Network Pharmacy Weekly

Transcription

1 Inside this issue: Anthem HealthKeepers Plus OTC 2 Anthem GA 360 Change Sept Anthem GA Community Care 4-6 Serving the Underserved: 50 Years of Medicare and Medicaid (Part 2) In 2004, Express Scripts began caring for our nation s aging population through the Medicare Discount Card Program, and then in 2006, with the beginning of the Medicare Part D Page prescription 2 Headline drug program. Part D is one of our nation s greatest J ;;sjfkdpofg success stories delivering a high quality, affordable and meaningful ]spfs benefit flkd for f millions of Americans, while reducing costs for Medicare. One Section widely acknowledged lead reason for the S;;f;;dkf program s skfds success: fs Part D embraces the clinical and cost-saving strategies Express Scripts has used successfully in commercial benefit plans. Part D beneficiaries have the flexibility to select a plan that meets their needs. Plans have the ability to offer beneficiaries incentives to encourage good health decisions. Clinical programs, such as Medication Therapy Management (MTM) and quality programs such as Star Ratings, help ensure beneficiaries optimize their medication use, experience better health outcomes, and receive care from a high quality program. In addition to serving Medicare plans, Express Scripts serves millions of Americans who find value in our Medicare Plan. As the nation s leading provider of Employer Group Waiver Plans (EGWPs), serving nearly 4 million retirees, we also help organizations sustain an attractive retiree pharmacy benefit, which is key to retaining the best talent. For more information, visit Are You Ready for ICD-10? Beginning October 1, 2015, Express Scripts will implement the ICD-10 standard and will only accept ICD-10 codes on prescription drug claims. If a pharmacist submits an ICD-10 code, the system will check that the selected qualifier is also ICD-10-compliant. Express Scripts will not validate the actual ICD-10 code. However, if a claim is submitted with a date of service after October 1, 2015, and with an ICD-9 qualifier, the claim will reject with NCPDP Reject Code BB (Diagnosis Code Qualifier Submitted Not Covered). Some medical benefit claims will require an ICD-10 code, and therefore the clinical segment of the pharmacy claim is situational, not required. When the clinical segment is submitted, however, the fields are required. (See chart below.) Field # NCPDP Field Name Value Payer Usage 492-WE Diagnosis Code Qualifier R 424-DO Diagnosis Code R The ICD-10 regulation impacts all HIPAA Covered Entities, and will require all health care providers to submit clinical information using ICD-10 codes. REMINDER: Submit DAW 9 ONLY for Anthem Nexium 40 mg Claims Last week we communicated that as of August 26, 2015, all Anthem commercial and healthcare exchange plan member claims for brand Nexium 40 mg capsules must submitted as a brand drug using Dispense As Written (DAW) code 9. Medicare, Medicaid, and Amerigroup claims are excluded from this requirement. If a DAW code other than 9 is submitted, the claim will reject with 8K (DAW Code Not Supported). If the generic alternative is submitted, the claim will reject with 70 or 75 and a secondary message prompts the pharmacist to submit the brand. Please note that this requirement applies ONLY to Anthem commercial and healthcare exchange member claims for Nexium 40 mg. capsules Express Scripts Holding Company. All Rights Reserved.

2 Anthem HealthKeepers Plus OTC Benefit Update Anthem Healthkeepers Plus offers an over the counter (OTC) medication benefit for their members nationwide. Selected OTC medications are covered when the member has a written prescription from his/her healthcare provider. Listed below are the categories of OTC drugs covered under this benefit. Medicines to help with allergies, fever and heartburn Cough and cold medications Laxatives Nicotine products Vitamins Please process claims for Anthem Healthkeepers Plus members using the following information, and reference the sample copy of the ID card shown below. Claim Submission Information BIN: PCN: A4 RxGroup: WQMA Card Front Card Back Change for Amerigroup GA Families 360 Begins Sept. 1, 2015 Beginning September 1, 2015, Express Scripts will be the pharmacy benefits manager (PBM) for Amerigroup Georgia Families 360 members. Following are some important updates about the pharmacy benefit for these members. Please see the sample Georgia Families 360 identification cards on the following page. If a member does not have a card, please call Amerigroup at for eligibility verification. (Continued on page 3) For assistance processing a claim, contact the Express Scripts Pharmacy Services Help Desk at or , or visit the Pharmacist Resource Center at 2

3 Change for Amerigroup GA Families 360 (Continued from page 2) Claims Submission Information To submit a pharmacy claim to Express Scripts for these members on or after September 1, 2015, use the following BIN/PCN/GroupRx information: Prescriber NPI Requirement For all pharmacy claims requiring written prescriptions, pharmacies must submit the prescriber s National Provider Identifier (NPI). Claims submitted without the prescriber s NPI, with an invalid or inactive NPI, or those submitted with other types of prescriber IDs will reject with code 25 (Missing or Invalid Prescriber ID). Quantity Limits Pharmacies may fill up to a 31-day supply. Claim Submission Information BIN: PCN: MA Group: WKJA Copayments Pharmacies cannot refuse to fill Medicaid prescriptions due to a member s inability to pay copayments; however, Georgia Families 360 members have no copayments. Transition of Care Benefit Members may receive temporary transitional fills of some medications, identified by secondary messaging on paid claims stating Paid under Transition Fill. If you see this transition message, please alert the member to the temporary nature of his/her fill and have the member call Amerigroup at or his/her prescriber to request a prior authorization (PA) or switch to a formulary medication. Prior Authorization (PA) Contact Numbers Pharmacists or prescribers may request PAs using the phone and fax numbers below: Prior Authorization Numbers Phone Fax (Continued on page 4) 3

