Medicare Part D/Medicaid Training
2013 Update for Pharmacies November 14, 2012 Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Questions?
Please send your questions via email to:
[email protected] Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Agenda Medicare Updates
CMS Requirements
Medicare Part D Benefit Update
• Medicare Part D Payer Sheet Updates for 2013 • Prescriber NPI Required
• Controlled Substance Prescribing Authority • Short Cycle Fill (LTC & Commercial / Medicaid Impact)
• Benefit Update for 2013 • Non-Covered Medicare Part D Drugs
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Agenda Medicare Part D Benefit Update (cont’d)
• NDC List Update • Covered Nebulized Medications • Transition Period Update
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
Medicaid Updates • Non-Covered Medicaid Drugs • State Updates
Appendix • Medicare Approved Part D Plans w/BAE • Best Available Evidence (BAE) Information • Beneficiary Rights Notice • Home and Community Based Services • Short Cycle Fill • Medicare / Medicaid Reminders
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Medicare Part D Payer Sheet Updates Effective January 1, 2013
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Medicare Part D Payer Sheet Updates Express Scripts is updating the Legacy ESI and Legacy Medco Medicare Part D Payer Sheets: In compliance with January 1, 2013 CMS requirements To provide consistent payer sheets for Legacy Medco and Express Scripts.
Payer Sheet changes should be made as soon as possible: 1. In preparation for compliance with CMS requirements, AND 2. In preparation for Legacy ESI clients moving to the new combined platform. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Medicare Part D - Payer Sheet Updates Standard processing information below will not change. BIN
BIN Description
PCN
PCN Description
003858
Legacy ESI
MD
Primary Medicare Part D Primary
003858
Legacy ESI
SC
Secondary claims to a Medicare D plan
610014
Legacy Medco
MEDPRIME
Primary Medicare Part D claims
610014
Legacy Medco
MEDDCOBSEG
Secondary claims to a Medicare D plan
610031
Legacy Medco
MEDDCOPAY
Secondary claims to a Medicare Part D plan
NOTE: Always follow processing information on the member Prescription Drug ID card. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Medicare Part D – Payer Sheet Updates Due to CMS requiring Patient Residence information on the PDE, Field 384-4X will now be required on all claim types. Field #
384-4X
NCPDP Field Name
Patient Residence
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
Value 00 = Not specified 01 = Home (Location, other than a hospital or other facility, where the patient receives drugs or services in a private residence). 02 = Skilled Nursing Facility 03 = Nursing Facility 04 = Assisted Living Facility 05 = Custodial Care Facility 06 = Group Home 09 = Intermediate Care Facility/Mentally Retarded 11 = Hospice 15 = Correctional Institution 8
Medicare Part D – Payer Sheet Updates CMS will also require Pharmacy Service Type on PDEs; Field 147U7 will now be required on all claim types. Field #
147-U7
NCPDP Field Name
Pharmacy Service Type
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
Value 01 - Community/Retail Pharmacy Services 03 - Home Infusion Therapy Provider 05 - Long Term Care Pharmacy Services
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Medicare Part D – Payer Sheet Updates Fields 42Ø-DK Submission Clarification Code (SCC) and 429-DT Special Packaging Indicator (SPI) will be required on LTC claims due to the new Short Cycle dispensing requirements. Field #
NCPDP Field Name
Value
42Ø -DK
Submission Clarification Code (SCC)
Values 16, 21-36 for Long Term Care short cycle dispensed claims. (See External Code List (ECL) for detailed descriptions.)
429-DT
Special Packaging Indicator (SPI)
Values 0 – 8 for Long Term Care short cycle dispensed claims. (See External Code List (ECL) for detailed descriptions.)
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Medicare Part D – Payer Sheet Updates For consistency, the following fields have been added to the legacy ESI Medicare Part D Payer Sheet for claims submissions. Field #
NCPDP Field Name
357-NV
Delay Reason Code
Values 1, 2, 7, 8, 9, 10 RW (Specify the reason that submission of the transaction has been delayed)
427-DR
Prescriber Last Name
RW (Prescriber ID Qualifier (466-EZ) = 08 (State License.)
367-2N
Prescriber State/Province Address
RW (Prescriber ID Qualifier (466-EZ) = 08 (State License) or 12 (DEA).
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
Value/Payer Usage
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Medicare Part D - Payer Sheet Updates For consistency, the following fields/segments have been added to the legacy ESI Medicare Part D Payer Sheet for claims reversals. Insurance Segment - Mandatory Field #
NCPDP Field Name
Value
111-AM
Segment Identification
04 = Insurance
302-C2
Cardholder ID
ID assigned to the cardholder
Coordination of Benefits/Other Payments Segment - Situational Field #
NCPDP Field Name
Value
111-AM
Segment Identification
05 = COB/Other Payments
337-4C
Coordination of Benefits/Other Payments Count
Maximum Count of 3
338-5C
Other Payer Coverage Type
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Prescriber NPI Required
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Medicare Part D Prescriber ID – NPI Required Effective January 1, 2013, CMS will require an active, valid Prescriber NPI on all Medicare Part D claims.
Express Scripts will begin rejecting invalid Prescriber NPI numbers submitted in field 411-DB (Prescriber ID) for all Medicare Part D claims on January 1, 2013.
If another Prescriber ID type, such as the Prescriber’s DEA, is submitted, Express Scripts will attempt to cross-walk the submitted ID to a valid Prescriber NPI.
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Medicare Part D Prescriber ID – NPI Required Claims will reject at point-of-sale if: • Prescriber NPI is invalid or missing. • Claim is submitted with an invalid DEA number.
• Prescriber DEA number cannot be cross-walked to the valid Prescriber NPI.
• Prescriber State License number is submitted and cannot be cross-walked to the valid Prescriber NPI.
• Claim is submitted on behalf of a foreign prescriber without a valid NPI (Prescriber ID Qualifier “17” Submitted in field 466-EZ).
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Medicare Part D Prescriber ID – NPI Required The following reject codes will be returned in field 511-FB (Reject Code) if the submitted Prescriber ID is invalid, inactive, missing, or if Express Scripts is unable to cross-walk to a valid Prescriber NPI: Reject Code
Description
EZ
M/I Prescriber ID Qualifier
42
Plan’s Prescriber database indicates the Prescriber ID Submitted is inactive or is not Found
543
Prescriber ID Qualifier Value Not Supported
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Medicare Part D Prescriber ID – NPI Required Pharmacists may override rejects by providing Submission Clarification Code value “42” (Prescriber ID Submitted has been validated, is active) in field 42Ø-DK, if the pharmacist believes the prescriber ID is active and valid.
