Prescription Solutions by OptumRx

Transcription

1 Prescription Solutions by OptumRx 2012 Pharmacy Manual Click here to get started.

2 Table of Contents Click on any section or page below to go directly to that portion of the document. I. Introduction...5 II. How to Contact Us and How We Contact You...6 Pharmacy Help Desk...6 Customer Service Numbers...6 Prior Authorization (PA) Department... 6 Electronic Data Interchange (EDI)... 6 Pharmacy Network Contracting Department...7 Member Services Contact Information....7 Provider Feedback Forms...8 Pharmacy Notification...9 III. Member Identification Cards Best Available Evidence (BAE)...13 All Pharmacy Types EXCLUDING Long-Term Care (LTC) Providers Long-Term Care (LTC) Providers ONLY IV. Claims Process A. General Process Complete Claims Online Processing Window...18 Migration to NCPDP Telecommunication Version D Submitting Compounds...20 National Drug Code (NDC) Number National Provider Identification (NPI) Number Claim Adjustments...22 Subrogation and Coordination of Benefits (COB) Retroactive Eligibility Changes...23 Average Wholesale Price (AWP) and Wholesale Acquisition Cost (WAC) B. Required Prescription Information Prescription Origin Code Requirements...26 C. Dispense as Written (DAW) DAW Codes...26 Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 2

3 D. Electronic Funds Transfer (EFT) Program Enrollment Requirements...27 Enrollment Steps...28 E. Member/Insured Appeals and Grievances Network Pharmacy Provider Responsibilities...28 F. Utilization Management (UM) Utilization Management Requirements for Select Drugs...29 Concurrent Drug Utilization Review (cdur) Retrospective Drug Utilization Review (rdur)/clinical Programs...30 V. Products...33 Claims Processing Information...33 VI. Medicare Product Information and Guidelines...38 Excluded Drugs Medicare Part A/B/D Coordination of Benefits...39 Medicare Part D Coverage Determinations Timeframes...40 Coverage Limitations Medication Therapy Management (MTM) Program Medicare Part D Transition Policy...42 Medicare Part D Transitioning Long-Term Care (LTC) Facility Residents Medicare Part D Sixty (60) Day Negative Formulary Change Notice Medicare Part D Annual Notice of Change for Continuing Members...45 Inform Members of Advance Directives...45 Provide Timely Notice of Demographic Changes...45 VII. Other General Terms and Conditions...46 A. Compliance B. Fraud, Waste and Abuse (FWA) C. Pharmacy Audits Policy Statement...49 Purpose Procedures for Policy Compliance...50 D. Credentialing E. Confidentiality and Proprietary Rights Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 3

4 F. Involuntary Disenrollment by Benefit Plan or Sponsor G. State Medicaid Requirements H. Definitions Exhibit A...58 NCPDP 5.1 or D.0 Submission Template Transaction Header Segment Insurance Segment Patient Segment Claims Segment...61 Pharmacy Provider Segment...62 Prescriber Segment...62 COB/Other Payments Segment...62 DUR/PPS Segment Pricing Segment...63 Coupon Segment...63 Compound Segment Prior Authorization Segment...63 Clinical Segment...63 Exhibit B Pharmacy Electronic Funds Transfer (EFT) Exhibit C Network Pharmacy Provider Credentials For Chain Pharmacies/PSAOs/GPOs...65 For Independent Pharmacies...66 Exhibit D...67 State Medicaid Regulatory Requirements...67 Exhibit E NCPDP Submission Clarification Code...70 Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 4

5 I. Introduction The Prescription Solutions by OptumRx (ORx) Pharmacy Provider Manual (Manual) is intended to be a guide regarding the policies of ORx for pharmacies, Pharmacists and pharmacy staff (collectively, Network Pharmacy Providers ) who are parties to and serve customers under a Pharmacy Network Agreement (the Agreement ), as amended from time to time, with ORx. PLEASE NOTE: The information in this Manual is current at the time of the Manual s printing. Although efforts are made to keep the information current, this Manual is subject to change without notice. This Manual is not designed to cover all circumstances or issues, nor is it a replacement for sound clinical judgment. Online adjudication of Claims will reflect the most current benefit and takes precedence over printed information. For your convenience, the defined terms in this Manual have the same meaning as used in the Agreement and are listed in the last section of this Manual. In the event that this Manual and the Agreement have conflicting language, the Agreement will supersede the Manual. For specific details regarding the governing elements of the relationship between ORx and its participating pharmacies, please refer to the Agreement. You may request a copy of the latest version of the Manual by calling or request to [email protected]. While we hope that most of your day-to-day questions concerning the ORx pharmacy program are adequately addressed in this Manual, please call us if you have any questions. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 5

6 II. How to Contact Us and How We Contact You If Network Pharmacy Providers need assistance in processing a Claim or have other questions concerning ORx s pharmacy programs, please contact the number as identified on the Member s Identification (ID) Card or the appropriate number below. Pharmacy Help Desk: AARP MedicareComplete, SecureHorizons and Evercare (MAPD) Plans and UnitedHealthcare Community Plan (MAPD): Evercare Medicaid Plans: UnitedHealthcare Community Plan Medicaid Plans: AARP MedicareRx and United MedicareRx: Quality Health Plans (QHP): All other Plans: Customer Service Numbers: For information regarding Benefit Plan exclusions, Disease Therapy Management (DTM) programs, or other customer service issues, please contact the Customer Service department using the following numbers: Customer Service: , TDHI: Medicare Prescription Drug Plan (PDP) Members: , TDHI: Medicare Advantage Prescription Drug Plan (MAPD) Members: , TDHI: Prior Authorization (PA) Department: For questions concerning utilization management requirements, Medicare Part A (Part A), Medicare Part B (Part B) or Medicare Part D (Part D) decisions, coverage limitations and Prior Authorizations (PA), please contact the Prior Authorization (PA) department at: Phone: Fax: (Oral) (Specialty) Electronic Data Interchange (EDI): For questions concerning Electronic Data Interchange (EDI), contact your EDI vendor or call ORx s EDI support at Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 6

7 Pharmacy Network Contracting Department: If Network Pharmacy Providers want or need information on network participation for a particular ORx Benefit Plan Sponsor or if you have any questions regarding our implementation of the National Council for Prescription Drug Programs (NCPDP) 5.1 or upcoming D.0 format, please call or contact our Pharmacy Network Contracting department at the phone and/or address below: Pharmacy Network Contracting Department 5995 Plaza Drive MS: CA Cypress, CA Monday through Friday Phone: Fax: address: [email protected] Member Services Contact Information: Product Name Enrollment Phone Number Service Phone Number TTY Phone Number United MedicareRx (PDP) UnitedHealthcare MedicareRx for Groups (PDP) AARP MedicareRx Preferred (PDP) (including U.S. territories) UnitedHealthcare Dual Complete (HMO SNP) UnitedHealthcare Community Plan Evercare Medicaid Plans Please click here for access to linked document containing this information. Please click here for access to linked document containing this information. Please click here for access to linked document containing this information. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 7

8 Provider Feedback Forms: To facilitate feedback and comments from our Network Pharmacy Providers regarding ORx s Prior Authorization (PA) Guidelines and Outpatient Drug Formulary, the following forms are available for providers to fill out: The Prior Authorization (PA) Guideline Change Request Form allows providers to request review of prior authorization (PA) guidelines. (online submission) The Formulary Change Request Form allows providers to request review of Formulary drug issues. (online submission) The New Prescription Fax Form allows the provider to download and print a standardized New Prescription Fax Form for submitting new prescription orders. (download, print, and fax) Network Pharmacy Providers should complete the form(s) in full and submit to the following: Prior Authorization (PA) Guideline Change Request Form Clinical Programs Prescription Solutions by OptumRx 2300 Main Street, CA Irvine, CA Fax: Formulary Change Request Form Clinical Formulary Management Prescription Solutions by OptumRx 2300 Main Street, CA Irvine, CA Fax: New Prescription Fax Form Fax: Provider Feedback Forms HealthcareProviderTools/FormsAndDocuments IMPORTANT NOTE: Prescription Solutions by OptumRx (ORx) is unable to accept incomplete forms for review and consideration. Incomplete forms will be returned to Network Pharmacy Providers for completion which will delay review and consideration. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 8

9 Pharmacy Notification: Faxblast Communications Periodically, ORx needs to communicate to our contracted Network Provider Pharmacies. These communications, Faxblasts, are sent electronically to the contracted network entity (independent pharmacy, Retail Chain (Chain), Group Purchasing Organization (GPO) or Pharmacy Services Administration Organization (PSAO)) corporate representative via facsimile (fax) process. You may request copies of previously sent year-to-date Faxblasts by contacting the following, Monday through Friday: Pharmacy Network Contracting Department Prescription Solutions by OptumRx 5995 Plaza Drive MS: CA Cypress, CA Phone: Fax: address: IMPORTANT NOTE: Updates to procedures, formularies, pharmacy manual, etc., are communicated via fax broadcast (Faxblast). Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 9

10 III. Member Identification Cards Eligible Members (Members) receive an identification (ID) card containing information that helps our Network Pharmacy Providers to submit Claims accurately and completely. Information may vary in appearance or location on the card due to employer, Benefit Plan, Sponsor or ORx s requirements. However, cards display essentially the same information (e.g., Member Name, Subscriber Identification (ID), Group Number, Processor Control Number (PCN), Bank Identification Number (BIN), RxGroup Number (GROUP), and telephone numbers such as those for Customer Care). Be sure to check the Member s ID card at each visit especially the first (1 st ) visit of each new benefit year when information is most likely to change. Below are a few sample Member ID Cards representing a few of our Benefit Plan Sponsors. This is a sampling ONLY and is NOT an all-inclusive list. Member ID Cards may be added, deleted or amended at any time. SAMPLE MEMBER ID CARDS: Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 10

11 Member ID Card_AARP MedicareRx Preferred_Website Card_2012 PDPEX _000 mber ID Card_United MedicareRx_Website Card_2012 PEX _000 AARP MedicareRx Preferred (PDP) RxBin RxPCN RxGrp Issuer ID Name PDPIND John A. Sample Plan member since: 2012 SXXXX XXX AARP MedicareRx Preferred (PDP) United MedicareRx (PDP) RxBin RxPCN RxGrp Issuer ID Name PDPIND John A. Sample Plan member since: 2012 SXXXX XXX Customer Care: TTY 711 Visit Providers submit claims to (pharmacy use only): AARP MedicareRx Preferred (PDP) P.O. Box Hot Springs, AR Provider Line (pharmacy use only): Medicare: MEDICARE ( ) TTY/TDD Issued: 2012 United MedicareRx (PDP) Customer Care: TTY 711 Visit Providers submit claims to (pharmacy use only): United MedicareRx (PDP) P.O. Box Hot Springs, AR Provider Line (pharmacy use only): Client Alts Internal & External Team Date: Creative/Prod. Mgr.: Missy Teff Medicare: MEDICARE ( ) TTY/TDD Creative: YMM: Yuliya/Stephanie Job Number: Issued: F YMM Project Details DMS Number: PDPEX _000 Depot Number: SPRJ1453 Name: AARP Web Card Preferred 2012 Stage: FINAL File Name: PDPEX _000_AARP_ indd Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition Color BLACK/485/072 K Color Proofs Required? Pulled? Client Approved? Dimensions Card: in. x 2.15 in. Software: InDesign CS4 11 Not

12 For those instances when a Medicare Part D (Part D) Member does not have a Member ID card, please see the following table: No ID Card Situations ORx Responses ORx Person is at the pharmacy, has no proof of coverage but states is enrolled in a Medicare Part D (Part D) Plan. Member may present generic marketing materials that were provided with the inquiry kits. ORx and UnitedHealthcare (UHC) UHC Step 1 Step 2 Step 3 Step 4 1) E1 transaction initiated to determine eligibility; this is done by the Pharmacist. (a) Eligibility validated; Pharmacist processes prescription. (b) Eligibility not validated or Pharmacist unable to access E1, move to Step 2. Note: An E1 transaction can be initiated with the Member s Social Security Number (SSN) or Member s ID. Pharmacist contacts ORx Pharmacy Help Desk twenty-four (24) hours a day, seven (7) days a week. UnitedHealthcare Dual Complete (HMO SNP) Plans: All other Part D Plans: All other Benefit Plans: (a) Pharmacy Help Desk validates eligibility and Claim is processed. (b) Unable to validate eligibility, move to Step 3. Pharmacy Help Desk completes transfer of Pharmacist to UnitedHealth s (UHC) Call Center. Alternatively, the pharmacy may direct the Member to call their plan. 1) Call center confirms eligibility; Member eligibility entered real-time into ORx system and Pharmacist fills prescription. 2) Unable to confirm eligibility or eligibility has been denied; person pays retail for drug; fourteen (14) day window to allow for online processing at pharmacy when eligibility issue resolved or person to submit a paper Claim for reimbursement. 3) Person unwilling to pay retail, prescription not filled. Person is at the pharmacy, has an acknowledgement or confirmation letter with an enrollee number and states that they are enrolled. 1) E1 transaction initiated to determine eligibility or Pharmacist attempts to process Claim online; this is done by the Pharmacist. (a) Eligibility validated; Pharmacist processes prescription online. (b) Eligibility not validated or Pharmacist unable to access E1, move to Step 2. Pharmacist contacts ORx Pharmacy Help Desk twenty-four (24) hours a day, seven (7) days a week. UnitedHealthcare Dual Complete (HMO SNP) Plans: All other Medicare Part D Plans: All other Benefit Plans: (a) Pharmacy Help Desk validates eligibility and Claim is processed. (b) Unable to validate eligibility, move to Step 3. Pharmacy Help Desk completes transfer of Pharmacist to UnitedHealth s Call Center. Alternatively, the pharmacy may direct the Member to call their plan. 1) Call center confirms eligibility; Member eligibility entered real-time into ORx system and Pharmacist fills prescription. 2) Unable to confirm eligibility, eligibility pending, eligibility has been denied, or a disenrollment was processed; person pays retail for drug; fourteen (14) day window to allow for online processing at pharmacy when eligibility issue resolved or person to submit a paper Claim for reimbursement. 3) Person unwilling to pay retail, prescription not filled. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 12

