make your voice heard in the halls - constant...
TRANSCRIPT
2 | 17 PPOk Pharmacies Achieve Best in Class through OutcomesMTM in 2016
3 | Updates to EQuIPP
3 | Reminders for Equipp
4 | Prime Therapeutics Payment Cycle Changes
4 | Prime Therapeutics - Phone Number Updates
5 | Drug Spotlight: Basaglar KwikPen
5 | Change Healthcare New BIN/PCN
6 | Caremark Updates to Performance Drug List
6 | Qualified Medicare Beneficiaries Reminder
7 | Navitus CDUR Edit
7 | United Healthcare M&R Adherence
8 | License Information and Contact Us
9 | Welcome to RxSelect and Synergy Conference Registration
Make your voice heard in the halls
of Congress. See page | 2
Insights - April 2017 | Page 2
Help NCPA hold PBMs’ feet to the fire! Fight back for your business and your
patients at the NCPA Congressional Pharmacy Fly-In April 26-27. Join the push:
Ban retroactive DIR fees - Pharmacy’s #1 Most Wanted is in the cross hairs
of new bipartisan legislation. We’re gaining new allies and momentum every
day.
Attack the MACs - Force PBMs to be more transparent and update MACs to
reflect real-world costs.
Preserve your access to patients - Fight cuts to pharmacy reimbursement
and restrictions like mandatory mail order… And more!
Get the scoop from USA TODAY’s Jayne O’Donnell, political tips from former Congressman Jim McCrery and hear from NCPA leadership. Learn more, plus register now at www.ncpanet.org/flyin.
17 PPOk Pharmacies Achieve Best in
Class through OutcomesMTM in 2016
Each year OutcomesMTM recognizes pharmacies with exceptional performance in
delivering MTM services to eligible patients. Providers prove community
pharmacists make a difference for patients every day. Best in Class designation is
based on the overall effectiveness in delivering CMRs and resolving drug therapy
problems. Being Best in Class is a testament to these pharmacies’ outstanding
work with their patients.
Dickson Apothecary of Dickson, TN
Clinic Pharmacy of Cynthiana, KY
Gibbs Pharmacy of Lebanon, TN
Boomtown Drug of Burkburnett, TX
Doctors Park Pharmacy of Norman, OK
Middleport Family Health Center of
Middleport, NY
Conrad Marr Drug of Yukon, OK
Asbury Pharmacy of Oklahoma City, OK
Hall Family Pharmacy of Jamestown,
TN
Super H Pharmacy of Bristow, OK
City Pharmacy of Lincolnton, GA
Baron’s Pharmacy of Hibbing, MN
Michelle’s Pharmacy of Gillespie, IL
Johnny’s Hometown Pharmacy of
Roland, OK
OU Clinic Pharmacy of Tulsa, OK
Hospital Discount Pharmacy of
Edmond, OK
Med-World Pharmacy of Sapulpa, OK
These pharmacies completed a total of 331 CMRs, 1,265 TIP cases, and 832 Star
TIP cases within the OutcomesMTM platform resulting in their patients avoiding
higher healthcare costs.
Insights - April 2017 | Page 3
Reminders for EQuIPP
Humana - Outliers will display with this update.
Outliers are provided by Humana and are typically refreshed on a weekly basis.
Outliers are currently being provided for 2016 beneficiaries until April 3rd, when 2017
outliers will then be provided.
Click the link below to learn more details about the changes to Humana outliers for 2017:
Humana Outliers Available in EQuIPP as of mid-February.
Prime Therapeutics - Additional data is now added to EQuIPP with the addition of
the following plans:
Vibra MAPD
BCBS Nebraska MAPD
BCBS New Mexico-H3251 (aka Lovelace MAPD)
Caremark - Additional data is now added to EQuIPP with the addition of the following
plans:
BCBS SC
BCBS MI Basic Blue Rx
Medica
Caremark - United American has now been absorbed by the Silverscript plan - those
patients will be migrating to that performance program listing.
Express Scripts - Anthem data will no longer be hosted in EQuIPP.