All claims re-submitted with SCC “42” will be returned as PAID claims with an Approved Message Code of “19” (Submitted Prescriber ID is not found or is inactive or expired – flagged for Retrospective Review) in field 548-6F.
Foreign Prescriber IDs (claims submitted with a Qualifier value of “17” in field 466-EZ) cannot be overridden using the SCC of “42”.
State License IDs (claims submitted with Qualifier value of “08” in field 466-EZ) cannot be overridden using the SCC “42”. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Medicare Part D Prescriber ID – NPI Required All claims re-submitted with an SCC of “42” are reviewed by ESI. A monthly report of invalid Prescriber IDs will be sent to providers for research, reversal, and reprocessing with a valid Prescriber NPI.
Pharmacies have 90 days from date of service to research, reverse, and reprocess claims with a valid Prescriber NPI.
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Medicare Part D – Controlled Substance Prescribing Authority
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Controlled Substance Prescribing Authority Per State and Federal regulations, pharmacies must validate the prescriber DEA schedule for controlled substances.
CMS and the Office of Inspector General (OIG) have indicated a growing concern about whether prescribers have appropriate prescribing authority to write for controlled substances.
Effective January 1, 2013, Express Scripts will begin review of controlled substance claims. • Prescriber’s registered DEA schedule must match the medication’s DEA Schedule.
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Controlled Substance Prescribing Authority The following reject codes will be returned in field 511-FB (Reject Code) if a submitted Controlled Substance prescription claim does not contain: • A valid Prescriber DEA number, as compared to the registered DEA schedule. • A Prescriber ID number that is cross-walked to a valid DEA number, as compared to the registered DEA schedule. Reject Code 43 44
46
Description Plan's Prescriber database indicates the associated DEA to submitted Prescriber ID is inactive Plan's Prescriber database indicates the associated DEA to submitted Prescriber ID Is not found Plan's Prescriber data base indicates associated DEA to submitted Prescriber ID does not allow this drug DEA class
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Controlled Substance Prescribing Authority Pharmacists may override rejects by providing one of the following Submission Clarification Code (SCC) values in field 42Ø-DK if the pharmacist believes the Prescriber’s DEA schedule is appropriate for the controlled substance medication prescribed: SCC Code 43 44 45 46
Description For prescriber ID submitted, associated prescriber DEA Renewed, or In Progress, DEA Authorized Prescriptive Right For prescriber ID submitted, associated prescriber DEA recently licensed or re-activated For prescriber ID submitted, associated DEA is a valid Hospital DEA with Suffix For prescriber ID submitted, and associated prescriber DEA, the DEA has authorized prescriptive right for this drug DEA Class
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Controlled Substance Prescribing Authority All claims re-submitted with SCC of 43, 44, 45, or 46 will be returned as PAID claims with one of the following Approved Message Codes in field 548-6F: Approved Message Code
21 22
Description
For the Submitted Prescriber ID, the Associated DEA Number is Inactive – Flagged for Retrospective Review For the submitted Prescriber ID, the Associated DEA Number Does Not Allow this Drug DEA Class – Flagged for Retrospective Review
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Controlled Substance Prescribing Authority All claims re-submitted with an SCC of ’43- 46,’ are reviewed by ESI. A monthly report of invalid Prescriber IDs will be sent to providers for research, reversal, and reprocessing with the a valid Prescriber ID for the dispensed controlled substance.
Pharmacies have 90 days from date of service to correct the claims.
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Medicare Part D Prescriber ID Validation in 2013 For both Prescriber NPI and Controlled Substance Prescribing Authority point-of-sale edits:
• CMS requires that communication between the pharmacy and payer must occur within 24 hours.
• By the time 24 hours have elapsed, the point-of-sale reject should be resolved.
• Express Scripts will follow up with pharmacies to ensure that all rejected claims have been resolved within 24 hours in order to ensure members are not negatively impacted. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Short Cycle Dispensing
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Medicare Part D – Short cycle Dispensing – CMS Guidance Overview – 2012 Final Rule Effective January 1, 2013 all pharmacies are required to dispense brandname oral solid drugs to enrollees in LTC facilities in no greater than 14-day increments.
Certain drug exclusions apply – (i.e., drugs that must be dispensed in their original containers, such as eye drops, nose drops or certain antibiotics).
Nothing precludes pharmacies from applying this new methodology to solid oral doses of generic drugs (but not required at this time).
Beneficiaries’ cost share will be based on the amount of the drug they receive and their benefit design.
Waiver for Indian/Tribal/Urban (I/T/U) pharmacies and pharmacies that service Intermediate Care Facilities for the Mental Retarded and Developmentally Disabled (ICFMRDD) and Institutes for Mental Disease (IMDs).
CMS Objective: Reduce waste and achieve program savings Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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What is Express Scripts Doing to Support Medicare Part D Short Cycle Dispensing? Express Scripts is: Adjusting its systems to accommodate appropriate short cycle fill (SCF) adjudication logic, including new Submission Clarification Codes (SCC) and Special Packaging Indicator (SPI) codes and adjusted DUR edits. Implementing new reject codes and additional messaging. New LTC Provider Agreements. Implementing retrospective monitoring to identify outliers, such as: Pharmacies that frequently process claims for brand solid oral medications as non-SCF, but which should have been processed as SCF. Rejected claims (to determine whether rejected claims submitted as SCF should have been processed). Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Medicare Part D – Short Cycle Dispensing Drug Utilization Review (DUR) Edits Concurrent DUR checks will continue for short cycle dispensed claims (SCF), but will be adjusted to accommodate the new short cycle dispensing adjudication logic.
New Refill-Too-Soon threshold for short cycle fills: • New: Days supply 0-14: Default at 50% (can fill as frequently as every 7 days, although expect to see most prescriptions written for 14 days).
• Existing: Days supply > 15: Set to existing RTS threshold: Typically 75% on hand (can fill as frequently as every 23 days for a 30-day supply). NOTE: Standard Refill-Too-Soon (RTS) logic may vary by plan. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Medicare Part D – Short Cycle Dispensing – Additional Information Additional considerations for short cycle dispensing: Transition policy To accommodate short cycle dispensing, the transition policy in LTC settings will include a 91-98 day supply. When a transition fill is requested, the short cycle dispensing logic will process first, then transition logic.