13 Best Available Evidence (BAE) UnitedHealth Rx Basic, United MedicareRx, AARP MedicareRx Plans insured through UnitedHealthcare, Evercare, AARP Medicare Complete from SecureHorizons, and UnitedHealthcare Dual Complete (HMO SNP). All Pharmacy Types EXCLUDING Long-Term Care (LTC) Providers If a Member questions their copay amount or states that they qualify for federal subsidy or extra help, they must have valid documentation supporting this position in order to receive the lower copay level amount. Any of the following documents are acceptable and meet the criteria as Best Available Evidence (BAE) supporting a Member s qualification for federal subsidy or extra help : A copy of the beneficiary s Medicaid card that includes the beneficiary s name and eligibility date status during a month which occurred after June 30 of the previous calendar year; A copy of a State document that confirms active Medicaid status during a month which occurred after June 30 of the previous calendar year; A printout from the State electronic enrollment file showing Medicaid status during a month which occurred after June 30 of the previous calendar year; A screen print from the State s Medicaid systems showing Medicaid status during a month which occurred after June 30 of the previous calendar year; Other documentation provided by the State or Centers for Medicare and Medicaid Services (CMS) showing Medicaid status during a month which occurred after June 30 of the previous calendar year; For individuals who are not deemed eligible, but who apply for and are found to be Low Income Subsidy (LIS) eligible, a copy of the Social Security Administration (SSA) award letter. To correct a Member s subsidy level utilizing BAE, please follow these steps: Secure one (1) of the above documents from the Member; and Fa x documentation to the Member s applicable health plan: (PDP) (MedicareComplete, Erickson, UnitedHealthcare Dual Complete, UnitedHealthcare Senior Care Options) UnitedHealthcare Dual Complete (HMO SNP), Pennsylvania (PA) UnitedHealthcare Dual Complete (HMO SNP), Michigan (MI) UnitedHealthcare Dual Complete (HMO SNP), All other states Quality Health Plans QHP Physicians United Plan PUP Fidelis SecureCare Golden State Medicare Health Plan Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 13

14 Public School Employees Retirement System (PSERS) International Brotherhood of Teamsters (IBT) PDP OR Mail documentation for PDP, SecureHorizons, MedicareComplete, Erickson, and Evercare Members to: P.O. Box Hot Springs, AR Mail documentation for UnitedHealthcare Dual Complete (HMO SNP) Members to: UnitedHealthcare 1300 River Drive, Suite 200 Moline, IL Attn: Medicare Enrollment BAE Mail documentation for UnitedHealthcare Dual Complete (HMO SNP), Pennsylvania Members to: Unison Plaza 1001 Brinton Rd. Pittsburgh, PA ATT: Enrollment Department BAE Mail documentation for Physicians United Plan Members (PUP) to: Physicians United Plan 9120 South Center Loop Dr., Suite 200 Orlando, FL Mail documentation for Fidelis SecureCare Members to: Fidelis SecureCare 20 N. Martingale Road Suite 180 Schaumburg, IL Mail documentation for Golden State Medicare Health Plan Members to: Golden State Medicare Health Plan 3010 Old Ranch Parkway, Suite 260 Seal Beach, CA Mail documentation for Public School Employees Retirement System (PSERS)/Health Options Program (HOP) Members to: PSERS Health Option Plan P.O. Box 1764 Lancaster, PA Attn: Low Income Subsidy Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 14

15 Mail documentation for International Brotherhood of Teamsters (IBT) PDP Members to: Physicians TEAMStar Medicare D 3700 S. Stonebridge Dr. McKinney, TX documentation for Quality Health Plan (QHP) Members to: [email protected] Provided that the documentation received meets the BAE criteria, the Member s copay will be adjusted within forty-eight (48) to seventy-two (72) hours of receipt of BAE documentation. Reprocess the prescription(s) to capture the lower copay amount. If you have any questions on BAE, please contact Customer Service, twenty-four (24) hours a day, seven (7) days a week, at the number on the back of the Member s ID card. Long-Term Care (LTC) Providers ONLY If a Member questions their copay amount, or states that they qualify for the institutional status zero (0) cost-sharing, they must have valid documentation supporting this position in order to receive the zero (0) copay amount. Any of the following documents are acceptable and meet the criteria as Best Available Evidence (BAE) supporting a Member s institutional status and qualification for zero (0) cost-sharing: A remittance from the facility showing Medicaid payment for a full calendar month for the beneficiary during a month after June 30 of the previous calendar year; A copy of a state document that confirms Medicaid payment to the facility for the beneficiary for a full calendar month after June 30 of the previous calendar year; A screen print from the State s Medicaid systems showing the beneficiary s institutional status for at least a full calendar month stay for Medicaid payment purposes during a month after June 30 of the previous calendar year. To correct a Member s subsidy level utilizing BAE, please follow these steps: Secure one (1) of the above documents from the Member; and Fa x documentation to the Member s below applicable health plan; (PDP) (MedicareComplete, Erickson, UnitedHealthcare Dual Complete, UnitedHealthcare Senior Care Options) UnitedHealthcare Dual Complete (HMO SNP), Michigan (MI) UnitedHealthcare Dual Complete (HMO SNP), Pennsylvania (PA) UnitedHealthcare Dual Complete (HMO SNP), All other states Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 15

16 Quality Health Plans QHP Physicians United Plan PUP Fidelis SecureCare Golden State Medicare Health Plan Public School Employees Retirement System (PSERS) International Brotherhood of Teamsters (IBT) PDP OR Mail documentation for PDP, SecureHorizons, MedicareComplete, Erickson, and Evercare Members to: P.O. Box Hot Springs, AR Mail documentation for UnitedHealthcare Community Plan (UHCCP) Members to: UnitedHealthcare 1300 River Drive, Suite 200 Moline, IL Attn: Medicare Enrollment BAE Mail documentation for UnitedHealthcare Community Plan (UHCCP) Members to: Unison Plaza 1001 Brinton Rd. Pittsburgh, PA ATT: Enrollment Department BAE Mail documentation for Physicians United Plan Members (PUP) to: Physicians United Plan 9120 South Center Loop Dr., Suite 200 Orlando, FL Mail documentation for Fidelis SecureCare Members to: Fidelis SecureCare 20 N. Martingale Road Suite 180 Schaumburg, IL Mail documentation for Golden State Medicare Health Plan Members to: Golden State Medicare Health Plan 3010 Old Ranch Parkway, Suite 260 Seal Beach, CA Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 16

17 Mail documentation for Public School Employees Retirement System (PSERS)/Health Options Program (HOP) Members to: PSERS Health Option Plan P.O. Box 1764 Lancaster, PA Attn: Low Income Subsidy Mail documentation for International Brotherhood of Teamsters (IBT) PDP Members to: Physicians TEAMStar Medicare D 3700 S. Stonebridge Dr. McKinney, TX documentation for Quality Health Plan (QHP) Members to: [email protected] Provided that the documentation received meets the BAE criteria, the Member s copay will be adjusted within forty-eight (48) to seventy-two (72) hours of receipt of BAE documentation. Reprocess the prescription(s) to capture the lower copay amount. If you have any questions on BAE, please contact Customer Service; twenty-four (24) hours, seven (7) days a week at the number on the back of the Member s ID card. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 17

18 IV. Claims Process A. General Process The following describes the ORx processes and procedures for processing Claims. Complete Claims ORx requires the submission of a Clean Claim. Because a Member s level of coverage under his or her Benefit Plan may vary for different services, it is particularly important to correctly code, according to the National Council for Prescription Drug programs (NCPDP) standards, in order to submit pharmacy Claims for proper payment and application of deductibles, coinsurance or copayments. Reversals and resubmissions should be submitted electronically within thirty (30) days of the original submission. Please note for federal programs that we support: Federal regulations prohibit us from paying Claims for medications prescribed by providers that have been excluded from federal program participation as evidenced by listing of the prescriber within the Health and Human Services (HHS) Office of Inspector General (OIG) or General Services Administration (GSA) Excluded and Sanctioned Providers listings. These lists are checked monthly and Claims for medications by excluded providers will be rejected. The Claim will reject with an NCPDP reject code of 71 along with the following message: MD NOT COVERED SANCTIONED PRESCRIBER Online Processing Window The Online Processing Window to submit electronic claims for Medicare Part D (Part D) claims is ninety (90) days. Please Note: ORx is unable to honor requests to extend these timeframes. Pharmacies that need to process claims outside the Online Processing Window timeframe for submission of electronic claims will be required to submit a Universal Claim Form (UCF) and an explanation for the late submission. Submission of the UCF is not a guarantee claim(s) will be paid. Payment is determined on a case-per-case basis upon review of explanation of late submission and plan approvals. Please mail completed UCF and explanation for late submission request to: Prescription Solutions by OptumRx P.O. Box Hot Springs, AR Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 18

19 Migration to NCPDP Telecommunication Version D.0 As the industry continues to prepare for the upgrade to the new NCPDP Telecommunication Standard Version D.0, ORx would like to update our network pharmacies on our progress and our current schedule. Phase Date Internal Testing September 2010 Limited External Testing November 2010 Begin Formal Trading Partner Testing January 2011 Begin to Accept D.0 Transactions September 2011 D.0 Required January 1, 2012 Certification At this time, ORx will not require pharmacies to certify in order to submit D.0 transactions. Important Note: D.0 transactions will not be accepted in advance of the go-live date. Testing ORx expects each network pharmacy to participate in D.0 testing. Testing instructions, including test scenarios, were provided in December Payer Sheets The ORx D.0 payer sheets are available on the ORx website, Healthcare Provider Portal via the following link: HealthcareProviderTools/FormsAndDocuments These payer sheets will provide the general claim processing instructions for ORx. We will notify pharmacies once payer sheets for specific lines of business are available. NCPDP Telecommunications Standard Version D.0 is an updated version of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standard for the communication of pharmacy claims transactions between the pharmacy and payers. ORx plans to begin accepting D.0 B1/B2/B3 transactions based on the following schedule. If you have not tested and would like to test, please contact Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 19

20 Bank Identification Number (BIN) Processor Control Number (PCN) Effective or Go-Live Date Payer Sheet /13/ /18/11 RxsolHcpWeb/cmsContent.do?pageUrl=/ HCP/HealthcareProviderTools/ ALL 10/20/11 FormsAndDocuments PRX /21/11 Document # /25/ MEDD 10/27/ MEDD 10/27/ MEDD 10/27/ /27/11 RxsolHcpWeb/cmsContent.do?pageUrl=/ HCP/HealthcareProviderTools/ FormsAndDocuments Document #2403 ANSI Electronic Remittance Advice ORx has already initiated conversion of trading partners from 4010 to If you have successfully completed testing, you will be contacted prior to making the changes to your production files. ORx has made every effort to contact and schedule trading partners for 835 testing. If you have not yet tested with ORx, please contact to schedule testing. If you have not completed testing prior to 12/15/2011, you will be reverted back to paper remittance advice starting with your first check in All partners must receive their 835 through our secure External Client Gateway. If your systems have not been updated and are not ready by 12/31/2011, all claims will reject beginning 01/01/2012. Submitting Compounds Applies to ALL BIN Numbers (BIN): IMPORTANT POINTS TO REMEMBER WHEN SUBMITTING MULTI-INGREDIENT COMPOUNDS: Single ingredient compound billing will not be accepted. Submit all compound claims using NCPDP version 5.1 or D.0 Multi-Ingredient Billing format or compound segment. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 20

