Oklahoma Medicaid Pharmacy Provider Training

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Oklahoma Medicaid Pharmacy Provider Training

• Presented by Kelly Charles Pensoneau,
• Pharmacy Training Coordinator

Please turn off all cell phones and pagers at
this time. Thank-you.
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Provider Education

• Goal Establish better communications with
  pharmacy providers
• Education Medium
• Provider letters, Pharmacy Update, Provider
  Update, Phone contacts, and Training programs
• Content
• Change in benefits, Coverage guidelines,
  Treatment protocols, and claims processing

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Whos Who?

• CMS Federal Agency
• Centers for Medicare Medicaid Services
• Oklahoma Health Care Authority (OHCA) State
  agency responsible for Medicaid program and
  policy
• Pharmacy Management Consultants Contracted
  partner to provide management services through
  the OU College of Pharmacy
• Electronic Data Systems (EDS) fiscal agent for
  OHCA
• Claim processing
• Payment coordination
• Remittance Advice

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Medicaid

• Federal State Financial Partnership
• 2.7 Billion program annually
• 30 represents state share
• Feds set the program requirements and the states
  each set up coverage
• Pharmacy is an optional program, not mandatory
  under the Federal requirements
• Eligibility
• Client must meet resource asset limits as
  determined by the Department of Human Services
  (DHS)

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Pharmacy Program Stats and Overview
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SFY 2004 Drug Benefit Stats

• 367 million Rx expenditures
• Monthly cost per Rx user - 164.00
• 5.6 million paid claims
• Average monthly Rx clients 150,000
• Average Rx cost - 65.64
• Average Claims/client/month 3.09
• State Maximum Allowable Cost (SMAC) savings 30.6
  million
• 57 generic utilization

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Pharmacy Benefit

• One pharmacy benefit package
• 6 Rx per month with 3 brand limit
• Some drugs dont count
• HIV antiretrovirals, Chemo, Birth Control
• Long Term Care no limit
• Children under 21 no limit
• ADvantage program 7 extra generics Therapy
  Management
• Family Planning
• Contraceptives

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Pharmacy Benefit (continued)

• Smoking Cessation
• Products are now available through the Pharmacy
  Program with out Prior Authorization for the
  first 90 days
• Clients should have a prescription for products
• Client must be enrolled in smoking cessation
  counseling to receive benefits after the 90 days
• Counseling provided by Oklahoma Tobacco Helpline
• 1-800-Quit Now (784-8669)

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Oklahoma Medicaid Pharmacy Policy

• Dispensing limitation
• 34 days supply
• Maintenance list up to 100 units
• Use of Prior Authorizations
• 100 drug products require PA

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Oklahoma Medicaid Pharmacy Policy

• Covered Drugs
• Federal Drug Rebate Agreement
• Excludable Coverage
• Cough and Cold
• Fertility
• Cosmetic
• Weight loss / gain
• Nutritional Supplements

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Pharmacy Management Consultants OU College of
Pharmacy
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Pharmacy Management Consultants at the OU College
of Pharmacy

• Contracted partner with OHCA
• Perform vital management tasks
• Pharmacy Help Desk
• Prior Authorizations processing and tracking
• Retrospective Drug Utilization Review
• Prospective Drug Utilization Review
• Therapy Management

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Pharmacy Help DeskTelephone Number 405-271-6349
or 1-800-831-8921

• Hours Monday-Friday (830a-700p)
  Saturday (900a-500p) Sunday
  (1100a-500p)
• Holidays
• Call Volume
• Call Types

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Drug Utilization Review (DUR) Board

• Established to advise OHCA about the appropriate
  and optimal use of pharmaceuticals for Oklahoma
  Medicaid
• Open meeting is held 2nd Wednesday of every month

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Prior Authorization Programs

• Utilization
• Benzo-barbs, Hypnotics, Toradol
• Scope
• Antihistamines, Growth Hormone, Multi-indication,
  Xolair, Synagis
• Step Therapy or Product Based (PBPA)
• Anti-Ulcer, NSAIDs, ACE, CCB, ADHD,
• SSRI, ARBs, Statins

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Product Based Prior Authorization Program

• Mechanism
• Group drugs by therapeutic category
• Look for categories with several drugs
• Assess for safety, efficacy, and cost
  effectiveness
• Assign to two or more Tiers

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Product Based Prior Authorization Program

• Description
• Tier 1 does not require PA
• Generics
• Supplemental Rebates
• Tier 2 requires PA
• Clinical Exceptions
• Step Therapy

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Product Based Prior Authorization Program

• Supplemental Rebates
• Tier 2 drugs can rebate to the price level of
  Tier 1
• Prior Authorizations removed
• Great participation from Anti-Ulcers, SSRIs,
  ARBs, and Statins

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Prior Authorization and Override Forms

• Prior Authorization
• Universal Petition
• Therapy Management Petition
• Override Requests
• Early Refill
• Quantity Limit

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Pharmacotherapy Management Program

• Assist health care providers to optimize safe and
  effective drug therapy for Medicaid clients
• Minimize adverse drug events and improve outcomes

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Pharmacotherapy Management Program

• Referrals
• Currently only Waiver clients (ADvantage)
• By physician, pharmacy, case manager
• Usually referred into program when client needs
  more than 3 brand prescriptions and / or more
  than 13 total prescriptions
• Forms

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Pharmacy Billing and Error Codes
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Pharmacy Billing and Error Codes
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Who to Call