Tenet - Will no longer be hosted in EQuIPP since its' business is no longer in operation.
EQuIPP Dashboard Refresh Process
Performance scores are updated monthly around
the 15th of the month
Outliers are updated as frequently as daily
depending on the health plan - frequently
reviewing outliers is an important process to
complete.
To better understand your performance, EQuIPP has
two helpful documents -
Understanding Quality Measure Calculations in
your EQuIPP Dashboard
Understanding Measurement Periods in your
EQuIPP Dashboard
Insights - April 2017 | Page 4
Prime Therapeutics - Phone Numbers Update
Effective April 1, 2017, Prime will be implementing a new
payment cycle. The new payment cycle will increase the number of
payments that a pharmacy might receive on a regular basis. When
your pharmacy is paid will vary depending on the line of business.
Prime will still be following all Medicare, Commercial, and Contractual
obligations when it comes to paying claims within the required time
allotments.
If you have any additional questions, please contact Prime’s
Pharmacy Operations at 888.277.5510, option 2 or at:
Global Change
Prime’s Prior Authorization -
855.457.0407
Specific to Texas Medicaid
Pharmacy Helpdesk
STAR Pharmacy Contact Center
at 855.457.0405
CHIP Pharmacy Contact Center
at 855.457.0403
STAR Kids (in the Travis service
area) Pharmacy Contact Center
at 855.457.0757
STAR Kids (in the MRSA Central
service area) Pharmacy Contact
Center at 855.457.0758
Prime Therapeutics has updated a few important phone numbers (listed
below):
Insights - April 2017 | Page 5
The FDA approved Basaglar in December 2015 as a follow-on biologic. Please be
advised that Basaglar is not a generic insulin product. For some insurances,
Basaglar may be the preferred product. For a patient to transition to Basaglar, a
new prescription will be needed.
Transitioning to Basalgar
(per manufacturer recommendations)
From Lantus to Basaglar: Basaglar dose should be the same as the discontinued
Lantus dose.
From Toujeo to Basaglar: Basaglar dose should be 80% of the discontinued Toujeo
dose.
From twice daily NPH to Basaglar: Basaglar dose should be 80% of the total discontinued
NPH dose.
Other intermediate or long-acting
insulins:
Change in Basaglar dose may be needed; evaluate on an
individual patient basis.
Change Healthcare
New BIN/PCN
Effective April 18, 2017, Change
Healthcare (formerly Emdeon) has
announced a new BIN/PCN.
Please note, this BIN/PCN is
currently associated with Envision
Rx Options so it may already exist
in your software.
For processing questions please use
the following Change Healthcare
Help Desk number: 866-440-3808.
Beginning April 18, 2017
BIN 637765
PCN CRX
Insights - April 2017 | Page 6
Effective April 1, 2017, identification of preferred drugs may help
optimize clinical results and economic value for your Caremark patients. The
drug list includes preferred products within 80% to 90% of the top therapeutic
categories. Updates or changes to these lists may affect cost share for your
patients.
Caremark may add or remove drugs from the Performance Drug List
throughout the year.
Qualified Medicare
Beneficiaries Reminder
Products to be added to the Performance Drug List
amiloride armodafinil darifenacin ext-rel dutasteride-tamsulosin
epinephrine auto-injector Ipratropium inhalation
solution nitroglycerin sublingual
tablet Sotalol
testosterone gel 2% zolpidem sublingual BELVIQ XR CLIMARA PRO
CORLANOR DESCOVY GENVOYA ODEFSEY
SOMATULINE DEPOT SOMAVERT STRIVERDI RESPIMAT VELTASSA
Products to be removed to the Performance Drug List
ARCAPTA NITROSTAT NUVIGIL ORTHO TRI-CYCLEN LO
The most up-to-date drug lists can be found at www.caremark.com/druglist.
Drugs that require prior authorization for medical necessity can be found at
www.caremark.com/padruglist.