21 Submit all of the ingredients in the compound and their respective quantities. Product Identification (ID) in the claim segment should be submitted as all zeros ( ). A minimum of two (2) and a maximum of twenty-five (25) ingredients will be accepted. Specific to Medicare Part D If one (1) or more of the ingredients in the compound is not covered (i.e., CMS exclusion), the Claim will reject. If this occurs, the Claim can be resubmitted with a denial clarification code of 08. The Claim will then process with only the covered ingredients paid. Please refer to the updated Medicare Part D Payer Sheet for further details on required fields and submission criteria. Specific to Commercial and Medicaid, please refer to the updated Commercial Payer Sheet for further details on required fields and submission criteria. As of the date of the printing of this pharmacy manual, ORx does not accept invalid National Drug Codes (NDCs) for any compounds. When prompted for the NDC number, submit the NDC number of the highest cost ingredient. When prompted for quantity, enter the total quantity of the highest cost ingredient. The combined cost shall not include labor costs, equipment costs, delivery charges, professional fees, etc. Use the compound indicator 2, which will better enable the Claim to process and pay accurately and submit electronically in accordance with the Agreement. To prevent audit chargebacks, make sure your software is not programmed to place an amount in the ingredient cost field that is equal to the Average Wholesale Price (AWP) of the most expensive NDC multiplied by the final product quantity. Powdered oral antibiotics that are mixed with distilled or tap water are not considered compounds. National Drug Code (NDC) Number Pharmacies should always submit to ORx the exact eleven (11) digit NDC number of the actual package size of the Drug Product dispensed. National Provider Identification (NPI) Number In compliance with Health Insurance Portability and Accountability Act of 1996 (HIPAA), all covered health care professionals and organizations must have obtained National Provider Identification (NPI) enumeration prior to May 23, 2007, to identify themselves in HIPAA standard transactions. Pharmacy ID ORx only accepts NPI as the pharmacy identifier for online Claims. Any Claims transmitted with an NCPDP or other ID number will be rejected. Although NPI numbers are required for Claims processing, we strongly encourage pharmacies to continue to register for an NCPDP Identification (NCPDP ID) and regularly update their information with NCPDP. Prescriber ID The NPI of the prescribing physician is required for all Claims. At this time, ORx will not reject Claims transmitted with a legacy ID (unless instructed otherwise by a specific client). Although Claims will not Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 21

22 be rejected, pharmacies should transmit the NPI whenever it is available. If the pharmacy does not have the prescriber s NPI on file, the pharmacy should make a reasonable attempt to obtain the NPI number. Medicare Part D Claims Submission without National Provider Identifier (NPI) Effective October 1, 2010 Provider pharmacies were encouraged to begin use of the prescriber s National Provider Identifier (NPI) number when submitting Medicare Part D (Part D) claims to ORx under Bank Identification Number (BIN) Part D claims submitted with a prescriber ID other than the prescriber NPI, i.e., Drug Enforcement Agency (DEA) numbers, will no longer be accepted when ORx has the NPI on file. These claims will reject with Point of Sale (POS) Messaging or Rejection Code 56 NPI exists. Prescriber ID invalid/not allowed, and the NPI number will be provided for use when resubmitting the claim. The prescriber DEA number will be accepted as an alternative to the NPI number only when there is no NPI number on file. If an invalid DEA is submitted, the claim will reject with POS Messaging or Rejection Code 25 Missing or Invalid Prescriber ID. Invalid DEA number is defined as any expired DEA number or DEA numbers that are not registered with the DEA (i.e., default or pharmacy constructed DEA numbers). Please submit valid individual prescribers NPI numbers and not the organizational NPI numbers. Prior to October 1, 2010, we asked that you review your pharmacy claims system and either refer to the website below, or contact prescribers not submitting or referencing their NPI on the prescription, if needed, to obtain the necessary NPI numbers. Please refer to NPPES (National Plan & Provider Enumeration System) website for lookup of prescribers NPI numbers not populated in your system or to verify individual prescribers NPI numbers We recognize that pharmacies cannot always obtain the prescriber s NPI at the point of service. If a prescriber s NPI absolutely cannot be obtained, a valid non-npi number will be allowed to prevent Member disruptions. However, we do encourage all pharmacies to use the prescriber NPI when possible. We also advise caution be exercised when searching prescriber DEA or NPI numbers by name only. We have had many instances of a sanctioned provider s DEA or NPI submitted which causes Member claims to be rejected due to sanctioned status. Please make every effort to ensure you have the correct DEA or NPI and validate on an address if possible. Claim Adjustments Members are responsible for applicable copayments, deductibles and coinsurance associated with their Benefit Plans. Medicare Part D Claim adjustments: Pharmacies will be unable to reverse Medicare Part D (Part D) claims that have been reprocessed internally by ORx. This is necessary because claim adjustments have been made and if a financial adjustment was owed to the member or Long Term Care (LTC) pharmacy, then a reimbursement process has already been initiated. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 22

23 Pharmacies attempting to submit reversal requests on claims that have been reprocessed by ORx will receive a rejection stating Claim not eligible for reversal. Contact Help Desk for assistance. If there is a need to resubmit Claims due to incorrect Medicare Part D Low Income Subsidy (LIS) level, please contact Customer Service at the number identified in Section II of this Manual. Manual changes to income subsidy levels may be overwritten by files received from CMS. This process would require monthly Manual updates until the Member s LIS level is transmitted by the appropriate Medicaid or Social Security Administration (SSA) office to CMS. Subrogation and Coordination of Benefits (COB) Benefit Plans are subject to subrogation and coordination of benefits (COB) rules. 1. Subrogation To the extent permitted under applicable law and the applicable Benefit Plan, we reserve the right to recover benefits paid for a Member s health care services when a third (3rd) party causes the Member s injury or illness. 2. COB Coordination of benefits (COB) is administered according to the Member s Benefit Plan and in accordance with applicable statutes and regulations. ORx can accept secondary Claims electronically. Retroactive Eligibility Changes Eligibility under a Benefit Plan may change retroactively if: The Benefit Plan, Sponsor or ORx receives information that an individual is no longer a Member; The Member s policy/benefit contract has been terminated; The Member decides not to purchase continuation coverage; or The eligibility information received by ORx is later determined to be incorrect. As determined by CMS, with respect to Medicaid, MAPD or Prescription Drug Plans. 1 Covered entities are health plans, health care clearinghouses, and those health care providers who transmit any health data in connection with a transaction for which the Secretary of Health & Human Services has adopted a standard (known as standard transactions). Most Medicare Organization health care providers send electronic Claims to Medicare (they are standard transactions), making them covered health care providers (covered entities). If a Network Pharmacy Provider has submitted a Claim(s) that is affected by a retroactive eligibility change, a Claim adjustment may be necessary. Average Wholesale Price (AWP) and Wholesale Acquisition Cost (WAC) Average Wholesale Price or AWP shall mean the average wholesale price of a Covered Prescription Service based on the Medi-Span Prescription Pricing Guide (with supplements) or any other nationally recognized pricing source selected by Administrator (the Pricing Source ), as updated at least monthly. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 23

24 Wholesale Acquisition Cost or WAC shall mean the average wholesaler acquisition cost of a Covered Prescription Service based on the Medi-Span Prescription Pricing Guide (with supplements) or any other nationally recognized pricing source selected by Administrator (the Pricing Source ), as updated at least monthly. Company acknowledges that Administrator shall be entitled to rely on Medi-Span or the publisher of any other nationally recognized Pricing Source selected by Administrator to determine AWP or WAC for purposes of establishing the pricing under this Agreement. Company further acknowledges that Administrator does not establish AWP or WAC, and Administrator shall have no liability to Company arising from the use of the Medi-Span Pricing Guide or information received from any other Pricing Source. Company further acknowledges that, to account for the rollback of AWP implemented by Medi-Span on or after September 26, 2009 ( AWP Rollback ), Administrator uses the following AWP adjustment processes for all pricing based on AWP under this Agreement: Administrator shall adjust the Medi-Span AWP Pricing Information for each of the Affected NDCs to reflect the markup factors utilized by Medi-Span immediately prior to the AWP Rollback. Affected NDCs shall mean all NDCs with adjusted markup factors by the Pricing Source pursuant to the AWP Rollback. Administrator shall adjust Affected NDCs with markup changes on or after September 26, 2009, to reflect the markup factors utilized by Medi-Span immediately prior to the AWP Rollback, and New NDCs with markup factors used by the Pricing Source shall be adjusted by Administrator to reflect a markup factor of New NDCs shall mean those NDCs first issued and listed on the Medi-Span AWP Pricing Information after the effective date of the AWP Rollback. Administrator shall continue to adjust the AWP Pricing Information, as described in this section ( Adjusted AWP ), until AWP is no longer published by Medi-Span or Administrator notifies Company of a change. Company acknowledges that in the event that the publisher of the Pricing Source ceases to publish AWP or Administrator elects to no longer adjust the AWP Pricing Information, then Company agrees that, (a) Administrator may elect to discontinue using the Adjusted AWP process and change the Prescription Drug Contracted Rate based on AWP that is provided to Company under the Network Pharmacy Agreement in the same proportion as the Pricing Source s change to the percentage by which it marks-up the wholesale acquisition cost of the medication drugs or ancillary supplies, as applicable ( Proportional Change ). For example, if the Pricing Source changed the percentage by which it marks-up wholesale acquisition cost from twenty-five percent (25%) to twenty percent (20%) for the Affected NDCs as a result of the AWP Rollback, Administrator may change a Prescription Drug Contracted Rate of adjusted AWP-16% plus a dispensing fee of two dollars ($2) to published AWP-11.57% plus a dispensing fee of two dollars ($2). (b) Administrator may elect to change the Prescription Drug Contracted Rate based on AWP that is provided to Company under this Agreement and replace it with the Wholesale Acquisition Cost (WAC). Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 24

25 Administrator may amend the Network Pharmacy Agreement and each Addendum and Exhibit for a Proportional Change to the Prescription Drug Contracted Rate by providing a unilateral notice amendment that does not require the Network Pharmacy Provider s signature to maintain the parties relative economic position under the Network Pharmacy Agreement as of the effective day of such change or cessation by the publisher of the Pricing Source. Any other methodology utilized by Administrator to change the Prescription Drug Contracted Rate in an attempt to maintain the parties relative economic position shall be in accordance with a mutually signed amendment to the Network Pharmacy Agreement. Both parties agree that any changes made in dispensing fees, or other professional or similar fees that are made concurrently with AWP changes pursuant to this section shall be used by Administrator to determine the parties relative economic position when calculating new pricing or revised AWP or WAC rates. B. Required Prescription Information For each Claim for a covered drug filled and dispensed by a Network Pharmacy Provider for a covered Member, all related Network Pharmacy Providers are required to transmit the following information to ORx: NCPDP 5.1 or D.0 format or later version as developed will be utilized. Attached as Exhibit A is the payer/billing specification sheet which details all of the requirements for submitting a Claim using the NCPDP 5.1 or D.0 format. Several fields are marked as situational and they will require data as needed under the defined situation in the comment section. Claims submitted that are missing data in mandatory or required fields, or where data is required under situational conditions, will be rejected. With the NCPDP 5.1 or D.0 format change being able to handle the exact metric decimal quantity correctly, you will no longer need to adjust the quantity by rounding prior to submitting Claims. All Claims submitted in 5.1 or D.0 format MUST use the PCN of 9999 (or 8888 if a wrap plan Member refer to ID card) and a submitted group. We have not provided specifications for the American National Standards Institute (ANSI) 837 format, as we believe that the NCPDP 5.1 or D.0 is the correct format to use for pharmacy dispensed non-drug items. Other non-prescription products and pharmacy-related supply items should also be billed using the NCPDP 5.1 or D.0 format. As of the date of the printing of this pharmacy manual, ORx is systematically unable to accept: The Worker s Compensation or coordination of benefits segments; Coupons and the Prior Authorization (PA) segments; and The fields associated with partial fill payments (# , #548, and #549) will not be supported. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 25

26 Prescription Origin Code Requirements Effective November 12, 2009, ORx began requiring that the Prescription Origin Code (419-DJ) be submitted with one (1) of the following values on all new prescriptions. A new prescription is one that is submitted with a refill indicator of = Written 2 = Telephone 3 = Electronic 4 = Facsimile (Fax) Claims submitted for a new prescription missing one (1) of these values will reject with the following NCPDP reject code: 33 - Rx Origin Code cannot be 0 on New Clm. If this occurs, please resubmit the Claim with the appropriate value. C. Dispense as Written (DAW) ORx supports the NCPDP standard Dispense as Written (DAW) codes. To ensure accurate reimbursement, always include the correct DAW code when you submit a Claim. Claims submitted to ORx with DAW codes of three through six (3-6) or eight through nine (8-9) will be adjudicated similarly to a DAW 0. If necessary, contact your software vendor for needed alterations to your pharmacy system. DAW Codes: DAW 0 NO DISPENSE AS WRITTEN (Substitution Allowed) (or no product selection indicated) Use the DAW 0 code when dispensing a generic drug; that is, when no party (i.e., neither Prescribing Physician, nor Pharmacist, nor Member) requests the branded version of a multi-source product. Use the DAW 0 code when dispensing a multi-source generic, even if the Prescribing Physician indicates the DAW code for the generic product and does not specify a manufacturer. Use the DAW 0 code when dispensing single-source brands (e.g., Lipitor ), because generic substitution is not possible. DAW 1 PHYSICIAN writes DISPENSE AS WRITTEN Use when the Prescribing Physician specifies the branded version of a drug on the hard copy prescription or in the orally communicated instructions. If the Member requests a Brand Name Drug, and it is not a Prescribing Physician-initiated instruction, transmit the DAW 2 code. (See following instruction.) DAW 2 PATIENT REQUESTED Use this code when the Member requests the Brand Name Drug even though the original prescription did not indicate Dispense As Written. DAW 3 PHARMACIST SELECTED BRAND DAW 4 GENERIC NOT IN STOCK Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 26

