Third Party Payers Direct Payment is when the patient pays for pharmacy services and drug directly out of pocket; very common before 1970’s Today most pharmacy reimbursement comes from Third Party Payers Patients hold insurance for medical expenses As a part of the insured’s coverage the third party payer contracts with a PBM (Pharmacy Benefits Manager) to provide pharmacy coverage Express Scripts is an example

Medicare Government insurance for those over 65 Patients young that 65 with certain disabilities Any age patient with end stage renal disease Part A=hospital (nursing home, skilled nursing care, hospice) Part B= MD office and physical therapy (also covers DMEPOS durable medical equipment, prosthetics, orthotics and supplies). For this patient pay a premium deducted from the social security check Part C= Medicare advantage Offered by private companies who work with the government Part A and Part B is required Offers extra coverage like dental, vision Larger Premiums but more coverage Part D= Rx drug coverage

Part D was signed into law in 2003 Provide Rx coverage to seniors Premium depends on plan Most drug classes are covered except, most notably, the BDZ’s All plans have coverage up to about $2,700/year after which the patient covers all the cost of the drug After the patients reaches about $4,500 in cost, Plan D kicks in as catastrophic Rx coverage where it pays 100% of the cost This gap in coverage is called the “donuthole” Open enrollment for any given year is October 15-December 7

Medicaid Government health insurance for needy people, pregnant women, teenagers, individuals who are legally blind State splits the cost with the federal government When a pharmacy submits a claim, we are paid at the MAC (maximum allowable cost) or the EAC Often patients are allowed to combine a managed care plan with their Medicaid. Common managed care plan are Fedelis card, Metroplus. Managed care pays for legend drugs and Medicaid picks up OTC and generic drugs

Other government programs Worker’s Compensation A worker injured on the job and that requires prescription medications will have no copay for drugs Pharmacy files paperwork with employer to the state and federal governments TRICARE is the health insurance plan that services uniformed armed services men and women CHAMPVA (civilian health and medical program of the veteran administration) is insurance for permanently disabled veterans and their family members

Private Third Party Payers Health Maintenance Organization (HMO) Insurance provider that contracts with medical providers, hospitals, and other institutions to provide services under an agreed upon fee called a capitation fee. Once agreed upon, the provider is now a “network provider” The insured person is to select a PCP (primary care provider) who controls access to specialist via referrals; specialist must also be in network Coverage is not provided for out of network providers Lowest premiums and no deductables Blue Cross/Blue Shield is an example of an HMO

Point of Services Plans (POS) Similar to HMO In network doctor called a Primary Care Provider (PCP) acts as a “point of service” PCP can make a referral for specialists out of the network Out of network providers can be seen Slightly higher premium and deductibles (not with HMO) but more freedom CIGNA health is an example

Preferred Provider Organization (PPO) Similar to a POS Main advantage is that referral are not needed to see specialists Provides most freedom but costs more

Adjudication formulas and Reimbursement Pharmacy Pricing Benchmarks AWP- Average Wholesale Price is published by the wholesalers across the country for the drug. The data is compiled by First Databank, a data collection company U&C – usual and customary is published by the manufacturer, wholesalers and government. Often your pharmacy software creates it own U&C based on your actual acquisition cost. This is often the cash price a customer with no insurance pays MAC – maximum allowable cost : used in calculating the reimbursement for older generic drugs by PBM’s A PBM will pay either MAC (for generics) AWP – a certain percentage U&C Which ever is smaller Actual Acquisition cost=AAC Estimated Acquisition cost (EAC)= what medicaid pays the pharmacy for drugs Profit, or the spread= what pharmacy is reimbursed- AAC + dispensing fee Capitation Fee Insurance company agrees to pay a flat fee per every covered patient that is client of the pharmacy. Patient only goes to that pharmacy

Paper Claims Some claims are still paid after submission of a paper claim form Standard form is the CMS1500 Billing codes include CPT for medications and the newly created MTM HCPCS for durable medical equipment and supplies (walkers) ICD 10 codes for other procedures

Prescription Drug Card When patients receive medical coverage cards they usually receive two cards One card provide office visit information Second card provide pharmacy coverage information Information on the Rx card Managed care plan (insurance company) Affinity Health Fidelis Care HIP MetroPlus Pharmacy Benefits Manager Express Scripts CVS Caremark (CVS health) Medco (acquired by Express Scripts) Prime Therapeutics (BCBS) United Health/OptumRx RX BIN (bank Identification number) identifies the PBM and the payor

RX BIN for express scripts 003858 for example PCN (processor control number) may or may not be needed Group Code: identifies the group that contracted with the managed care plan, may be a large group of employers i.e. RX1199 identify 1199 union members Cardholder: name of the primary beneficiary Person code: relationship to cardholder primary beneficiary is 01 Spouse is 02 Sequential dependents are 03,04, etc

Rejection Codes National Council for Prescription Drug Program (NCPDP) rejection codes Claims that are rejected have at least one or more rejection codes Rejection codes are standardized across the country Code 1= missing BIN Code 8= invalid person code Code 19 = invalid day supply Code 71= Prescriber not covered Knowledge of the actual code is not required on the PCTE but the meaning should be understood

Common Rejections Invalid DOB, or person code Enter corrected information and resubmit claim Filled after coverage terminated Ask for new insurance card; patient may have changed insurance or insurance may have new PBM or patient may have new ID# Quantity exceeds plan limitation Try to enter prescription with a reduced quantity with more refills and resubmit. i.e. 90 tablets with 2 refills = 30 tablets with 8 refills Refill too soon Patient must come back for refill 75 % time allotment on regular RX If vacation supply is needed, may obtain override code from PBM and resubmit Prescriber is not covered Prescriber is out of the network for the plan; patient must pay full price

Prospective Drug Utilization Review ProDUR Rejections DUR errors and rejections results from a proDUR that flags a problem from the prescription and the patient’s current patient profile information as required by OBRA90 Normally these rejections can be overridden by the pharmacist or pharmacy technician with special NCPDP codes called conflict codes, intervention codes and outcome codes

Conflict Codes (Common ones) TD= Therapeutic duplication ER= Early Refill DD= Drug Drug Interaction HD= high dose LD= low dose DC= drug contraindicated with patient’s disease states

Intervention codes (most common) M0 (zero)= MD consulted P0 (Zero)= patient consulted R0 (zero)= Pharmacist consulted other reference Outcome code 1B= filled as is