Provider Manual. Section 10: Pharmacy

Transcription

1 Provider Manual Section 10: Pharmacy

2 Table of Contents SECTION 10: PHARMACY SERVICES PHARMACY FORMULARY FORMULARY ACCESS How to Use the Lexicomp Online Formulary SERVICES PROVIDED AND BENEFIT LIMITATIONS REQUESTING COVERAGE OF A NON-FORMULARY MEDICATION FOR AN INDIVIDUAL MEMBER Instructions for Completing Paper Request for Drug Coverage Forms: Request for Drug Coverage Form Request for Drug Coverage Form for COX-2 Inhibitor Use ADVERSE DRUG REACTION REPORTING Adverse Drug Reaction Report Form APPEAL PROCESS DISCOUNTS ON OVER-THE-COUNTER PRODUCTS SYNAGIS RSV Assessment Form MAIL ORDER PHARMACY GENERIC MEDICATION POLICY FIRST FILL PROCEDURE FOR KAISER PERMANENTE HEALTH MAINTENANCE ORGANIZATION (HMO) MEMBERS PLAN PHARMACIES Kaiser Permanente Medical Facility Pharmacy Directory

3 See Section 11 of this Manual for a description of Pharmacy Services for Self-Funded Plans Pharmacy Formulary Kaiser Permanente has two Formularies: Commercial and Medicare Part D. The medications included in the Kaiser Permanente Formularies are regulated by a group of Kaiser Permanente Practitioners, pharmacists and nurses known as the Pharmacy and Therapeutics Committee. This committee meets regularly to evaluate and choose medications that are most effective, safe and useful in caring for our Members. Using Formulary medications helps Kaiser Permanente maintain high quality of care for our Members, while helping to keep the cost of prescription medications affordable. Kaiser Permanente commercial plans use a closed Formulary, which means that only those medications included in the Kaiser Permanente Commercial Formulary are covered under the Member s prescription drug benefit. Members who choose to purchase a Non-formulary medication should expect to pay the full retail cost of the medication, unless issued a Formulary exception, also known as a prior authorization. Prescription drug coverage may vary, based upon the Member s health benefit plan. Not all Kaiser Permanente health plans include prescription drug coverage. Additionally, some prescription drug plans may exclude certain drugs, cover drugs at varying levels based upon drug cost or limit the amount of the drug the Member can receive with a prescription or Copayment. Members should consult their Evidence of Coverage (EOC) or call the Kaiser Permanente Customer Relations Department, Monday through Thursday, 8:15 a.m. to 5 p.m., and Friday, 9 a.m. to 5 p.m. at (toll free) for specific drug coverage information. The hearing/speech impaired may call (toll free TTY). The Kaiser Permanente Medicare Part D Formulary is a tiered, open Formulary. The Centers for Medicare & Medicaid Services (CMS) regulates this Formulary and requires Part D sponsors, like Kaiser Permanente, to include drug categories and classes that cover all disease states. The Kaiser Permanente Part D Formulary is developed nationally and approved by CMS. All Part D drugs qualified by Medicare are covered (except Medicare excluded drugs) and are on Kaiser Permanente s Medicare Part D Formulary. 3

4 2013 Kaiser Permanente Part D Design (CMS Approved) Tier Level Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 6 Tier Name Value Generics (filed with CMS as preferred generics) Generics (filed with CMS as non-preferred generics) Brand Drugs (filed with CMS as preferred brand-name drugs) Non-Preferred Brand Drugs Specialty-Tier (no change) Injectable Part D Vaccines Kaiser Permanente Formularies are designed to meet the needs of the majority of our Members. The Pharmacy and Therapeutics Committee reviews and updates the Formularies throughout the year and notifies Plan Providers, pharmacists and other clinicians about any changes via Drug Therapy Advisories. Copies of Drug Therapy Advisories are available by calling your Network Associate, the Kaiser Permanente Customer Relations Department, Monday through Thursday, 8:15 a.m. to 5 p.m., and Friday, 9 a.m. to 5 p.m. at toll-free , option 1, or on the Kaiser Permanente Community Providers website at providers.kaiserpermanente.org/oh Formulary Access Contact your Network Associate or the Kaiser Permanente Customer Relations Department at toll-free , option 1, for a copy of current Kaiser Permanente Drug Formularies. Online access to the Kaiser Permanente Ohio Region Drug Formulary is also available through the Community Providers website at providers.kaiserpermanente.org/oh or Lexicomp Online. The Lexicomp Online Drug Formularies contains a search engine for easy information retrieval and convenient links to other Lexicomp Online references. Online Drug Formularies can be accessed through the internet at online.lexi.com/login (a login and password are required). Contact Regional Formulary Management Services at for information. Member drug Formularies are also available online at kp.org/formsandpubs. 4

