DC DEPARTMENT OF HEALTH Pharmaceutical Procurement and Distribution Pharmaceutical Warehouse. DC Health Care Safety Net ALLIANCE PROGRAM

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1 DC DEPARTMENT OF HEALTH Pharmaceutical Warehouse DC Health Care Safety Net ALLIANCE PROGRAM OPERATIONAL PROTOCOLS Operational protocols for the DC Health Care Alliance program through the DOH Pharmaceutical Warehouse. Program protocols for approved pharmacy service providers to dispense selected medications to eligible District residents enrolled in the Alliance program. October 1, 2013

2 DC Alliance Operational Protocols OVERVIEW The District of Columbian (DC) Department of Health (DOH) manages a number of public health centers located throughout the District. These clinics serve all eligible District residents including that portion of the population enrolled in the DC Health Care Alliance (Alliance). The Alliance serves residents not eligible for medical assistance but still needing help with medical issues. As of September 21, 2013, all the pharmacies that have served these clinics have closed and recipients of Alliance services are able to fill their prescriptions at any of the twenty-three (23) pharmacies of the DC Specialty Care Pharmacy Provider Network (DC PPN). DC PPN pharmacies are located throughout the District and will allow Alliance members access to a greater choice of pharmacy providers coupled with specialty care services. BACKGROUND The Department of Health Care Finance was established by the Health Care Privatization Act of 2001 to administer and monitor compliance of the health care functions formerly provided by the defunct Public Benefit Corporation, DC General Hospital System. The Health Care Safety Net Administration is a health care entity within the Department of Health Care Finance. Health care services have been provided through a Managed Care Contract with Unity Health Care. Pharmacy benefits were provided by DOH through six (6) Unity Health Care clinic locations across the District. Unity Health Care administered a point-of-sale electronic claims management system that provided pharmacy service for eligible residents. The system administered a Retrospective Drug Utilization Review that incorporated the uniqueness of the District program, its policies, and operations. The goal was to lessen administrative costs for the program by retroactively eliminating payments for prescriptions that were excessive, inappropriate, unnecessary or otherwise inconsistent with sound medical practice. A new system offering the real time adjudication of pharmacy claims was needed to promote favorable health outcomes to District Alliance recipients by proactively screening for possible adverse drug interactions and inappropriate drug therapies. Additionally, such a system would maintain timely and accurate payment of claims through the real time verification of recipient eligibility, drug coverage, and reimbursements.

3 ALLIANCE PROGRAM PARTICULARS As of October 1, 2013, the DOH Bureau began to administer the Alliance pharmacy services benefit through the DOH Pharmaceutical Warehouse and use of the Pharmacy Benefit Management (PBM) point of sale (POS) claim system at the pharmacy provider sites. The approximately 14,000 recipients of Alliance services are able to utilize any of the twenty-three (23) specialty care pharmacies of the DC Pharmacy Provider Network (DC PPN) for their pharmacy benefits. Provider Particulars The Alliance Program requires the pharmacy NPI identifier on all prescription claim transactions. The PBM system will insure the NPI is on file as a DC-Medicaid-enrolled provider on the date of service. Failure to pass the pharmacy provider ID edits at the time the claim is processed at the pharmacy will cause the claim to deny. Alliance providers must be in the DC Pharmacy Provider Network (DC PPN). This specialized network is a subset of all DC Medicaid Providers. It encompasses those providers that are contracted with the District to dispense HIV/AIDs medications through the ADAP and Medicaid programs. Recipient Particulars Alliance issues each recipient an ID number which is eight (8) numeric digits. This is referred to as the cardholder, or recipient, ID and will start with the number seven (7). The recipient ID contains two leading zeros. However, the leading zeros will not be required during POS entry. Each Alliance recipient has his or her own unique ID number; dependents are not covered under a primary cardholder ID. The system will insure the recipient s first name, last name, gender and date of birth, as entered at the pharmacy, match the information on file for that recipient. It will also use the recipient ID to insure the recipient is eligible for services on the date of service. If any of these edits fail, the claim will be denied and a brief message will be transmitted to the dispensing pharmacy to describe the problem.