27 DAW 5 BRAND DISPENSED, PRICED AS GENERIC Use when dispensing a brand as a generic. Claims submitted with DAW 5 will be reimbursed at the generic price. DAW 6 OVERRIDE DAW 7 SUBSTITUTION NOT ALLOWED; BRAND MANDATED BY LAW DAW 8 GENERIC NOT AVAILABLE DAW 9 OTHER Most Members have a choice between Brand Name and Generic Drugs. However, in some programs the Member will pay the difference between the cost of the Brand Name Drug and the available Generic Drug. Accordingly, correct DAW submissions indicate if a penalty is applicable. D. Electronic Funds Transfer (EFT) Program ORx Network Pharmacy Providers have the option to participate in the Electronic Funds Transfer (EFT) Program. This service provides improved analysis, reporting, and a cost-effective alternative to the traditional hard copy process. Enrollment Requirements To use the ORx Pharmacy EFT Program, you must meet the following requirements: Be a current Network Pharmacy Provider. Have the ability to receive and read the 835 electronic remittance advice file. Check with your Information Technology support staff or pharmacy software provider to confirm that you have the ability to receive the encrypted Claims information via File Transfer Protocol (FTP). CMS also offers free software to view and print the 835 electronic remittance advice file for professional providers and suppliers. For more information on this software, Medicare Remit Easy Print, please access the CMS website at: No paper remittance advice will be mailed once you are enrolled in the Pharmacy EFT Program. The 835 electronic remittance advice file will be your indicator that your EFT has been transmitted to your designated Financial Institution. Complete the Pharmacy EFT enrollment form containing contract and banking information. Please allow four (4) weeks for your enrollment to be processed. Claims received after your Pharmacy EFT enrollment has been processed will be paid electronically. Please see a copy of the EFT Enrollment Form attached as Exhibit B. Complete the EFT Trading Partner Information Request on the ORx website. To complete the trading partner information, you will need to provide your Pretty Good Privacy (PGP) Key. This ensures the delivery of secure data. PGP Encryption is a computer program that provides cryptic graphic privacy and authentication. PGP and similar products follow the Open PGP standard for encrypting and decrypting data. You will need to get this information from your software vendor. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 27

28 Enrollment Steps Follow these simple steps to enroll in the ORx Pharmacy EFT Program: To obtain detailed program information, a Pharmacy EFT Enrollment Form and an online EFT Trading Partner Information Request or use the EFT Enrollment Form attached as Exhibit B. Log on to the following - HealthcareProviderTools/PharmacyEFT Print, complete and return the enrollment form via fax or U.S. Mail to: Prescription Solutions by OptumRx P.O. Box 6104 Cypress, CA OR Fax: Click on the online link to complete the EFT Trading Partner Information Request. This form will be used to set up the 835 electronic remittance advice file transfer. 835 electronic remittance advice file will be delivered to pharmacy or payee via ORx external client Gateway. Files can either be sent via Secure FTP or they can be retrieved from the gateway. Files cannot be delivered in any other method (i.e., compact disk (CD), , etc.). E. Member/Insured Appeals and Grievances ORx has established mechanisms to ensure all members and Prescribing Physicians have equal access to, and can fully participate in, the Appeals process. Either the Member or the Member s appointed representative and Physician can initiate an appeal. The Appeals Department can be contacted by mail, fax, or phone. The Prescribing Physician, Member, or his/her authorized representative may contact the ORx customer service number located on the back of the Member s identification (ID) card to initiate an appeal request. Member complaints or grievances are used to continually improve the quality of our services. Grievances will be handled in a timely manner by contacting the customer service number located on the back of the Member s ID card. Network Pharmacy Provider Responsibilities The Network Pharmacy Provider will assist, as requested by the Benefit Plan or Sponsor or ORx on behalf of a Client, in processing Member grievances and appeals, consistent with the Benefit Plan s or Sponsor s appeals and grievances procedures. If the Network Pharmacy Provider receives an appeal or a complaint/grievance from a Member, the Network Pharmacy Provider should redirect the Member to call the Customer Service number listed on his or her ID card. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 28

29 F. Utilization Management Utilization Management Requirements for Select Drugs Some covered medications may have additional requirements or limits that help ensure safe and effective use. Requirements and limits may include: Prior Authorization (PA) Plan approval is required to guide the appropriate use of certain drugs or to ensure that the medication will be used for indications for which it has been shown to be safe and effective. Medications requiring PA may require confirmation of diagnosis or submission of laboratory and other supporting information. Step-Therapy (ST) Step Therapy (ST) supports the use of effective alternative medications prior to receiving approval for specified medications. When a medication has a step therapy check applied, it means that other clinically appropriate and/or more cost-effective alternatives are available as first-line therapies. When Members have tried the alternatives without success, the medication that requires an override may be approved for coverage. Quantity Limits (QL) Quantity limits (QL) restrict the amount of medication a Member can receive in a given timeframe or the number of days he or she can receive it. Quantity limits (QL) may be used for safety reasons or to encourage dose optimization. Certain drugs may be approved for quantities above the limited amount, if proven to be medically necessary. Prior Authorization (PA) Review Process Both Member and prescribing physician may request to initiate the prior authorization (PA) review process. Coverage determinations made through the PA review process will be based on Benefit Plan s/client s approved criteria, clinical guidelines approved by the National Pharmacy & Therapeutics Committee (National P&T), or other professionally recognized standards of practice. If a Member s medication has step therapy (ST) or quantity limit (QL) restrictions, or requires prior authorization (PA), the Member or his/her authorized representative should contact ORx s customer service number located on the back of the Member s ID card. In addition, the prescribing physician may contact our PA department to start the prior authorization process by providing relevant, patient-specific clinical information to be reviewed by a licensed pharmacist or medical director. Prescribers can also submit a PA request via fax, mail, or online at: first.html?frmpastptherdrg=true Our PA process includes the following key steps: 1. The Prescriber or Member can submit a PA request. 2. A pharmacy technician enters the information into our PA system and performs the initial request review. 3. If the request falls outside the established guidelines, a pharmacist reviews the request and contacts the prescriber if additional information is required. 4. If required by state law, the request will be reviewed by a medical director before issuing the final decision. 5. Additionally, where required by law, the prescriber is offered the opportunity for a peer-to-peer consultation prior to the issuance of an adverse medical necessity determination. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 29

30 Once the request is approved or denied, our PA system will automatically generate written correspondences to both the member and provider. We comply with all State and Federal regulations for PA turnaround time. Our typical turnaround times are as follows: Non-urgent cases have a turnaround time of fifteen (15) days for commercial plans, or seventy-two (72) hours for Medicare plans from receipt of all information required to review the case. Urgent cases have a turnaround time of seventy-two (72) hours for commercial plans, or twenty-four (24) hours for Medicare plans from receipt of all information needed to review the case. * Based on health care reform, the urgent case adjudication timeframe may be changed to twenty-four (24) hours as of 01/01/2012 for some plans. Our PA department is staffed with licensed pharmacists and pharmacy technicians. They also have access to a contracted physician reviewer when required. After PA requests are reviewed, determinations are rendered in accordance with State and Federal regulations, independent body accreditation standards, such as National Committee for Quality Assurance (NCQA), or Employee Retirement Income Security Act (ERISA), and the clinical guidelines developed by our National Pharmacy and Therapeutic (NP&T) guideline subcommittee. The Prescriber and Member or authorized representative will be notified of the final decision within the required timeframe according to State and Federal regulations. Concurrent Drug Utilization Review (cdur) In order to detect and address clinical quality and safety issues, certain concurrent drug utilization reviews (cdurs), or clinical edits, are applied at the time the prescription is dispensed. Concurrent screenings are for such things as duplicate therapies, age or gender-related contraindications, over-utilization or under-utilization, drugdrug interactions, incorrect drug dosage or duration of drug therapy, drug-allergy contraindications, and clinical abuse or misuse. System thresholds/criteria and accompanying pharmacy messaging are developed and set by Medi-Span, and are validated and implemented by ORx. Dispensing pharmacists should exercise their clinical knowledge and expertise in reviewing and overriding warning messages if deemed medically appropriate. Retrospective Drug Utilization Review (rdur)/clinical Programs The Retrospective Drug Utilization Review (rdur)/clinical Program uses detailed data review and analysis to identify potential problems, implement appropriate interventions, and evaluate the impact of the interventions. rdur programs can yield measurable results, including reduction in emergency room visits, unnecessary and inappropriate drug use, and overall costs. The programs focus on pre-catastrophic populations with high-cost and high-impact conditions that have the greatest potential for improvement via Member and/or provider interventions. Specific program objectives include optimizing the use of certain therapeutic agents to improve health outcomes, reducing the risk for drug-related adverse events, and promoting the use of the most cost-effective medications. rdur program examples include, but are not limited to, the following: Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 30

31 Drug Interaction Alert Program (DIAP) Some medications can have harmful effects when used in conjunction with others. These potentially dangerous drug-drug interactions (DDIs) can negatively impact Members health and increase both prescription and medical plan costs. The Drug Interaction Alert Program (DIAP) helps to protect members from potential drug-related adverse events and control overall Benefit Plan costs by intervening with providers when clinically significant DDI issues are detected. DDIs are categorized according to severity. For example: A 1 indicates a DDI that should always be avoided, while a 2 indicates an interaction that should usually be avoided. Medications interacting with a severity of 1 or 2 are considered clinically significant DDIs. The DIAP involves a daily review of pharmacy claims to detect clinically significant DDIs. When Members who filled medications with potentially serious DDIs are identified, their providers receive a faxed report within twenty-four (24) to seventy-two (72) hours. Each report details only clinically significant DDIs found for Members under the specific provider s care. Geriatric RxMonitor Program Certain medications, or medication combinations, are not recommended for use by people sixty-five (65) years and older because of potential side effects, lack of effectiveness, or interaction with specific medical conditions. With the Geriatric RxMonitor Program, pharmacy plans can reduce the use of these potentially inappropriate medications among elderly members while improving quality of care. Using pharmacy claims data, we identify Members who are at least sixty-five (65) years old and have filled prescriptions for one (1) or more medications that should be avoided in the elderly or due to a medical condition (medications are determined based on applicable Health Plan Employer Data and Information Set (HEDIS ) criteria). Misuse and Abuse Drug Monitoring Program While opioid analgesics, benzodiazepines, muscle relaxants, and acetaminophen (APAP)-containing medications are an important part in managing pain and other medical conditions for many patients, these medications are also associated with risks. The Misuse and Abuse Drug Monitoring Program identifies Members who may benefit from having their medication regimens re-evaluated by their health care providers. By reducing potentially inappropriate usage of opioids, benzodiazepines, muscle relaxants, and APAP-containing medications, the Misuse and Abuse Drug Monitoring Program improves the quality of patient care. We analyze pharmacy claims data to identify Members who meet at least one (1) criteria: overlapping use of at least two (2) different long-acting opioid medications; multiple providers prescribing opioids, benzodiazepines, or muscle relaxants; multiple pharmacies dispensing opioids, benzodiazepines, or muscle relaxants; high doses of opioids; chronically refilling oxycodone containing opioids; and total average daily APAP dose exceeding four (4) grams. Polypharmacy Program Unnecessary or duplicate use of medications, also known as polypharmacy, can lead to serious health complications for Members, as well as increased pharmacy and medical costs. To lower the health risks Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 31

32 associated with polypharmacy, we offer actionable, provider-based interventions designed to reduce polypharmacy issues and associated pharmacy plan costs. There are two (2) distinct Polypharmacy Programs; duplicate therapy and medication-disease interaction. For the duplicate therapy program, pharmacy claims data are used to identify Members who show evidence of taking two (2) or more medications indicated to treat the same condition. For the medication-disease interaction program, pharmacy and/or medical claims data are used to identify Members taking one (1) or more medications that may adversely affect certain medical conditions. Generic Strategy Program ORx developed a generic utilization program designed to promote the use of lower cost and clinically appropriate generic medications. The program targets first-time generics as well as select existing generics in certain therapeutic classes. Depending on the medication, both Members and providers may be targeted to receive notifications and information regarding generic availability and the efficacy and safety of generic products relative to branded products. This program includes, but is not limited to, the following therapeutic drug classes: Angiotensin Receptor Blockers (ARBs) Bisphosphonates Nasal steroids Proton Pump Inhibitors (PPIs) Statins Triptans To assist in the decision process, Member education can be conducted through a number of channels, including: Mailings to Members who are utilizing one (1) or more specific Brand Name Drugs for which a potentially appropriate generic medication is available. The communication informs the Member of the potential cost savings and directs the Member to talk to his or her Prescribing Physician or Pharmacist. Automated telephonic communication affirming the potential cost savings and directing the Member to talk to his or her Prescribing Physician or Pharmacist. This program also communicates the following information to Network Providers: Information regarding generic availability and the efficacy and safety of generic products relative to branded products. Reports detailing the specific Members who may save on prescription expenses by generic utilization. Maximum (Max) Dollar Edits Claims rejecting for maximum dollar exceed can be addressed by calling the ORx Pharmacy Help Desk. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 32

