PHARMACY DEPARTMENT Sheryl D. Waudby, MS, RPh Pharmacy Director

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1 PHARMACY DEPARTMENT Sheryl D. Waudby, MS, RPh Pharmacy Director

2 Pharmacy Benefit Manager (PBM) Formulary Generics Prior Authorization Process Specialty Pharmacy UPHP Web Site Reasons Why a Prescription May Not Process Electronic Prescribing Important Information & What s New Medicare Part D Prescriber Enrollment

3 4D Pharmacy Management, Inc. Michigan Based Company Contact Information Plan Medicaid/CSHCS HMP MIChild UPHP Advantage UPHP Plus Prior Authorization Contact Numbers M-F 8 am-6pm * (phone) (fax) Pharmacy Help Desk 24/ UPHP MMP

4 Promotion of rational, clinically appropriate, safe and fiscally responsible pharmaceutical care for the residents of the Upper Peninsula.

5 Medicaid formulary developed by UPHP Reviewed quarterly What is on the formulary? epocrates Website Electronically prescribe Average erx Rate 41 to 61% Generic mandate What happens when a drug goes generic? Active metabolite or active isomer is developed. Xyzal (levocetirizine) A different dosage form is developed. Zolpimist A delayed release of the generic is developed Ambien CR

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7 The Generic Pharmaceutical Association offers consumer education on generics, including a frequently-asked-question and answer section and downloadable brochures in the About Generics section.

8 Make sure to complete: 1. Length of therapy 2. Diagnosis 3. Prior formulary agents attempted and other pertinent information 4. Labs, if applicable Fax to 4D

9 Diplomat Specialty Limited Distribution Drugs Short Cycle Dispensing (aka Split Fills) Fax request to DIPLOMAT at

10 Formulary Information Searchable links Utilization Edits listed Prior Authorization Drugs listed Preferred Drug List Contraceptive Coverage Prior-Authorization Forms Provider Newsletters Updates and more

11 1. Medication requires prior authorization. 2. A refill is too soon or direction have changed. 3. Age limitations. 4. Prescription is outside the Federal Drug Administration (FDA) dosage recommendations or what UPHP allows. 5. Step therapy or prior therapy is not documented or available. 6. A medication has multiple indications, but not all indications are covered. 7. A pharmacy is running the prescription incorrectly. 8. Rejection for duplication therapy from another provider. 9. The member is not enrolled in UPHP. 10. Coordination of Benefits issues. Contact 4D Customer Service at the appropriate phone number.

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13 Prescription Benefits UPHP Benefit Information UPHP Formulary Information Prescription History What you have prescribed What other clinicians have prescribed Useful as a cross reference for what patients state they are taking and how they are taking it Prescription Routing and Patient Portals Prescription will be routed to the pharmacy specified by the patient. Patient s prescription will be ready when they arrive at the pharmacy Patients to notify you when refill are needed

14 Compliance BMP (Beneficiary Monitoring Program) Champs Flag MAPS Prescription Overrides Vacation Overrides Lost Medications Early refills Provider Outreach ADHD Notices Opiate Prescriber Letters Prescription Rate Multiple Prescribers Adherence

15 What s New Medicaid Co-Pays Contraceptive coverage What s Coming Medical Formulary Drugs paying through Medical (J Codes) Implementation of UM Edits Kick-Off January 1, 2016

16 Workgroup Medical Directors and Pharmacy Directors of Health Plans MDHHS representatives MAHP representatives Finalized by November 1, 2015 Transition members starting April 1, 2016 Quarterly Review and Updates Ongoing

17 Products UPHP MMP (MI Health Link) Formulary (2 tier) Integrated Medicare and Medicaid UPHP Advantage HMO Formulary (5 tier) 90 days fills at Retail or Mail Order for 2016 UPHP Plus (HMO SNP) Formulary (1 tier)

18 Medicare Part D Formularies Step therapy/quantity limits Prior authorization Brand vs. generic B vs. D Put diagnosis on prescriptions Coverage Determinations Information Prescribe electronically epocrates Searchable on-line

19 Provider Outreach Medication Therapy Management (MTM) Quality Measures (HEDIS/STARs) High Risk Medication Adherence Opiate Prescribing Letters Transition Fills and Transition Letters

20 Effective June 1, 2016 Medicare Part D prescription claims will only be covered if the Prescriber is enrolled in Medicare or has a valid opt-out affidavit on file with his/her Medicare Administrative Contractors (MAC).

21 Enroll electronically: Complete the paper CMS-855I or CMS-855O application, which is available at Forms/CMS-Forms-List.html If you are a physician or eligible professional who wants to opt out of Medicare, you must submit an opt-out affidavit to the MAC within your specific jurisdiction.

22 CMS asks that to ensure that MACs have sufficient time to process the applications or opt out affidavits, prescribers should submit their enrollment or opt-out affidavit prior to January 1, Please note the enrollment process takes an average of 60 days to complete. For more information on this requirement, or to help you decide which enrollment option above is best for you, please reference the CMS MLN Matters article SE1434 at Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE1434.pdf. Failure to enroll will directly impact the financial responsibility of the prescription for your patient. For additional information on the enrollment process, please contact your MAC. You may also contact UPHP Provider Relations

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