5 How to Use the Lexicomp Online Formulary Login: Formulary Search: Formulary Information: Refined Search: Navigating Monograph Content: Access Mobile Device Software: Optional: Go to online.lexi.com/login Login: ohkprx Password: ohkprx From the opening screen, enter generic or brand drug name in the search box and click the Search button. To assist with searching, a possible keyword list will appear after you enter at least four characters. To select a suggested term, simply click on the desired search term and the system will automatically perform a search and display the results. To review the Ohio Formulary status of a drug, click on the hyperlink drug name listed under Kaiser Permanente Ohio Region database. Review the information in the respective Formulary Dosage Forms Covered fields within the drug monograph that opens in the right side frame. The formulary database monographs contain specific Kaiser Permanente Ohio information such as Formulary dosage forms, formulary restrictions, guidelines, and related information links. For many Non-formulary drugs, preferred Formulary alternatives may be listed in the Commercial Formulary field. Lexicomp Online allows users to perform a more refined search within a specific section of the monograph, by clicking the Limit search to drop-down arrow to view a list of possible sections that can be searched. To limit your search to a particular field, simply click on the desired listing from the drop-down list. Within a specific drug monograph window, Plan Providers can navigate the content quickly by using the Navigation Tree on the left side or the Jump To Section drop-down list on the top right. Click on the Mobile App Access link on the right of the Ohio Region Online Formulary home page for instructions to download the Lexicomp mobile device software. The Indexes button in the top left search frame may also be used to search the Kaiser Permanente Ohio Region database. This allows Plan Providers to view: A list of drugs starting with a selected letter by generic name or U.S. brand name. A list of available Charts/Special Topics or Freetext sections. All changes made in the past 7 to 30 days or new documents created in the last 90 days. A list of drugs in a specific pharmacology/therapeutic category. 5

6 10.3 Services Provided and Benefit Limitations Drugs are covered when prescriptions are required by Law and when they are listed in the Kaiser Permanente Formularies. This includes coverage for off-label Formulary drug usage in the treatment of a particular condition for a drug that is approved by the Food and Drug Administration and is recognized as safe and effective for that condition in published, authoritative medical, scientific, or pharmaceutical literature. The brand name form of a drug that appears on the Formulary will be provided only when the generic form is not available on the Formulary. Coverage of certain Formulary medications may be subject to restrictions established by the Pharmacy and Therapeutics Committee or by any federally mandated restrictions. If prescribed by a practitioner, a small number of non-prescription drugs (listed in the Kaiser Permanente Formularies) and accessories are also covered such as insulin and disposable insulin syringes/needles. Drugs and materials that must be administered by a practitioner, such as injections and tubing for administration of a drug, may be covered by the base medical benefit, not the Member s pharmacy benefit, and cannot be dispensed directly to the Member by an outpatient pharmacy. Drugs and accessories are covered only when Medically Necessary for treatment of a specific illness, injury or condition; prescribed by a practitioner or dentist; and obtained at pharmacies in Kaiser Permanente medical Facilities or at affiliated Plan pharmacies. Prescribed covered drugs and accessories are provided at a single Copayment for each prescription, not to exceed the amount prescribed, up to a 30-day supply except that, if the regular charge is less than the Copayment, Members pay the regular charge. Each prescription refill is provided on the same basis as the original prescription. If a prescription or refill is for a quantity greater than the limits described above, the charge is an additional Copayment for each multiple quantity or fraction of a 30-day supply. Kaiser Permanente reserves the right to dispense only a 30-day supply when the prescription or refill is of a quantity greater than a 30-day supply. Plan pharmacies provide up to a 30-day supply based upon the prescribed dosage, the standard manufacturer s package size, and specified dispensing limits. Some medications have other limitations on the amount or quantity of the drug that may be dispensed per prescription or Copayment. The following are not covered under the outpatient prescription drug benefit: Drugs when prescribed for cosmetic purposes. Drugs necessary for or related to an excluded service. Drugs used for the purpose of weight loss. Drugs and materials that require administration by medical personnel or observation by medical personnel during or after administration (these may be covered under the base medical benefit). Proton Pump Inhibitor drugs, unless Precertified for the treatment of Barretts Esophagitis and Zoellinger Syndrome. 6

