Provider Update

Volume 13, Number 1 

January/February 1996

Message from the Project Manager

We would like to start 1996 on a positive note by welcoming the new Secretary of the Department of Health and Hospitals (DHH), Bobby Jindal, and John LaCour and David W. Hood, in the respective positions of Deputy Secretary and Undersecretary.  We look forward to working with these new members of the DHH, especially as we begin this new year with the implementation of new components to the Louisiana Medicaid Program.  As we enter 1996, federal and state agencies are closely examining new approaches to managed health care and their cost constraints.

The Department of Health and Hospitals has, in the past year, proposed to restructure the state Medicaid Program, incorporating more managed care concepts into the program with the 1115 Waiver.  While the federal approval of the Section 1115 Medicaid Waiver has not been finalized, this issue of the Provider Update contains a recent modification to the Medicaid Program that is based upon managed care concepts:  The Louisiana Medicaid Pharmacy Benefits Management (LMPBM) system.

The LMPBM represents many months of research, discussion, and planning by DHH representatives and health care industry professionals and associations.  These collaborations have resulted in a unique Pharmacy Benefit Management program for Louisiana; it is, in fact, the only Medicaid-incorporated program of its kind of this time in the United States.  The LMPBM is unique because it contains all the features of a traditional Pharmacy Benefits Management program - Point-of-Sale (POS), Drug Utilization Review, and patient and provider education programs - while featuring (among many innovations) an enhanced Pharmacy Network and a Pharmacy Provider POS Help Desk.  These innovations will facilitate disease and outcome management for the patient under the direction of the Medicaid Program.

It is envisioned that the LMPBM will become a component of intervention as well as education in the Louisiana Medicaid Program, one that will be used extensively by pharmacists, physicians, institutions, and patients.  The LMPBM represents an important directional shift for the Medicaid Program as well; it will continue to emphasize the health care needs of the patient, while at the same time balancing those needs with the needs and financial constraints of Louisiana providers and the Medicaid Program itself.

As the features of the LMPBM are phased in during the beginning months of this new year, we will provide updates of this unique benefit management program.  As always, we thank you for your continued health care support of Medicaid recipients, who comprise our Louisiana Medicaid Program.

Gary Hulshoff, Ph.D.

  Cancellation of Fertility Preparation Reimbursement

Effective since August 15, 1995, the Department will not reimburse for fertility preparations when they are used solely for the treatment of infertility.  This action is being taken in accordance with Act 991 of the 1995 State Legislature.  The drugs include Clomiphene citrate tablets 50mg, Urofollitropin ampules 75IU and 150IU, and Menotropins ampules 75IU and 150IU.

 If prescriptions for these products are prescribed for any indication other than infertility, the physician shall certify the indications, in his own handwriting, on the prescription or an attachment.

In order for the pharmacist to be reimbursed for the product, a hard copy claim along with a copy of the original prescription and all supporting documentation will have to be submitted to Unisys for processing.  The documentation must indicate a diagnosis other than infertility.

Fee Increase for CPT Code 32215

  The Bureau of Health Services Financing is pleased to inform you of an increase in fee for CPT code 32215 (Pleural scarification for repeat pneumothorax) to $362.42 effective with date of service January 1, 1996.

  Mental Health Rehabilitation Reimbursement Methodology

Effective December 1, 1995 and after, the Department of Health and Hospitals, Bureau of Health Services Financing, adopted a monthly flat fee reimbursement schedule for Mental Health Rehabilitation services. Services are prior authorized and reimbursed based on services specified in the 90-day strategy plan and are paid monthly contingent upon the delivery of 80 percent of the prorated 90-day services approved in the Mental Health Rehabilitation service agreement. The reimbursement rates and billing codes are as follows:

              Code               Description                                        Fee

            X0130             MHR Child/Youth Assessment              $800
            X0131             MHR Adult Assessment                         $700
            X0132             MHR Low Need Adult                             $250
            X0133             MHR Medium Need Adult                      $550
            X0134             MHR High Need Adult                            $1300  
            X0135             MHR Low Need Child                             $250  
            X0136             MHR Medium Need Child                      $800
            X0137             MHR High Need Child                            $1375

Please note that codes X0132 through X0137 will be reimbursed monthly, and codes X0130 andX0131 will be reimbursed based on the approval of the Mental Health Rehabilitation service agreement and will be paid semi-annually.