COB – secondary payer claims will also be pro-rated subject to short cycle dispensing requirements.
Initial Coverage Limit (ICL)/Coverage Gap/Catastrophic – short cycle logic will apply regardless of where a beneficiary is in the Part D benefit.
Compounds – compound claims with appropriate SCC/SPI combinations will process as short cycle dispense. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Commercial/Medicaid Impact LTC facilities may choose the same dispensing method, regardless of payer (Medicare, Medicaid, Commercial).
• ESI’s operating systems will reject* Commercial and Medicaid LTC claims that have been short-cycle filled.
• Additional response messaging will be provided to help educate providers.
• Internal reporting will identify LTC claims that have been incorrectly short-cycle dispensed, and outreach will be made to providers. * (Reject codes are included in the Appendix.)
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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2013 Medicare Part D Benefit Update
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Medicare Part D – 2013 Benefit Preview Enrollee Out-of-Pocket Expenses
Total Drug Expenditures (TDS)
Catastrophic Coverage Phase
80% CMS Risk
15% Plan Risk
5% Co-Ins.
$4,750+
$6,733.75 Coverage Gap Phase TDS Indemnity Limit
MOPS (TrOOP) Indemnity Limit
“Donut Hole”
79% Enrollee Payment for Generic 47.5% Enrollee Payment for Brands
$2,970
$986.25
Initial Coverage Phase
75% Plan Risk
$325 Deductible Phase
$0 Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
25% Co-Ins.
Deductible Indemnity Limit
$325
$320 Enrollee Deductible $0 33
Explanation of 2013 Medicare Part D Basic Benefit Beneficiary Cost
Total Drug Cost 95% Medicare
5% Catastrophic Phase coins
$6,733.75
$2,970
75% Medicare
2013 Benefit Details: 1. 2. 3. 4. 5.
Coverage Gap Phase
5% Beneficiary $4750 Coverage Gap
100% Beneficiary $986.25
Initial Coverage Phase
25% Beneficiary
Deductible Phase
100% Beneficiary
First $325
Beneficiary pays $325 annual deductible Beneficiary then pays 25% of allowable costs up to $2,970: 25% of ($2,970 - $325) = $652.50 Coverage gap/“doughnut hole”: Beneficiary pays $4750 - (Now 50% subsidized by Pharma) After $5672.50 out-of-pocket ($325 + $661.25 + $4750 = $5736.25), catastrophic coverage begins at $6,733.75 Beneficiary pays nominal amount (e.g., 5% - either $2.65 or $6.60 copayment) of allowable costs over $6,733.75
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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2013 Changes for Non-Covered Medicare Part D Drugs Barbiturates (seizure drugs) – These are now Part D-eligible starting in 2013 if used for treatment of epilepsy, cancer, and chronic mental health.
Benzodiazepines (anxiety drugs) – These are now Part D eligible starting in 2013. NOTE: These drugs will now require a PA in order to be covered under Medicare Part D. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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FDA’s Comprehensive NDC Structured Product Labeling (SPL) Data Elements File On September 1, 2012, CMS began editing prescription drug events (PDEs) using the Structured Product Labeling (SPL) Data Elements File.
Part D plans implemented point-of-sale edits to reject non-listed NDCs if submitted on Medicare Part D claims
In order to minimize member disruption, please stock an alternative NDC whenever possible
The SPL is available at the link below: http://www.fda.gov/ForIndustry/DataStandards/StructuredProduc tLabeling/ucm240580.htm. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Medicare Part D Covered Nebulized Medications These medications are covered under Medicare Part D when a Medicare Part D-eligible beneficiary resides in a long-term care (LTC) or skilled nursing facility. Albuterol Sulfate Soln Nebu 0.083% (2.5 MG/3ML)
Iloprost Inhalation Solution 10 MCG/ML
Albuterol Sulfate Soln Nebu 0.5% (5MG/ML) Albuterol Sulfate Soln Nebu 0.63 MG/3ML (Base Equiv) Albuterol Sulfate Soln Nebu 1.25MG/3ML (Base Equiv) Albuterol-Ilpratropium Nebu Soln 2.5.(3)-0.5 MG/3ML Arformoterol Budesonide Inhalation Susp 0.25 MG/2ML Budesonide Inhalation Susp 0.5 MG/2ML Budesonide Inhalation Susp 1 MG/2ML Cromolyn Sodium Soln Nebu 20 MG/2ML Dornase Alfa Epinephrine Formoterol
Ipratropium Bromide Ihnal Soln 0.02% Isoetharine Levalbuterol Metaproterenol Sulfate Soln Nebu 0.4% Metaproterenol Sulfate Soln Nebu 0.6% Metaproterenol Sulfate Soln Nebu 5% Mucolytics Pentamidine Isethionate for Nebulization Soln 300 MG Legend Sodium Chloride (Inhalant) Treprostinil Tobramycin Nebu Soln 300 MG/5 ML Methacholine
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Yellow highlight = change for 2013
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2013 Medicare Part D Transition Period
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Med D 2013 Transition Period For 2013, eligible new and current enrollees will continue to have a 90-day transition period to receive a temporary supply of Medicare Part D covered medication(s) which are not on their Part D Plan formulary, or are subject to UM programs such as Step Therapy, PA required, or Quantity Level Limits.
CMS is raising concerns that the Part D transition process is not applied consistently for eligible members, and has issued a best practices memo.
CMS considers member access crucial. If a member is eligible for a transition fill, he/she must receive required medications.
To ensure CMS requirements are met, pharmacies should be aware of and responsive to online reject messaging and secondary instructions. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Med D 2013 Transition Period ESI approach to 2013 Medicare Part D Transition process: • System will verify member and drug eligibility o No edits for formulary and UM visible to pharmacy
• Medicare B vs. D determinations: o Non Part D covered medications, Exceeded Days supply, DUR and other
appropriate edits may occur at point-of-sale. o It is important that pharmacies review online messaging for further
instruction to assure member access in these circumstances.
• If member’s benefit allows a max days supply and transition fill is lower, the next claim will allow the member to receive a fill until the days supply limit is met.