4 CLAIMS MANAGEMENT DC Department of Health The PBM system will adjudicate POS drug claims in real-time for all Alliance Program pharmacy claims according to the Alliance Program s formulary of approved medications, coverage policies, reimbursement pricing and/or formulas, and pharmacy program plan designs (e.g., maximum days supply, monthly prescription limits etc.). DOH will be able to add, change, or remove claim adjudication processing rules to accommodate changes to the pharmacy program over time. The system will immediately send a message back to the dispensing pharmacy stating that a claim was paid or denied. Denied claims will additionally contain denial reasons. The PBM applies a unique identification number to each claim and any supporting documentation. These complete records are maintained by the Alliance Program for review as necessary. The PBM also provides audit capabilities that can assist the Alliance Program in identifying providers who report inaccurate or fraudulent primary payer payment amounts and/or adjudication results. Edits and Validation Refills The PBM system will restrict prescription refills to one (1) original fill plus up to eleven (11) refills within twelve (12) months of Date Rx Written. Refill Too Soon The system will monitor all prescription claims presented for refill. 90% of the days supply of a fill/refill must elapse before the next refill is allowed. If there is an increase in dosage the early refill edit will not post, however a change in the Rx number for the same drug item within a span of 30 days may be subject to review and audit. The system will not override the refill too soon edit for controlled substances under any conditions. The refill too soon edit cannot be overridden by the Pharmacy at the point-of-sale without a prior authorization from the Department of Health care Finance.

5 Drug Coverage Limits The PBM system will enforce the drug coverage edit of a per claim days supply maximum of 31 days. Exception: Contraceptives will have a 90 day supply limit. Flomax is limited to males. Proscar is limited to males. Non-Formulary Requests Prescriptions written for medications that are not on the Alliance formulary should be submitted to the member s Medicaid Managed Care plan for coverage consideration under the particular Managed Care plan s formulary limits. Scheduled Drugs Scheduled drugs on the Alliance formulary are covered but are not replenished by the DOH Pharmaceutical Drug Warehouse. They are priced using the standard Medicaid lesser of logic.

6 PHARMACY SERVICE REQUIREMENTS Prior to the October 1 transition date, educational information will be provided to physician providers, and all District of Columbia participating pharmacies, in order to maximize beneficiary education and awareness. During and after the transition: Medications are to be dispensed according to the medications available on the DC Alliance program formulary. The pharmacist is responsible for the appropriate control and distribution of all medications in the Alliance program formulary and should adhere to all applicable Federal, District of Columbia laws and Alliance program policies and procedures regarding the maintenance, dispensing and distribution of these medications. The Network will also provide clinically appropriate dispensing services in support of these requirements, including: Client counseling Monitoring of clients prescription history Refill compliance Quality improvement activities Drug interaction On-hand inventory of Alliance medications Adherence counseling On-hand controlled substances medications Patient confidentiality should be ensured in the distribution process. Pharmacist must keep a record of all dispensing and client counseling. A detailed record must be keptof all activity and these records will be made available to the Contract Administrator (CA) upon request. The Alliance program directly pays to the participating pharmacy a dispensing fee for each prescription dispensed. A Signature Log record must be maintained of client signatures for all Alliance medications dispensed upon receipt of medications. The dispensing pharmacy must keep a log or record of all dispensed medications, client counseling records and provide such record to the CA upon request. Failure to maintain and provide a Signature Log record for such proof of dispensing may result in a pharmacy program audit. Mailing of Alliance client prescription medications is prohibited in this program. Pharmacist Licensure and Certification: All pharmacists must possess a current District of Columbia license to practice pharmacy. Board of Pharmaceutical Specialties certification of pharmacists to provide specialty services to patients and selected patient care is encouraged.