LADUR Education Article

Losartan: An Angiotensin II Receptor Antagonist

Robert L. Judd, Ph.D.
Assistant Professor of Pharmacology
Northeast Louisiana University
School of Pharmacy  

  Issues

• The side effects of traditional pharmacological agents used in treating hypertension make many people noncompliant with their drug therapy.  Losartan does not have those same effects.  
  
  

•  Losartan (Cozaar) is the first of unique class of hypertensive agents called angiotensin II (AG II) receptor antagonists.  
  
  

• Unlike ACE inhibitors, losartan has little effect on potassium concentrations even though aldosterone concentrations decrease during therapy.  
  
  

• This drug is very effective in the treatment of hypertension, whether in monotherapy or in the polytherapy approach.

Hypertension affects more than 43 million people in the United States each year, many of whom are noncompliant with their therapy because of side effects associated with their antihypertensive medication.  Traditional pharmacological agents used to treat this disease include beta blockers, diuretics, calcium channel blockers and angiotensin converting enzyme (ACE) inhibitors.  Losartan (Cozaar) is the first of a unique class of antihypertensive agents called angiotensin II (AG II) receptor antagonists.  Losartan, as monotherapy, appears to be less effective in controlling blood pressure in patients without renin-dependent hypertension.  Saralasin, a peptide, was the first AG II receptor antagonist discovered, but due to its poor pharmacokinetic and pharmacodynamic profiles it was not marketed.  Unlike ACE inhibitors, losartan has little effect on potassium concentrations even though aldosterone concentrations decrease during therapy.

While ACE inhibitors inhibit the actions of angiotensin II (AG II) by preventing its formation from AG I, losartan interferes with the binding of formed angiotensin II to its endogenous receptor.  Thus, losartan and a metabolite (EXP-3174) that is 10-40 times more potent by weight directly antagonize the actions of AG II by reversibly, non-competitively binding to the Type 1 angiotensin receptor (AT₁).  Losartan and its metabolite have no agonist activity at the AT₁ receptor.  AGII is the primary vasoactive hormone of the renin-angiotensin system and plays an important role in the pathophysiology of hypertension.  Besides being a potent vasoconstrictor, AG II stimulates aldosterone secretion by the adrenal gland.  AT₁ receptors are found in many tissues, including vascular smooth muscle and the adrenal gland.  Type 2 angiotensin (AT₂) receptors are also found in many tissues, although their relationship to cardiovascular hemostasis is not known.  The affinity of losartan and its metabolite is about 1000-fold greater for the AT₁ receptor than for he AT₂ receptor.  Neither losartan or its metabolite inhibit the angiotensin converting enzyme, other hormone receptors, or ion channels.

Losartan is administered orally, with or without food.  The usual starting does is 50mg once daily, with 25mg used in patients treated with diuretics or in patients with a history of hepatic impairment.  If blood pressure is not controlled by losartan alone, a diuretic may be added at a low dose.  Trials conducted so far have indicated that the addition of a low dose of a diuretic in combination with losartan results in excellent control of the vast majority of hypertensive patients.  It is well absorbed, but undergoes substantial first-pass metabolism.  The systemic bioavailability is approximately 35%; about 14% of an oral dose is carboxylated in the liver to its active metabolite.  Oral bioavailability is approximately 2 times higher in patients with hepatic impairment.  Peak serum concentrations occur at 1 hour and 3-4 hours, respectively for the parent drug and metabolite.  Maximum serum concentrations are similar for losartan and its metabolite, but the AUC for the metabolite is approximately 4 times greater.  Food decreases the maximum concentration and slightly (around 10%) decreases the AUC.  Losartan and its active metabolite are highly protein bound, mainly to albumin.  The free fraction in plasma of losartan is 1.3% and 0.2% for its metabolite.

Losartan is metabolized to its active and inactive metabolites by cytochrome P450 2C9 and 3A4.  In 1% of patients, less than 1% of the active drug is metabolized to its active metabolite, compared with 15% in the majority of patients.  Total plasma clearance was 50% lower in patients with hepatic impairment.  Approximately 35% of the oral dose is renally excreted; overall 4% is excreted unchanged and 6% as metabolite is excreted in the urine.  Approximately 60% of a dose is excreted in the feces.  In patients with renal impairment (creatinine clearances 30ml/minute), AUCs are about 50% greater, and AUCs are doubled in hemodialysis patients.  Neither losartan or its active metabolite are removed by hemodialysis.  The terminal half-life of losartan is 2 hours and 6 hours for its active metabolite in patients without renal impairment.  The maximal effects of losartan usually occur within the first week of therapy, although in some studies maximal effect took 3-4 weeks.