• The Transition Fill status will be identified when the claim pays. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Med D 2013 Transition Period Example: Days Supply Exceeded If the prescription is for an amount greater that the plan’s days supply allows, the claim will reject with a message instructing the pharmacist to reduce the days supply and resubmit the claim. Reject Code
Sample Secondary Message
19 (Max Days Supply)
“TRANSITION FILL; LIMITED TO XX DAY SUPPLY”
7X (Days Supply Exceeds Plan Limitation
“DAYS SUPPLY EXCEEDS PLAN LIMITATION”
Pharmacy Action
Reduce quantity for Max days supply and resubmit claim
Messaging appears in NCPDP field 504-F4 Pharmacist enters appropriate PA code in NCPDP field 462-EV Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Med D 2013 Transition Period Messaging on the Paid Claim NCPDP Recommended Message
Paid under transition fill. PA Paid under transition fill. Non-formulary Paid under transition fill. Other reject Transition fill
Pharmacy Action
Advise Member that this was a Transition Fill and a temporary supply. Member needs to work with plan to either file an exception or move to a formulary alternative.
Messaging appears in NCPDP field 504-F4 Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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CMS Requirements Outside the Transition Period Outside the 90-day transition period, manual transition fills must be provided for the following:
• Level of Care Changes • Transition Extension Requests • LTC Emergency Fills (if not auto-effectuated and required)
In these situations, pharmacies may call the ESI help desk or the Part D Plan at the number(s) listed on the member’s ID card to request a one-time PA for the needed supply.
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Med D 2013 Transition Period – Benzodiazepines & Barbiturates – New CMS Requirement During the member’s transition period, CMS expects all claims for benzodiazepines and barbiturates to be considered continuing therapy to comply with transition requirements. Express Scripts will: • Process Benzodiazepine claims under Medicare Part D for all members during their 90-day transition period, regardless of prior utilization. • Process Phenobarbital claims under Medicare Part D for all members during their 90-day transition period, regardless of prior utilization. • Reject claims for Barbiturates (Other than Phenobarbital) for confirmation of Part D usage. o NCPDP Reject codes are 75 (Prior Authorization Required) and 70
(Product/Service Not Covered – Plan/Benefit Exclusion). o The pharmacy should review online messaging for further instruction to assure member access in these circumstances. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Part B Durable Medical Equipment Transition Starting in 2013, CMS is adding new requirements for Transition of Part B Durable Medical Equipment (DME). • A transition supply is required if the item is limited by the plan to specific brands or manufacturers.
ESI systems will allow transition of Part B DME for diabetic supplies including Test Strips, Lancets, Lancing Devices, Control Solutions and Glucometers.
New and current members will have 90-day transition for Part B DME. • Members are allowed an initial fill and one (1) refill o Limited to the benefit allowed max days supply.
o 3rd fill attempt will reject with 70 (NDC Not Covered).
• Transition Fill status will be identified when the claim pays using standard transition messaging. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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2013 Medicaid Updates and Reminders
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Non-Covered Medicaid Drugs for 2013 Agents used for: • Anorexia or weight loss/gain • Promoting fertility or for sexual dysfunction/ED
• Cosmetic purposes or to promote hair growth
• Symptomatic relief of cough/colds
DESI Drugs Covered outpatient drugs when a manufacturer seeks to require, as a condition of sale, that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee
Agents for which there is no rebate agreement between the manufacturer and CMS NOTE: Some plans will choose to cover non-prescription (OTC) or other excluded medications. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Arizona 340B AHCCCS mandates specific 340B pricing when the drug is dispensed by an FQHC/lookalike to AZ Medicaid members.
AHCCCS mandates that all AHCCCS pharmacies be paid lesser of their 340B acquisition cost, the 340B ceiling cost or the AHCCCS-defined 340B MAC rate + AHCCCS 340B dispensing fee for any drug identified as 340B regardless of purchase type.
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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New York Medicaid Serial Number The New York Dept. of Health (DOH) requires all pharmacies serving New York Medicaid patients to submit the official New York prescription serial number when submitting claims for prescriptions written on an official New York State prescription form.
For New York Medicaid claims: • Submit the prescription serial number in NCPDP Scheduled
Prescription ID Number Field 545-EK
Medicaid claims submitted without a serial number or with an invalid serial number will reject with EK (Missing/Invalid Scheduled Prescription ID number). Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Texas Medicaid 72-hour emergency fills, submit: • In PA Type Code field 461-EU, submit a value of “8” • In PA Number Submitted field 462-EV, submit a value of “801”
CHIP contraceptives for non contraceptive use, submit: • In PA Type Code field 461-EU submit a value of “2” • In PA Number Submitted field 462-EV, submit one of the following values: o “31” = Dysmenorrhea o “32” = Acne Treatment o “33” = Miscellaneous, other than contraception
Compounds and SCC 8 • For compounds with non-covered ingredients, submit: o Submission Clarification Code value of “8” Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Other Primary Insurance Carrier Messaging When a Medicaid claim is submitted and the member is determined to have other health insurance coverage, the Medicaid claim will reject 41 - Submit Bill to Other Processor or Primary Payer.
Ohio & Texas
Ohio & Texas requires the return of the Primary Payer information to the pharmacy (when known) in the Additional Message Information field 526-FQ.
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Questions?
Please send your questions via email to:
[email protected] Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
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Thank You
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Appendix • 2013 Medicare Approved Plans with BAE
• HCBS
• BAE Information
• Short Cycle Fill
• Beneficiary Rights
• Medicare & Medicaid Reminders
• Non-Matched NDC List
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Medicare Approved Part D Plans with BAE
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2013 Medicare Approved Plans – Legacy ESI Plan Type
MA-PD
PDP
100% Med D Business?
NO
NO
Medicare Plan Name
Abrazo Advantage, Phoenix Health Plan
BCBS of Louisiana
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
Prior Auth
800-4178164 Fax: 877837-5922
800-4178164 Fax: 877837-5922
Web Site
BAE Phone/Fax/Email Information
RxGroup
Yes www.abrazoadvantage.com
Member Services; Ph: 602-8243900 or 888-864-1114; TTY/TDD users call 602-824-3909 or 800489-1472 toll free; Fax: 602-6746673; Hrs: M–F, 8 am -5 p.m. or after hrs, holidays or weekends (8 am-8 pm) call 800-842-4681 to access AZ Relay Service
PH7A
Yes www.bcbsla.com
BAE Contact: Raquel Woods, BAE Back Up Contact: LaKitha Lewis, Phone: 1-888-223-BLUE (2583); Hours: 8 a.m.- 8 p.m., 7 days/wk Email:
[email protected] Attn: RXBLUE, Fax Number: 1-225-2981848, Attn: Rx BLUE
BSLA
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2013 Medicare Approved Plans - Legacy ESI Plan Type
MA-PD
100% Med D Business?
