Pharmacy Manual. Pharmacy Policy & Procedure Manual May 2002

Transcription

1 Pharmacy Manual Pharmacy Policy & Procedure Manual May 2002

2 TABLE OF CONTENTS Subject Pages Section 1 - General Information 1-3 General Information 1 Commonly Used Terms 2 Section 2 - The Assure Card 4-5 Assure is a Registered Trademark of BCE Emergis 4 Sample Assure Card Data 4 The Cardholder Identification Number 4 The Cardholder Name Line 4 The Second Name Line 5 Other Text 5 Section 3 - Electronic Submissions 6-12 Electronic Claims Process 6 Electronic Adjustments/Error Descriptions 6 Relationship Code and Date of Birth 8 Common Reasons for Rejections 9 Classes of Drugs with Restrictions 10 Vacation Supply 10 Claim Void 10 Balancing Transactions 10 Policy for Lost or Stolen Prescriptions 11 Pharmacy Payment Options 11 Communications with Cardholders 11 WCB in British Columbia 12 Deferred Payment 12 Section 4 - Support Centre 13 General Information 13 Restricted Support Centre Hours 13 Section 5 - Drug Plan Types Coverage 14 Generic Plans 14 Frozen Formularies 14 Assure National Formulary 15 Exclusions 15 Dispensing Limitations 15 Reference Board or Maximum Allowable Cost (MAC) Pricing 16

3 TABLE OF CONTENTS Subject Pages Section 6 - Co-ordination of Benefits 17 Provincial Co-ordination of Benefits 17 Private Co-ordination of Benefits 17 RAMQ Opt-Out (Quebec Only) 17 Spouses - 65 and over (Alberta and Quebec) 17 Section 7 - Drug Utilization Review (DUR) Seven Checks to Health Awareness 18 Section 8 - Trial Drug Program The Trial Drug Program 21 Trial Prescription Process 21 Identify Eligibility Day 5-7 Call-back Section 9 - Audits and the Audit Department On-site Audits 23 Pricing - Keeping a Level Playing Field 24 Prescription Pricing - a Concern of your Customers 24 What Cash Payments Can You Collect from Your Customers who use the Assure Card 24 Dispensing Fees, when dispensing the same drug more than once in a five (5) day period 25 Day s Supply 25 Section 10 - General Policies and Procedures Procedure for submitting claims for extemporaneous preparations (Compounds) 26 Reimbursement Guidelines for Extemporaneous Mixtures 26 Procedure for submitting claims for needles and syringes 27 Procedure for submitting claims for Diabetic Supplies (Excluding Diabetic Devices) 27 Policy for determination of prescription pricing 27 Appendices Appendix 1: Provider Agreement (November 2000) Appendix 2: Change in Provider Information 34 Appendix 3: Request for Change in bank Account Information 35 Appendix 4: Diabetic Supply PINS 36-39

4 SECTION 1 General Information 1 General Information Assure Health Inc. was established in September of In November of 1999, Assure Health joined with BCE Emergis and now operates as a facility for the electronic transmission of pay-direct health claims including prescription drug claims from point-of-service to the adjudicator/payer. The following insurance companies currently use BCE Emergis Inc., ehealth Solutions Group (BCE Emergis) to provide drug benefit plans to their clients employee groups. (The preceding numbers represent the insurer s identification number.) 11 Great West Life 21 National Life 14 Canada Life 22 Imperial Life 16 Sun Life 26 Zurich Life 19 Clarica 29 Equitable Life 20 Standard Life 41 Royal Bank Insurance As a part of our network, your pharmacy realizes benefits processing, as follows: no guesswork on your part as to eligible expenses balancing of transactions instant access to our data base of employees and their dependents instant confirmation of coverage automated payment of each transaction to a bank account of your choice (EFT, Electronic Funds Transfer ) toll-free access to people who will help you, whether it be answering a question, or helping you with a problem. BCE Emergis SUPPORT CENTRE: Monday - Friday 8am - midnight Eastern Time (ET) Saturday and Sunday 8am-8pm ET As of January 1st 1998, BCE Emergis processes your claims by Electronic Data Interchange (EDI) only. This means that we no longer accept paper claims submitted by a pharmacy for reimbursement. EDI brings more options to plan designs and formularies as the system s on-line facility makes communication of every variation instantaneous. Where provincial plans offer drug benefits to residents, we co-ordinate the public and private sector obligations as to primary payment responsibility and lets you know, while the customer is still at the dispensary, whether we (on behalf of our insurer clients) are responsible for the claim. At this time, we do not provide co-ordination of benefits between 2 private sector plans. All claims are adjudicated based on the various co-pay and deductible amounts selected by the insurers and their policyholders.