Unlike ACE inhibitors, losartan does not cause cough and has not been associated with edema.  Insufficient clinical experience precludes detailed information regarding adverse reactions of AT₁ receptor antagonists.  Like ACE inhibitors, AT₁ receptor antagonists may cause hypotension in patients with high plasma renin levels and hyperkalemia in patients with renal disease or in patients taking potassium-sparing diuretics.  Also, as the ACE inhibitors AT1 receptor antagonists have fetopathic potential, and should be discontinued before the second trimester of pregnancy.  Losartan is generally well tolerated, with gastrointestinal complaints, headache, light-headedness, and musculoskeletal pains being the major complaints.  No clinically significant drug interactions have been reported for losartan.

In summary, losartan is the first member of a new group of antihypertensive drugs known as angiotensin receptor antagonists.  This drug is very effective, whether in the monotherapy or in the polytherapy approach.  Side-effect profile is similar to that of traditional ACE inhibitors.  Newer angiotensin receptor antagonists are currently in various stages of clinical development.

  References

Clinical Pharmacology (An Electronic Drug Reference and Teaching Guide), v. 1.5, Gold Standard Multimedia Inc.

S. Biro, "FDA Approves Losartan, First New Class of Antihypertensive in a Decade," Pharmacy Today, 1:11 (1995): 3.

J.G. Hardman, L.E. Limbird, et al., ed., "Renin and Angiotensin," Goodman and Gilman's The Pharmacological Basis of Therapeutics, 9 (New York:  McGraw-Hill, 1995):  733-758.

M.J. Robertson et al., "Angonist-Antagonist Interactions and Angiotensin Receptors:  Applications of a Two-State Receptor Mode," Trends in Pharmacological Sciences, 15 (1994):  364-369.

P.B. Timmerman et al., "Angiotensin II Receptors and Angiotensin II Receptor Antagonists," Pharmacological Reviews, 45 (1993):  205-251.

The Louisiana Medicaid Pharmacy Benefits Management (LMPBM) System

The Department of Health and Hospitals has implemented the Louisiana Medicaid Pharmacy Benefits Management (LMPBM) system, effective January 1996.  The LMPBM is a significant addition to the management initiatives underway in the Medicaid Program.

The goal of the LMPBM is for the Medicaid patient to receive the most appropriate pharmaceutical therapy in the most cost-effective manner.

The LMPBM integrates the existing components of traditional pharmacy program administration (Retrospective Drug Utilization Review, Formulary Management, Drug Rebates, Claims Management, Pharmacy Audit, Patient Education Program, Pharmacy Provider Network, and Provider Service) with new features, which include an enhanced Pharmacy Network, Pharmacy Provider POS Help Desk, Point-of-Sale (POS) electronic claims management network, a prospective drug utilization review system (ProDUR), a Patient/Physician/Pharmacist Education component, disease and outcomes management, and clinical interventions.

The LMPBM greatly enhances the existing features of the pharmacy program with the new components, allowing greater capability to determine if appropriate pharmaceuticals are being utilized for optimal disease management of the patient.

The LMPBM is administered by the Department of Health and Hospitals staff and through contracts with Unisys (Louisiana Medicaid Fiscal Intermediary), Northeast Louisiana University - School of Pharmacy, University of New Orleans, and an audit firm.  The Department has initiated an Interdisciplinary Medicine and Pharmacy Team to assist in the development of various educational intervention components.  The purpose of this team is to involve the medical and pharmacy schools in a joint effort to improve the understanding of pharmacoeconomics and clinical therapeutics through educational programs, journals, curriculum integration, and other educational initiatives.

The Point-of-Sale/Prospective Drug Utilization Review (POS/ProDUR) system will begin operation on April 1, 1996.  Incorporating the Point-of-Sale system will enhance the efficiency of processing and adjudicating drug claims at the point of sale.  Another feature of the POS technology is the prospective drug utilization review which enables the pharmacist to provide pharmaceutical therapeutic screening at the time of dispensing a patient's medication.  Participating providers will be electronically accessing the system by entering specific provider and recipient information.

