Oklahoma Medicaid Pharmacy Provider Training

1. 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.

2. 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

3. Who’s 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

4. 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)

5. Pharmacy Program Stats and Overview

6. 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

7. Pharmacy Benefit • One pharmacy benefit package • 6 Rx per month with 3 brand limit • Some drugs don’t 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

8. 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)

9. Oklahoma Medicaid Pharmacy Policy • Dispensing limitation • 34 days supply • Maintenance list up to 100 units • Use of Prior Authorizations • 100+ drug products require PA

10. Oklahoma Medicaid Pharmacy Policy • Covered Drugs • Federal Drug Rebate Agreement • Excludable Coverage • Cough and Cold • Fertility • Cosmetic • Weight loss / gain • Nutritional Supplements

11. Pharmacy Management Consultants OU College of Pharmacy

12. 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

13. Pharmacy Help DeskTelephone Number 405-271-6349 or 1-800-831-8921 • Hours: Monday-Friday (8:30a-7:00p) Saturday (9:00a-5:00p) Sunday (11:00a-5:00p) • Holidays • Call Volume • Call Types

14. 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

15. 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

16. 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

17. Product Based Prior Authorization Program • Description: • Tier 1 does not require PA • Generics • Supplemental Rebates • Tier 2 requires PA • Clinical Exceptions • Step Therapy

18. 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-Ulcer’s, SSRI’s, ARB’s, and Statins

19. Prior Authorization and Override Forms • Prior Authorization • Universal Petition • Therapy Management Petition • Override Requests • Early Refill • Quantity Limit

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

21. 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

22. Pharmacy Billing and Error Codes

23. PharmacyBilling and Error Codes

24. 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

25. When to Call the Pharmacy Help Desk • Do call when you have pharmacy claim issues • Do have the client’s 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

26. 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

27. OHCA Secure Website

28. 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

29. Eligibility Verification System (EVS) • Touch Tone & Automated Voice Response • Available 20 hours a day – 5:00 a.m. to 1:00 a.m. • Client Eligibility • Provider Warrant • Prior Authorization • Claims Inquiry • Change EVS / AVR PIN

30. OHCA Public Website & Epocrates

31. 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

32. 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

33. Medicare Part D & Extra Help Presented by: Kelly Charles Pensoneau, Pharmacy Auditor

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

35. Standard Benefit • Medicare Recipient’s will be able to enroll in a Prescription Drug Plan (PDP) • Oklahoma will have at least 2 PDP’s 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

36. Subsidized Benefit“Extra 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

37. 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

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

39. 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.

40. 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

41. 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

42. 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

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