5 2 SECTION 1 General Information Commonly Used Terms Actual Acquisition Cost (AAC): The real cost paid to obtain a drug. This may be the purchase price direct from the manufacturer or from a recognized pharmaceutical wholesaler. Adjudication: Processing a claim through a series of edits that determine appropriate payment. Assure National Formulary : This is BCE Emergis own managed care plan. It is not necessarily related to any specific provincial drug plan. Base Plan: Few restrictions on eligible drugs. May include most OTC items (except oral vitamins, herbal and homeopathic products) or may be restricted to Prescription-by-Law drugs. Cardholder Exception: The plan sponsor has instructed the insurance company to allow coverage of one drug or a group of drugs for a specific cardholder. Other family members and employees at that company are not eligible unless they too have had an exception authorized. Carrier: Insurance company insuring the plan or providing administration services. Co-Insurance: A percentage (e.g. 10% or 20%) of the cost of the drug that must be paid on each item every time a prescription is dispensed. Co-Pay: A set dollar amount applied to each individual prescription dispensed (e.g. $2.00 or $5.00 per prescription). Deductible: A set dollar amount that must be paid by the insured individual before coverage of health benefits can begin. Deductibles are normally reset annually. (e.g. $10.00 or $50.00) Dependent Coverage: The employee is contributing to insurance that would include coverage for a spouse and/or eligible children. Dispensing Fee Caps: The plan sponsor may only be prepared to pay a fixed dollar value towards the dispensing fee. This may be $5 per prescription or may be equivalent to the provincial fee. DUR (Drug Utilization Review): Most pharmacy software has a program to identify levels of potential drug interactions. Health Assure DUR will also alert pharmacy staff of potential interactions with drugs dispensed for the patient in any other pharmacy where a transaction went through on an Assure Card. Electronic Data Interchange (EDI): On-line, real time interaction between two or more computer systems that provide information between each location. Electronic Funds Transfer: The paperless transfer of money from one bank account to another. Formulary: A specific list of eligible drugs, which may mimic a provincial formulary and will be updated at the same time as the province makes changes. A formulary may also be created at the request of a plan sponsor and maintained on their behalf.

6 SECTION 1 General Information 3 Issue Number: This two-digit number (usually 01) acts as a control if a card is lost or stolen. It is essential to make sure that the most current issue number is recorded. Lowest Cost Alternative: The lowest unit cost established for a drug within a set of interchangeable generics. A plan with a generic rider will reimburse the pharmacist to the level of the lowest cost generic in the province of submission. Maintenance and Non-Maintenance Drugs: Maintenance drugs are those that are used long term, e.g. thyroid drugs, hormone replacement, blood pressure drugs, oral contraceptives. Non-maintenance or acute drugs are those taken for a shorter period of time, e.g. antibiotics, short-term pain control, coughs suppressants. Managed Health (Care) Plans: Restricted formularies where not all drugs are eligible. These may be based on a provincial formulary (e.g. ODB or RAMQ) or may be designed by the plan sponsor and administered by BCE Emergis. Multi-Tier Plans: The plan sponsor has chosen to pay for specific drugs at a different level of co-insurance than others. A plan sponsor may choose an Assure National Formulary on tier 1 to pay at 100% and all other prescription-requiring drugs not eligible on the National Formulary to be paid on tier 2 at perhaps 50%. PBM: Pharmacy Benefit Manager. A company, like BCE Emergis, ehealth Solutions Group that adjudicates on-line prescription claims from registered pharmacies that have signed a Provider Agreement with them. Plan Sponsor: The employer or organization that pays for the insurance. Policy Year: The anniversary of the date when the coverage came into effect. This may determine when the annual deductible is reset; however, on most plans deductibles are managed on a calendar year basis. Positive Enrolment: A complete enrolment of all eligible family members of a group plan membership for the purpose of determining benefit eligibility. Information such as date of birth, name, coverage status and effective date of coverage is included. Preferred Provider Network (PPN) or Preferred Provider Option (PPO): Plan sponsors may decide to have their members prescriptions filled from certain pharmacies or chains of pharmacies. These pharmacies have agreed to provide additional control services on prescribed drugs at the point of sale. (Not applicable in Quebec) Settlement Period: The payment schedule determined by the pharmacy. This may be next day electronic fund transfer or it may be twice monthly or it may be every thirty days. Sliding Co-Pay: Plan sponsors will pay a percentage of the first x dollars spent and then may pay a higher percentage of all claims above that limit. Unlisted Compound Code: The number supplied by the software company to indicate whether the extemporaneous compound is a cream, ointment, liquid for internal use, etc.

7 4 SECTION 2 The Assure Card Assure is the registered trademark of BCE Emergis, ehealth Solutions Group. The Assure Card will vary with respect to artwork and design depending on the insurance company and/or the policyholder. While BCE Emergis does permit a great deal of flexibility in design/art work on the Assure Card there are some characteristics that are typical of all cards: The Assure logo is always present in the bottom right hand corner of the card. The cardholder s unique 20 digit ID # is always embossed in the lower left side of the card. There will always be a name embossed on the name line directly beneath the 20 digit ID#. This could be the employee s name, the spouse s name or the name of a dependent child. Sample Assure Card Data ABC COMPANY LIMITED Carrier Group Certificate Issue { { Employee Name Other Text (Optional) { { The Cardholder Identification Number Each cardholder is issued a unique 20-digit certificate number that is embossed on their Assure Card. That 20-digit number contains the following information necessary to correctly process claims: Digits 1-2: this number identifies the patient s insurance company (see chart on page 1 of this manual) Digits 3-8: this represents the plan sponsor s group or policy number Digits 9-18: this is the employee s certificate number Digits 19-20: the last two digits represent the issue number. This is a built-in security feature used when cards are lost or stolen. When a card is reported lost or stolen, the insurance carrier will issue new cards to the employee changing the last two digits of their 20- digit number. It is very important that claims be processed using the correct issue number to ensure that there are no unnecessary rejects for the patient when new cards are issued. The Cardholder Name Line There are many options available when embossing the name on the Assure Card. Some plan sponsors choose to emboss the name of the employee on all cards issued for the family. Some will have cards issued with the name of the employee on one and the spouse s name on the other. Some cards for dependent students may be issued in the name of the student if attend-

