Retroactive Eligibility

Drug - Retroactive Eligibility

July 2011

Authorization will be granted for generic when brand is the preferred agent if:

• The recipient was not eligible for MHCP on the date the medication was filled AND
• The brand name is the preferred agent AND
• The pharmacy dispensed the generic product

The authorization for the generic drug will be limited to the retro eligibility period. 

Nursing Home Retroactive Eligibility

Important Note: Pharmacies serving nursing home residents are encouraged to consult the Minnesota Health Care Programs (MHCP) Preferred Drug List in advance of filling prescriptions for MHCP-eligible residents or residents who may be pending MHCP eligibility. Using preferred medications from the first fill will minimize the overall administrative burden for the pharmacy, the facility, and DHS.

Authorization will be granted for nursing home retroactive eligibility if:

• Recipient is a resident of a nursing home AND
• The recipient was not eligible for MHCP on the date the medication was filled AND
• Recipient was granted retroactive eligibility for MHCP
• The drug requested is eligible for coverage under state and federal law (rebating manufacturer, covered category, etc.) AND
• The drug requested is not a brand name for which a generic product is available AND
• The recipient is not enrolled in Medicare Part D OR
• The recipient is enrolled in Medicare Part D and the requested drug is an excluded category under Part D but is otherwise eligible for coverage under MHCP

In order to meet retroactive eligibility criteria, recipients must NOT be enrolled in MHCP on the date of dispensing. If the patient was enrolled in MHCP but the pharmacy did not check eligibility on the date of dispensing, the prescription must meet MHCP drug-specific PA criteria for payment approval.

Authorization for additional fills will be granted only if the recipient meets the MHCP drug-specific PA criteria.

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411