471 Neb. Admin. Code, ch. 16, § 013

Current through June 17, 2024

Section 471-16-013 - QUANTITY LIMITATIONS

The Department imposes the following quantity limitations on certain drugs.

013.01QUANTITIES NOT ALLOWED. Payment from Nebraska Medicaid will not be approved for:

(A) More than a three month supply of any maintenance medication:

(B) More than a one month supply of any controlled substance: and

(C) More than a one month supply of any injectable medication except insulin and those injectable drugs with a duration of greater than one month from one dose.

013.02QUANTITIES. The following types of limits may be utilized to ensure appropriate utilization and billing:

(A) Maximum quantity over time;

(B) Maximum daily dose;

(C) Maximum days' supply per fill;

(D) Maximum Quantity per fill;

(E) Minimum quantity per fill:

(F) Maximum cost per fill;

(G) Tablet splitting; and

(H) Number of units to require medication be submitted in multiples of the package size.

013.03INJECTIONS. The Department applies the following limitations to injectable drug products:

(A) Only those injections which are either self-administered by the client or are administered for the client at the client's place of residence are reimbursable. Injections administered by the provider or hospital are not reimbursable through the pharmacy services program:

(B) Whenever available and necessity warrants, multi-dose vials of medication are dispensed rather than single-dose vials or unit-dose syringes;

(C) Single-dose syringes may be reimbursed at the proportionate cost of a multi-dose vial;

(D) Maintenance injectable medications which are not reconstituted or admixed by the pharmacy prior to administration to the patient are dispensed and billed for the full month's supply;

(E) Non-maintenance injectable medications and those injectable medications which must be reconstituted or admixed by the pharmacy prior to administration to the patient including subcutaneous, intramuscular, and intravenous medication delivery by large volume parenteral, piggyback, syringe pump, or other methods may be provided at the pharmacist's discretion. Courses of therapy of ten days or less duration are billed at the end of the course of therapy. Courses of therapy of greater than ten days duration are billed at the end of the course of therapy or after each ten days of therapy;

(F) Injectable medications administered by implanted or similar devices may not be billed to the pharmacy services program when the device is filled in the clinic or hospital: and

(G) Total parenteral nutrition is billed through the Durable Medical Equipment and Medical Supplies program. This includes the amino acids, carbohydrates, lipids and all additives. All total parenteral nutrition-compatible additives are billed through the supplier program regardless of who completes the addition of the ingredient or the method of administration.

013.04MAINTENANCE DRUGS. The Department requires any other maintenance drug or any drug used in a chronic manner be prescribed and dispensed in a minimum of a one-month supply. Providers will not reduce prescriptions which are written for quantities larger than a month's supply to a month's supply. The Department considers prescription splitting to be fraudulent except when such reduction is done to comply with State or Federal regulations or statute.

013.05EXCEPTIONS TO QUANTITY LIMITATIONS. The Department allows the following exceptions to the quantity limitations of this subsection only for those clients receiving medications through a non-unit-dose system, except where noted otherwise:

(A) When the prescriber first introduces a maintenance drug to a patient's course of therapy, the prescriber may prescribe a smaller Quantity as his or her judgment dictates. Pharmacists must indicate this is the initial filling of the medication when filing the drug claim. Any subsequent dispensing of this maintenance drug must be prescribed and dispensed in at least a month's supply;

(B) When the prescriber's professional judgment indicates these Quantities of medication are not in the patient's best medical interest, the prescriber may prescribe as his or her judgment directs. This includes limitations for lock-in clients. The pharmacist must maintain documentation when an exception is being made to the Department's requirements;

(C) The Department will consider replacement of any lost, misplaced, or stolen drug products for clients only when the pharmacy provider or prescriber documents the conditions requiring replacement. The Department will require additional information prior to replacing controlled substances;

(D) Schedule II drugs are an exception to the quantity limitations. This also applies to unit dose systems, unless the Schedule II drug is used in a chronic or maintenance manner; and

(E) The Department will accept certain original shelf package sizes of medication, under the following conditions;

(i) An original shelf package of 480 ml or less when not packaged in the pint size, is sufficient for the quantity limitations requirement for liquids. This also applies to unit dose systems;

(ii) An original shelf package of 100 tablets or capsules, or less when not available in the 100 tablet or capsule size, for seldom-prescribed solid dosage drugs is sufficient for the quantity limitations requirement;

(iii) Original shelf packages of 100 tablets or capsules of routinely prescribed drugs are not acceptable as sufficient for fulfillment of the quantity limitations requirement. The full month's supply must be prescribed and dispensed; and

(iv) Ready-made ointments and creams, when used in a chronic or maintenance manner, may be dispensed in an original shelf package size provided the original size is closest to the needed amount of medication. This also applies to unit dose systems.

471 Neb. Admin. Code, ch. 16, § 013

Adopted effective 12/26/2021