The POS/ProDUR will be administered in accordance with the standards of the National Council of Prescription Drug Plan.  Pharmacy providers will choose one of the participating switching companies who will process data to the fiscal intermediary.  The POS system will then verify eligibility of the client and coverage of the drug, and then process the claim information in an on-line environment which adjudicates the claim and advises the provider as to the claim's disposition.  Simultaneously, the ProDUR system will process information about the patient and the drug through therapeutic modules.  The ProDUR modules may screen for drug interactions, therapeutic duplication, improper duration of therapy, incorrect dosages, clinical abuse/misuse, and age restrictions.  Information regarding the therapeutic criteria categories will be available to the dispensing providers.  Issues of overutilization/misutilization will be communicated to the dispensing provider as a means of educating the dispenser, prescriber, and the recipient.  The ProDUR system will reduce costly duplicate drug therapy, prevent potential drug to drug interactions, and assure appropriate drug use, dosage, and duration.  The Department will encourage the dispensing provider to interact with the prescriber to prevent adverse drug therapy outcomes and to ensure the health and safety of the patient.

Provider participation will include the following:

1. A point of sale enrollment amendment and certification will be required prior to billing POS/ProDUR system as well as an annual recertification.  
   
   

2. All Medicaid enrolled pharmacy providers will be required to participate in the Pharmacy Benefits Management System.  
   
   

3. All Medicaid enrolled pharmacy providers whose claim volume exceeds 100 claims or $4,000.00 per month and all providers enrolled on January 1, 1996 or after will be required to participate in the Point-of-Sale system.  Long term care pharmacy provider claims may be processed through Electronic Medical Claims (EMC).  
   
   

4. Providers accessing the POS/ProDUR system will be responsible for the purpose of all hardware for connection to the switching companies and any fees associated with connection to or transmission of information to the fiscal intermediary.  
   
   

5. The Bureau of Health Services Financing will not reimburse the provider for any ongoing fees incurred by the provider to access the POS/ProDUR system.  
   
   

6. Physician and pharmacy providers will be required to participate in the education and intervention features of the LMPBM.  
   
   

7. Disease management will be focused on improving drug therapy for certain disease states by developing procedures to assure direct interventions and increasing compliance of patients.

The Department's decision to administer these areas through the LMPBM will provide the capability to effectively manage health care dollars, to assure health care access, and to give he best quality of care for Medicaid recipients.  The impact of pharmaceutical care management will assure that the patient has received appropriate drug therapy in the most cost-effective manner.

Additional information regarding the LMPBM and the necessary forms will be mailed to enrolled providers in the upcoming weeks.  Provider training is scheduled to occur for enrolled providers and proper notification will be mailed to each provider.

Attention Pharmacy Providers

If you have not done so already, we encourage you to establish contact with "switch" vendors to establish your capability of submitting claims to Unisys through the Point-of-Sale (POS) system.  Unisys has already distributed POS technical  specifications to the following "switch" vendors:  Envoy (800/366-5716), Mede America (800/433-4893), NDC (800/388-2316), and QS-1.

Notice to Pharmacists:  LTC Facilities and Exemption from Pharmacy Copayments

Recipients in Long Term Care facilities with Type Case 25 and 63 have been added to those type cases exempt from pharmacy copayments.  This is retroactive to July 1, 1995.  Please submit adjustments to P. O. Box 91019, Baton Rouge, LA 70821 for claims which may have been incorrectly paid.

When submitting claim adjustments for recipients in Long Term Care facilities due to copayments being deducted incorrectly because our system did not carry Long Term Care identifies (other than Type 25 and 63 mentioned above), the pharmacy provider should submit the adjustment and a copy of BHSF Form 148 (Medicaid Program Notification of Admission or Change) to the following address:

                              Department of Health and Hospitals
                                   P. O. Box 91030 Box #24
                                   Baton Rouge, LA  70821
                                   ATTN:  Pharmacy Program

Facilities Whose Physicians May Bill the NICU Codes: 

New Listing as of January 1996  

Notice to Neonatologists:  Per Diem Rate Changes

Effective with date of service January 21, 1996, adjustments are being made in the per diem rates for neonatology professional services to the amounts listed below for the following procedure codes:

                                            CPT Code 99295 - $596.46
                                            CPT Code 99296 - $279.52
                                            CPT Code 99297 - $143.42
                                            CPT Code 99297-52 ("step-down"
                                             babies) $57.37  

Code J9391 Placed in Nonpay Status

Effective with date of service January 1, 1996, code J9391 - Carboplatin, 50mg vial - was placed in nonpay status. The code to bill in its place is J9045 (which is the code Medicare uses for Carboplatin, 50mg).  The fee for J9045 is $69.38.

Notice to Physicians:  CPT Codes 93797 and 93798

  Effective with date of service January 1, 1996, we will place CPT codes 93797 and 93798, which are cardiac rehabilitation procedures, into nonpay status.