7 Technician Certification: Certification of pharmacy technicians by the Pharmacy Technician Certification Board is also strongly encouraged. Pharmaceutical Distribution Overview The pharmacy network providers will receive medications through the Department of Health on a replenishment model. Distribution processes relative to drug dispensing are transparent at the recipient level. Pharmacy network providers will fill prescriptions from their own stock and closely monitor the utilization of their Alliance drugs in order to reconcile replenishment of their supply as needed. The DOH Pharmaceutical Warehouse will replace formulary stock used by the pharmacies on a weekly basis. As prescriptions are processed at the store level (point of sale), claims are adjudicated at the Pharmacy Benefit Management (PBM) level. A prescription dispensing report for the entire DOH Specialty Care Pharmacy Provider Network is provided to the DOH Pharmaceutical Warehouse on a weekly basis by the PBM. The report contains prescription-dispensing information from the previous week. Data from this report serves as the basis for weekly drug replenishment. The Alliance Program also pays the participating pharmacy a dispensing fee for each prescription dispensed. Inventory and Deliveries The Pharmacy Provider will, at a minimum, provide the following in support of the inventory and delivery requirements: Inventory The Pharmacy Provider must ensure that their pharmacy maintains sufficient on hand drug inventory of the Pharmacy Provider s own stock to support the dispensing of Alliance and other selected medications to eligible District beneficiaries at least 95% of the time. The Pharmacy Provider will maintain an inventory of the Pharmacy Provider s own stock of Alliance formulary medications sufficient to dispense on demand requests for these medications at least 95% of the time. The DC Department of Health will not replenish the Pharmacy Provider s stock for nonformulary and controlled substances. Delivery The Pharmacy Provider will identify the pharmacy delivery site located within the District of Columbia where the DOH Pharmaceutical Warehouse will make weekly delivery of replenishment medication orders.

8 The Pharmacy Provider (s) will provide prescription delivery services to an Alliance client s home or the Alliance client s business office only within the District of Columbia at no additional charge to the eligible client. DC Alliance formulary medications will not be mailed, transported to another facility, provided to recipients outside of the District of Columbia or otherwise delivered without the expressed, written consent of the Contract Administrator. Dispensing The Pharmacy Provider will adhere to all applicable Federal and District of Columbia laws and policies regarding dispensing of medications and shall provide at a minimum the following dispensing services in support of the required services. FORMULARY MANAGEMENT: Alliance replenishment will only provide formulary medication. Non-formulary medications dispensed by a participating pharmacy will not be replenished by the DOH Pharmaceutical Warehouse. The Alliance Formulary may not totally eliminate the need to participate in compassionate use programs or other public or privately funded medication access programs. The program does not cover anti-retroviral medications. Alliance patients are eligible to participate in the AIDS Drug Assistance Program (ADAP). ADAP currently carries every commercially available antiretroviral. Non-formulary psychotropic drugs should be available through the Department of Mental Health. FORMULARY ADDITIONS AND DELETIONS The Alliance Pharmacy and Therapeutics Committee (P&T) makes recommendations for formulary changes. The Committee utilizes a class review process to evaluate the formulary and approval authority of all formulary medications rests with the Department of Health. Formulary reviews take into consideration the following criteria: the client population served, effectiveness, risk and cost.

9 FORMULARY STATUS DC Department of Health Formulary Drug: A drug approved by the Alliance Pharmacy and Therapeutics Committee (P&T) for inclusion on the Alliance formulary. Formulary drugs are generally available for routine use. Restricted Drug: A drug approved by the Alliance Pharmacy and Therapeutics Committee (P&T) for inclusion on the Alliance formulary, however, prescribing of this drug will be limited in scope (i.e., to a particular physician, medical service or protocol). Non-formulary Drug: Any drug that has not been reviewed by the Alliance Pharmacy and Therapeutics Committee (P&T) or has been reviewed and denied inclusion on the formulary. Non-formulary drugs are not available to Alliance recipients through the Alliance program. The DOH Pharmaceutical Warehouse has provided to the PBM the following list of approved medications with NDC numbers. The attached list is updated periodically to include any new Alliance formulary additions and/or deletions.

10 DOH PHARMACEUTICAL WAREHOUSE LIST OF ALLIANCE FORMULARY MEDICATIONS The DOH Pharmaceutical Warehouse has provided to the PHARMACY BENEFIT MANAGER the following list of medications approved for use by the Alliance Pharmacy and Therapeutics Committee (P&T). This list contains the NDC numbers of medications available for replenishment by the DOH Pharmaceutical Warehouse. The Status Key at the end of this list provides guidance for the information contained in the NDC List and may provide insight into the PBM rejection codes that may appear when adjudicating an Alliance claim. STATUS KEY CONTROLLED NON REPLENISHED DO NOT STOCK NDC OBSOLETE NON-ACTIVE NDC NON-CONTRACT ITEM NON-FORMULARY ITEM PRIOR AUTHORIZATION REQUIRED CNR D/S N/O N/A N/C N/F PA The attached list will be updated periodically to include any new medications that are added to or deleted from the ALLIANCE Formulary. Any questions regarding the information contained herein may be directed to the DOH Pharmaceutical Warehouse at (202)

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