NO
Medicare Plan Name
BCBSMA Medicare Options Blue MedicareRx
MA-PD
YES
EmblemHealth* ConnectiCare, Group Health NY Med D
MAPD/PDP
NO
First Care Advantage Medicare Plans
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
Prior Auth
800-3667778
888-4477364
866-2294969
Web Site
BAE Phone/Fax/Email Information
For LTC Pharmacies: Janice Brown Ph# 617-246-8513 Fax: 617-2468506 Hours: 8 am to 4 pm Backup - Shannon Foley Ph# 617-246-8513 Fax: 617-246www.bluecrossma.com/ 2509; Hours: 8 am to 4 pm medicare All Other Pharmacies: Pharmacy Operations Ph#: 1-800-366-7778 Fax: 866-463-7700 Hours: 8 am to 6 pm
BAE Contact: J’Nisha Der Weer; BAE Back Up Contact: Lester www.emblemhealth.co Lachuk; Phn: 877-444-7241;Fax: m/ 212-510-5054 Email:
[email protected] Hours: 9am - 5pm EST First Care Customer Service Phone www.firstcare.com/adva Number (866) 229-4969, First Care ntage Customer Service Fax Number (806) 784-4190
RxGroup
MASA, MAKA, MDXA
CN3A, GH3A KHXA, KHYA
FTCA
(*EmblemHealth maintains its own BIN/PCN.)
57
2013 Medicare Approved Plans - Legacy ESI Plan Type
100% Med D Business?
MA-PD
NO
MA-PD
YES
MA-PD
YES
MA-PD
NO
Medicare Plan Name
Prior Auth
Web Site
BAE Phone/Fax/Email Information
Ph: 888-260-1010; Fax: 646-313-4645; Healthfirst Medicare Plan www.healthfirstny.com Mcareenrollment@healthfirst. org Member/Provider Services, Ph: 305-421-1244; Toll-free 800-407-9069; Fax: 305-476Medica Health Care 0616; 866-273-9444 www.medicaplans.com Plans Hrs: 8 pm-8 am Mon-Sun Email:
[email protected] m MediSun Member Services, (Banner) Medisun Plans: Ph: 800-417Ph: 623-974-7430; Fax: 623Classic, Plus, Premier, 8164 Fax: 877www.medisun.com 974-7439; Hrs: M-F, 8 am - 5 and HeartSmart 837-5922 pm Ph: 800-378-5234; Network Platinum Select, Fax: 920-720-1909 Platinum Plus Phcy & http://www.nppdrugplans.c 800-378-5234 Hrs: 8 am - 5 pm CT Platinum Premier Phcy, om/provider_information/ Email: Network Cares
[email protected]
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
800-417-8164 Fax: 877-8375922
RxGroup
HEFA
V39A
HMSA, BHSA, HMNA
NHPA
58
2013 Medicare Approved Plans - Legacy ESI Plan Type
100% Med D Business?
Medicare Plan Name
Prior Auth
Web Site
BAE Phone/Fax/Email Information
RxGroup
MA-PD
NO
Healthfirst Health Plan of NJ
800-417-8164 Fax: 877-8375922
www.healthfirstnj.com
Ph: 888-260-1010; Fax: 646 313-4645
[email protected]
B7PA
www.healthfirstny.com
MA-PD
NO
Healthfirst Medicare Plan
800-417-8164 Fax: 877-8375922
MA-PD
YES
Medica Health Care Plans
866-273-9444
www.medicaplans.com
YES
MMM Healthcare
Ph: 866-5167703 Fax: 787-3005503
www.mmm-pr.com
No BAE as Puerto Rico does not have LICS
MMHA
NO
Network Platinum Select, Platinum Plus Phcy & Platinum Premier Phcy, Network Cares
800-378-5234
http://www.nppdrugplans. com/provider_information /
Ph: 800-378-5234; Fax: 920-720-1909 Hrs: 8 am - 5 pm CT Email:
[email protected]
NHPA
MA-PD
MA-PD
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
Ph: 888-260-1010; Fax: 646-313-4645;
[email protected] Phone number & fax: Member/Provider Services 305421-1244; Phn: 1-800-407-9069, fax: 1-800-517-6924 Hours: 8pm-8am Mon-Sun e-mail:
[email protected]
HEFA
V39A
59
2013 Medicare Approved Plans - Legacy ESI Plan Type
PDP
100% Med D Business?
NO
Medicare Plan Name
Prior Auth
Web Site
BAE Contact/Phone/Fax/Email Information
Bethany Bondy – BAE Primary Contact 419-887-2327
[email protected] www.paramounthealthcare.c Kelly Auble – BAE Backupom 419-887-2324 Fax # 419-724-0691 Hrs: 8am – 5pm EST
Paramount Health Care
RxGroup
PH6A
MA-PD
YES
PMC Medicare Choice
Ph: 866-5167703 Fax: 787300-5503
MA-PD, PDP
NO
Rocky Mountain Health Plans
800-8544558
www.rmhp.org
Pharmacy Help Desk 800-641-8921 Fax: 970-248-5034
MHYA
MA-PD
NO
SCAN Health Plans
800-4178164
www.scanhealthplan.com/de fault.aspx www.villagehealthca.com
Phn: 800-559-3500 7am – 6pm PST, Fax: 1-562-989-5243
AN9A, MRPA
617-2526366
Mary Sullivan (primary) Gayle Dichter (BAE back-up) phone: Mon-Fri 8 am-5 pm 617-252No 6366 (Other hours 1-617-494-5353); fax www.seniorwholehealth.com #: 888-251-7823
[email protected] [email protected] Hours- (M-F) 8 am - 8 pm
MA-PD
NO
Senior Whole Health
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
www.pmcpr.org
No BAE as Puerto Rico does not have LICS
MMHA, PM3A
WH3A
60
2013 Medicare Approved Plans - Legacy ESI Plan Type
MA-PD
100% Med D Business?
