Apple Health: Dental-related prescriptions and prescriptions covered under fee-for-service (FFS)

Trouble viewing this email? View as a web page.

Health Care Authority (HCA) logo

Apple Health (Medicaid) Provider Alert

Dental-related prescriptions and prescriptions covered under fee-for-service (FFS) 

Dear pharmacy providers,  

Washington Apple Health, administered by the Health Care Authority, would like to remind pharmacies that the following dental services for Apple Health clients are covered under fee-for-service (FFS)—even for those clients whose primary coverage is through an agency-contracted managed care organization (MCO):

  • Dental-related prescriptions
  • Prescriptions written by dentists

If a prescription is rejected by an MCO because it is written by a dentist, please do not attempt to charge the client or turn the client away.

For information on additional products and services which are covered under FFS for MCO clients, see pages 97 and 98 of the Prescription Drug Program Billing Guide.

How do I handle these claims?

These claims must be billed directly to the Health Care Authority, through FFS.

In some cases it may not immediately be clear that the reason for rejection is that the prescription was written by a dentist or dental surgeon. Depending on the pharmacy benefit manager (PBM), claims may reject with reasons such as:

  • “Restricted Provider”
  • “Prescriptive Authority Restrictions Apply”
  • An indication that the prescriber is out of network. If a prescription for an MCO client is written by a dentist or prescribed for the purposes of dental care, bill the claim directly to Washington Apple Health by entering Prior Authorization Type Code 2 (field 461-EU of the Claim Segment in the NCPDP claim standard).