33 V. Products As of the date of the printing of this pharmacy manual, the following is a list of the Clients/Sponsors that ORx currently serves and their respective Claims processing information: Claims Processing Information (Note: This list is NOT all-inclusive but only a sample of some of the 2012 Clients and related processing information. This list may be modfied at any time.) Client AARP MedicareComplete Retiree Plans from SecureHorizons SecureHorizons MedicareComplete Retiree Plans Evercare Plans Note: The submitted group varies see ID Card. AARP MedicareRx Plans insured through UnitedHealthcare (AARP MedicareRx Enhanced and AARP MedicareRx Preferred) Required Submitted BIN PCN Group SHAZ SHCA SHCO SHNV SHOK SHOR SHTX SHWA COS PDPIND WRAPGR United MedicareRx Note: The submitted group and PCN varies see ID Card. Archdiocese of Cincinnati AOC Bakers Health & Welfare Fund - Local BHW24 Capstone Health Plan PRXCAP City of Dallas Employees UHC Dolese Brothers Company PRXDBC Evercare a UnitedHealth Group Company Erickson Advantage SHAZ SHCA Note: The submitted group varies see ID Card SHCO SHNV SHOK SHOR SHTX SHWA COS OXF COS COS continued next page Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 33

34 Client Required Submitted BIN PCN Group Evercare at Home COS Evercare Coordination of Long-Term Services (CoLTS) COS Evercare Coordination of Long-Term Services (CoLTS) (Dual Eligibles) Requires other coverage code of 2 or higher. Evercare Medicaid Supplement Plan Requires other coverage code of 2 or higher COS COS Fidelis FID Florida (FL) Share of Cost Requires other coverage code of 2 or higher COS Golden State Medical GSM HealthEsystems Not Required Not Required Illinois CaresRx Plus (MAPD) Illinois CaresRx ADA/Basic (MAPD) Illinois CaresRx ADA/Plus (MAPD) COS Illinois Cares/Rx Basic (MAPD) Illinois CaresRx Plus (PDP) Illinois CaresRx ADAP/Basic (PDP) Illinois CaresRx ADAP/Plus (PDP) WRAPGR Illinois Cares/Rx Basic (PDP) Local L301 Maryland (MD) Senior Prescription Drug Assistance Program SPDAP WRAPGR North Coast Trust NCT P.S.E.R.S. (Pennsylvania Public School Employees Retirement System) PSR P.S.E.R.S. (Pennsylvania Public School Employees Retirement System) Early Retirees SER PartnersRx and Avalon Healthcare PRXTRV PartnersRx and Interlock Metal Sales PRXUMK Physicians United Plan PUP Preferred Health Plan and PartnersRx PRXPHK PROACT JOHNSON NEWSPAPERS JSN PROACT ONONDAGA OND PROACT ST LAW COUNTY SLC continued next page Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 34

35 Client Required Submitted BIN PCN Group PROACT ST LAW/LEWIS BOCES SLL PROACT VILLAGE OF POTSDAM VOP ProAct Inc. Fox Dealerships FOX ProAct Inc. Fruth Pharmacy FRU ProAct Inc. Pulaski Health Center PUL ProAct Inc. Town of Canton TOC ProAct Inc. Village of Canton VOC Public Works Commission PRXJSL Quality Health Plans (QHP) Florida (FL) MEDD Not Required Quality Health Plans (QHP) Medicare Advantage Only MEDD Not Required Quality Health Plans (QHP) New York (NY) MEDD Not Required RETA Trust Refer to RETA Trust ID Card SecureHorizons MedicareDirect Retiree Plans (PFFS) COS Sierra MAPD Health Plan of Nevada (NV) SIE South Counties Employer Employee Trust (SCEET) SCEET Southern California Local Union 831 Employer Health Trust Fund L831 Southwest Teamsters STS State of South Carolina (SC) SPAP WRAPGR TeamStar International Brotherhood of Teamsters (IBS) PIB U.S. Virgin Islands Senior Citizens Affairs Pharmaceutical Assistance Program WRAPGR UnitedHealth Rx for Groups (PDP) BER Note: For employer group Michelin ONLY. UnitedHealthcare Community Plan in New York (NY) ACUNY UnitedHealthcare Community Plan in South Carolina (SC) ACUSC UnitedHealthcare Community Plan in the District of Columbia (DC) ACUDC continued next page Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 35

36 Client UnitedHealthcare Community Plan of New Jersey (NJ): NJ FamilyCare UnitedHealthcare Community Plan Share Advantage of Nebraska (NE) UnitedHealthcare Community Plans of Arizona (AZ): Arizona Physicians IPA Medicaid Plans UnitedHealthcare Community Plans of Arizona (AZ): Arizona Physicians IPA-CRS Plan UnitedHealthcare Community Plans of Florida (FL): M*Plus (Medicaid) Plan and Florida Healthy Kids Plan UnitedHealthcare Community Plans of Michigan (MI): Great Lakes Health Plan (Medicaid) Required Submitted BIN PCN Group AMNJ ACUNE ACUAZ ACUFL ACUMI UnitedHealthcare Community Plans of Michigan (MI): MIChild (CHIP) UnitedHealthcare Community Plans of Ohio (OH) ACUOH UnitedHealthcare Community Plans of Pennsylvania (PA): Medicaid Plans and Children s Health Insurance Program ACUPA (CHIP) Plans UnitedHealthcare Community Plans of Rhode Island (RI): Medicaid Plans Including RiteCare and Rhody Health ACURI Partners Plans UnitedHealthcare Community Plans of Rhode Island (RI): Rhody Health Partners Program (SSI) UnitedHealthcare Community Plans of Rhode Island (RI): Rhode Island s Rite Care Medicaid Program (Rite Care) UnitedHealthcare Community Plans of the Mid-Atlantic: Healthy Choice (Medicaid) ACURI RXSOLPRD ACUMD UnitedHealthcare Community Plans of the Mid-Atlantic: Primary Adult Care (PAC) UnitedHealthcare Dual Complete (HMO SNP) in Arizona (AZ) MPDACUAZ UnitedHealthcare Dual Complete (HMO SNP) AMCNJ in New Jersey (NJ) UnitedHealthcare Dual Complete (HMO SNP) MPDACUNY in New York (NY) continued next page Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 36

37 Client UnitedHealthcare Dual Complete (HMO SNP) in Pennsylvania (PA) UnitedHealthcare MedicareComplete (HMO) in Pennsylvania (PA) UnitedHealthcare Dual Complete (HMO SNP) in Wisconsin (WI) UnitedHealthcare Dual Complete Preferred (HMO SNP) in Tennessee (TN) UnitedHealthcare Group Senior Supplement and Senior Security Retiree Plans Note: Group Supplement plans include Senior Supplement and Senior Security. UnitedHealthcare MedicareRx for Group (PDP) Note: The submitted group and PCN varies see ID Card. Required Submitted BIN PCN Group MPDACU MPDACUWI AMCTN SRPLH WRAPGR PDPIND Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 37

38 VI. Medicare Product Information and Guidelines Excluded Drugs As of the date of the printing of this Manual, certain types of drugs or categories of drugs are not normally covered by Medicare Prescription Drug Plans (PDPs). These drugs are not considered Medicare Part D (Part D) drugs and may be referred to as exclusions or non-part D drugs. The following are drug classes or categories of drugs excluded from Part D coverage with examples of drugs within each class. Prescription vitamins and mineral products, with the exception of formulary prenatal vitamins and fluoride preparations Examples: Ascorbic Acid, Folic Acid, Vitamin B Agents when used for anorexia, weight loss, or weight gain Examples: Ionamin, Meridia, Phentermine Agents when used to promote fertility Examples: Clomiphene Citrate, Fertinex, Follistim, Gonal-F, Serophene Agents when used for cosmetic purposes or hair growth Examples: Botox Cosmetic, Eldoquin, Hydroquinone, Lustra, Propecia, Renova Agents when used for the symptomatic relief of cough and colds Examples: Benzonatate, Tessalon Nonprescription or over-the-counter (OTC) drugs (with the exception of Insulin and associated medical supplies) Examples: Aspirin, Sudafed, Tylenol Less Than Effective Medicaid Drug Efficacy Study Implementation (DESI) Drugs Examples: Anucort HC, Tigan Suppositories Barbiturates Example: Phenobarbital Benzodiazepines Examples: Alprazolam, Clonazepam, Diazepam, Lorazepam Agents when used for the treatment of sexual or erectile dysfunction Examples: Viagra, Cialis, Levitra and Caverject Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 38

39 Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale. End-Stage Renal Disease (ESRD) agents furnished to ESRD patients on dialysis Examples: Iron, Vancomycin, Daptomycin Agents without New Drug Application (NDA) or Abbreviated New Drug Application (ANDA) with the Food and Drug Administration (FDA) Agents that are not discounted for Medicare beneficiaries in the coverage gap Compounds that contain at least one ingredient covered under Medicare Part B Self-administered oral anti-cancer agents with the same active ingredients and indications as chemotherapy agents administered as incident to a physician s professional service Examples: Temodar, Xeloda Call the Member s Medicare Prescription Drug Plan for more information as listed on the back of the Member s identification (ID) card. Many of the Benefit Plans we support may cover Medicare Part D excluded drugs through enhanced coverage. Medicare Part A/B/D Coordination of Benefits Some drugs may be billed to either the Medicare Part A (if a Member is an inpatient), Medicare Part B or Medicare Part D benefit, depending on the intended use and other factors. The Network Pharmacy Provider may determine which Medicare benefit applies. Medications may be covered in one (1) of three (3) ways: Under Medicare Part A if Member is an inpatient; or Under Medicare Part B; or The Medicare Prescription Drug Plan (PDP) in conjunction with Medicare Part D. Medications will never be covered through Medicare Part A, Medicare Part B and the Medicare Part D Prescription Drug Plan at the same time. Online messaging, e.g., Covered under Part B, bill Medicare, is provided at the point of service. When it is not clear which coverage applies, the prior authorization process should be initiated in order to determine the appropriate coverage. Beginning January 1, 2012 MAPD claim responses will have benefit stage qualifier values that have been approved through the NCPDP External Code List (ECL) process. These qualifier values will allow pharmacies to identify Medicare MAPD plans that offer additional benefits besides Part D covered drugs: The Medicare Advantage (MA) portion of the MAPD plan = Benefit Stage Qualifier (393-MV) value of 50 (Not paid under Part D, paid under Part C benefit (for MAPD plan) Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 39

40 Employer Group Waiver Plans (EGWPs) and supplement plans where Part D and non-part D supplemental benefits are co-administered = Benefit Stage Qualifier (393-MV) value of 60 (not paid under Part D, paid as or under a supplemental benefit only). Negotiated Price Non-formulary Part D drug = Benefit Stage Qualifier (393-MV) value of 70 (Part D drug not paid by Part D plan benefit, paid by the beneficiary under plan-sponsored negotiated pricing). Negotiated Price Non-Part D Drug = Benefit Stage Qualifier (393-MV) value of 80 (Non-Part D drug not paid by Part D plan benefit, paid by the beneficiary under plan-sponsored negotiated pricing). These benefit stage qualifiers are not applicable to standalone MA plans and PDP plans; these plans will have separate 4Rx since they may be sold independently (a beneficiary can choose to use one company s MA and another company s Prescription Drug Plan (PDP)). Medicare Part D Coverage Determinations Coverage determinations allow requests for exceptions to waive coverage restrictions or limits applied through prior authorization (PA), step-therapy (ST), quantity limits (QL), and Medicare Part A/Part B/Part D coordination of benefits (COB). The Member, Member s Authorized Representative, Prescribing Physician, or other Authorized Prescriber may request an exception. If the Benefit Plan or Sponsor approves an exception request, the approval is valid for the remainder of the plan year, unless clinically inappropriate or unnecessary, so long as the prescribing physician continues to prescribe the medication and it continues to be clinically appropriate and necessary, safe and effective for treating the Member s condition. If the exception request results in an adverse coverage determination, a Member may appeal the decision. Timeframes Standard coverage determination requests are generally provided within seventy-two (72) hours of receipt of the request, or, for an exceptions request, the physician s supporting statement. If the Benefit Plan or Sponsor has not provided an answer within seventy-two (72) hours after receiving a request, the request will be automatically forwarded to an independent organization called an Independent Review Entity (IRE) for review. If the Member s life, health, or ability to regain maximal function may be jeopardized and requires a more immediate decision, the Member can request to expedite the request. Expedited coverage determinations are provided no later than twenty-four (24) hours of receipt of the request, or, for an exceptions request, the physician s supporting statement. Coverage Limitations A prescription drug is a Medicare Part D drug only if it is for a medically accepted indication as defined in the Medicare statutes. This definition includes prescribed uses supported by a citation included, or approved for inclusion, in one (1) of the following three (3) compendia: American Hospital Formulary Service Drug Information Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 40

