Indiana Health Coverage Program Seminar Presented by MDwise Pharmacy October 22-24, 2007 P0153 (9/07)

Transcription

1 Indiana Health Coverage Program Seminar Presented by MDwise Pharmacy October 22-24, 2007 P0153 (9/07)

2 Overview Pharmacy Benefit Manager Pharmacy Claims Processor Preferred Drug List Pharmacist Override Options Prior Authorization/Emergency Fill MDwise/PerformRx Provider Manual Charging Members for Covered Services Questions

3 Pharmacy Benefit Manager Philadelphia, PA 100% Medicaid and Medicare Part D in total just over 1 million lives: AL; TN; WV; LA; OH; DE; MD; DC;GA; FL; VA; PA; KY;CA; SC; IN Philadelphia (PA) - The Pharmacy Benefit Management Institute (PBMI) awarded its 2005 Rx Benefit Innovation Award today to AmeriHealth Mercy's pharmacy benefit management program, PerformRx. The award recognizes PerformRx's development of drug utilization management and clinical intervention programs for the Medicaid population and its creative approaches to drug benefit program management.

4 Pharmacy Help-Desk Hours M-F 8:30 a.m. to 6:00 p.m. Eastern time (after-hours forwards to claims processor, ARGUS) Staffed by certified pharmacy technicians

5 Pharmacy Claims Processor ARGUS Health Systems Kansas City, MO As of July 1, 2005 Argus Health Systems, Inc. processes claims for MDwise members Provides technical assistance and support to pharmacies with host processing issues Pharmacies experiencing difficulty transmitting claims for MDwise members due to host processing or claim submission errors, can contact ARGUS directly at

6 Prescriber ID State requires license number to be submitted on all claims National Provider ID near future MDwise requires Prescriber license number to adjudicate claim Submit the prescriber s ID that appears on the face of the valid prescription IN.gov Website for look-up function:

7 Coordination of Benefits Medicaid (MDwise) payer of last resort by law Argus supports on-line secondary billing NCPDP coverage codes for version 5.1 (enter applicable code in Eligibility Clarification field)

8 Paper Claim Submissions PerformRx CLAIMS DEPARTMENT: MDwise/AmeriHealth Mercy P.O. Box 496 Essington, PA UCF accepted

9 Preferred Drug List Updated quarterly All restrictions approved by the State Drug Utilization Review (DUR) Board Released in hardcopy at least once annually. Distributed to prescribers at network level; mailed to pharmacies Updated quarterly online

10 Preferred Drug List Generic medications are included as part of the pharmacy benefit. Some exclusions exist Safety - lindane Law - anorectics Newly released generic medications Generics are mandatory by law when an FDA AB rated generic is available

11 Preferred Drug List Step Therapy: Uses a patient s prior MDwise pharmacy claims history at any participating pharmacy to allow successful claims adjudication when there is a prior claim for a first-line agent within the specified timeframe Concurrent Therapy: Uses patient s claims history to allow claim to process if there is a prior claim for the required concurrent agent. For example: If there has been no recent claim (45 days) for the required concurrent agent, authorization is required

12 Preferred Drug List Age Limits An age edit allows claims for members within a defined age range to adjudicate without prior authorization Quantity Level Limits Are limits on the specific quantity, days supply or prescriptions that can be dispensed within a given timeframe. A normal 30 day supply is available unless specified otherwise. Exception: For Oral Contraceptives a 90 day supply is available

13 OTCs Over the Counter products Require a prescription Available for package C only if the drug is a firstline agent as noted on the PDL e.g. Prilosec OTC AB rated generics are mandatory when available

14 Override Options Prior Authorization field to dispense emergency supply to override refill too soon when prescriber has made dosage change COB override (if member no longer has primary coverage): 502 Vacation overrides: Pharmacist must call PerformRx for auth during business hours CODES SUBJECT TO AUDIT

15 Prior Authorization Clinical Authorizations should be initiated by prescriber in order to collect clinical record Via Fax: (For MDwise St. Catherine ONLY) Via Telephone: Forms available online and in PerformRx pharmacy provider manuals A determination will be made within 24 hours, M-F

16 Prior Authorizations Prior authorizations include prior claims verification Items that normally would go through on step therapy without prior authorization will not go through if the member has not filled the first-line or concurrent therapy requirement

17 Emergency Supply Emergency situations Three day supply available for brand named antibiotics Five day supply available for all other meds Federal and State laws require payment to pharmacies Not required to split a manufacturers prepackaged item e.g. corticosteroid dose pack Charging Members for Covered Services

18 Charging Members for Covered Services Against the law: Federal (42 CFR ) and State (405 IAC (i)). A Medicaid provider shall not collect from a Medicaid member or from the family of the Medicaid member any portion of his charge for a Medicaid covered service which is not reimbursed by the Indiana Medicaid program, except for co-payment and any member liability payment as authorized by law. Covered services can and do require authorization

19 Charging Members for Covered Services ONLY exceptions: An IHCP non-covered service (e.g. anorectics) A covered service for which the member has exceeded the program limitations for the particular service It is up to the provider to verify member benefit limits Pharmacies caught violating laws and their PerformRx/MDwise contract will receive one warning Subsequent violations will result in exclusion of pharmacy from network

20 Restricted Card Program The purpose of the RCP is to monitor and manage a member's use of services for a specified period of time. Under state law (405 IAC 1-1-2) the Office of Medicaid Policy and Planning (OMPP) may restrict benefits available to a member for a period of time, between two and five years. A review of claims history detects over-utilization in the following areas: Pharmacy Services Hospital Services and/or Emergency Room Visits Physician Services

21 Restricted Card Program Restricts member to one of each of the following: Pharmacy Prescriber Hospital Providers may call to refer their patients for evaluation for this program Please notify police of any violations of the law

22 Pharmacy Services Manual MDwise Jan 2006 Each contracted independent pharmacy was mailed a pharmacy provider manual July 2005, and an update in Jan 2006/Nov The 2007 update to be mailed soon Chain Stores: Corporate was sent manuals per Corporate Policy Posted to website

23 Questions