visit MMIS procedure codes (see pages 7-49 of the MMIS Physicians Provider Manual).
2. Does the fee increase apply to physician consultation services?
   • No. The fees for physician consultation services have not changed.
3. Does the fee increase apply to Medicaid payment for PPAC services?
   • No. The fees for the PPAC Program have not changed.
4. Does the fee increase apply only to general practitioners and other primary care physicians, or does it apply to all physician specialties?
   • The fee increase applies to primary care physicians, as well as to physician specialties who may bill office visit fees as appropriate. Please call the Department of Health, Bureau of Program Guidance at 518-474-9219 if you have questions on billing.
5. How do I adjust previously submitted claims for dates of services on and after October 1 which were paid at the lower fee so that I can get reimbursement for the increased fee?
   • You should follow the instructions in the Billing Section 3.0, of your MMIS Provider Manual, which describes how to adjust paid claims. If you need assistance, please contact the Practitioner Services Unit, Computer Sciences Corporation, at 1-800-522-5518 or 518-447-9860.
6. Why are the ER physician fees only raised from $12.50 to $17.00, when the office visit fees have been raised to $30?
   • State law specifically appropriated $2 million dollars for increasing physician specialist fees. The Department used the funding to increase anesthesia fees (increase in the conversion factor from $5 to $10) and to increase ER physician fees (for physicians with specialty code 250).
     Other physician specialist fees were not increased.
     In contrast to the $2 million specifically appropriated in State statute for increasing physician specialist fees, State statute specified that physician office visit fees be increased to $30 per visit.
     Additionally, the office visit fee includes the physician's professional fee and the overhead cost of running the office (rent, utilities, salaries, and equipment). When an emergency room service occurs, the Emergency Medicine Physician specialist is paid $17.00 and the hospital is paid the emergency room rate. The latter payment covers the overhead costs of operating the emergency room where the service occurs.
7. Is the $17 fee for procedure codes 99281-99285 payable to any medical specialist providing services in the Emergency Department?
   • Physicians who provide services in the hospital emergency room and whose services are not included in the emergency room rate should continue to bill procedure codes 99281 through 99285 as appropriate (Emergency Department Services, New or Established Patient). However, the enhanced fees will only be paid to physicians who have a physician specialty in Emergency Medicine (Physician Specialty Code 250).
     To receive the enhanced fee, the physician's specialty credential must be submitted to and verified by Medicaid Provider Enrollment. If a physician has the specialty but has not submitted his credentials he or she will be paid the lower emergency room visit amount.
8. If I am already enrolled in the Medicaid program but my MMIS Provider ID Number is now inactive, what needs to be done to activate the ID number?
   • Please contact the NYS Department of Health, Office of Medicaid Management's Division of Provider Relations at 518-486-9440 for assistance with your enrollment status.
9. Does Medicaid plan to increase the dispensing fee for eyeglasses?
   • The office visit fee for an optometry exam is included in the office visit fee increases and was increased to $30.00 effective October 1, 2000. The dispensing fee for eyeglasses has not changed.

All other questions should be directed to the NYS Department of Health, Bureau of Policy Development and Agency Relations at 518-473-5873.

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The Medicaid program places maximum quantity edits on all reimbursable NDCs. Quantity limits are based upon FDA approved indications, appropriate medical treatment, storage considerations, and packaging guidelines. Quantity edits are continually reviewed and updated.

Providers should be aware of these edits when transmitting claims on-line and not override them. Some edits are intended to prevent inadvertent billing errors, especially when billing for injectable products. Most powder filled injectables are reimbursed as " each unit. " Injectable products such as Fragmin, Lovenox, and Neupogen syringes are billed by the milliliter. The quantity of vials or syringes dispensed for these types of medications must first be converted to the appropriate quantity of milliliters before billing. Providers experiencing problems with quantity edits should contact the NYS Department of Health, Pharmacy Policy and Operations Unit at 518-486-3209.

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In the MMIS Pharmacy and DME Provider Manuals (Rev. 7/00), prices are listed for specialized and modular component enteral formulae:

CODE	PRODUCT	QUANTITY	PRICE
B4154	#Enteral formulae; Category IV: defined formula for special metabolic need, 100 calories=1 unit	up to 600 caloric units/month	$0.8494* per caloric unit
B4155	#Enteral formulae, Category V: modular components, 100 calories=1 unit	up to 600 caloric units/month	$2.2940 * per caloric unit

Reimbursement is limited to the lower of the actual acquisition cost (by invoice to the provider) plus 50%, or the usual and customary charge to the general public. When billing for codes B4154 and B4155, providers may either:

1. Charge up to the price listed (Pharmacy claims may be submitted electronically), or
2. When the charge is greater than the price listed (*), use "By Report" (BR) rules. When billing BR, appropriate documentation (e.g.: itemized invoice) indicating the total cost of the item, and any other factors that may be pertinent, must be submitted with the claim.

(Please note: The calculation for billing Enteral Formulae is as follows: Number of calories per can divided by 100 equals the number of caloric units per can. When the code description is preceded by a " # ", Electronic Medicaid Eligibility System (EMEVS) dispensing validation is required.)

Questions may be directed to the NYS Department of Health, Bureau of Medical Review and Payment at (518) 474-8161.

