Download Pharmacy Benefits Consolidation

Pharmacy Benefits
Consolidation
Implemented on December 31, 2009
February 2010
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Agenda
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Objectives
What is the Pharmacy Benefit Consolidation
The population of members that will be affected
The impact this will have on the members and
providers
Tamper Resistant Prescription Pads
Claim Billing Guidelines
Helpful Tools
Questions
February 2010
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Objectives
• Following this session, providers will be
able to:
– Understand what a Pharmacy Benefit Consolidation
is and it’s advantage
– Identify the population that will be affected
– Bill claims appropriately
– Understand how they will be impacted by the
changes
– Understand that written prescription must meet
federal tamper resistant prescription pads
requirements
February 2010
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What is the Pharmacy Benefit
Consolidation
• The Office of Medicaid Policy and
Planning (OMPP) will assume
responsibility for the administration of the
Hoosier Healthwise (HHW) managed care
organizations (MCOs) and Healthy Indiana
Plan (HIP) pharmacy benefits for claims
February 2010
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What members will be affected by
the consolidation?
February 2010
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What does the consolidation
include?
• All outpatient pharmacy dispensed drugs
• Certain procedure coded drugs when dispensed
by an enrolled Indiana Health Coverage
Programs (IHCP) pharmacy
• Certain medical supplies codes (supplies
necessary to use/administer a drug such
diabetic test strips, blood glucose meters,
spacers etc) and medical devices when
dispensed by a Durable Medical Provider or
IHCP enrolled pharmacy
• Please refer to BT200948
February 2010
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What impact will this have on my
Pharmacy?
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February 2010
Extended Helpdesk Hours. The HP claims processing helpdesk and the ACS
pharmacy prior authorization helpdesk will both be open from 8am to 8pm M-F and
10am to 6pm on Saturday
ACS will have coverage on the following Holidays:
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New Year’s Day
– Memorial Day
– Independence Day
– Labor Day
– Thanksgiving
– Christmas
One Preferred Drug List. Members will utilize the Indiana Medicaid Preferred Drug
List (PDL), which represents a subset of the overall FFS pharmaceutical benefit
and the Over-the-Counter (OTC) Drug Formulary. The HIP pharmaceutical benefit,
in general, will follow the FFS PDL. With regard to coverage of OTC drugs for HIP
members, only those OTC drugs listed on the PDL are covered. HIP members do
not have coverage for other OTC drugs on the OTC Drug Formulary. This means
no variances between plans and therefore a simpler process for pharmacies and
prescribers.
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Supplies currently billed via point of sale such as diabetic test strips to the MCOs
and HIP will now be billed to the FFS medical benefit and will need to be billed on
a CMS 1500 or 837p transaction.
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All non-electronic prescriptions for claims paid by the fee-for-service pharmacy
benefit must meet applicable federal Tamper Resistant Prescription Pad
requirements.
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Tamper Resistant Prescription
Pads (TRPPs)
• Refills of prescriptions written for Hoosier Healthwise and HIP
members prior to the December 31, 2009, but will not be
dispensed until on or after that date, must meet TRPP
requirements.
• New Prescriptions written for Hoosier Healthwise and HIP
Members on or after December 31, 2009 must meet federal
TRPP requirements
• Indiana Board of Pharmacy security prescription blanks meet
all TRPP requirements.
• Find additional information related to TRPPs by visiting
www.indianamedicaid.com
– BR200733, dated August 14, 2007
– BT200724, dated September 18, 2007
– BR200741, dated October 9, 2007
– BT200810, dated February 22, 2008
– BT200947, dated December 22, 2009
February 2010
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What impact will this have on my
patients?
• Some MCO Members will now have a $3 copay for each
drug except:
– Emergency services provided in a hospital, clinic, office, or other facility
equipped to furnish emergency care
– Services furnished to individuals less than eighteen (18) years of age
– Services furnished to pregnant women if such services are related to
the pregnancy or any other medical condition that may complicate the
pregnancy
– Services furnished to individuals who are inpatients in hospitals, nursing
facilities, intermediate care facilities for the mentally retarded, or other
medical institutions
– Family planning services and supplies furnished to individuals of
childbearing age
– This is a change from the zero dollar copay with the MCOs. Note: The
majority of members in a MCO are either pregnant or under 18
February 2010
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What impact will this have on my
patients?
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Package C (CHIP) members will have a $3 copay for generic drugs and a $10 copay
for brand drugs
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As in the past, Presumptive Eligibility and HIP members will not have copays for
drugs.
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Members received a letter communicating the changes in early December
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BT200949
Note: 42 CFR 447.15 mandates that a provider may not refuse to provide services to a
recipient who cannot afford the copayment. IHCP policy is that the member remains liable to
the provider for the copayment, and the provider may take action to collect it. The provider
may bill the member for that amount and take action to collect the delinquent amount in the
same manner that the provider collects delinquent amounts from private pay customers.
Providers may set office policies for delinquent payment of incurred expenses including
copayments. The policy must apply to private pay patients as well as IHCP members. The
policy should reflect that the provider will not continue serving a member who has not made
a payment on past due bills for “X” months, has unpaid bills exceeding “Y” dollars, and has
refused to arrange for or not complied with a plan to reimburse the expenses. Notification of
the policy must be done in the same manner that notification is made to private pay
customers. In accordance with 407 IAC 3-10-3.
February 2010
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Where do I send my claims after the
consolidation?
Pharmacy Point of Sale Transactions
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If you are a pharmacy provider billing via an NCPDP point-of-sale
transaction or NCPDP batch transaction, claims should be routed to
HP:
BIN 610467
PCN INCAIDPROD
This applies for pharmacy claims with a date of service greater than
or equal to 12/31/09. All reversals and adjustments of claims
previously paid by an MCO or HIP health plan should be sent back to
the original payer for adjudication by March 31, 2010.
February 2010
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Where do I send my claims after
the consolidation?
Pharmacy Paper Claims
• All paper claims submitted on the Indiana
Medicaid Drug Claim Form or the Indiana
Medicaid Compound Prescription Claim
Form should be mailed to:
HP Pharmacy Claims
PO Box 7268
Indianapolis, IN 46207-7268
February 2010
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Where do I send my claims for medical
supplies impacted by the consolidation?
• Claims for supply items or drugs billed
using procedure codes that are part of the
consolidation must be billed utilizing Web
interChange, an 837P transaction or via
paper. Paper claims can be mailed to:
HP Enterprise Services
PO Box 7269
Indianapolis, IN 46207-7269
February 2010
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Who can I contact if I have questions?
• IHCP Web site at www.indianamedicaid.com
• ACS RX Services
– Prior Authorization 1-866-879-0106
• IHCP Provider Manual (Web, CD-ROM, or
paper)
• HP Pharmacy Customer Assistance
– 1-800-577-1278, or
– (317) 655-3240 in Indianapolis local area
• Written Correspondence
– P.O. Box 7263
Indianapolis, IN 46207-7263
• HP Provider Relations Field Consultant
February 2010
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Questions
February 2010
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