8 SECTION 2 The Assure Card 5 ing school away from home. For this reason it is important to determine the relationship of the patient to the employee prior to submitting the claim to BCE Emergis for adjudication. The Second Name Line This is an optional 27-digit field used to enter customized messages. Types of information that could appear on this line are: The employee s company name The spouse s name if the surname is different to that of the employee O/A which indicates that the patient is an overage dependent student covered through the employee Plan design messages i.e. Ded Equals Disp Fee or EDI Processing Only Other Text Other forms of text or messages that could appear on front of the Assure Card are as follows: Expiry Date - the date (day/month/year) after which the card becomes invalid. When an expiry date appears on the card, it expires at 11:59 p.m. E.T. on that day. Prior to the expiry date a new card will be issued to the employee if coverage is to be continued. In order to extend the useful lifetime of the Assure Card, most cards are now issued without expiry dates. Dependent - this indicates the age at which benefits cease for dependent children (i.e. 18, 19, 21 or 25) for those cardholders with family coverage. On the day that the dependent reaches the maximum age coverage is automatically terminated. If the dependent is in fulltime attendance at an accredited school, college, or university and has been approved for coverage, then their coverage would be continued until they reach the maximum age as determined for overage dependents. Some overage dependents will have their own card with OA and/or an expiry date. A disabled dependent may have DD embossed on their card. Deductible - this varies among policyholders and refers to an amount of money that represents the patient s out of pocket portion OF EACH PRESCRIPTION. Their deductible could be indicated as a dollar/cents amount ( $.35, $2.00 etc.) as a percentage of the total cost of the claim ( 10%, 20%, 10% MAX TO $5.00 ) or equal to the professional fee ( FEE ). A policyholder can choose to combine both a deductible and a co-insurance. Some plans incorporate a two-tiered level of coverage where the deductible and/or co-insurance vary depending on the DIN dispensed. For example, a plan could have one level of co-insurance for those drugs which fall under a Managed Health Care (MHC) plan and a different level of co-insurance for drugs not covered under the first tier but which would be covered under the BCE Emergis plan chosen as the second tier of eligible DINS. As an EDI pharmacy, you will be advised of the exact amount owed by the patient at the time of processing. Maximum Professional Fee (Fee Caps) - a plan sponsor may set a limit (dollar or percentage) to the amount of professional fee that will be paid out by the plan. Any amount above the set limit up to the Usual and Customary Fee becomes the responsibility of the patient and is charged to them at the discretion of the pharmacy. Due to the increasing complexity of plan designs, some plan sponsors will elect to keep some fields on the card blank (i.e. deductibles, maximums and plan types). Other cards, for example those issued to College or University students may require secondary identification such as a student ID card. In this case, the cardholder number is left un-embossed on the front of the card.

9 6 SECTION 3 Electronic Submissions Electronic Claims Process The pharmacist submits claims electronically (via a modem and the pharmacy management software) while the cardholder is at the dispensary. It is at all times the responsibility of the Pharmacy and the dispensing Pharmacist to ensure that: the patient (or the authorized dependent of the patient) requesting a billing to an Assure Card is in fact in possession of a valid Assure Card. the patient who is requesting a billing to an Assure Card is in fact the same person (or is a dependent of the same person) who is on record on the Assure Card and/or within the Assure Card system. the patient claiming benefits through the use of an Assure Card number is eligible for those benefits when they do not provide an Assure Card at the time of the dispensing of the product and/or when the individual alleges to be or is within the Pharmacy system on record as an authorized user of a valid certificate number within the Assure Card system. The pharmacist is immediately advised of the amount to be paid on the transmitted claim. Electronic submission offers the advantage of immediate verification of cardholder eligibility and instant processing of each transmitted claim. Rejected claims are accompanied by an explanation of the reason for rejection. Pharmacies have 7 days from the dispensing date to submit or re-submit the claim(s). Occasionally a transaction may need to be processed at a different date from the original dispense date. The dispense date must reflect the actual supply date. Any claim transmitted electronically beyond the 7-day limit will be rejected as claim too old. The pharmacy can collect cash from the patient who will then submit the receipt to their insurance carrier for reimbursement. If a previously transmitted transaction is incorrect for any reason, the pharmacy must reverse this using the Prior Day Void function, within 7 days of the original transaction. If the difference is greater than 7 days, it is necessary to contact the audit department. Electronic Adjustment/Error Descriptions Depending on the individual software vendor, pharmacy staff may see the BCE Emergis message or the CPHA message. CPHA Code CPHA Message BCE Emergis Message 03 Transaction code error Invalid tran code 21 Pharmacy ID code error Invalid provider number/not one of PPO allowed 22 Provider transaction date error Invalid dispense date 30 Carrier ID error Invalid client code 31 Group number error Invalid group number 32 Client ID # error Invalid cardholder 33 Patient Code error Invalid person code 34 Patient DOB error Invalid birthdate 36 Relationship error Inv.relationship 40 Patient gender ID Invalid sex code