NO
Medicare Plan Name
Prior Auth
Ucare for Seniors Medicare Advantage Plans
Ph: 877558-7521 Fax: 877837-5922
MA-PD, PDP
NO
UPMC for Life UPMC for Life Specialty Plan
PDP
YES
UPMC (PACE)
MA-PD, PDP
YES
Ph: 800-3964139
BAE Phone/Fax/Email Information
RxGroup
Sue Wooldridge, Enrollment and Billing Dir, Phone: 612-676-3647, http://www.ucare.org/provider Fax: 612-884-2162, email: s/Pages/MedicareAdvantagea
[email protected]; After hrs – ndSpecialNeedsPlans.aspx calls should go to Cust Svc for MSHO or UFS–see member ID card
MNUA
7 days/wk 8 am - 8 pm EST UPMC for You Advantage/UPMC Community Care 1-(800)-606-8648 (TTY/TDD) 1-(866)-407-8762) Fax# 412-454-5295 Attn: Pharmacy Resource Desk
PMDA
Pharmacy Resource Desk; Ph: 412-454-5295
PM4A
Call ESI Pharmacy Help Desk to request BAE PA. Contact WLP for all other BAE processes. Fax BAE documents to 502-889-3344
WM2A, WM3A
Ph: 877-5393080 http://www.upmchealthplan.co Fax: 412m/medicare/ 454-7920
WellPoint Part D Plans: Ph: 800-203Anthem BCBS; Anthem BC Life & 0267 Health Ins. Co; BCBS of GA; 800-338-6180 BCBS HC Plan of GA; BCBS of KS; BCBS of KC; Empire Blue 877-824-7370 Cross; Empire BCBS; Unicare Life (Empire) & Health Ins. Co.
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
Web Site
61
2013 Medicare Approved Plans – Legacy Medco Medicare Plan Name
BAE Phone/Fax/Email Information
Aloha Care
Roberta Peralto, Enrollment Manager AlohaCare,1357 Kapiolani Blvd, Suite 900 Honolulu, HI 96814 Phone Number: (808) 973-7415
AvMed Health Plans - Medicare
Michelle Burton, 9400 S Dadeland Blvd Miami, FL 33156, (305) 671-5437
[email protected]
Blue Cross Blue Shield of North Carolina
refer to customer service number on ID card
BSNENY MAPD BS NORTHEASTERN NY BCBS WESTERN NY HN SmartSaver RX PDP BCBSWNY MED D MAPD SMARTHHEALTH RX PDP
Lauren Villano, 1701 North Street, Endicott, NY13760 (607) 766-3023
[email protected]
Care Improvement Plus
Centerlight Healthcare
Cynda Gibbs, 4350 Lockhill-Salem Road, Suite 300, Shavano Park, TX 78249 (210) 587-2112
[email protected] Bracha Portnoy, 1250 Waters Pl, Tower 1, Suite 602, Bronx, NY 10461
[email protected] (347) 640-6150
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
BAE Phone/Fax/Email Information (secondary contact) N/A
N/A
N/A
N/A
N/A
N/A
Carrier ID
6180
Umbrella Group ALOHAMA WHA3333 ALLIANZ
MDAVMED
15323
3633 3634
NCPARTD
HNMED
13820
CARERX01
14394
CCMCRX1
11300
62
2013 Medicare Approved Plans – Legacy Medco Medicare Plan Name
BAE Phone/Fax/Email Information
BAE Phone/Fax/Email Information (secondary contact)
Carrier ID
Umbrella Group
Coventry HC - Med D
[email protected] Fax: (210) 366-6058 Phn: (804) 934-4203
[email protected]
Stephanie Block,
[email protected] (412) 865-3615
KHPW001
14377
Global Health
David Thompson, Phn: (918) 878-7306 Fax: (918) 878-7350 Email:
[email protected] Hours: 8am-5pm CST
Britney Gilbert, Phn: (405) 280-5620 Fax: (405) 280-5881 Email:
[email protected] Hours: 8-5pm CST
GHMEDDRX
45442
Pharmacies and providers should call Highmark Pharmacy Affairs, (800) 600-2227. Members should call the number on the back of the ID card.
Jennifer Arnal, 120 Fifth Avenue Ste. P5501, Pittsburgh,PA15222
[email protected] (412) 544-2179
Highmark BLUE RX FREEDOM BLUE SECURITY BLUE
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
SPBLUE2 KHPW001 SPBLUE3 SPBLUE1
11411
63
2013 Medicare Approved Plans – Legacy Medco BAE Phone/Fax/Email Information
BAE Phone/Fax/Email Information (secondary contact)
Carrier ID
Umbrella Group
Preferred Care Partners
Vanessa "Trini" Ayala
[email protected] (305) 670-8446, ext. 1338
Cary Lopez,
[email protected] (305) 670-8446, ext. 1357
KHPW001
14330
State of New York
Paul Nand, 2725 Mall Drive Eau Claire, WI 54701 (715) 858-2429
[email protected]
N/A
SNYMDRX
16688
The Health Plan
Tammy Robinson 52160 National Road East St. Clairsville, OH 43950, (740) 695-7595 (740) 695-7596,
[email protected]
Judy Kyer,
[email protected], (740) 699-6137 or Linda Kostelia,
[email protected], (740) 699-6122
SPBLUE3 THPMEDI
15646
Universal Health Care
Darlene Diaz, Director, Enrollment (727) 456-6579,
[email protected] Fax: (727) 823-3840
Dr. SZ Kabir, Medical Analyst 727-456-6509,
[email protected] Fax: (727) 823-3840
SPBLUE1
14371
Wisconsin Physicians Service Insurance
Kyle Konop (800) 944-2656, ext. 4901
N/A
6181
WPSPDP
Medicare Plan Name
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
64
BAE– Express Scripts PDP Best Available Evidence (BAE) information for all plans under the Express Scripts Part D Plan (PDP) is as follows:
• Express Scripts Eligibility Medicare Operations • Phone: 1-866-275-0953 (M - F, 8 am - 5 pm CST) • Fax: 1-888-837-0307
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
65
BAE Information
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
66
Background on Best Available Evidence (BAE) Policy CMS relies on eligibility files from states and Social Security to establish an individual’s low-income subsidy, deemed eligibility and appropriate cost-sharing level.
In certain cases, CMS systems do not reflect a beneficiary’s correct LIS deemed status. • A state has been unable to successfully report the beneficiary as Medicaid eligible, or
•
Is not reporting him/her as institutionalized or participating in a Home Based Community Services (HCBS) program.
