Oregon Medical Bill Reviewer Training Program

1. Oregon Medical Bill Reviewer Training Program Unit 3: Ancillary Services Module 1: Pharmacy Guidelines

2. Hi! In this module, you will learn about pharmacy guidelines. Let’s learn how other types of services are reimbursed. Overview • Pharmacy Reimbursements • Drugs and Supplies

3. Key all pharmacy charges as billed. The National Drug Codes (NDCs) are available in the system. If the NDC code is not found in the fee schedule, payment will be recommended at the usual and customary value (at the applicable percentile), or will be recommended for payment at the provider’s billed charge, whichever is less. Oregon reimburses all pharmacy bills according to Blue Book. Pharmacy Guidelines

4. Generic drugs should be dispensed when they are available. If a physician prescribes a brand name drug and the generic drug is not listed, then the prescription can be filled and reimbursement is made for the brand name drug. If the prescribed brand name drug has a generic equivalent per the Blue Book, then reimbursement is based upon the generic drug unless there is a specific medical problem such as an allergy to the generic drug. Pharmacy Guidelines

5. Prescriptions require a few pieces of information that you can locate on a pharmacy bill. The required information is: Prescription Reimbursement • NDC number • Number of units • Billed Charge • Date of Service

6. Whether dispensed by a pharmacy or a physician, the dispensing fee per prescription is $2.00. Reimbursement for prescription drugs is based on a discount from AWP (average wholesale price) as follows: Brand and Generic drugs: 83.5 % of the dispensed drug’s AWP plus the $2.00 dispensing fee Prescription Reimbursement

7. Prescription Reimbursement • Payment for drugs Oxycontin, Celebrex, Cymbalta, Fentora, Kadian, Lidoderm, Lyrica, and COX-2 inhibitors is limited to an initial five-day supply. However, there are exceptions to this rule, such as . . . • The prescribing medical service provider writes a clinical justification for prescribing that drug rather than a less costly drug with a similar therapeutic effect. • The clinical justification must accompany the prescription and be submitted by the pharmacist or may be given directly to the insurer by the medical provider.

8. Prescription Reimbursement • When drugs are dispensed within a hospital (inpatient or outpatient), payment will be at the hospital’s current adjusted cost/charge ratio.

9. Supplies and/or materials normally necessary to perform a service are included in the primary procedure or office visit. These materials are not separately reimbursable. • These include supplies such as: • Cotton balls • Band-Aids • Applied meds/ointments Drugs and Supplies

10. Supplies and materials provided by the physician over and above those usually included with the office visit or other service rendered may be charged for separately. Unless a contract states otherwise, the fees for medical supplies are allowed at the provider's usual rate. Drugs and Supplies

11. If the HCPCS code is not found, unidentified or not quantified, internal procedure codes are used to insure the proper pricing. Drugs and Supplies When charge is under $25.00, use D0010 (manual allow code) and TOS of “L”. When charge is over $25.00, use D0010 and deny the line with an appropriate message requiring documentation.

12. Pharmacy Reimbursement Guidelines Summary Reimbursement of Drugs & Supplies