10 SECTION 3 Electronic Submissions 7 CPHA Code CPHA Message BCE Emergis Message 54 Refill/repeat authorization error Invalid # refills authorization 55 Current Rx number error Invalid Rx number 56 DIN/PIN error Invalid DIN 58 Quantity error QTY not available 59 Days supply error Invalid days supply 61 Prescriber ID error Invalid prescriber ID 63 Unlisted compound code error Invalid compound code 64 Special authorization #/code error Invalid authorization number 66 Drug cost/product value error Invalid ingredient cost A1 Claim Too Old Claim Too Old A2 Claim is post- dated Claim is post-dated A3 Identical claim has been processed Duplicate prescription number A4 Claim has not been captured Claim not captured A7 Submit manual reversal Submit reversal A8 No reversal made original claim missing Non match prescription number C1 Patient age over plan maximum Max age exceeded C2 Service provided before effective date Card not effective C3 Coverage expired before service Coverage expired C4 Coverage terminated before service Card terminated C5 Plan maximum exceeded Maximum exceeded C6 Patient has other coverage DIN covered by other C7 Patient must claim reimbursement Patient must claim reimbursement C8 No record of this beneficiary Claimant not covered C9 Patient not covered for drugs N/match person code CC This spouse not enrolled Inv sp. crdhld ID CJ Patient not covered by plan Resubmit with client XXgroupYYYYYY D1 DIN/PIN/SSC not a benefit DIN not covered D3 Prescriber not authorized N/Match prescriber ID D4 Refills are not covered Refills not covered D6 Maximum cost is exceeded Cost exceeds maximum D7 Refill too soon Refill too soon D9 Call adjudicator Call Help Desk DB Adjusted to interchangeable gen. plan Generic substitution DE Fill/refill too late Refill too late DG Duplicate prescription number Duplicate DUR rx number DH Professional fee adjusted Disp. fee adjusted

11 8 SECTION 3 Electronic Submissions CPHA Code CPHA Message BCE Emergis Message DI Deductible not satisfied Deductible not satisfied DJ Drug cost adjusted Rx. amount adjusted DK Cross selection pricing Cross select pricing DM Days supply exceeds plan limit Qty. adjusted DO Future require prior approval Submit 3 months next DP Quantity exceeds maximum per claim Resubmit 1 month or 3 month supply E2 Claim co-ordinated with government plan DIN covered by other KE Authorization dollar maximum exceeded Total authorized dollar amount exceeded KK Not eligible for COB Rebill WCB with intervention code ME Drug/drug interaction potential Drug interaction MJ Dose appears high Dose appears high MK Dose appears low Dose appears low MQ Duration of therapy may be excessive Excessive duration of therapy MT Drug/gender conflict indicated Potential drug/gender conflict MU Age precaution indicated Potential drug/age contraindication MX Duplicate therapy Potential duplicate therapy QJ Deferred payment-patient to pay Deferred payment-patient to pay pharmacist pharmacy QK Sent to insurer to reimburse $ To be reimbursed to cardholder: $ Relationship Code (Check) and Date of Birth Just as input of the correct date in the approved format is critical to the EDI adjudication process, so is the correct Relationship Code (Rel. Code) of the patient for whom drugs are being dispensed. Use of the proper Rel. Code is important to allow BCE Emergis to be able to validate claims as well as apply the Health Assure Drug Utilization Review (DUR) and to determine various individual plan limits such as deductibles, maximums, out-of-pocket accumulator, etc. BCE Emergis and the CPHA/3 standard use the following Rel. Codes. If your software is using the CPHA 3 standard or another approved format, the system will automatically change it to the BCE Emergis Rel Code.

12 SECTION 3 Electronic Submissions 9 BCE Emergis CPHA 3 Code Standard Assure Card Description 01 0 The Primary Cardholder: usually an employee of the policyholder. The name of the primary cardholder almost always appears on the card Spouse of the Primary Cardholder: In some instances the name of the spouse appears on the card, either secondary to that of the primary cardholder, or by itself. A separate card may be issued in the name of the spouse alone in such cases as when the spouse goes by a different surname Dependent Child of the Primary Cardholder: usually a minor up to age 18 or 19 but could be 20 or older, depending on the terms of the group benefit plan or 5 Overage Dependent Child of the Primary Cardholder: is still eligible for coverage because of full-time education. In some cases, separate cards are issued in the name of the overage student. Such cards will be embossed with the letters OA and an expiry date, usually the end of the school year Overage Disabled Dependent Child of the Primary Cardholder: is still eligible for coverage because of a mentally or physically disabling condition. In some cases, separate cards are issued in the name of the disabled dependent. Such cards will be embossed with the letters DD. Use of the correct Rel. Code with the wrong date of birth (DOB) will result in the rejection of the claim. This also applies when the correct DOB is used with the wrong Rel. Code. It is essential that both match the information in our system in order to facilitate payment. The Support Centre representatives are not permitted to release DOB information. The DOB is similar to the PIN used for banking transactions and is part of the eligibility check. Invalid birthdate means that the DOB provided by the cardholder to the pharmacy and that supplied by the cardholder to his or her employer and subsequently to the insurance company do not match. It may be a simple reversal of day and month, which is easily altered on the pharmacy software. However if the dates are obviously different, the cardholder should contact their plan administrator to correct the problem. Common Reasons for Rejection 1. DIN not covered 2. Card not in effect at time of claim 3. Card terminated 4. Cardholder has single coverage 5. Over age dependent not registered 6. Cardholder information is incorrect (usually DOB difference)

