April 2022 Apple Health PDL changes

Washington State Health Care Authority sent this bulletin at 05/09/2022 03:11 PM PDT

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April 2022 Apple Health PDL changes

On April 1, 2022, Apple Health (Medicaid) contracted managed care (MCO) and fee-for-service (FFS) plans made changes on the Apple Health Preferred Drug List to make some brand name products preferred and their associated generic products non-preferred with prior authorization required.

After considering feedback received from the provider community, Apple Health (Medicaid) will be reversing the changes made to the generic products listed in the table below. Brand name products will continue to be preferred. This change will be made retroactive to dates of service on or after April 1, 2022.

Apple Health (Medicaid) contracted MCO and FFS plans will make these changes as soon as possible, but no later than June 1, 2022.

Apple Health (Medicaid) FFS discovered an issue with the reimbursement on the brand name products listed below. This issue has been resolved. For all claims submitted between April 1, 2022 and April 27, 2022, Apple Health (Medicaid) FFS will submit a mass adjustment to correct the payment for these products. If you have a claim that was under paid, you may also reverse and reprocess the claim to get the brand name reimbursement rate.

If you have any questions, please email applehealthpharmacypolicy@hca.wa.gov

Generic Products that will change to preferred by June 1, 2022

Brand Products that will be reprocessed for dates of service 4/1/2022 thru 4/27/2022

AMPHETAMINE/DEXTROAMPHETAMINE

METHYLPHENIDATE HYDROCHLORIDE ER

DIAZEPAM RECTAL GEL

CARBAMAZEPINE ER

DIVALPROEX SODIUM

CLONIDINE HCL

BUDESONIDE/FORMOTEROL FUMARATE DIHYDRATE

FLUTICASONE PROPIONATE/SALMETEROL

FLUTICASONE PROPIONATE/SALMETEROL DISKUS

MESALAMINE ER

MESALAMINE DR

ADDERALL XR

ADVAIR DISKUS

APRISO

CARBATROL

CATAPRES-TTS-1

CATAPRES-TTS-2

CATAPRES-TTS-3

CONCERTA

DEPAKOTE SPRINKLES

DIASTAT ACUDIAL

DIASTAT PEDIATRIC

LIALDA

SYMBICORT

TEGRETOL-XR

About the Health Care Authority (HCA)

The Washington State Health Care Authority (HCA) is committed to whole-person care, integrating physical health and behavioral health services for better results and healthier residents.

HCA purchases health care for more than 2.5 million Washington residents through Apple Health (Medicaid), the Public Employees Benefits Board (PEBB) Program, the School Employees Benefits Board (SEBB) Program, and the COFA Islander Health Care Program. As the largest health care purchaser in the state, we lead the effort to transform health care, helping ensure Washington residents have access to better health and better care at a lower cost.

Please do not reply directly to this message. For more information, visit the HCA website, where you'll also find contact information.

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