41 United States Pharmacopeia-Drug Information or its successor publication DRUGDEX Information System Based on this statutory definition, indications supported in peer reviewed medical literature are not medically accepted if they are not yet included, or approved for inclusion, in one of the compendia. Therefore, the use of a medication for such indications would not meet the definition of a Medicare Part D medication and the medication would not be covered under the Benefit Plan, even if the Member s prescribing physician states that the medication is medically necessary. The following additional coverage limitations may apply: Early refills for lost, stolen or destroyed medications are not covered except during a declared National Emergency. Early refills for vacation supplies may be limited to a one (1) time fill of up to thirty-one (31) days per calendar year according to Benefit Plan. Medications will not be covered if prescribed by physicians or other providers who are excluded from Medicare program participation (unless they have an approved waiver on file with the OIG; these occurrences are very rare). A Member may refill most prescriptions when a minimum of seventy-five percent (75%) of the quantity is consumed based on the number of days supplied. This minimum quantity consumed amount is seventy percent (70%) for eye drops. Medication Therapy Management (MTM) Program Consistent with the Medicare Modernization Act (MMA) requirements for Medication Therapy Management (MTM) Programs, the Benefit Plan provides an MTM Program at no additional cost for eligible plan Members. This program is designed to ensure that Members get the most medically appropriate, safe and cost-effective medications. It focuses on improving medication use and reducing adverse drug events. Eligibility CMS requires that MTM Programs be offered to Members who have multiple chronic diseases, take multiple chronic/maintenance Medicare Part D covered medications, and are likely to exceed three-thousand dollars ($3,000) in annual cost for covered Medicare Part D medications. Each plan is to define the number and type of chronic diseases and number of Medicare Part D medications to include in the MTM Program. The criteria selected for ORx s MTM Program are: 1. A Member must have at least three (3) of the following four (4) medical conditions: Hypertension Chronic Heart Failure Diabetes Dyslipidemia Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 41

42 2. A Member must have filled prescriptions for at least eight (8) distinct Medicare Part D covered chronic/ maintenance medications during the identification period. 3. A Member must be identified as likely to incur annual costs for Medicare Part D covered medications that exceed three-thousand dollars ($3,000). The Benefit Plan identifies and invites Medicare Part D plan Members who meet the criteria to take part in the MTM Program. Scope of MTM Program Services The scope of the MTM Program (MTMP) services is determined by each plan, as there are no required services by CMS. In selecting MTM Program services, ORx has considered the final regulations of the Medicare Modernization Act (MMA), which include some examples of best practices, and also considered the potential impact of each service on maximizing therapeutic outcomes. Therefore, the selected services exemplify the best practices stated in the MMA and can potentially impact clinical outcomes. The MTM Program includes, but is not limited to: Providing patient and physician education; Improving medication adherence through refill reminder and notification on selected chronic medications; Performing an annual comprehensive medication review which consists of telephonic, interactive, person-to-person consultation with a pharmacist with medication review and individualized written summary with action plan and recommendations; and Performing quarterly targeted medication reviews on an ongoing basis. Reimbursement As of the date of the printing of this Manual, ORx is solely responsible for designing, developing and implementing MTM Program-related clinical services on behalf of its clients. Therefore, there are no plans for reimbursement to health care providers at this time. Enrollment Process The MTM Program (MTMP) is offered at no cost to Members. Members who do not want to participate may opt out of the entire MTMP or its components. ORx reviews the available medical and pharmacy claims data to determine MTMP eligibility. In the absence of medical claims data, a drug proxy tool may be used for verification of diagnosis. Medicare Part D Transition Policy At the time an individual joins a Medicare Part D Plan, a new Member may be taking a medication that is either not on the Benefit Plan s Formulary or is subject to Benefit Plan requirements or restrictions. If there are no appropriate alternative therapies on the Formulary, the Member or the physician may request a Formulary exception. During this review process, the Member may be eligible to receive a temporary transition Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 42

43 supply of the medication. The maximum days supply allowed is a thirty-one (31) day supply (unless the prescription was written for fewer days) at any time during the first ninety (90) days of Membership in the Member s Medicare Part D Plan. The Benefit Plan or Sponsor provides notice to its Members who receive a transitional supply of a prescription drug. This notice is sent by U.S. mail within three (3) business days of the temporary fill. It includes: An explanation of the temporary nature of the transitional supply Instructions for working with the Benefit Plan or Sponsor and the Prescriber to identify appropriate Formulary alternatives An explanation of the Member s right to request an exception A description of the procedures for requesting an exception Network Pharmacy Providers receive electronic notice of a temporary transition fill via NCPDP 5.1 or D.0 billing transaction at the Point of Sale (POS). If the exception is approved, the Member will be able to obtain the medication for a specified period of time. After the initial temporary thirty-one (31) day transition supply, the Benefit Plan or Sponsor may not continue to pay for these medications under the transition policy. The Member should discuss appropriate alternative therapies on the Formulary with the Prescribing Physician. If there are no alternatives, the Member and physician may request a Formulary Exception. Medicare Part D Transitioning Long-Term Care (LTC) Facility Residents If the Member is a resident of a long-term care (LTC) facility, the Benefit Plan or Sponsor will also cover a temporary transition supply. The maximum days supply allowed is a thirty-one (31) day supply (unless the prescription was written for fewer days) with refills provided, and if needed, up to a ninety-three (93) day supply during the first ninety (90) days the individual is a Member of the Benefit Plan. If the Member needs a medication that is not on the Formulary or the Member s ability to get the medication is limited, but the individual has been a Member of the Benefit Plan for more than ninety (90) days, the Benefit Plan may cover a one (1) time, thirty-one (31) day supply of that medication (unless the prescription was written for fewer days) or an extension of the transition period, on a case-by-case basis, while the Member pursues a Formulary Exception. There may be unplanned transitions such as hospital discharges or level-of-care changes that occur after the first ninety (90) days that an individual is a Member of the Benefit Plan. If the Member is prescribed a drug that is not on the Formulary or the ability to get a drug is limited, the Member is required to use the Benefit Plan s Formulary Exception process. The Member may request a one (1) time emergency supply of up to thirty-one (31) days (unless the prescription is written for fewer days) to allow time to discuss alternative treatments with his or her physician or to pursue a Formulary Exception. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 43

44 Medicare Part D Sixty (60) Day Negative Formulary Change Notice Notice of Negative Formulary changes will be available online and disseminated periodically through fax broadcast (faxblast) to Network Pharmacy Providers sixty (60) days prior to the removal or adverse change in the preferred or tiered cost-sharing status of a Medicare Part D drug. In certain cases for Food and Drug Administration (FDA) market withdrawals, the notice may or may not be retrospective. The posting will include: The name of the affected covered Medicare Part D drug Information on whether the covered Medicare Part D drug is being removed from the Formulary, or adversely changing its preferred or tiered cost-sharing status The reason why the covered Medicare Part D drug is being removed from the Formulary, or changing its preferred or tiered cost-sharing status Alternative drugs in the same therapeutic category, class or cost-sharing tier, and the expected cost sharing for that drug The means by which Members may obtain an updated coverage determination or an exception to a coverage determination Affected Members will also be notified in the Explanation of Benefits (EOB) about a Formulary change sixty (60) days before it takes effect. Changes to the 2012 Medicare Part D formulary, for the following plans, will be posted on the websites listed below. (Note: This list is NOT all-inclusive but a sample ONLY, and may be amended at any time.) Websites Plans AARP MedicareComplete AARP MedicareRx Enhanced AARP MedicareRx Preferred Erickson Advantage Evercare Plan Evercare Plan IH (HMO) Evercare Senior Care Options UnitedHealthcare Personal Care Plus IBT (International Brotherhood of Teamsters) PartnersRx Fidelis PartnersRx Golden State PartnersRx PUP Select PSERS (Pennsylvania Public School Educators Retirement System) continued next page Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 44

45 Websites Plans Quality Health Plan (QHP) SecureHorizons MedicareComplete SecureHorizons MedicareDirect Plan Sierra MAPD UnitedHealthcare Community Plan (UHCCP) UnitedHealthcare Arizona Physicians IPA UnitedHealthcare Great Lakes Health Plan (GLHP) UnitedHealthcare MedicareRx Medicare Part D Annual Notice of Change for Continuing Members Each fall, Members receive a combined Annual Notice of Change (ANOC)/Evidence of Coverage (EOC) packet from their Plan Sponsor(s). Packet materials identify changes in the drug plan for the coming year. Changes explained in the packet become effective January 1 and will apply through December 31 of the upcoming plan year. A Member may notice that a Formulary medication he or she is currently taking is either not on the upcoming year s Formulary or its cost-sharing or coverage is limited in the upcoming year. In this case, the Benefit Plan or Sponsor will work to prospectively transition current Members who are affected by negative formulary changes in the new contract year. If the Member is unable to transition to another product prior to the new benefit year, the Member will be entitled to a one (1) time transition fill during the first ninety (90) days of the new benefit year. Inform Members of Advance Directives The Federal Patient Self-Determination Act (PSDA) gives individuals the legal right to make choices about their medical care in an advance directive. Under the PSDA, physicians and providers including hospitals, skilled nursing facilities, hospices, home health agencies and others must provide written information to Members on State law about advance treatment directives, about Members right to accept or refuse treatment, and about Network Pharmacy Provider s own policies regarding advance directives. To comply with this requirement, Benefit Plans or Sponsors also inform their respective Members of state laws on advance directives through Member handbooks and other communications. ORx encourages these discussions with Members presenting at a Network Pharmacy Provider for covered services. Provide Timely Notice of Demographic Changes A Network Pharmacy Provider must notify ORx of changes to demographic information that differs from the information reported with Agreement, including, but not limited to, tax identification (ID) changes, address changes, and new service locations within the timelines described in the Agreement. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 45

46 VII. Other General Terms and Conditions A. Compliance All Medicare Advantage Organizations, Part D sponsors, and Medicaid Managed Care Organizations are required to have developed a compliance plan that is based on the Federal Sentencing Guidelines and that is reasonably designed, implemented, and enforced so that it generally will be effective in preventing and detecting non-compliance with regulatory requirements, including program specific (for example Medicare Part D) requirements and preventing and detecting potential criminal or fraudulent conduct. ORx has a compliance plan in place that is in alignment with federal sentencing guidelines and that, among other things, supports the monitoring and detectection of fraud, waste or abuse within federal programs. ORx and our client Medicare Advantage Organizations, Medicare Part D Sponsors, and Medicaid Managed Care Organization Compliance Plans include the following recommended elements around which our program has been built: 1. Written Policies and Procedures: Standards of conduct to assist employees, independent contractors, and agents to comply with applicable laws, including Medicare and Medicaid. 2. Compliance Officer/Compliance Committee: Designation of a compliance officer and compliance committee. 3. Education and Training: Education and training programs for appropriate employees that include among other things, the Network Pharmacy Provider s standards of conduct and ethical and compliance expectations. 4. Effective Lines of Communication: A process to report violations of the standard of conduct. 5. Monitoring and Auditing: A system to monitor and audit activities within the Network Pharmacy Provider for compliance with applicable laws. 6. Enforcement and Discipline: A system to respond to allegations of violations of the standard of conduct and procedures to enforce appropriate disciplinary action against employees, independent contractors and agents who have violated the standards of conduct. In addition, the Network Pharmacy Provider must have a system to monitor whether employees, independent contractors and agents have been sanctioned by the Medicare or Medicaid Programs upon hire or at least monthly. Network Pharmacy Providers should be aware that ORx and/or Benefit Plan Sponsors shall not pay for drugs provided by a Network Pharmacy Provider excluded by either the United States Department of Health and Human Services (HHS) Office of Inspector General (OIG) or General Services Administration (GSA) pursuant to 42 C.F.R. (Code of Federal Regulations) Responding to Detected Offenses and Developing Corrective Action Initiatives: A system to investigate allegations of noncompliant behavior by employees, independent contractors, or agents. Sponsors, first-tier and down-stream entities (including Network Pharmacy Providers) should initiate a reasonable inquiry immediately, but no less than 2 (two) weeks from the date that a potential fraud matter Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 46