13 10 SECTION 3 Electronic Submissions Classes of drugs that may have restrictions Plan sponsors may choose to exclude or restrict access to specific classes of drugs for a group or division and unit within the company. Restriction may be in terms of dollar value paid in a year or as a lifetime maximum. The classes most commonly affected are: Infertility treatments Smoking cessation drugs Preventative vaccines Antiobesesity/Anorexant drugs Erectile dysfunction drugs Migraine drugs (Triptans) Vacation Supply Most plan sponsors will allow a maximum of 100 days for maintenance drugs. When a cardholder or dependent requests a supply greater than 3 months (i.e., that exceeds the plan maximum days supply), indicating that this represents a vacation supply, it is important to note that this extra quantity must not be sent to BCE Emergis for electronic adjudication. At no time should the patient have in excess of 100 days of medication on hand without prior approval from the plan sponsor and insurance company. Claim Void The claim void (reversal) transaction is used to cancel a claim that has been successfully processed at BCE Emergis. Most pharmacy software uses the CPHA 3 message format which will allow voids up to seven days after the dispense date. If the claim is too old to be voided electronically, please fax the following information to the Audit Department at (905) : Provider number Prescription number(s) Dispensing date(s) Cardholder information Amount of claim Reason for cancellation The manual reversal will be processed and a notice will be sent to your pharmacy indicating the date on which the amount outstanding will be deducted from your daily claims total. It is important to retain these notices for account reconciliation. Balancing Transactions It is important that the pharmacy complete some balancing transactions to reconcile with the BCE Emergis bank deposit. In order to do this we recommend that you follow this procedure: 1. At the beginning of each day, submit a totals request for the previous business day (net settlement report) to us via EDI. This report will show you a summary of any applicable transactions. 2. At the end of each day, it is important to submit a daily totals request (claims balance inquiry) to us. This report will show you the total number of claims submitted, voids

14 SECTION 3 Electronic Submissions 11 submitted and the sum total of the amount to be paid. This total does not include transactions fees or deposit information. We recommend that you compare this report with a totals report that is generated from your pharmacy management software to ensure that the two systems balance. Should discrepancies be found, a more detailed report can be obtained from your pharmacy management software to assist in finding the error. Should it be necessary to void a claim and re-send it, it should be dealt with immediately. The BCE Emergis Support Centre will also be available to assist you with the same day discrepancies. Note that if a detailed report is requested on paper, a processing charge may apply. Note: For Western provinces, ehealth Solutions operates on Eastern Time (ET). Claims processed after midnight ET will show up in the next day s totals. Policy for lost/stolen prescriptions The patient must pay for the prescription and submit the receipts to their insurance company with a note of explanation. The pharmacist is not to submit the claim to BCE Emergis a second time. Pharmacy Payment Options We currently offer three (3) different payment options via Electronic Funds Transfer (ETF), to your bank account, the most popular choice being deposit on the day following submission of the claim. The following options are those currently available to providers; Payment directly into the Provider s Authorized Account value dated from the next banking day for an established transaction fee. (Not applicable in Quebec) Two-monthly payments into the Provider s Authorized Account for an established transaction fee: (1) On the 1st of the month for transactions submitted between the 16th and the end of the prior month. (2) On the 16th for transactions submitted between the 1st and the 15th of the same month. Payment directly into the Provider s Authorized Account value dated for 30 days after the date of the transaction at no cost. From time to time the availability of payment options may change. We will communicate these changes to all providers well before they occur. Communicating with Cardholders: the Insurer s Prerogative BCE Emergis sincerely appreciates the role that pharmacy staff plays in facilitating the smooth operation of pay direct drug plans. Thank you for helping your customer take advantage of the most efficient means of processing their insurance claims. We administer drug plans on behalf of the majority of Canadian Life Insurance Companies. Between them they account for over 60% of the group insurance market. They have given us the mandate to deal with pharmacies and other electronic providers on their behalf, in order to facilitate the efficient operation of their various pay-direct benefit programs. The most frequent reasons for problems occurring at the point of service is that the cardholder information provided to us by the carriers does not match that transmitted by the pharmacy or

