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West Virginia Income Maintenance Manual Chapter 28

West Virginia Income Maintenance Manual Page 20 Chapter 28 Special Pharmacy

28.14 ANTIPSYCHOTIC (ATYPICAL) DRUG MANAGEMENT AND TESTING Individuals for whom antipsychotic (atypical) drugs have been prescribed, and who are not eligible for Medicaid due solely to failure to meet a spenddown, may have the cost of the medication paid by the Department of Human Services (DOHS). To qualify, it must be established that the cost of the antipsychotic drugs, if paid by the client, would reduce the family’s income to below 100% of the Federal Poverty Level (FPL) for a family of the same size. The individual must have been denied Medicaid for the above reason within six months of the date of the client’s request for payment. In addition, the Worker must review the case every six months to determine if the client remains ineligible for failure to meet a spenddown. If he continues to be ineligible for Medicaid due solely to failure to meet a spenddown at the time he requests payment of the antipsychotic (atypical) drugs, special approval is considered. The Worker must submit a completed DFA-SP-1 to the Bureau for Medical Services (BMS) Medicaid Policy Unit to have the client considered for this special approval. The form must contain all of the information specified in Section 28.3.1, with the following additions: • The average monthly out-of-pocket cost of antipsychotic drugs; • The average monthly cost of lab tests; and • The name of the facility that will perform the lab tests. No verification of the information submitted is required, unless the client does not know the information, or the Worker has reason to doubt the client’s statement. Certain recipients of benefits from the Office of Children and Adult Services (CAS) are eligible to receive coverage for immunosuppressant drugs through the child welfare information system. During the application or renewal process, the Worker must inquire if the Special Pharmacy applicant is receiving medical coverage through CAS. If the Worker believes the individual may be receiving duplicate coverage or services through both the child welfare information system and the eligibility system, the Worker must electronically notify the BMS Medicaid Policy Unit with the following information: • Applicant/Recipient’s Name • Date of Birth • Social Security Number (SSN) • Client’s child welfare information system ID (if known) Once the eligibility decision is made, the local office is notified by BMS Medicaid Policy Unit. The local office must notify the client of the decision in writing. BMS will notify the service provider and the service provider will notify the client how to obtain payment for