7 Nonprescription drugs and medications, except for nonprescription nicotine replacement products covered under the Kaiser Permanente drug Formulary. Non-formulary nicotine replacement products. Investigational or experimental drugs or drugs limited to investigational use. Replacement of lost or damaged prescriptions. Unless an exception is approved by Health Plan, drugs not approved by the FDA and in general use as of March 1 st, of the year immediately preceding the year in which the Member s agreement became effective or was last renewed. Non-formulary drugs at the request of the Member, when a Plan Practitioner believes that the Formulary alternative is effective. Drugs used to enhance athletic performance. Medical supplies such as dressings and antiseptics (these may be covered under a supplemental Durable Medical Equipment benefit). Vitamins and nutritional supplements that can be purchased without a prescription. Medical foods. Special medication packaging, other than Health Plan standard packaging, unless required by Law. Drugs used to shorten the duration of the common cold. Drugs prescribed for the treatment of involuntary infertility or sexual dysfunction may or may not be covered, depending on the Member s drug benefit. Not all Kaiser Permanente health benefit plans include coverage for prescription drugs. Some Members have limitations on the dollar amount of coverage. Members should consult their Evidence of Coverage (EOC) booklet or call the Kaiser Permanente Customer Relations Department, Monday through Thursday, 8:15 a.m. to 5 p.m., and Friday, 9 a.m. to 5 p.m. at (toll free) for more information. The hearing/speech impaired may call (toll free TTY). See Section 4 of this Manual for more information regarding coverage for infertility drugs and contraception Requesting Coverage of a Non-Formulary Medication for an Individual Member Kaiser Permanente Formularies are designed to meet the needs of the majority of our Members. However, there are times when use of a Non-formulary drug is Medically Necessary. Prescriptions for Non-formulary medications may be filled at Kaiser Permanente pharmacies. However, the Member should expect to pay the full retail cost unless the prescribing Practitioner has obtained approval for the Non-formulary medication or the Member has a benefit that provides coverage at a higher Nonformulary Copayment. There may be a delay in filling the prescription because the pharmacy may need to place a special order. Coverage of certain Formulary medications may also be subject to restrictions established by the Regional Pharmacy and Therapeutics Committee. Non-formulary medications may be covered under the Formulary Exception Policy in the 7