4 Change for Amerigroup GA Families 360 (Continued from page 2) Prescription Origin Codes (POC) This field must be populated with a valid value for all claims, or the claim will reject with code 33 (Missing or Invalid Prescription Origin Code). One of the following values should be placed in the POC field (419-DJ) on all claims: 1 = Written 2 = Telephone 3 = Electronic 4 = Facsimile 5 = Pharmacy 72-Hour Emergency Fills A 72-hour fill should only be used in the event of an emergency. Drug Coverage Submit claims for emergency fills with: To obtain a Prior Authorization, please call Emergency Fill Claim Submission Information Field Name Field Number Submission Codes Days Supply: 405-D5 3 Prior Auth Type Code 461-EU 1 Prior Auth Number Submitted 462-EV 1111 Members must use generics when available. Claims for brand-name or generic drugs that require approval will reject if prior approval was not received. When dispensing brand-name drugs as generics, submit Dispense As Written (DAW) code 5 to receive reimbursement at generic prices. Some over-the-counter (OTC) items will be covered with a prescription. Please submit a claim to determine coverage. Only drugs covered under the Medicaid Drug Rebate Program will process for these members. Claims not covered by a federal rebate will reject with code AC (Product Not Covered, Non-Participating Manufacturer). HELPFUL CONTACT NUMBERS: Express Scripts Pharmacy Help Desk: Eligibility Verification: Change for Amerigroup Community Care GA Begins Sept. 1, 2015 Beginning September 1, 2015, Express Scripts will be the pharmacy benefits manager (PBM) for Amerigroup Community Care Medicaid members. Following are important updates about the pharmacy benefit for these members. Please see the sample Amerigroup identification cards on page 5. If a member does not have a card, please call Amerigroup at for eligibility verification. (Continued on page 5) 4

5 Change for Amerigroup Community Care GA (Continued from page 4) Below are sample Amerigroup identification cards: Claims Submission Information To submit a pharmacy claim to Express Scripts for Amerigroup members on or after September 1, 2015, use the following BIN/PCN/GroupRx information: Prescriber NPI Requirement For all pharmacy claims requiring written prescriptions, pharmacists must submit the prescriber s National Provider Identifier (NPI). Claims submitted without the prescriber s NPI, with an invalid or inactive NPI, or those submitted with other types of prescriber IDs will reject with code 25 (Missing or Invalid Prescriber ID). Quantity Limits Pharmacists may fill up to a 31-day supply for all Medicaid plans excluding the Family Planning Waiver (FPW) and Inter- Pregnancy Care (IPC) programs. Claim Submission Information BIN: PCN: MA Group: WKJA Pharmacists may fill up to a 34-day supply for FPW and IPC programs. Copayments Pharmacies cannot refuse to fill Medicaid prescriptions due to a member s inability to pay copayments. Copayments vary based on the medication dispensed as illustrated in the chart below: Calculated Ingredient Cost Less than or equal to $10 $0.50 $ $25.00 $1.00 $ $50.00 $2.00 Greater than or equal to $50.01 $3.00 Member Copayment* * Copayments do not apply to any member under the age of 6 regardless of plan. * CHIP members age 6 and older the copayment is the same as listed above for non-preferred brand-name only and $.50 for generic. Copayment Exclusions: Native Americans, Alaskan Natives, pregnant women, non-k Chip children (under 19) and members in long-term care. (Continued on page 6) 5

6 Change for Amerigroup Community Care GA (Continued from page 5) Transition of Care Benefit Members may receive temporary, transitional fills of some medications, identified by secondary messages on paid claims stating Paid Under Transition Fill. If you see this transition message, please alert the member to the temporary nature of his/her fill and have the member call Amerigroup at or his/her prescriber to request a prior authorization (PA) or switch to a formulary medication. Prior Authorization (PA) Contact Numbers Pharmacists or prescribers may request PAs using the phone and fax numbers below: Prior Authorization Numbers Phone Fax Prescription Origin Codes (POC) This field must be populated with a valid value for all claims, or the claim will reject with code 33 (Missing or Invalid Prescription Origin Code). One of the following values should be placed in the POC field (419-DJ) on all claims: 1 = Written 2 = Telephone 3 = Electronic 4 = Facsimile 5 = Pharmacy 72-Hour Emergency Fills A 72-hour fill should only be used in the event of an emergency. Submit claims for emergency fills with: Emergency Fill Claim Submission Information Field Name Field Number Submission Codes Days Supply: 405-D5 3 Prior Auth Type Code 461-EU 1 Prior Auth Number Submitted 462-EV 1111 To obtain a prior authorization, please call Drug Coverage Members must use generics when available. Claims for brand-name drugs will reject. When dispensing brand-name drugs as generics, submit Dispense As Written (DAW) code 5 to receive reimbursements at generic prices. Some over-thecounter (OTC) items will be covered with a physician prescription. Please submit a claim to determine coverage. Only drugs covered under the Medicaid Drug Rebate Program will process for these members. Claims not covered by a federal rebate will reject with code AC (Product Not Covered, Non-Participating Manufacturer). HELPFUL CONTACT NUMBERS: Express Scripts Pharmacy Help Desk: Eligibility Verification: Prior Authorization Requests: