This bulletin applies to NC Medicaid Managed Care.
What is 42 CFR Part II?
42 CFR Part II regulations prohibit the disclosure of patient records absent patient consent. Disclosure means to communicate any information identifying a patient as being or having been diagnosed with a substance use disorder (SUD), having or having had a SUD, or being or having been referred for treatment of a SUD.
Records include information regarding diagnosis, treatment, referral for treatment, billing information, emails, voice mails and texts. Withdrawal management means the use of pharmacotherapies to treat or attenuate signs and symptoms arising when heavy and/or prolonged substance use is reduced or discontinued.
New PA is Required for Patients Subject to 42 CFR Part II
To ensure a smooth transition of care during the launch of the Behavioral Health and Intellectual and Developmental Disabilities (I/DD) Tailored Plans, Tailored Plans were required to ingest existing PAs to reduce administrative burden and improve patient experience, with the exception of PAs subject to 42 CFR Part II. Because of this exception, providers will need to resubmit previously approved pharmacy PAs to the member’s new health plan.
During the transition of care period, through Sept. 30, 2024, if a pharmacy is having an issue with filling a SUD prescription refill due to missing PA not on file, the pharmacy should reach out to the member’s Tailored Plan Pharmacy Help Desk and let them know that the member was previously receiving the medication. The Pharmacy Help Desk will assist in obtaining support to override the PA rejection.
Tailored Plan Pharmacy Help Desk Numbers:
Alliance Health: 1-855-759-9300
Partners Health Management: 1-866-453-7196
Trillium Health Resources: 1-866- 662-0277
Vaya Health: 1-800-540-6083
Prescribers can also call the Pharmacy Help Desk (numbers listed above) to receive assistance with submitting a new PA for these medications.
For more details on the transition flexibilities for Tailored Plan launch, please see Flexibilities to Ease Provider Administrative Burden at Tailored Plan Launch.
Ongoing, providers prescribing SUD medications should work to resubmit SUD pharmacy PAs to the member’s health plan when a member transitions from one health plan to another.
Contact
For questions, please contact health plans leveraging the information on the Health Plan Contacts and Resources page.