Medicaid Pharmacy Benefit Management
Information regarding the Medicaid Pharmacy Benefit Management program
To reduce NH Medicaid spending while still ensuring access to quality care, the Department of Health and Human Services (DHHS) implemented NH Medicaid Pharmacy Benefit Program initiatives as indicated below. Prime Therapeutics State Government Solutions (Prime) is the Pharmacy Benefit Administrator for NH Medicaid.
Preferred Drug List
The Preferred Drug List (PDL) on the Prime website is a list of effective prescription drugs within therapeutic drug classes. These drugs are the recommended first choice when prescribing for NH Medicaid patients. To request a non-preferred drug, fill out the Preferred Drug List Non-Preferred Drug Approval Form.
Clinical Prior Authorization
The Clinical Prior Authorization (PA) Program criteria was implemented to improve quality and manage drug classes that have been identified as requiring additional monitoring. This program is also intended as a means of ensuring that drugs are being prescribed for the right patients and for the appropriate reasons, while still monitoring drug expenditures. The Clinical PA criteria can be found on the Prime website under Resources - Forms & Documents - Select Type of Documents - Clinical PA Criteria. Request forms for these drugs can be found on the Prime website under Resources - Forms & Documents - Select Type of Documents - Fax Forms.
Helpful Pharmacy Information
Important Resources
Over the Counter Drugs
NH Medicaid covers over the counter drugs that are medically necessary. Only generic versions of certain over the counter drugs are covered.
NH Medicaid does not pay for:
- Over the counter (OTC) items to maintain comfort or treat discomfort;
- Any items, both prescription and OTC, to treat coughs and colds;
- OTC vitamins (NH Medicaid will cover prescription prenatal vitamins.)
Pharmacy Quantity Limits
A pharmacy quantity limit is the maximum allowable quantity of a drug that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed. Prescribers who have questions about this information or have patients with unique clinical needs may call the Prime Technical Call Center at 1-866-664-4511.
Maximum Allowable Cost
The Maximum Allowable Cost (MAC) Price Research Request Form on the Prime website allows a provider to request a review of the NH Medicaid pricing for multi-source generic drugs. The proprietary MAC list is updated weekly and managed by Prime.
90 Day Supply for Maintenance Medications
Maintenance medications are those pharmaceuticals that have been previously prescribed for the recipient for the treatment of chronic diseases. Treatment must have been for continuous daily therapy of at least 120 days duration.
If you have any questions, you may contact the DHHS Customer Service Center at 1-844-ASK-DHHS or Prime Client Services at 1-866-664-4506.
What are the advantages of a Preferred Drug List (PDL)?
The PDL provides continued access to prescription medications while ensuring that Medicaid pays the lowest cost for medications. All drugs currently covered will remain available to Medicaid recipients; however, non-preferred drugs will require prior authorization by the prescriber.
How are drugs placed on the PDL?
Drugs within specified therapeutic drug classes will be approved for the PDL based on safety and clinical efficacy first, and then based on cost.
What are the criteria for non-PDL drug approval?
The prescriber will determine and document that the non-preferred drug is medically necessary. The criteria for approval were recommended by the Drug Utilization Review (DUR) Board
Why isn't there a specific list of non-covered or excluded medications?
There are over 98,000 over the counter drug packages. The number of drugs is too large to list individually, thus Medicaid has provided a listing by therapeutic class of covered OTC drugs.
How do I request a prior authorization?
Requests for prior authorization must be initiated by the prescriber and may be initiated via phone, fax or mail. The Prime Therapeutics phone number is 1-866-675-7755 and the fax number is 1-888-603-7696.
How are the clinical criteria determined?
The Drug Utilization Review (DUR) Board recommends the specific clinical criteria. The DUR is composed of practicing pharmacists and physicians.
How often are the drugs and clinical criteria reviewed?
DHHS periodically reviews the drugs and the clinical criteria. Updates to the list of drugs and the clinical criteria are made in accordance with current clinical practices.
Who can I contact for more information on clinical criteria?
Prescribers may call the Prime Therapeutics Clinical Call Center at 1-866-675-7755. Recipients who have questions may call the DHHS Customer Service Center at 1-844-ASK-DHHS (1-844-275-3447) (TDD Relay Access: 1-800-735-2964), Monday–Friday, 8:00 a.m.–4:00 p.m. ET.
Medicaid Care Management (MCM) Prescription Drug Information
The links below will take you directly to the Medicaid health plans participating in the Medicaid Care Management (MCM) program. Questions and requests should be referred directly to the health plan.
