This page includes information on the Nebraska Medicaid program's pharmacy services, including ones given to Medicaid members at the doctor's office and ones picked up at the pharmacy.
The pharmacy point of sale (POS) is a system that allows pharmacists to enter outpatient, self-administered prescription claims in real time into the payment system. Within seconds, providers receive confirmation that a claim has been processed. A POS system is most commonly used in a retail setting.
If you are assisting a Heritage Health member, please see the following guide:
Heritage Health pharmacy reference guide
Heritage Health pharmacy reference guide (New August, 2021)
Physician-administered drugs are administered by medical professionals in a physician or outpatient clinic. Nebraska Medicaid fee-for-service reimburses for rebate-eligible National Drug Codes (NDCs), which must be billed with a valid healthcare common procedure code system (HCPCS) or current procedural terminology (CPT) code.
Nebraska Medicaid participates in the Medicaid Drug Rebate Program, which requires drug manufacturers to enter into an agreement with the Centers for Medicare and Medicaid Services (CMS) to provide rebates for drugs paid for by states. Due to the Deficit Reduction Act of 2005, states are required to collect Medicaid rebates for physician-administered drugs by collecting the 11-digit NDC on physician clinic and outpatient claims. The state does not cover non-rebateable NDCs.
Providers must submit claims with the exact NDC on the product administered. Using an NDC other than what was actually administered is considered fraudulent billing. The appropriate HCPCS associated with the NDC as well as accurate NDC units are also required.
An accurate NDC and HCPCS are also required for Medicare crossover claims for all applicable procedure codes. A drug HCPCS/NDC combination must be accurate when it crosses over to Medicaid or it will be denied.
Vaccines are not considered covered outpatient drugs and an NDC is not required.
CMS Rebatable Drug List