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1 February 2010 Pharmacy Benefits Consolidation Implemented on December 31, 2009.

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Presentation on theme: "1 February 2010 Pharmacy Benefits Consolidation Implemented on December 31, 2009."— Presentation transcript:

1 1 February 2010 Pharmacy Benefits Consolidation Implemented on December 31, 2009

2 2 February 2010 Agenda 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

3 3 February 2010 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

4 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

5 5 What members will be affected by the consolidation?

6 6 February 2010 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

7 7 February 2010 What impact will this have on my Pharmacy? 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: – 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. 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. All non-electronic prescriptions for claims paid by the fee-for-service pharmacy benefit must meet applicable federal Tamper Resistant Prescription Pad requirements.

8 8 February 2010 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 –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

9 9 February 2010 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

10 10 What impact will this have on my patients? Package C (CHIP) members will have a $3 copay for generic drugs and a $10 copay for brand drugs As in the past, Presumptive Eligibility and HIP members will not have copays for drugs. Members received a letter communicating the changes in early December –BT –Note: 42 CFR 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 February 2010

11 11 February 2010 Where do I send my claims after the consolidation? Pharmacy Point of Sale Transactions 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 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.

12 12 February 2010 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

13 13 February 2010 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

14 14 February 2010 Who can I contact if I have questions? IHCP Web site at ACS RX Services –Prior Authorization IHCP Provider Manual (Web, CD-ROM, or paper) HP Pharmacy Customer Assistance – , or –(317) in Indianapolis local area Written Correspondence –P.O. Box 7263 Indianapolis, IN HP Provider Relations Field Consultant

15 15 February 2010 Questions


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