• Pharmacy Help Desk 800-831-8921
• Pharmacy Training - 405-522-7141
• OHCA Main number 800-522-0114
• Security helpdesk (password reset) Option 8,
  option 1
• Medicaid on the Web Option 8, option
• Electronic Data Interchange (EDI) Option 8,
  option 2
• DME Medical Authorization Option 9, option 1

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When to Call the Pharmacy Help Desk

• Do call when you have pharmacy claim issues
• Do have the clients ID number and your pharmacy
  provider ID number
• Do request an emergency PA if in the best
  interest of the patient
• Do request early refill or quantity limit
  override if in the best interest of the patient
• Do call to obtain correct prescriber number when
  in doubt

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When to Call the Pharmacy Help Desk (continued)

• Know who switches your claims
• NDC, Argus, Envoy, WebMD
• Wait 24 hours before calling or resending
  petition
• Call if it has been more than 24 hours and you do
  not have a response
• Call for ANY questions and the pharmacy helpdesk
  will relay the message

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OHCA Secure Website
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OHCA Secure Provider Website

• https//www.ohcaprovider.com
• Or through public website
• Secure server
• File claims
• Check claim or PA status
• Verify eligibility
• Training for Medicaid on the Web
• Free 1st Tuesday of every month
• OKC and Tulsa call 405-416-6803
• Schedule on-site training through your EDS Field
  rep

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Eligibility Verification System (EVS)

• Touch Tone Automated Voice Response
• Available 20 hours a day 500 a.m. to 100 a.m.
• Client Eligibility
• Provider Warrant
• Prior Authorization
• Claims Inquiry
• Change EVS / AVR PIN

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OHCA Public Website Epocrates
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Epocrates

• www.epocrates.com
• Free program for PDA users
• Provides Oklahoma Medicaid specific information
  via PDA and website
• Prior authorization needs
• Quantity limits
• Step therapy
• Age restrictions
• Lower-cost alternatives
• Preferred drugs

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The OHCA Public Website

• www.ohca.state.ok.us
• Broad source of information
• Statistics
• Annual reports
• Forms
• Policy information
• Provider updates fax blasts, letters
• Benefit information
• Updated frequently

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Medicare Part D Extra Help

• Presented by Kelly Charles Pensoneau, Pharmacy
  Auditor

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Medicare Part D

• What is the Medicare Part D benefit?
• Standard Benefit
• Subsidized Benefit
• Dual Eligibles (Medicare and Medicaid)
• Extra Help (Low Income Subsidy)

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Standard Benefit

• Medicare Recipients will be able to enroll in a
  Prescription Drug Plan (PDP)
• Oklahoma will have at least 2 PDPs to choose
  from
• Premiums around 37 per month
• Co-pays for medications (approx. 1-5)
• Effective January, 2006
• Must be eligible for Part A or B
• Enrollment is voluntary

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Subsidized BenefitExtra Help

• Low Income Subsidy is now called Extra Help
• Low Income Medicare Beneficiaries
• Extra Assistance with premium and cost sharing
  under the new drug benefit
• Feds will help pay Deductibles, Premiums,
  Co-Payments, and Coinsurance

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Extra Help (continued)

• Certain groups are automatically eligible for a
  subsidy (dual eligibles)
• SSA will mail letters to inform beneficiaries
  that have been deemed eligible for Extra Help
• Those that are not automatically eligible must
  submit an application
• Eligibility based on income and asset tests

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Dual Eligibles

• Medicare Beneficiaries who receive some or all
  Medicaid Benefits
• Full Benefit Dual Eligibles (FBDE)
• Medicare beneficiaries with (comprehensive) Full
  Medicaid benefits
• Non FBDEs
• Medicare beneficiaries with some Medicaid
  benefits, but do not qualify for Full benefits
  (SLMB, QI1, and QI2)

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Full Benefit Dual Eligibles Coverage Under Part D

• As of January 1, 2006 Medicaid will no longer pay
  for prescription medications for dual eligible
  beneficiaries
• Except for excludable drugs (weight loss and
  certain psych drugs) not covered by Medicare
• Prescription Medications for Duals will be
  covered by Medicare Part D.

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Full Benefit Dual Eligibles

• Deemed Eligible for Extra Help
• Do not have to submit an application for Extra
  Help
• Auto-enrolled in a Medicare Part D Prescription
  Drug Plan
• Auto-enrollment begins in November, 2005
• If they do not like the plan that is selected for
  them, they will be able to change plans later.
• No premiums and minimal co-pays

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Non-Full Benefit Dual Eligibles

• Qualifying Individuals (QI1 and QI2)
• Specified Low-Income Medicare Beneficiaries
  (SLMB)
• Deemed Eligible for Extra Help and do not have
  to fill out an application.
• Need to enroll in a Medicare Part D Prescription
  Drug Plan starting in November, 2005.
• No premiums and minimal co-pays

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Important Dates

• May, 2005
• CMS began mailing notices to approximately 4.7
  million people who are eligible for both Medicare
  and Medicaid, notifying them that they
  automatically qualify for Extra Help.
• July 1, 2005
• SSA will make the Extra Help Application
  available
• November 15, 2005
• Enrollment in Medicare Part D Prescription Drug
  Plans Begins
• January 1, 2006
• Medicare Part D and Extra Help Start Date

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Important Information

• Phone Number
• 1-800-Medicare
• Website
• www.cms.hhs.gov/medicarereform/pdbma/