47 is identified. If upon investigation, the Network Pharmacy Provider believes that potential misconduct has occurred, the Network Pharmacy Provider should report the alleged activity to ORx through ORx Network Help Line at In addition, the Network Pharmacy Provider may report this information to any of the following: a. The Member services number identified on the back of a Member s identification card. b. The Medicare Integrity Contractor (MEDIC) at SAFERX or In addition, ORx and Benefit Plan Sponsors maintain files on Network Pharmacy Providers who have been the subject of complaints, investigations, violations and prosecutions. Upon notification of potential issues, ORx may request information regarding the corrective action initiatives implemented by the Network Pharmacy Provider to identify or prevent the identified misconduct from reoccurring. 8. Fraud, Waste and Abuse (FWA): A system to identify and prevent fraud, waste and abuse. ORx has a zero-tolerance policy on fraud, waste and abuse. The Agreement includes language to address instances of fraud, waste and abuse. ORx will administer corrective action up to and including reclaim of the overpayments associated with fraud, waste and abuse, and/or termination of the Agreement as warranted. Network Pharmacy Providers must comply with all applicable laws and rules concerning compliance with federal requirements. To obtain a copy of ORx s compliance program or Code of Conduct ( Principles of Ethics & Integrity ), please contact or your request to [email protected]. B. Fraud, Waste and Abuse (FWA) ORx appreciates the support and collaboration of our Network Pharmacy Providers to assist in efforts to combat fraud, waste and abuse occurring in Medicaid and Medicare plans, as well as other pharmacy benefits. This section is intended to provide information to the Network Pharmacy Provider on possible schemes, activities and behaviors that are examples of potential fraud, waste and abuse behavior. This is included for educational purposes only and is not an all-inclusive list. Illegal remuneration schemes: Prescriber is offered, paid, solicits, or receives unlawful remuneration to induce or reward the Prescriber to write prescriptions for drugs or products. Prescription drug switching: Drug switching involves offers of cash payments or other benefits to a Prescriber to induce the Prescriber to prescribe certain medications rather than others. Script mills: Provider writes prescriptions for drugs that are not medically necessary, often in mass quantities, and often for patients that are not his or hers. Theft of Prescriber s Drug Enforcement Administration (DEA) number or prescription pad: Prescription pads and/or DEA numbers can be stolen from Prescribers. In the context of e-prescribing, includes the theft of the provider s authentication (log in) information. Inappropriate relationships with health care provider: Potentially inappropriate relationships between pharmaceutical manufacturers and health care providers, such as switching arrangements to induce a Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 47

48 health care provider to switch the prescribed drug from a competing product; incentives offered to health care providers to prescribe medically unnecessary drugs; consulting and advisory payments, payments for detailing, business courtesies and other gratuities, educational and research funding; improper entertainment or incentives offered by sales agents. Illegal usage of free samples: Providing free samples to health care providers knowing and expecting those health care providers to bill the federal health care programs for the samples. Network Pharmacy Providers should be aware that there are schemes perpetrated by Members. The following is a sample list of some types of FWA that could be perpetrated by beneficiaries, including beneficiaries enrolled in the Medicare Part D Program: Over-utilization and drug-seeking members: The number of persons admitting to abuse of controlled substances has increased in the past decade. The abuse has risen dramatically in prescription drugs. Altered and forged prescriptions: Member alters the quantity and/or strength on a valid prescription. Pharmacy hopping and doctor shopping: Persons that visit numerous doctors to obtain prescriptions for prescription drugs and/or controlled substances and visit numerous pharmacies to facilitate the filling of excessive quantities of prescription drugs. Prescription diversion and inappropriate use: Beneficiaries obtain prescription drugs from a Network Pharmacy Provider and give or sell these medications to someone else. Also can include the inappropriate consumption or distribution of a beneficiary s medications by a caregiver or anyone else. Resale of drugs on black market: Beneficiary falsely reports loss or theft of drugs or feigns illness to obtain drugs for resale on the black market. Misrepresentation of status: A Medicare beneficiary misrepresents personal information, such as identity, eligibility or medical condition in order to illegally receive Medicare benefits. The following is a list (not all-inclusive) of types of FWA that could be perpetrated by a Network Pharmacy Provider: Billing for brand and dispensing generic medications. Over-billing of quantity prescribed and inappropriate billing of compounds. Over-billing of quantity in relation to days supply that exceeds plan maximums, or not in conformance with that prescribed. Submitting Claims for medications not rendered and/or prescribed. Use of Dummy DEA/NPI or Invalid DEA/NPI numbers to obtain a paid response. Billing for Brand with DAW 1 when a physician has not specified Do Not Substitute on the prescription, or other inappropriate use of DAW codes. Billing for larger pack sizes when one (1) smaller pack size will meet the directions of the physician and remain within the plan s maximum days supply. Billing for more fills or refills than were authorized. Prescription splitting to obtain multiple dispensing fees, etc. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 48

49 Billing for invalid prescriptions due to lack of a legal Prescriber, forgery, or false or fictitious documents. Dilution of product provided to Member/consumer. Acquisitions of prescription drugs on black market and black market sales. Collusion with Prescribing Physician and kick-back schemes. Pill shorting to Members/consumer dispensing less than quantity billed. Selling the same medication twice recycling pills. Long-term care (LTC) pharmacy billing for unused medications and not applying credit to Member. Inappropriate, inaccurate or incomplete record keeping practices related to billed prescriptions. Prospective billing. To help facilitate knowledge transfer of fraud, waste and abuse requirements, ORx, on behalf of all of its Medicare Advantage Organization and Medicare Part D Sponsor clients, has developed an annual training that will be delivered online to all of our Network Pharmacy Providers. In addition, we have developed an online attestation that allows us to demonstrate to our Sponsors that our Network Pharmacy Providers have received FWA training consistent with CMS requirements. As per CMS guidelines, each year our Network Pharmacy Providers will be asked to complete the ORx online attestation process indicating that they have received and completed with all their respective staffs, the ORx FWA training program, or an equivalent FWA training program consistent with CMS requirements. Network Pharmacy Providers must keep a copy of the annual training conducted, along with a list of all participants or recipients of FWA training for audit purposes. Upon completion of annual training requirements as outlined and required by CMS and Medicare Part D, ORx will require a copy of certification from the pharmacies indicating that they have completed a FWA training program, along with all training logs indicating Pharmacy employees who have been trained. The pharmacy will also be required to provide this documentation upon initial credentialing and upon recredentialing as completed by the ORx Pharmacy Network Credentialing team. C. Pharmacy Audits Policy Statement It is the policy of ORx to perform audits of prescription Claims billed by ORx pharmacy network. Audits may be conducted by ORx or its authorized agents by means of either desktop audit or on-site audit to review the accuracy, authenticity, and completeness of Claim submissions, as well as retention of adequate documentation and record keeping of prescribed medication submitted under ORx programs. These audits are necessary for Benefit Plans or Sponsors to comply with State and Federal requirements. ORx only has an obligation to pay clean claims and is not a guarantor of payment of claims. Therefore discrepant claims found during audit will require reimbursement to ORx. Audit recoveries will be deducted from future remittances to Pharmacy. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 49

50 Should insufficient funds be available to offset such recoveries, pharmacy will be responsible to submit payment within fifteen (15) days of demand. Purpose The purpose of the ORx policy is: A. To validate any and/or all of the following: 1. Accuracy of paid Claims, contractual compliance, regulatory compliance, various aspects of medication inventories, presence of required signage and/or documentation, and/or B. To observe any and/or all of the following: 1. Overall facility operations and conditions, and/or C. To monitor for, detect, and prevent FWA activities, or transaction submission errors in the billing of prescription Claims. Network Pharmacy Providers are also expected to comply with State and Federal requirements including access to records, documentation and record retention, chargeback and audit policies. Procedures for Policy Compliance Pharmacy will be given two (2) weeks advance written notification of a pending audit. Auditor staff will call pharmacy to confirm a date and a time. Network Pharmacy Provider will be contacted two (2) days prior to on-site audit with written or oral confirmation of date and time. Auditors must be given full access to the books, records, files, lists, signature logs and documentation associated with ORx Claims submitted by the Network Pharmacy Provider. A denial of this request will be determined to be denial of access. Auditor must be given a safe work space with a sufficient work surface that has adequate lighting and access to an electrical outlet within the confines of the pharmacy. Auditor reserves the right to request copies of original purchase invoices for medications associated with the submitted Claims. A summary statement of purchases by NDC for the date range requested will be accepted when provided direct to ORx by the distributor. A denial of this request will be determined to be denial of access. Auditor reserves the right for an extension of the original desk audit or on-site audit. A denial of this request will be determined to be denial of access. Auditors must witness the physical extraction of original records from the Network Pharmacy Provider archives. A denial of this request will be determined to be a denial of access. A denial of access is determined to be a breach of the audit provisions of the Agreement. The Network Pharmacy Provider may be subject to immediate suspension or termination for non-compliance. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 50

51 Auditor may inspect books, records, files, lists, signature logs and documentation pertaining to the provision of Covered Prescription Services during the term of the Agreement and for a period of two (2) years subsequent to the termination of the Agreement. Network Pharmacy Provider must retain an original document of record in its archives as required under State and Federal law and for a period of no less than five (5) years from the date of the applicable transaction, and ten (10) years in the case of Medicare Part D records. Original document of record is defined as an original prescription order from a licensed prescriber, or duly authorized health care professional, executed as required under State and Federal laws, a fully compliant fax order, or fully compliant phone-in order slip reduced to writing and noting the date and time of the phone order and the name of the individual authorizing the medication, or a fully compliant e-prescription. Each document as listed above is to be filed as an original document in the archives of the Network Pharmacy Provider, to be retrieved for inspection at the request for audit by auditor. An original or digital image of the signature log will be accepted as audit evidence for receipt of goods. The Network Pharmacy Provider will receive a full written disclosure of formal audit findings subsequent to the field work. The Network Pharmacy Provider will be given thirty (30) days from the date of the mailed audit results letter to submit any and all appeal documentation for any discrepancy identified in the audit. Such documentation must be sent via certified mail or other method that evidences tracking such as FedEx, etc. to the attention of the ORx Network Audit Manager or as otherwise instructed in the audit results letter. Upon reasonable request, an extension to submit an appeal may be granted at ORx s sole discretion. Receipt of such an extension request must be received within the required thirty (30) days or as otherwise instructed in the audit results letter. The Network Pharmacy Provider will receive a chargeback on their next remittance statement for any discrepancies found during the audit. Payments to ORx are only necessary if the Network Pharmacy Provider is no longer operating, if there is no current Pharmacy Network Agreement in effect, or if insufficient payment activity is available to offset the chargebacks. ORx at its sole discretion may elect to notify a Pharmacy Services Administrative Organization (PSAO) of any significant audit findings, if the pharmacy in question is affiliated with a PSAO. Network Pharmacy Provider is required to answer reasonable telephone inquiries by the audit department, as determined solely by ORx, to validate a Member being billed, prescription directions, compounding ingredients, quantities being dispensed, etc. All in-depth audits will be directed by written correspondence. Where billing agents are utilized by a Network Pharmacy Provider, ORx may coordinate audits with the billing agent, but Network Pharmacy Provider remains responsible for all billing outcomes, verification and validation. Network audits may be performed by ORx staff, or by an agent solely authorized by ORx. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 51

52 In situations where cumulative errors rise to the level of negligence, fraud, waste or abuse, as determined solely by ORx, ORx reserves the right to extrapolate audit sample exceptions against the entire population under audit. The following is a partial list of audit violations that could be perpetrated by a Network Pharmacy Provider resulting in Claims being reversed in total and no reimbursement will be forthcoming for what was actually dispensed. In addition, legal or other action may be taken against the Network Pharmacy Provider, including immediate termination from the Network: Billing for brand and dispensing generic medications. Over-billing of quantity prescribed. Inappropriate billing of compounds. Submitting Claims for medications not rendered and/or prescribed. Use of Dummy DEA/NPI or Invalid DEA/NPI numbers to obtain a paid response. Billing for Brand with DAW 1 when a physician has not specified Do Not Substitute on the prescription, or other inappropriate use of DAW codes. Billing for more fills or refills than were authorized. Billing for invalid prescriptions due to lack of a legal prescriber, forgery, or false or fictitious documents. Prescriptions mis-filled based on original order. Billing under the wrong physician. Refills too soon that were paid due to a prior day s supply violation. Inability to locate the original prescription (missing). Prescriptions lacking sufficient proof of delivery to Member. Long-term care pharmacy billing for unused medications and not applying credit to Member. Inappropriate, inaccurate or incomplete record keeping practices related to billed prescriptions. The following is a partial list of audit violations that could be perpetrated by a Network Pharmacy Provider resulting in Claims being recovered in total and no reimbursement will be forthcoming for what was actually dispensed. In addition, legal or other action may be taken against the Network Pharmacy Provider, including immediate termination from the Network: Over-billing of quantity in relation to day s supply that exceeds plan maximums, or not in conformance with that prescribed. Billing for larger pack sizes when one (1) smaller pack size will meet the directions of the physician and remain within the plan s maximum day s supply. Prescription splitting to obtain multiple dispensing fees, etc. Billing multiple lower strengths when one (1) higher strength medication prescribed. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 52

53 Again, the above is only a partial listing of sample audit violations. ORx reserves the right to assess a penalty equal to the entire amount of the Claim (including copay) for each violation in addition to the prescription value or difference in billing being recovered. Material repetition or pattern of practice of any given category of audit violation or the material combination of different categories of violations discovered during an audit may subject Network Pharmacy Provider to termination. Instances of FWA discovered during audit shall subject Network Pharmacy Provider to immediate termination. Any Network Pharmacy Provider terminated from ORx network(s) for reason(s) other than fraud, must wait a minimum of three (3) years from date of effective termination before applying for reconsideration regarding network participation. D. Credentialing Network Pharmacy Providers and Pharmacists shall be credentialed pursuant to the ORx credentialing policy prior to submitting any Claims. Network Pharmacy Providers shall complete and submit to ORx a Credentialing Form, a copy of which is attached as Exhibit C. Network Pharmacy Providers and their Pharmacists have the following rights regarding the credentialing process: To request previous submissions supporting the credentialing application; To correct erroneous information; and To be informed of the status of the Network Pharmacy Provider credentialing or re-credentialing application, upon request. Pharmacy Providers requesting mail service and/or specialty network access must be certified with both Verified Internet Pharmacy Practice Sites (VIPPS) and URAC (formerly Utilization Accreditation Commission). Additional information regarding these organizations and criteria for certification may be found at the following websites: VIPPS: URAC: In addition to credentialing, Federal regulations prohibit providers, individuals or entities that have been excluded from Federal program participation as evidenced by listing in the HHS OIG or GSA Excluded and Sanctioned Providers listings. Pharmacies must check these lists upon hire and at least monthly to ensure employees working with Medicare business have not been excluded from Federal program participation. Pharmacy staff can check these lists by using the following links: OIG: GSA: Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 53

