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CAPT Pamela Schweitzer IHS Pharmacy Consultant.  General Information, 2013  Coverage Gap  Creditable coverage notice/letter  Fraud Waste & Abuse Training.

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Presentation on theme: "CAPT Pamela Schweitzer IHS Pharmacy Consultant.  General Information, 2013  Coverage Gap  Creditable coverage notice/letter  Fraud Waste & Abuse Training."— Presentation transcript:

1 CAPT Pamela Schweitzer IHS Pharmacy Consultant

2  General Information, 2013  Coverage Gap  Creditable coverage notice/letter  Fraud Waste & Abuse Training  Plan Information, 2013  Processing Claims  Resources

3  Open Enrollment: ◦ October 15th through December 7 th  Medicare & You 2013 handbook  CMS, Social Security and Plan Mailings

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5  Indian Health Services—Joining a Medicare drug plan may help your Indian health facility because the drug plan pays the Indian health facility for the cost of your prescriptions. Talk to your local Indian health benefits coordinator who can help you choose a plan that meets your needs and tell you how Medicare works with the Indian health care system.

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7  Medicare Part D - For those AI/AN beneficiaries that reach the coverage gap (donut hole), and use I/T/U pharmacy, spending counts toward out-of-pocket threshold.  Duel-eligible patient (those receiving Full Low Income Subsidy) are not affected by coverage gap.

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9  Review and be familiar with policy  Newly eligible Medicare eligible Indian beneficiaries may not be aware that they have creditable coverage.  Beneficiary might need to show proof of creditable coverage if changing plans.

10  Affects all staff involved in enrolling and billing Medicare Part D  Documentation of Annual FWA training required  OIG Exclusion list – checking on hiring and annually thereafter  Attestation  Local policy and procedures

11 Previous PBM NameNew PBM Name Prescription SolutionsOptum Rx SXCCatamaran CatalystCatamaran MedcoExpress Scripts BenecardRxAlly

12  Smart D Rx Saver (PDP)  Readers Digest ValueRx (PDP)  Community Care RX and HealthNet Orange are now SilverScript

13 Agreements in place with all stand-alone PDP’s

14  Medicare Drug Plans are rated on how well they perform in four different categories:  Drug Plan Customer Service  Member Complaints, Problems getting service and choosing to leave the plan  Member experience with drug plan  Drug pricing and Patient safety  A plan can get ratings between one and five stars (5 = excellent, 1 = poor).

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17 To obtain your own access: https://secure.erxnetwork.com/NewUserReque st.aspx Be sure to include pharmacy NCPDP and NPI number

18  New Safety edits for patients patients older than 65 years old.  Overrides are not allowed  Prescribers are encouraged to use safer alternative.  For more information and list of drugs: update-HRM-measure-2012NL.pdf update-HRM-measure-2012NL.pdf

19  Significant increase in audits this year: - Provider ID (prescriber NPI required) - Signature log - E-prescribing - Focus on high cost claims - Completion of FWA training - Double billing

20  – FTP site: ftp://ftp.ihs.gov/rpms/POS/ftp://ftp.ihs.gov/rpms/POS/  Medicare & You 2013: 

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