TennCare Pharmacy Network Re-contracting

1. TennCare Pharmacy Network Re-contracting

2. The federal government requires all Medicaid providers to disclose information on ownership and control information, as well as business transactions. A CMS audit found the current TennCare pharmacy network agreement did not adequately meet disclosure requirements. The new pharmacy network agreement requires submission of a mandatory disclosure form. Why re-contract the pharmacy network?

3. Owning entity must re-contract For chains, corporate office can re-contract for all their chain stores For independents, the pharmacy owner must re-contract For franchise stores, the franchise owner must re-contract The corporate office of franchise brand cannot re-contract on behalf of individual franchise stores Who is required to re-contract?

4. Clarified definition of ambulatory pharmacy Clarified that auto-refills are not allowed Clarified “as directed” or “prn” are not considered acceptable directions on Rx claims Inserted a link to the specialty rate table Clarified requirements for reporting fraud; included new fraud reporting form as attachment Disclosure form required Key Changes in the New Pharmacy Network Agreement

5. Must submit 3 documents: Signed pharmacy network agreement Pharmacy network application Disclosure form Documents can be found under the Pharmacy Network Information link at: https://tnm.providerportal.sxc.com Pharmacies may submit either an Ambulatory/LTC application/agreement or a Specialty Pharmacy application/agreement Conference call will focus on the Ambulatory/LTC network Instructions for Re-Contracting

6. Lays out all of the terms and conditions Must fill out pages 1 and 25 of the network document (signature mandatory) Attachment A contains the pharmacy fee schedule No changes in reimbursement from last contracting period Attachment B contains specialty rates As in the last contracting period, this list is subject to change Updated specialty rate table posted on SXC’s website Pharmacy Agreement Instructions

7. Pages 27-28 of the network document 2 page form – both pages required Mostly collects basic information such as NPI, pharmacy name, address, phone, owner Also includes some questions about any license suspensions, probationary status, disciplinary actions, etc. Pharmacy Application Instructions

8. Disclosure form instructions begin on page 30 of the network document Form consists of 6 sections, labeled Items I – VI. Item I: Identifying information Provider Type Choose individual pharmacy provider if independent pharmacy with only one location. Choose disclosing entity if chain pharmacy or independent pharmacy with more than one location. Disclosure Form Instructions

9. Item II – Ownership and Control Information Must disclose any individual/entity having ≥5% ownership or controlling interest in the pharmacy. If individuals with ≥5% ownership are related, must identify how related. Must disclose any subcontractor or disclosing entity in which the pharmacy has ≥5% ownership or controlling interest. Item III – Business Transaction Information Must disclose ownership of any subcontractor with whom the pharmacy has had business transactions totaling >$25,000 in the last year. Must disclose any significant business transactions between the pharmacy and any wholly owned subsidiary or subcontractor in the last 5 years. Disclosure Form Instructions

10. Item IV – Criminal Offenses Must disclose any criminal offenses related to involvement in a Medicare, Medicaid, or Title XX services program Applies to any owners or employees of the practice Item V – Status Changes Only fill out if chain or independent pharmacy with more than one location Must disclose any changes in ownership within the past year Must disclose any past or present chain affiliations Disclosure Form Instructions

11. Item VI – Board of Directors / Board of Governors Must disclose identities and percentage of controlling interest Signature / Date Disclosure Form Instructions

12. 3 documents required: Signed Agreement Application Disclosure form Documents posted on SXC’s website: https://tnm.providerportal.sxc.com Documents must be returned before 2/1/11 Submission by 1/1/11 required to ensure adequate time for processing Documents submitted after 1/1/11 will be processed as quickly as possible in the order received Direct any questions to: SXC Provider Relations: ProviderRelations@sxc.com, 480-362-5227, or SXC Provider Educators: Western TN: Jud Jones, 630-352-8897 Middle TN: Robert Dinwiddie, 630-352-8895 Eastern TN: Kim Brunger, 630-352-8896 SXC will send confirmation notices to pharmacies informing them of network status Take Away Points

13. Questions?