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Pharmacy

Nebraska Medicaid Preferred Drug List

The medications on the Nebraska Medicaid Preferred Drug List (PDL) are covered by Nebraska Total Care. Non preferred drugs on this list may be covered when certain requirements are met. Other limitations for specific drugs may exist and are explained in the Nebraska Medicaid Claims Limitations (PDF).

Nebraska Total Care is committed to providing appropriate, high-quality, and cost-effective drug therapy to all Nebraska Total Care members. Nebraska Total Care covers prescription medications and certain over-the-counter medications with a written order from a Nebraska Total Care provider. The pharmacy program does not cover all medications. Some medications may require prior authorization and some may have limitations. Other medically necessary pharmacy services may be covered as well. Current maximum allowable cost (MAC) pricing information for all products can be found on the ESI Pharmacist Resource Center (effective January 1, 2024).

Heritage Health - Nebraska Total Care

Pharmacy Policies

Electronic Prior Authorization Submissions

Submit your prior authorization (PA) requests electronically through our preferred solution CoverMyMeds. Electronic prior authorization (ePA) automates the PA process making it a quick and simple way to complete PA requests. The ePA process is HIPAA compliant and enables faster determinations. You may also use this link to track ePA requests.

We are pleased to announce that, effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.

Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.

Members will receive a new ID card with updated pharmacy information, so that they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.

Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change.

Please contact your Provider Relations Representative with any additional questions.

Nebraska Total Care Claim Processing Update

Effective January 1, 2024, Nebraska Total Care will transition to Express Scripts as their pharmacy benefits manager. Please ask members to provide their new member ID cards and enter the new Member ID Number, Rx Group, BIN, and PCN.

Please use the following information when submitting claims for Nebraska Total Care members.

BIN: 003858
PCN: MA
GROUP: 2ETA

If you need a member’s specific prescription processing information or other help with a claim, please visit our Pharmacist Resource Center at prc.express-scripts.com. If you still need assistance processing a claim, please call the Pharmacy Help Desk at 1-833-750-4471.

Express Scripts Transition: Frequently Asked Questions

This FAQ provides additional information on the migration of our Pharmacy Benefit Manager

(PBM) services from CVS® to Express Scripts®, effective January 1, 2024.

Who is Express Scripts?

Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.

What is the rationale for changing PBM vendors?

Express Scripts as our PBM will bring increased levels of transparency and value, positioning us to provide the highest level of quality at the lowest possible cost to our members.

What PBM services will Express Scripts be providing?

Express Scripts will be the PBM of record providing pharmacy claims adjudication, pharmacy network administration and rebate administration on behalf of our health plan.

How will this PBM transition impact our members?

There will be no immediate change in service for our members. We will continue to provide the same member-focused care and support as we do today.

Our highest priority continues to be serving all our members, and we remain committed to providing affordable quality healthcare services. Our team is working closely with both CVS and Express Scripts to ensure a seamless migration.

Is Amazon part of the Express Scripts Network?

Yes, Amazon is part of the Express Scripts network.

You Can Help Protect Your Patients and Your Community Against Respiratory Syncytial Virus (RSV)

You have the best interest of your patients at heart. More than that, you have their trust. Your patients trust you more than any other source when it comes to vaccines. And your recommendation is the most effective way to ensure they get the ones they need.

Respiratory syncytial virus (RSV) is the leading cause of childhood respiratory illness in the United States, resulting in thousands of hospitalizations and hundreds of deaths per year. Infants six months and younger are at highest risk. Prevention is essential to combat the severity of RSV. The Food and Drug Administration (FDA) has approved, and The Centers for Disease Control and Prevention's (CDC) recommends maternal RSV vaccine and the infant RSV monoclonal antibody providing two opportunities to protect against the negative side-effects of RSV.

Maternal RSV Vaccination (Abrysvo)

Pfizer’s bivalent RSVpreF vaccine, Abrysvo is the only RSV vaccine approved for use during pregnancy.

  • A single injection given to pregnant individuals at 32 weeks through 36 weeks gestational age have shown reduction in severe RSV infection in infants by 81% within 90 days of life, and 69% within 180 days of life.
  • Should be given seasonally, September through January.
  • May administer with other vaccines recommended during pregnancy, such as flu, COVID-19, and Tdap.
  • Provides protection for infant if maternal vaccination occurred at least 14 days prior to birth.
  • Common side effects include injection site pain, headache, muscle pain, and nausea.

Infant RSV Monoclonal Antibody (Nirsevimab)

For the 2023-2024 RSV season, there are known supply shortages of Nirsevimab. In areas with shortages, guidance is to encourage maternal RSV vaccination as an alternative.

  • A single intramuscular injection for infants younger than 8 months of age born during or entering into their first RSV season to prevent severe RSV disease.
  • Available for infants if maternal RSV not given or if vaccine was given but delivery occurred prior to 34 weeks gestation.
  • The RSV vaccine has shown an 80% reduction in RSV-related healthcare visits and hospitalizations.

Want to Learn More?

Access the Centers for Disease Control and Prevention's Recommendations for Use of Nirsevimab for the Prevention of RSV Among Infants and Young Children.

View The American College of Obstetricians and Gynecologists (ACOG) clinical guidance on Maternal Respiratory Syncytial Virus Vaccination.

Contact your provider relations team for additional information and answers to coding and billing requirements.

 

 

 

 

 

 

Quick Links

Contact Us

ESI Express Scripts Helpline
Phone: 833-750-4471
(effective January 1, 2024)

Pharmacy Services
Prior Auth Phone: 844-330-7852
Prior Auth Fax: 833-404-2254

Nebraska Total Care
Phone: 1-844-385-2192 (TTY 711)