CMS prohibits Providers from collecting cost-share for
Medicare-covered services from Qualified Medicare
Beneficiaries (QMBs). QMBs have no legal obligation
to make further payments to a Provider for Part B-
covered medications/supplies. Balances should be
billed to Medicaid as the secondary payer. CMS
guidelines state: If a balance remains after billing
Medicaid, or if the Provider is unable to bill Medicaid,
they are still required to dispense the medication/
supply without balance billing the beneficiary. Please
be aware that providers who inappropriately bill QMB
patients may be subject to sanctions.
Insights - April 2017 | Page 7
United Healthcare M&R Adherence
Conversion Program is Back
The United Healthcare M&R Adherence Conversion Program pays $50.00 for
the successful conversion of an identified medication from a 30-day supply to
a 90-day supply. This program is designed to be brief, lasting from 5 to 10
minutes. Cases will begin to arrive in your queue soon.
The new prescription for a 90-day
supply must be dispensed within
60 days of providing the service to
the patient, and pharmacy
payment will occur after the new
90-day prescription is filled and
billed through United Healthcare.
Retail pharmacies are uniquely positioned to make this program a success. Be sure to address all opportunities as soon as they appear in your MirixaPro queue.
30-90 Conversion with $50 Payment for Positive Outcome
On March 20, 2017, Navitus instituted a new CDUR (Concurrent
Drug Utilization Review) edit for Medicare Part D members. This edit
identifies patients who have a prescription for an opioid medication
and a history of buprenorphine product that could have been used to
treat opioid dependence. This edit results in a soft rejection at the
point-of-sale and will be categorized under Therapeutic Duplication
(TD, HX OF BUPRENORPHINE). A pharmacist can review the
clinical appropriateness of the claim, contact the prescriber if
applicable, and override the rejection using standard NCPDP DUR
Codes.
Insights - April 2017 | Page 8
Pharmacy State License
Pharmacist-in-Charge and Staff Licenses
Pharmacy DEA License
Pharmacy Liability Insurance
Ownership Changes
Please notify PPOk, as soon as possible, or in any event no less than 30 days prior to going through an ownership change. We
are contractually required to notify our PBMs in a timely manner when an ownership change has occurred with one of our
network pharmacies. The new owner is required to complete new contracts with PPOk as well as several PBMs to prevent claims
from rejecting.
Are You Moving or Closing a Pharmacy?
It is important that you notify PPOk as soon as possible if you will be closing or moving your pharmacy. We are contractually
obligated to notify our PBMs in a timely manner when any of our network pharmacies have any changes to their status.
Report Disciplinary Action of Pharmacy & Pharmacy Staff
PPOk requires pharmacy owners to provide written notice to our office within 5 business days of any disciplinary or adverse
action brought against the pharmacy or any pharmacy staff. This includes action by the State Board, DEA, State Narcotics Board,
and OIG.
Mailing Address:
P.O. Box 16430
Oklahoma City, OK 73113
Street Address:
3000 E. Memorial Rd.
Edmond, OK 73013
Please fax updated copies of the following document to Credentialing
405-213-1680.
RxSelect, 3rd Party Contracting, Central Pay, Claims Inquiry, and MAC Appeals
RxProtect Audit Services
Credentialing
eRecon Services
Sales & Marketing
Main Number - 1-877-557-5707
Option 1
Option 2
Option 3
Option 4
Option 6
Insights - April 2017 | Page 9
CLINIC PHARMACY, SHAWNEE, OK
MCLOUD CLINIC PHARMACY,
MCLOUD, OK
PATRIOT PHARMACY, JENKS, OK
RED OAK DRUG, RED OAK, TX
SPENCERPORT FAMILY
APOTHECARY, SPENCERPORT, NY
THE PRESCRIPTION SHOP,
WAXAHACHIE, TX
We are excited to be collaborating with the Oklahoma Pharmacists
Association (OPhA) and PBA Health for the 2017 Synergy Conference!
To learn more about the topics being covered and to register for the
conference please visit www.pbahealthconference.com.
Synergy Conference June 23-25, 2017
PBA Health PPOk PBA