8 same manner as Formulary drugs for commercial Members if: Formulary medications have proven ineffective, or the Formulary medication causes or is reasonably expected by the Plan Practitioner to cause harmful or adverse reactions, and the use conforms to guidelines and criteria reviewed and approved by the Pharmacy and Therapeutics Committee. All Non-formulary medications for commercial Members require Authorization through Kaiser Permanente s Pharmacy Utilization Management Service prior to dispensing to assure coverage by the Member s drug benefit. To seek approval for coverage of a Non-formulary drug for a Member, prescribing Practitioners will need to complete the Request for Drug Coverage form (see Section of this Manual). When requesting coverage of a COX-2 inhibitor, use the specific form for these drugs (see Section of this Manual). Both forms are also available from Pharmacy Utilization Management Service by calling (toll free) or , any Kaiser Permanente medical Facility pharmacy, MedImpact at (toll free), or online in the Forms section of the Kaiser Permanente Community Provider s website at providers.kaiserpermanente.org/oh. Plan Providers may submit Request for Drug Coverage forms to Kaiser Permanente electronically via KP Online-Affiliate. See Section of this Manual for more information regarding electronic communication options for Plan Providers. The purpose of completing the form is to document the Medical Necessity for using Non-formulary medication. Practitioners should complete the form using specific laboratory data, physical exam findings, and other supporting documentation whenever possible Instructions for Completing Paper Request for Drug Coverage Forms: 1. Provide all information requested. 2. Submit a separate form for each patient and for each drug you wish to have reviewed. 3. Keep a copy for your records. 4. Fax the form(s) to the Kaiser Permanente Utilization Management Service at OR mail the form(s) to: Kaiser Permanente Pharmacy Utilization Management Service 5500 Lancaster Drive Brooklyn Heights, OH

9 Requests will be processed within 15 calendar days from the time of receipt for Members with the Commercial Formulary drug benefit. Expedited requests may be made by calling the Pharmacy Utilization Management Service Center at (toll free) or The expedited process can take up to 24 hours for Members with the Commercial Formulary drug benefit. One of the following criteria must be met to make an expedited request: The drug is necessary to complete a specific course of therapy after discharge from an acute care facility. The time frame required for a standard review would compromise the Member s life, health or functional status. The drug requires administration in a time frame that will not be met using the standard process. Each request will be reviewed by the Pharmacy Utilization Management Service staff against criteria reviewed and approved by the Regional Pharmacy and Therapeutics Committee and the appropriate department Physician chiefs of the Ohio Permanente Medical Group (OPMG). Approvals will be granted only if the Practitioner can document the ineffectiveness of Formulary alternatives or the reasonable expectation of harm from the use of Formulary medications. In most cases, patients must have failed at least two Formulary alternatives or have experienced adverse effects from the use of the Formulary medications. If a request does not meet criteria, a pharmacist will recommend Formulary alternatives to the requesting Practitioner. However, if the requesting Practitioner disagrees with these recommendations, the request will be sent to a Pharmacy Utilization Management Service Center Practitioner for a decision. A response will be either faxed to the requesting Practitioner, if the form was submitted on paper, or via KP Online-Affiliate in response to electronic submissions. Members will be notified by mail. In most cases, approvals will be given an unlimited Authorization date, so that you will not be required to resubmit a request every year Request for Drug Coverage Form See the following page. 9

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11 Request for Drug Coverage Form for COX-2 Inhibitor Use See the following page. 11

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13 10.5 Adverse Drug Reaction Reporting An adverse drug reaction (ADR) is any non-preventable, unexpected, unintended, undesired, or excessive response to a medication (including allergic and idiosyncratic reactions) that: Requires discontinuing the medication (therapeutic or diagnostic). Requires changing the medication therapy. Requires modifying the dose (except for minor adjustments or dosage titration within normal limits). Necessitates admission to a hospital or clinical decision unit. Prolongs stay in a health care facility. Necessitates supportive treatment. Significantly complicates diagnosis. Negatively affects prognosis. Results in temporary or permanent patient harm, disability, or death. Example: a severe adverse reaction to penicillin in a patient with no prior allergic history or other contraindications. All new ADRs should be reported by the Plan Physician, nurse, or other health care provider by completely filling in the requested/applicable information concerning the reaction on the Adverse Drug Reaction Report form (see the following section of this manual). Plan Providers can download an Adverse Drug Reaction Report form in the Forms section of the Kaiser Permanente Community Provider s website at providers.kaiserpermanente.org/oh. Once the form is completed, signed, and dated, it should be faxed to Kaiser Permanente Pharmacy Administration at the number on the form. Pharmacy Administration staff will add noted allergies in the Kaiser Permanente electronic medical record system, HealthConnect, in an effort to prevent further prescribing of the drug. All information received on ADR forms is entered into an annual, cumulative spreadsheet for tracking and trending. In addition, the Kaiser Permanente Pharmacy Department computer system is updated. The Regional Pharmacy & Therapeutics Committee is responsible for reviewing quarterly summary reports and distributing recommendations and/or results as to Plan physicians and other professional staff Adverse Drug Reaction Report Form See the following page. 13