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Tobacco-Free Awareness Week will be celebrated January 14-20, 2001 in New York State. The tobacco coalitions and health partners, such as the American Lung Association and the American Cancer Society, have been invited to participate in a health and tobacco fair on the Concourse Level of the Empire State Plaza in Albany on January 16-18, 2001. In December, an educational packet with a fill-in-the-blank press release, public service announcements, proclamation for an official to sign, suggested community activities to prevent tobacco use, as well as fact sheets and brochures on smoking prevention, treatment and cessation, will be mailed to county health departments and health educators and professionals. If you would like to receive a free packet, call (518) 474-5370 or write Publications, Box 2000, Albany, NY 12220.

The New York State Medicaid program supports this effort and reminds our providers that Medicaid covers prescription and non-prescription tobacco cessation products. For additional information on tobacco cessation products and coverage, call the NYS Department of Health, Division of Provider Relations at 518-474-9219.

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As noted in your MMIS Pharmacy Provider Manual (Rev. 7/00) or your MMIS DME Provider Manual (Rev. 7/00) as specified below, the following items had price changes effective July 1, 2000. When the description is preceded by a "#", Electronic Medicaid Eligibility Verification System (EMEVS) dispensing validation (DVS) is required.

CODE	PRODUCT	PRICE	MANUAL
Z2638	#Spacer, bag or reservoir without mask, for use with metered dose inhaler	16.50	Pharmacy
Z2639	#Spacer, bag or reservoir with mask, for use with metered dose inhaler	27.75	Pharmacy
A4614	Peak expiratory flow meter, hand held	19.24	Pharmacy/DME

These items are now available from the following category of service providers:

• 0161 - D/T Clinic/Pharmacy
• 0261 - Home Health Agency, Medical/Surgical Supply and Equipment
• 0262 - Personal Care Agency, Medical/Surgical Supply and Equipment
• 0288 - Hospital Pharmacy
• 0321 - Medical Equipment, Appliance, Supply Dealer
• 0441 - Pharmacy, Free Standing
• 0442 - Pharmacy, Medical Supplies, Equipment and Appliances
• 0604 - Transportation/DME

Please retain a copy of this notice in your MMIS Provider Manual. If you have questions, call the NYS Department of Health, Bureau of Program Guidance at (518) 486-3209.

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The NYS Department of Health, Medicaid Pharmacy Policy & Operations Unit has received a large number of calls from pharmacy providers requesting correct or billable National Drug Codes (NDCs). It appears that pharmacists may be billing computer generated NDCs instead of the NDC on the actual package being dispensed.

To assure that you bill Medicaid correctly, verify that the computer generated NDC number is the same as the number on the bottle from which you are dispensing. Please contact Computer Sciences Corporation at 1-800-522-5535 to confirm whether a particular NDC number is covered. You may contact the State Medicaid Pharmacy Policy and Operations Unit at 518-486-3209 to inquire if a NDC number should be added to the Medicaid List of Reimbursable Drugs.

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As noted in the October 2000 Medicaid Update, effective for dates of service on or after December 1, 2000, claims for compounded prescriptions must be submitted using the NDC codes for the ingredients. Codes Z0900 Ointment, Z0920 Lotion, Z0930 Cream, Z0940 Capsule, Z0950 Tablet, and Z0960 Other, are discontinued.

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In support of Governor Pataki's and Commissioner Novello's smoking cessation initiative, the Medicaid program began coverage of prescription smoking cessation products effective October 1,1999 and non-prescription products effective February 15, 2000. Over the last year, various guidelines and resources have been documented in the Medicaid Update. The following is a compilation of the articles that have been published. If you have any questions about the NYS Medicaid program's Smoking Cessation Initiative, please contact the NYS Department of Health, Bureau of Program Guidance at 518-474-9219.

Coverage Guidelines

• Smoking cessation therapy consists of prescription and non-prescription agents. Covered agents include nicotine patches, inhalers, nasal sprays, gum, and Zyban (bupropion).
• Two courses of smoking cessation therapy per recipient, per year are allowed. A course of therapy is defined as no more than a 90-day supply (an original order and two refills, even if less than a 30 day supply is dispensed in any fill).
• Multiple smoking cessation therapies, using different routes of administration, are allowed (e.g., Zyban and nicotine patches may be used concomitantly if warranted). Professional judgement should be exercised when prescribing/dispensing multiple smoking cessation products.
• Duplicative use of any one agent is not allowed (i.e., same drug/same dosage form/same strength).

Previous articles on smoking cessation published in the Medicaid Update are available on-line. The following are some of the topics addressed.

DECEMBER 1999
Free Smoking Cessation Resources

JANUARY 2000
Medicaid Smoking Cessation Initiative: Toll Free Smoker's Quitline

FEBRUARY 2000
Tobacco Free Awareness

MARCH 2000
Smoking Cessation Supports

MAY 2000
Smoking and Diabetes

JUNE 2000
Smoking and Pregnancy

JULY 2000
Teens and Smoking

AUGUST 2000
Tobacco-Free Women and Girls

SEPTEMBER 2000
Smoking Cessation and Weight Control

OCTOBER 2000
NYS Quitline Gears up for the Great American Smokeout--November 16, 2000


To access these articles on-line, go to:

http://www.health.state.ny.us/health_care/medicaid/program/main.htm

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The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210
(e-mail MedicaidUpdate@health.state.ny.us )

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site: http://www.health.state.ny.us/health_care/medicaid/program/main.htm