15 12 SECTION 3 Electronic Submissions the prescribed drug is not covered by the plan. The carrier is the only party capable of addressing these situations in that they maintain all cardholder eligibility records and determine all parameters for claims payment. The insurers are very protective of their relationships with plan sponsors (employers) and their employees. Therefore, they have asked that we have no direct contact with either. The only exception is for audit purposes; occasionally cardholders may be contacted directly to verify transactions. When we tell you that we cannot talk to your customer to try and resolve your problems, it does not mean we do not want to get involved. Rather, it means that the carriers have reserved communications with cardholders to themselves and we respect their wishes. When the problem cannot be resolved by calling the Support Centre, please advise your customer to contact their employers benefits administrator. If the issue has resulted in non-payment of the claim, your best course of action is to collect cash from your customer. When the problem is resolved, the cardholder can submit your receipt to the insurer for reimbursement. WCB in British Columbia The Workers Compensation Board of British Columbia has a specific card for injured workers. The WCB Client Benefit Card is for client use only and does not supply benefits for the spouse or other dependents. WCB is the primary payer of eligible injured workers claims. The pharmacy should initially send the claims to Pharmacare with an intervention code of DE so that the DUR process takes place. Then the claim should be sent to BCE Emergis for adjudication. Deferred Payment Plans A Deferred Payment program differs from regular pay direct plans in that it provides payment to the insured at a future date based on a predetermined period of time or dollar threshold as determined by the plan sponsor. The patient will present their Assure Card to the provider along with their prescription for processing. The provider submits the claim in real time to BCE Emergis for adjudication. At this point the patient will be required to pay the provider the entire cost of the claim and will be automatically reimbursed for the portion of the claim that their plan sponsor is responsible for either by cheque or by EFT. Payment is generated once the specified period of time has elapsed or the accumulation of claims reaches a specified dollar threshold. For example, a cheque may be issued once a claim is 30 days old or the accumulated claims reach $100, whichever happens first.

16 SECTION 4 The Support Centre 13 General Information The Support Centre may be contacted at , Monday to Friday, 8am to midnight, Eastern Time and Saturday and Sunday 8 a.m - 8 p.m., Eastern Time. The only exceptions are the days indicated at the bottom of the page, when restricted hours apply. When contacting BCE Emergis, please have your 10-digit provider number available. These lines are for pharmacies and dental offices ONLY. DO NOT give cardholders the Support Centre telephone number. If cardholders have any questions or concerns, they must contact their Benefits Department at their place of employment. Electronic providers do not need to contact the Support Centre with questions regarding drug or cardholder eligibility or plan parameters prior to submitting the claim. Simply submit the claim and eligibility is automatically verified. The Support Centre is unable to confirm eligibility in advance. The Support Centre is not able to change any eligibility information such as incorrect dates of birth or relationship codes. The Support Centre is not able to assist if you are experiencing a systems problem. These should be referred to your software vendor. Restricted Support Centre Hours Holiday Hours of Operation Good Friday Easter Victoria Day Canada Day Civic Holiday (August) Labour Day Thanksgiving Day Christmas Eve Christmas Day Boxing Day New Year s Eve New Year s Day Noon to 8:00 p.m. E.T Noon to 8:00 p.m. E.T. Noon to 8:00 p.m. E.T. Noon to 8:00 p.m. E.T. Noon to 8:00 p.m. E.T. Noon to 8:00 p.m. E.T. Noon to 8:00 p.m. E.T. 8:00 a.m. to 8:00 p.m. E.T. Noon to 8:00 p.m. E.T. Noon to 8:00 p.m. E.T. 8:00 a.m. to 8:00 p.m. E.T Noon to 8:00 p.m. E.T.

17 14 SECTION 5 Drug Plan Types Coverage BCE Emergis administers a number of different types of plans. These plans range from comprehensive coverage of many prescription-by-law drugs and OTC drugs with DINs, to more restricted managed care plans that may be frozen as of a specific date. Managed care plans that are similar to the provincial formulary are also available. Our comprehensive plans generally allow: Prescribed medications bearing a valid Drug Identification Number (DIN) and listed as prescription requiring in Federal or Provincial drug schedules. Injectable drugs, injectable vitamins, insulins, and allergy extracts bearing a valid DIN. Extemporaneous preparations or compounds where one of the ingredients is an eligible benefit. Disposable needles for administration of insulin (including disposable needles only, for non-disposable insulin delivery devices), disposable syringes, lancets and chemical reagent testing materials used for monitoring diabetes. If a plan includes non-prescription-requiring DINs, the following classes will be eligible: acne preparations antiseptics pediculocides analgesics cough and cold preparations potassium replacements antacids diarrhoea preparations scabicides antifungals fibrinolytics single entity calcium salts antihistamines laxatives single entity fluorides antimalarials mucolytic agents single entity iron salts antinauseants muscle relaxants topical emollients antipsoritics nitroglycerin topical enzymatic debriding agents If a plan is prescription-by-law the following over the counter products may be eligible benefits: nitroglycerin potassium replacements selected single entity single entity fluorides iron salts Generic Plans If a plan has a Generic rider, then the adjudicated ingredient cost will be based on the lowest priced interchangeable product, regardless of product dispensed, plus a professional fee. Prescriptions bearing the notation No Substitution on the actual prescription as ordered by the prescriber, are eligible for payment above the cost of the lowest priced interchangeable product, when flagged as N for No Substitution or Product Selection = 1 (Prescriber s Choice) for CPHA/3 EDI claims. Please note that certain groups may have a mandatory generic substitution plan where the lowest cost interchangeable product will still be paid even if No Substitution is indicated on the actual prescription. Frozen Formularies A frozen formulary is a plan that does not automatically allow for the inclusion of new products. The benefit list will remain constant as of a specific date. Any new product introduced after this date will be evaluated on an individual basis for inclusion to the plan.