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15 10.6 Appeal Process If coverage is denied, the prescribing Practitioner can appeal the decision by submitting written comments, documents, records and other information needed in the reconsideration process to: OR Kaiser Permanente Appeals Unit P.O. Box Cleveland, OH by contacting the Kaiser Permanente Appeals Unit at (toll free) or The prescribing Practitioner will be notified in writing as to the outcome of his/her Appeal. Additionally, a Member may file an appeal by contacting the Customer Relations Department, Monday through Thursday, 8:15 a.m. to 5 p.m., and Friday, 9 a.m. to 5 p.m. at (toll free). The hearing/speech impaired may call (toll free TTY) or See Section 4.12 of this Manual for more information regarding Member and Provider Appeal policies and Procedures Discounts on Over-the-Counter Products Pharmacies at Kaiser Permanente Medical Facilities offer a large selection of over-thecounter (OTC) products exclusively to our Members at very competitive prices. Some of the key OTC product categories include: Cough, cold and allergy. Gastrointestinal and digestive aids. Oral analgesics and pain relievers. Skin care items such as sunscreen, hydrocortisone, antibacterials, and antifungals. Vitamins including multiple and prenatal. Feminine products such as clotrimazole vaginal cream. A Kaiser Permanente pharmacist is available to answer Members questions and assist them in the selection of products to meet their health care needs Synagis Synagis injections are covered for Kaiser Permanente Members who meet American Academy of Pediatrics medical criteria. All Synagis injections must be Precertified. To Precertify a Synagis injection, complete a Kaiser Permanente Referrals Management and Clinical Review Referral form (see Section of this Manual) and attach a completed RSV Assessment form (see the following section of this Manual). Plan 15

16 Providers can download Referral and RSV Assessment forms in the Forms section of the Kaiser Permanente Community Provider s website at providers.kaiserpermanente.org/oh. Specify on the Referral form if you will: Administer the Synagis from your own supply, or order the Synagis from Kaiser Permanente s Advance Care Pharmacy for administration in your office, or direct the Member to a Synagis Clinic at a Kaiser Permanente medical Facility. Synagis Clinics are available at the Kaiser Permanente medical Facilities in Bedford, Chapel Hill, Cleveland Heights and Parma. Note: If you do not administer Synagis in your office, and the Member resides more than 30 miles from a Kaiser Permanente Synagis Clinic, Kaiser Permanente will consider authorizing injections from a Plan Home Health Care Provider. Fax the completed forms for review to the Referrals Management and Clinical Review Department at To order Synagis from Kaiser Permanente's Advanced Care Pharmacy (ACP) following receipt of your Authorization number, call , option 2, Monday through Friday, 8:30 a.m. to 5 p.m. and arrange for delivery to your office. After hours, call the pager at RSV Assessment Form See the following page. 16