BAE policy is used when the low-income subsidy information in either plans’ and/or CMS’ systems are incorrect. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
67
BAE: Purpose Best Available Evidence
Correct LIS Status
Provides beneficiaries access to Part D drugs at a lower cost-sharing level (or $0 cost sharing if BAE also verifies beneficiary’s institutional or HCBS status). Includes a process to correct a beneficiary’s LIS status in plans and CMS systems. Involves action by the Part D sponsors and CMS. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
68
Best Available Evidence: Process Documents
Provided to Sponsor
Sponsor follows BAE policy
Sponsors must: • Accept one of the established forms of BAE evidence. • Update their systems.
• Provide beneficiary access to Part D drugs at a reduced or $0 cost-sharing level, as appropriate. • Send a request to IntegriGuard to correct, if necessary.
• Receive information via TRR. • Send an EOC rider. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
69
BAE Process at Point of Service When a beneficiary presents supporting documentation of LIS eligibility (BAE), the pharmacy is required to call Express Scripts Prior Authorization (PA) Contact Center for a copay override.
Copay override is granted upon validation that documentation presented to pharmacy is CMS-approved BAE documentation.
The Pharmacy is required to fax BAE documents to beneficiary’s health plan. • The Express Scripts Medicare Part D Health Plan Matrix with BAE Fax numbers is provided with this presentation
• Use the NCPDP-approved BAE fax cover sheet; include the Health Plans BAE Contact if available.
If the beneficiary has no BAE to present, but claims to qualify for a LIS benefit: • Pharmacist will direct the beneficiary to contact their health plan by calling number on back of Medicare Part D card. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
70
BAE: Documentation Establishes LIS status Establishes $0 institutional or HCBS cost-sharing Establishes LIS status of LIS applicants
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
71
Valid BAE Documents Non Institutionalized–Non-HCBS:
Medicaid card with name and eligibility date. State document confirming active Medicaid status. Printout from the State electronic enrollment file showing Medicaid status.
A screen print from the State’s Medicaid systems showing Medicaid status.
Other documentation provided by the State showing Medicaid status; or
• For individuals who are not deemed eligible, but who apply and are found LIS eligible, a copy of the SSA award letter. (1) Documents are valid if dated after June of the previous calendar year. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
72
Valid BAE Documents Institutionalized: Zero Dollar Copay
A remittance from the facility showing Medicaid payment for a full calendar month for that individual during a month;
A copy of a state document that confirms Medicaid payment on behalf of the individual to the facility for a full calendar month; or
A screen print from State’s Medicaid systems showing individual’s institutional status based on at least a full calendar month’s stay for Medicaid payment purposes. Full-benefit dual-eligible individuals who are institutionalized or who are receiving home and communitybased services have no cost sharing for Part D drugs covered under their PDP or MA–PD plans. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
73
Valid BAE Documents Non-Institutionalized HCBS: Zero Dollar Copay
State-issued Notice of Action, Notice of Determination, or Notice of Enrollment that includes beneficiary’s name and HCBS eligibility date during a month after June of previous calendar year;
State-approved HCBS Service Plan that includes beneficiary’s name and effective date beginning during a month after June of previous calendar year;
State-issued prior authorization approval letter for HCBS that includes the beneficiary’s name and effective date beginning during a month after June of the previous calendar year;
Other documentation provided by State showing HCBS eligibility status during a month after June of the previous calendar year; or,
State-issued document, such as a remittance advice, confirming payment for HCBS, including beneficiary’s name and dates of HCBS. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
74
BAE Assistance If beneficiary is unable to locate appropriate documentation to establish LIS eligibility award, or if the beneficiary has no BAE to present but claims to qualify for a LIS benefit:
• The pharmacy will direct beneficiary to contact the Health Plan by calling the number on back of his/her Medicare Part D benefit card. • If beneficiary calls Express Scripts for assistance, Patient Care Advocate will assist the beneficiary by providing telephone and fax number of BAE contact at Health Plan. • The Sponsor and Regional Office will work together to assist
the beneficiary in obtaining documentation. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
75
Beneficiary Rights Notice
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
76
Beneficiary Rights Notice Your Medicare Rights You have the right to request a coverage determination from your Medicare drug plan if you disagree with information provided by the pharmacy. You also have the right to request a special type of coverage determination called an “exception” if you believe:
• You need a drug that is not on your drug plan’s list of covered drugs. The list of covered drugs is called a “formulary;”
• A coverage rule (such as prior authorization or a quantity limit) should not apply to you for medical reasons; or
• You need to take a non-preferred drug and you want the plan to cover the drug at the preferred drug price.
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
77
Revised Beneficiary Rights Notice (Cont’d) What you need to do You or your prescriber can contact your Medicare drug plan to ask for a coverage determination by calling the plan’s toll-free phone number on the back of your plan membership card, or by going to your plan’s website. You or your prescriber can request an expedited (24 hour) decision if your health could be seriously harmed by waiting up to 72 hours for a decision. Be ready to tell your Medicare drug plan:
1.
The name of the prescription drug that was not filled. Include the dose and strength, if known.
2. 3. 4.
The name of the pharmacy that attempted to fill your prescription. The date you attempted to fill your prescription. If you ask for an exception, your prescriber will need to provide your drug plan with a statement explaining why you need the off-formulary or non-preferred drug or why a coverage rule should not apply to you.
Your Medicare drug plan will provide you with a written decision. If coverage is not approved, the plan’s notice will explain why coverage was denied and how to request an appeal if you disagree with the plan’s decision. Refer to your plan materials or call 1-800-Medicare for more information. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
78
Home and Community-Based Services (HCBS)
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
79
Home and Community-Based Services (HCBS) CMS has eliminated cost-sharing for full-benefit dual eligible individuals. • Patients may receive home and communitybased services (HCBS) under a home and community-based waiver. • Authorized for a state by the federal government or if such services are provided through enrollment in a Medicaid MCO.