18 SECTION 5 Drug Plan Types 15 Assure National Formulary The Assure National Formulary has been created to serve the needs of the working population and relies upon the recommendations of an external, independent group of health care experts. Medical, clinical and scientific research provides standards of therapy for most medical conditions. Protocols for the first and second line therapies initially developed by TEG (Therapeutic Evaluation Group) and continued by ReVue, have been considered in the creation and dynamic development of the Assure National Formulary. Exclusions Most BCE Emergis plans exclude the following categories of products. 1. Atomisers, appliances, prosthetic devices, colostomy supplies, first aid kits or equipment, electronic diagnostic monitoring or testing equipment (such as Glucometer ), non-disposable insulin delivery devices (such as Novolin Pen ), delivery or extension devices for inhaled medications (such as Rotohaler, Diskhaler, Aerochamber ), spring loaded devices used to hold lancets, alcohol, alcohol swabs, disinfectants, cotton, bandages, or supplies and accessories for the aforementioned. 2. Oral vitamins, minerals, dietary supplements, infant formulas, or injectable total parenteral nutrition (TPN) solutions, whether or not such a prescription is given for a medical reason, except where Federal or Provincial law requires a prescription for their sale. 3. Diaphragms, condoms, contraceptive jellies/foams/sponges/suppositories, intrauterine devices (IUDs), contraceptive implants, or appliances normally used for contraception whether or not such a prescription is given for a medical reason. 4. Homeopathic and Herbal preparations. 5. Prescriptions dispensed by a physician, clinic, or dentist or in any non-accredited hospital pharmacy, or for treatment as an inpatient or outpatient in a hospital, including emergency status and investigational status drugs, unless otherwise approved by BCE Emergis. 6. All preventative immunization vaccines and toxoids. 7. All allergy extracts, compounded in a lab, and not bearing a DIN. 8. Items deemed cosmetic (even if a prescription is legally required), such as topical minoxidil or creams considered cosmetic in nature, or sunscreens, whether or not such a prescription is given for medical reasons. 9. Any medication that the person is eligible to receive under the applicable Provincial Drug Benefit Plans. Dispensing Limitations Most plans allow the lesser of the amount prescribed or a 34-day supply for non-maintenance medication. Maintenance drugs may be dispensed up to 100-days supply if ordered by the physician. This means a patient should not receive more than 100 days supply within a three-month period. For example, two prescriptions dispensed for 100 days supply separated

19 16 SECTION 5 Drug Plan Types by dispense dates two weeks apart exceed the 100-day supply limit. Claims that exceed these limitations are subject to recovery by BCE Emergis on behalf of the insurance carrier. Any request for quantities greater than a three-month supply should be referred to the patient s benefit department. Maintenance classification is assigned on a per DIN basis and includes most of the drugs in the following classes: antiasthmatics antiparkinson hypoglycemics antibiotics for acne antidepressants oral contraceptives anticoagulants cardiac agents potassium replacements anticonvulsants estrogens thyroid agents Where appropriate, please dispense 100 days of supply of these medications, with only one dispensing fee charged per 3 months. This is an excellent example of how pharmacies can work with us to provide cost-efficient, quality, pharmaceutical care. WCB in BC: Days supply follows the BC Pharmacare guidelines. Reference Based or Maximum Allowable Cost (MAC) Pricing A number of plan sponsors offer managed care plans that are similar to the British Columbia Formulary or the Alberta and the Nova Scotia Formularies. Drugs that are included in the RBP program in British Columbia, or in the MAC program in Alberta, or in the Special MAC program in Nova Scotia will be paid in a manner similar to the provincial formulary.

20 SECTION 6 Co-ordination of Benefits 17 Provincial Co-ordination of Benefits BCE Emergis co-ordinates claim payment with all provincially administered plans. All claims must (initially) be submitted to the Provincial government for payment. The above is the basic submission rule for the co-ordination of benefits with a provincial plan. However, please be advised that with the changes to the various provincial plans (i.e. Ontario), some plan sponsors will decide that they do not wish to incur provincial deductibles, etc. These plans may retain the old rules regarding provincial liability. For example, a group in Ontario may wish to continue the practice of not paying for any portion of a claim for a senior on an ODB covered drug. These groups would ignore the Prior Paid Amount and not pay any portion of the drug. Whatever shortfall would have to be collected from the patient. It is important that you pay close attention to the paid amount on the transaction received back from us, as it is the amount that will be covered by the plan. Private Co-ordination of Benefits At this time, we do not support electronic co-ordination of benefits between two (2) or more private payers. The patient should be instructed to send receipts for any residual amount to the second private payer for reimbursement. RAMQ Opt Out for persons 65 years old or over (Quebec Only) Bill 33 (RAMQ) became effective in January, The purpose of the law is to guarantee all residents in Quebec affordable access to prescribed drugs. This plan is offered to all residents who do not have access to a private insurance plan. At 65 years of age, all Quebec residents are automatically registered with RAMQ. A senior can opt out of RAMQ coverage if he has access to a private plan. It is important that the pharmacy does not use the EU code to signify that the patient has chosen to opt-out unless the group and cardholder have been registered on the BCE Emergis system, thereby allowing the claim to be paid according to the parameters of the private plan chosen by the plan sponsor. Spouses - 65 or over (Alberta and Quebec) In Quebec and Alberta various rules for cardholders 65 years old or over and their dependents occur. Although it varies in Quebec vs. Alberta, if the cardholder or spouse is over the age of 65, dependents are generally covered on the provincial plan. In Quebec, if the primary cardholder is registered with RAMQ, the spouse and dependents also have to be registered with RAMQ, even if they are not 65 years old. This means that BCE Emergis is the second payer in these cases. If you receive a message stating, submit to other, this means that we are the second payer. Please reverse the claim and send it to the appropriate provincial drug plan first.