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18 10.9 Mail Order Pharmacy Members may be able to order larger quantities of maintenance medications through the Direct Mail Pharmacy for their mail order benefit Copayment. Not all prescriptions are available for mail order Service Generic Medication Policy Kaiser Permanente s Direct Mail Pharmacy 5500 Lancaster Drive Brooklyn Heights, OH Phone: (toll free) Kaiser Permanente has over 30 years experience in the successful use of generic drugs. Our comprehensive quality assurance program for the selection of drugs is managed by a group of experts with many years of experience in evaluating generic drugs. Kaiser Permanente pharmacies stock only generic products that have met the high standards of both the Food and Drug Administration and of Kaiser Permanente. Generic drugs offer Kaiser Permanente a means of providing quality care with a significant reduction in cost. These savings are directly passed on to our Members in the form of lower prescription prices and indirectly in lower membership rates. Medications selected for Formulary inclusion are in accordance with the principles of high quality pharmaceutical care and the standards set forth by the Kaiser Permanente National Drug Purchasing Department. Medications that are designated as Nonformulary are not covered under the drug benefit. Members pay the full Member cash price for the Non-formulary product unless a medical exception is approved. Prescribing Practitioners may prohibit generic substitution under Ohio s generic substitution Law. In this case, the pharmacist may not select and dispense a generic equivalent without Authorization from the prescriber. However, the corresponding Nonformulary brand will not be covered unless a medical exception has been approved. Members may request the Non-formulary brand name equivalent of a Formulary generic product. However, the Non-formulary brand will not be covered unless a medical exception has been approved or the Member has a tiered Copayment benefit under which it is covered at a higher Copayment First Fill Procedure for Kaiser Permanente Health Maintenance Organization (HMO) Members Effective January 1, 2012, in the event of an urgent/emergent situation or when a Kaiser Permanente Pharmacy is unavailable, Kaiser Permanente HMO Members can have prescription(s) filled one time each 365 days, per medication, per strength, at any Rite Aid or Walgreens Pharmacy within the Ohio Service Area. Members pay their standard 18

19 prescription Copayments for first fill medications. Formulary rules apply. Any subsequent prescriptions or refills required for the same strength medication during the next 365 days must be obtained through a Kaiser Permanente Plan or Mail Order Pharmacy. Members can easily order refills online at kp.org. See Section of this Manual for a list of Kaiser Permanente Plan Pharmacies Plan Pharmacies An ancillary directory with a listing of participating and Plan operated pharmacies is posted on the Kaiser Permanente s Community Provider s website at providers.kaiserpermanente.org/oh. If you prefer a paper directory, contact your Network Associate or the Kaiser Permanente Customer Relations Department, Monday through Thursday, 8:15 a.m. to 5 p.m., and Friday, 9 a.m. to 5 p.m. at toll-free , option Kaiser Permanente Medical Facility Pharmacy Directory See the following page. 19

20 KAISER PERMANENTE PHARMACY LOCATION Kaiser Permanente Avon Medical Offices American Way Avon, OH Kaiser Permanente Bedford Medical Offices Rockside Road Bedford, Ohio Kaiser Permanente Concord Medical Offices 7536 Fredle Drive Concord, Ohio Kaiser Permanente Fairlawn Medical Offices 4055 Embassy Parkway, Suite 110 Fairlawn, Ohio Kaiser Permanente Kent Medical Offices 2500 State Road 59, Suite 28 Kent, Ohio Kaiser Permanente Mentor Medical Offices 7695 Mentor Avenue Mentor, Ohio Kaiser Permanente Parma Medical Center Snow Road Parma, Ohio Kaiser Permanente Strongsville Medical Offices Royalton Road Strongsville, Ohio Kaiser Permanente Willoughby Medical Offices 5105 SOM Center Road Willoughby, Ohio PHONE NUMBER KAISER PERMANENTE PHARMACY LOCATION (toll free) Kaiser Permanente Chapel Hill Medical Offices 1260 Independence Avenue Akron, Ohio (toll free) Kaiser Permanente Cleveland Heights Medical Center 10 Severance Circle Cleveland, Ohio (toll free) Kaiser Permanente Direct Mail Pharmacy 5500 Lancaster Driver Brooklyn Heights, Ohio (toll free) Kaiser Permanente Home Infusion Pharmacy Snow Road Parma, Ohio (toll free) Kaiser Permanente Medina Medical Offices 3443 Medina Road, Suite 108 Medina, Ohio (toll free) Kaiser Permanente North Canton Medical Offices 4914 Portage St. NW North Canton, Ohio (toll free) Kaiser Permanente Rocky River Medical Offices Center Ridge Road, Suite 500 Rocky River, Ohio (toll free) Kaiser Permanente Twinsburg Medical Offices 8920 Canyon Falls Blvd., Suite 100 Twinsburg, Ohio (toll free) PHONE NUMBER (toll free) (toll free) (toll free) (toll free) (toll free) (toll free) (toll free) (toll free) 20