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
80
LTC Short Cycle Fill – Additional Information
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
81
42Ø-DK - Submission Clarification Codes (SCCs) New Submission Clarification Codes have been created to indicate dispensing methodology. Values 16, 21 - 36 are specific to Long-Term Care for Short-Cycle Fill. Code
Description
Code
Description
16
Long Term Care Emergency box (kit) or automated dispensing machine
29
Daily and 3-day weekend
21
14 days or less not applicable
30
Per shift dispensing
22
7 days
31
Per med pass dispensing
23
4 days
32
PRN on demand
24
3 days
33
7 day or less cycle not otherwise represented
25
2 days
34
14 day dispensing
26
1 day
35
8-14 day dispensing
27
4-3 days
36
Dispensed outside short cycle
28
2-2-3 days
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
82
429-DT - Special Packaging Indicators (SPI) Value
Description
Ø
Not Specified
1
Not Unit Dose – Indicates the product is not being dispensed in special unit dose packaging
2
Manufacturer Unit Dose – Indicates a distinct dose as determined by the manufacturer
3
Pharmacy Unit Dose – Indicates when the pharmacy has dispensed the drug in a unit of use package
4
Pharmacy Unit Dose Patient Compliance Packaging
5
Pharmacy Multi-Drug Patient Compliance Packaging
6
Remote Device Unit Dose
7
Remote Device Multi-Drug Compliance
8
Manufacturer Unit of Use Package (Not Unit Dose)
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
83
Submission Clarification Code (SCC) & Special Packaging Indicator (SPI) – Short Cycle Dispensing The combination of SCC and SPI will be used at point-of-sale for additional detail on days supply and packaging type: • SCC values (16 or 22-35) provide detail about the increments in which the pharmacy dispensed the drug, (e.g., value of 22 = 7-day supply; value of 23 = 4-day supply)
• SPI values (1-7) will display type of dispensing packaging (e.g., value of 1 = not unit dose; value of 2 = manufacturer unit dose)
The system will recognize when the intent is for the claim to be treated as short cycle fill by the following: • Med D Member • Patient Residence Code = 3 • Valid SCF SCC/SPI combination Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
84
Example 1 – Claim Using New SCC/SPI
Lipitor (SCF Eligible)
Medicare Patient = Y Patient Residence Code = 3
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
SCC=22 (7-day supply)
SPI =1 (Not Unit Dose)
Valid SCC/SPI Combo
Claim Successful – Processed as SCF
85
Example 2 – Claim Using Invalid SCC/SPI
Valium (SCF Eligible)
Medicare Patient = Y Patient Residence Code = 3
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
SCC=22 (7-day supply)
SPI=0 (not specified)
Invalid SCC/SPI Combo
Claim Rejected
86
Short Cycle Dispensing FAQs Q: Will members pay full co-payments for fewer days’ supply? A: No. A member’s co-pay will be pro-rated based on the days’ supply for each short-cycle fill. Q: Will LICs co-payments also be pro-rated? A: Yes, LICS co-payments will also be pro-rated. Q: Can any drug be short-cycle dispensed? A: Only solid oral brand-name drugs are required to be short-cycle dispensed; however, generics can also be short-cycle filled if the pharmacy can support it. Q: What will ESI do to report unused prescription drugs in the long-term care setting? A: CMS announced in early August that a separate report will not be required for unused prescription drugs. Instead, CMS will use information found on the PDE, plan utilization data and other information to better understand how short-cycle fill impacts prescription drug waste. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
87
Non-Matched NDC List Update
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
88
Non-Matched NDC List Update CMS will not provide any additional updates for 2013. The current non-matched NDC list is available on the FDA website: http://www.accessdata.fda.gov/scripts/cder/ndc/default.cfm
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
89
Reminders: Medicare & Medicaid
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
90
Vaccine Administration Reminder Express Scripts offers a point-of-sale solution for coverage of vaccinations, which has proven popular with benefit plan sponsors and their members. All vaccine claims covered by a plan sponsor should be submitted as follows: Field # 455-EM 473-7E
NCPDP Field Name Prescription/Service Reference Number Qualifier DUR/PPS Code Counter
Submission Criteria 1 = Rx Billing 1= Rx Billing If dispensing and administering the vaccine to the patient If dispensing vaccine without Blank administration Provider’s Vaccine Administration Fee to include administration and all supplies necessary for injection MA (Medication Administered)
440-E5
Professional Service Code
438-E3
Incentive Amount Submitted
409-D9
Ingredient Cost Submitted
Vaccine drug ingredient cost
426-DQ
Usual and Customary Charge
Amount submitted should include the cost for the vaccine PLUS provider’s Vaccine Administration Fee
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
91
Vaccine Administration Reminder (Continued) If a plan sponsor does not cover the administration fee/professional service fee, the pharmacy will receive the following online response message: REIMBURSEMENT DOES NOT INCLUDE PAYMENT OF PROFESSIONAL SERVICE FEE. If you receive this response, the member may be charged the administration fee.
If a plan sponsor does cover the administration fee/professional service fee, the following response will be returned: REIMBURSEMENT DOES INCLUDE PAYMENT OF PROFESSIONAL SERVICE FEE.
If the vaccine is injected, please be sure the claim is submitted accurately with the MA code and the incentive fee amount. Please read the messaging regarding reimbursement of the Professional Service Fee (PSF) before charging a member for the PSF. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
92
End Stage Renal Disease Reminder Effective January 1, 2011, services provided to Medicare beneficiaries by an ESRD dialysis center are covered through Medicare Part B.
This means all renal dialysis services are to be provided through a dialysis facility, including the prescription drugs associated with these procedures.
If a Medicare beneficiary on dialysis fills a prescription for one of the specified renal dialysis service drugs, the claim rejects at point-of-sale with one of the following NCPDP Rejects: NCPDP Reject 70 - Message reads “ESRD DRUGS COVERED BY DIALYSIS FACILITY” or “MEMBER IS ESRD”. NCPDP Reject 75 - Message reads “PA TO ASSESS ESRD STATUS” or “CLAIM IS FOR ESRD BENEFICIARY, CALL HELP DESK”. Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
93
NY Medicaid Dummy Serial Numbers Reminder Some valid prescriptions may still be dispensed when not written on Official New York Prescription Forms. The table below lists specific situations when this is allowed and indicates the appropriate code to enter instead of the Prescription Serial Number in these instances only: Code HHHHHHHHHHHH ZZZZZZZZZZZZ EEEEEEEEEEEE NNNNNNNNNNNN 999999999999
• • • • • •
Confidential and Proprietary Information © 2012 Express Scripts Holding Company. All Rights Reserved.
Value Prescriptions written on hospital prescription pads and the prescription pads of their affiliated clinics Prescriptions written by out-of-state prescribers Prescriptions submitted electronically or via fax Prescriptions for carve-out drugs for nursing home patients Oral Prescriptions Refills when the original prescription was dispensed prior to 9/20/2012 (for a period of no longer than one year post implementation) 94