21 18 SECTION 7 Drug Utilization Review (DUR) Seven Checks to Health Awareness One thing on which physicians, pharmacists and drug manufacturers all agree is the importance of consumer education and health awareness. While many consumers are striving to learn more about the medications they take, not everyone has the time to learn the intricacies of drug interactions. For this, patients look to their physicians and pharmacists. However, many individuals have no knowledge of past drug regimens and so the advice provided may be based on limited information. While many patients only fill their prescriptions at one pharmacy, there are a substantial number that frequent multiple pharmacies. As the number of prescriptions used per year by a patient increases so does the pattern of using multiple pharmacies. Studies show this can be as high as 40%. This probably represents a high number of chronic medication users. These patients probably visit multiple doctors and these physicians may not always be aware of all the medications a patient has taken. Health Assure, our concurrent DUR service, provides an answer to this problem. When a pharmacist transmits a claim, Health Assure (DUR) accesses the centralized database at Assure to monitor for potential problems relating to medications. It references each specific patient s drug claim history, and checks the current prescription against any medications dispensed within the last 100 days from any pharmacy. If any potential problem is detected, a warning is sent back to the pharmacy. Health Assure (DUR) performs these checks at the point of service in addition to the regular claim adjudication checks. The criteria for these checks come from First DataBank, an international organization that provides drug information to governments, insurers, hospitals and other Pharmacy Benefit Managers. First DataBank, a division of The Hearst Corporation, is the world s leading provider of health information. FDB employs a large staff of clinical experts that include clinical pharmacists, physicians and a world-renowned independent panel of clinical drug experts. The Health Assure Drug Interaction database is updated every 2 weeks from First DataBank. As new scientific information about drug interactions becomes available, our Health Assure DUR reflects them. Examples of some of the checks Health Assure (DUR) performs: Drug Interaction - Looks for other known medicinal ingredients that may interact adversely with ingredients in the current medication. Therapeutic Duplication - Same therapeutic class as historical claims that may still be active in the patient s body. This could cause a drug concentration higher or lower than the prescriber intended. Duration of Therapy - Reviews the medication s duration of therapy against the manufacturer s published norms and warns the pharmacist if there is a difference. Refill Too Soon/Too Late - Indicates if a maintenance drug prescription is being refilled too early or too late, providing a strong indication of non-compliance. Minimum/Maximum Dosage - Determines if the daily dosage of the current medication falls within the prescribed age band limits as established by the drug manufacturer. Drug Gender - Alerts the pharmacist if this medication is intended for use by a member of the opposite gender only.

22 SECTION 7 Drug Utilization Review (DUR) 19 Drug Age - Indicates if the product may be harmful if the patient is a child or a senior. First DataBank identifies drug interactions that have been reported in the scientific literature and ranks them by potential significance levels. Level 1: a possibility of significant interaction that is well documented in clinical studies and actual case reports. Level 2: interactions that are of moderate significance. Level 3: these could be significant but there is insufficient documentation to place them in Level 1 interactions. An example is a contraindication that is only described in the manufacturer s prescribing information with no medically published documentation in the literature. Only potentially harmful drug interactions (significance level 1) will reject payment of the claim and require the pharmacists to use their professional judgement based on patient specific factors. Level 1 interactions may potentially have the most significant risk to the health of the patient. All other check results are sent to the pharmacist as text warning messages only. Important note: We request that all pharmacies transmit the proper days supply as per the medication directions when submitting claims. For prescriptions with directions take as needed and take as directed, please base the days supply on a reasonable estimate. When the day s supply of medication transmitted by pharmacists is not accurate, the following can result: inaccurate refill too late/early messages inaccurate dosage too high or too low inaccurate minimum/maximum dosage check Transmitting the proper days supply of medication greatly reduces the number of inappropriate messages. The significant majority of the claims that receive a Health Assure warning will eventually be filled, though perhaps at a later date. Of these, most will lead to discussions with the pharmacist and physician, and provide the opportunity for increased health awareness. What can a pharmacist do when the Health Assure DUR check rejects a prescription? When a DUR problem is identified the pharmacist must rely on his or her professional judgement to assess the potential risk to the patient and take the appropriate action. Computer programs can facilitate screening but cannot replace the pharmacist s knowledge in this regard. After this process has taken place the pharmacist can re-transmit the prescription with the proper intervention code to successfully complete the claim and fill the prescription.

23 20 SECTION 7 Drug Utilization Review (DUR) Pharmacies are requested to use the most appropriate two-letter code from the following list when resubmitting each DUR rejected claim. The following are intervention codes that a pharmacy can transmit to BCE Emergis to override a DUR rejected claim. Please use the most appropriate override code applicable to the situation. CODE UA UB UC UD UE UF UG UI UJ UN TRANSLATION Consulted prescriber and filled Rx as written Consulted prescriber and changed dose Consulted prescriber and changed instructions for use Consulted prescriber and changed drug Consulted prescriber and changed quantity Patient gave adequate explanation. Rx filled as written Cautioned patient. Rx filled as written Consulted other source. Rx filled as written Consulted other sources. Altered Rx and filled Assessed patient. Therapy is appropriate