54 E. Confidentiality and Proprietary Rights Network Pharmacy Providers agree to keep confidential and proprietary the following: Terms of the Agreement and documentation related to the performance of the Agreement, including, and without limitation, the drug Formulary and Maximum Allowable Cost (MAC) list; Methods of doing business, including the operations of the National Pharmacy & Therapeutics (P&T) Committee and ORx s utilization review and quality assurance procedures and programs; and Any and all symbols, logos, trademarks, trade names, service marks, patents, inventions, copyrights, copyrightable material, trade secrets, personnel information, operating manuals, memoranda, work marketing programs, plans and strategies, operating agreements, financial information and strategies, and computer software and other computer-related materials developed or used in ORx s business. F. Involuntary Disenrollment by Benefit Plan or Sponsor Network Pharmacy Provider shall cooperate with ORx and its Clients in gathering and/or providing information on Members for which the Benefit Plan or Sponsor is seeking involuntary disenrollment for conduct considered abusive and disruptive to the point where service is disrupted for the Member or other Members. If Network Pharmacy Providers encounter abusive and disruptive Members, they should call the ORx Customer Service Department. As a Network Pharmacy Provider, ORx encourages that you keep notes and any documentation concerning abusive and disruptive contact as you may be asked to provide this information at the time you report abusive and disruptive Members. G. State Medicaid Requirements Particular states have certain Medicaid regulatory requirements, including specific provisions to be included in all Client subcontractor agreements ( State Medicaid Regulatory Requirements ). Such State Medicaid Regulatory Requirements are contained in the state specific appendix, which is attached as Exhibit D ( State Appendix ). Pursuant to the terms of the Agreement, Network Pharmacy Provider shall comply with all applicable requirements in each applicable State Appendix, as determined solely by ORx. H. Definitions The following terms are used throughout this document and are derived from Network Provider Agreements, CMS regulations and other program documents: Abuse: Abuse generally refers to practices that while not generally considered fraudulent, and which do not involve knowing misrepresentation of facts, are inconsistent with accepted and sound medical, fiscal or business practice. These practices may directly or indirectly result in unnecessary costs to an insurance program, improper payment, or payment for services that fail to meet professional standards of care or are medically unnecessary. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 54

55 AWP: Average Wholesale Price or AWP shall mean the average wholesale price of a Covered Prescription Service based on the Medi-Span Prescription Pricing Guide (with supplements) or any other nationally recognized pricing source selected by Administrator (the Pricing Source ), as updated at least monthly. For prescription drug products dispensed somewhere other than a mail service pharmacy, AWP is based on the individual units dispensed or smallest package size available (e.g., per vial, per suppository, etc.). For prescription drugs dispensed by Administrator s mail service pharmacy, AWP is based on a package size of one hundred (100) units for pills, capsules and tablets and four hundred eighty (480) ML quantities for liquids (or the next closest package size if such quantities or sizes are not available). Benefit Plan: The benefit provided to Members, including under any Medicaid, Medicare Advantage Prescription Drug (MAPD) Plan or Prescription Drug Plan (PDP). Benefit Plan coverage shall include, without limitation, any deductible or coverage gap provided for under such coverage, without regard to any subsidy by any third party of a Member s cost sharing obligations under the applicable Benefit Plan. Benefit Plan Sponsor or Plan Sponsor: The entity that is sponsoring a Benefit Plan. Brand Name Drug: A drug marketed under a proprietary and trademark-protected name. Claim: A Pharmacy s billing or invoice for a single prescription for Covered Prescription Services dispensed to a Member. Clean Claim: A Claim, prepared in accordance with the standard format promulgated by the National Council for Prescription Drug Programs (NCPDP), which contains all of the information necessary for processing (including, without limitation, the Member identification number, the Member s name and date of birth, Prescription Drug Product NDC number, drug quantity, days supply, correct health care provider Drug Enforcement Agency (DEA)/National Provider Identifier (NPI) number, NPI number, date of service, submitted cost amount and the usual and customary charge (U&C)). Client: Any person or entity which has entered into, or in the future enters into, a written agreement with Administrator pursuant to which Administrator provides certain consultative, administrative, and/or Claims processing services in connection with the operation of one or more Benefit Plans sponsored, issued or administered by such person or entity and/or that person s or entity s customer. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 55

56 Drug Product: The Brand Name Drug or Generic Drug which is (i) required under applicable laws and regulations to be dispensed only pursuant to a prescription and (ii) is approved by the FDA. Financial Institution: The financial institution used by Network Pharmacy Providers. Formulary: The entire list of Drug Products, devices, products and/or supplies covered by the applicable Benefit Plan. Fraud: An intentional deception or misrepresentation made by an individual or entity that the person or entity knows to be false or does not believe to be true, knowing that the deception could result in some unauthorized benefit to himself or some other person. Generic Drug: A drug product, whether identified by its chemical, proprietary or non-proprietary name, that is accepted by the FDA as therapeutically equivalent to an originator Drug Product. Medicare Drug Prescription Plan Member: See Member. Medicare Prescription Drug Plan: The CMS-approved Medicare Part D prescription drug coverage offered under a policy, contract or plan that is sponsored, issued or administered by Clients pursuant to a contract with CMS, as defined in 42 C.F.R , and includes, but is not limited to, any CMS demonstration programs that provide prescription drug benefits. For purposes of this Agreement, Prescription Drug Plan or PDP Plan also includes any employer-sponsored group prescription drug plans, as defined in 42 C.F.R Member: An individual who is eligible and enrolled to receive coverage through a Benefit Plan from a Client for Covered Prescription Services. Network Pharmacy Provider: The entity that is contracted with ORx or indirectly contracted through a Pharmacy Services Administration Organization (PSAO) to provide covered prescriptions to ORx Clients. Pharmacist: An individual appropriately licensed in their respective States to dispense medications to Members of those States. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 56

57 Prescriber: An individual appropriately licensed in their respective States to write prescriptions for Members. Prescribing Physician: An individual appropriately licensed in their respective States as a physician. Sponsor: The sponsor of a Benefit Plan. WAC: Wholesale Acquisition Cost or WAC shall mean the average wholesaler acquisition cost of a Covered Prescription Service based on the Medi-Span Prescription Pricing Guide (with supplements) or any other nationally recognized pricing source selected by Administrator (the Pricing Source ), as updated at least monthly. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 57

58 Exhibit A NCPDP 5.1 or D.0 Submission Template General Information Payer Name: Prescription Solutions by OptumRx (ORx) Benefit Plan Name/Group Name: All Benefit Plans and Groups Administered by Prescription Solutions by OptumRx (ORx) Processor: Prescription Solutions by OptumRx (ORx) Switch NDC-Envoy/WebMD Effective: (To be provided) Version/Release: NCPDP or D.0 Contract/Information Source (Provider contracts): Certification Testing Windows: Certification Not Required Pharmacy Claims/Eligibility Help Desk Information: Other versions supported: NCPDP Version 3.2 until October 16, 2003 TRANSACTIONS SUPPORTED: B1 Billing Format Claims 1-4 B2 Reversal Request 1 Claim only B3 Rebilling (1 Reversal, 1 Billing only) Date: Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 58

59 Billing Transaction: Segments The following lists the segments available in a Billing Transaction. The document also lists values as defined under Version 5.1. The Transaction Header segment is mandatory. The Segment Summaries included below list the mandatory data fields. See Template comments for mandatory or optional field requirements. Fields designed as Mandatory (M) are in accordance with the NCPDP Telecommunication Implementation Guide Version 5.1 or D.O and are the only fields designated mandatory. Fields designated as Required (R) must always be sent. Transaction Header Segment: Mandatory in All Cases VALUE COMMENTS 101-A1 BIN NUMBER M A2 Version/Release# 51 M Valid only for Version A3 Transaction Code M Billing format 104-A4 Processor Control Number (4 digits) M All production Claims use Test Claims may have other values greater than four (4) digits. 109-A9 Transaction Count A number between 1-4 M A number between one (1) and four (4) specifies the number of transactions. 202-B2 Service Provider ID Qualifier 01 or 07 M The NPI, ten (10) digits, will be accepted if the service provider NPI is on file. Confirm with the ORx Pharmacy Network Contracting Team before using. NPI qualifier 01 is required. 201-B1 Service Provider ID Number or M The NPI, ten (10) digits, will be accepted. 401-D1 Date of Service M Date on which the product or service was provided format CCYYMMDD. 110-AK Software Vendor/Certified Not used at this time. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 59

60 Insurance Segment: Mandatory on All Claims VALUE COMMENTS 111-AM Segment Identification 04 M Insurance Segment. 302-C2 Cardholder ID Value M Number taken from patient insurance card. 312-CC Cardholder Last Name Value Req Last name of cardholder/patient from ID card. 313-CD Cardholder First Name Value Req First name of cardholder/patient from ID card. 301-C1 Group ID Number Value S Required for payment when submitting with a PCN of C3 Person Code Value S To be used when included on ID card. 306-C6 Patient Relationship Code Value S Required when person code is not used, or when ID card instructions require it to be included. Patient Segment: Required VALUE COMMENTS 111-AM Segment ID 01 M 331-CX Patient ID Qualifier 99 Req Required for all Claims 332-CY Patient ID Value Req Number taken from Member ID card Required. 304-C4 Patient Date of Birth CCYYMMDD Req Required for all Claims 305-C5 Patient Gender Code M or F Req Required for all Claims 310-CA Patient First Name Value S Required when patient is not cardholder 311-CB Patient Last Name Value S Required when patient is not cardholder Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 60

61 Claims Segment: Mandatory Explanation: ORx prefers that Network Pharmacy Providers use the bill/rebill process for partial transactions. Bill the Claim originally for the initial dispensed amount (partial). Then when the prescription Claim is completed, reverse the original and rebill for the final quantity. VALUE COMMENTS 111-AM Segment ID 07 M 455-EM Rx/Service Reference 01 M Rx Billing only allowed at this time. Number Qualifier 402-De Rx/Service Reference Value M Prescription Number, seven (7) digits. 436-E1 Drug Product/Service 03 M NDC only until notified otherwise. ID Qualifier 407-D7 Drug Product/Service ID Value M Use only the eleven (11) digit format. 442-E7 Quantity Dispensed Value S Required for payment. 403-DS Fill Number Value S Required for payment. 405-D5 Days Supplied Value S Required for payment. 406-D6 Compound Code Value M 1=Not a compound 2=Compound 408-D8 PSC Value Opt 414-DE Date Rx Written Value Opt 415-DF Number of Refills Authorized Value Opt 419-DJ Rx Origin Code Value Opt 460-ET Quantity Prescribed Value Opt 429-DT Unit Dose Indicator Value Opt 343-HD Dispensing Status Value Req Blank=Filled Rx P=Partial Fill C=Completion of Partial Fill 308-C8 Other Coverage Code 0 or 1 S Use zero (0) or one (01) if billing a primary Claim. 2 or 3 Use two (02) or three (03) if billing a secondary Claim. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 61

62 Pharmacy Provider Segment: Optional VALUE 111-AM Segment ID 02 M COMMENTS Prescriber Segment: Required VALUE 111-AM Segment ID 03 M 466-E2 Prescriber ID Qualifier 12 or 08 M 01 COMMENTS DEA or NPI, ten (10) digit, used at this time. State licenses valid from selected states. 411-DB Prescriber ID Value Req Required for payment. NPI, ten (10) digit, will be accepted if prescriber NPI is on file with ORx. 427-DR Prescriber Last Name Value Opt COB/Other Payments Segment: Required when billing secondary coverage. VALUE COMMENTS 111-AM Segment ID Value M Required for payment C Coordination of Benefits/ Value M Required for payment. Other Payments Count 338-5C Other Payer Coverage Type 01 M***R*** 339-6C Other Payer ID Qualifier 01, 02, or 03 S***R*** If used, only one (01), two (02) or three (03) are accepted C Other Payer ID S***R*** Use appropriate ID - generally the other payer Bank Identification Number (BIN) number. 443-E8 Other Payer Date S***R*** 341-HB Other Payer Amount 1, 2 M Use only one (01) or two (02). Paid Count 342-HC Other Payer Amount 07, 08 M Use only seven (07) or (08). Paid Qualifier 431-DV Other Payer Amount Paid M Submit zero dollars ($0.00) if no primary payment was allowed E Other Payer Reject Count O Not used 472-5E Other Payer Reject Code O***R*** Not used DUR/PPS Segment: Not Used. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 62

63 Pricing Segment: Mandatory VALUE 111-AM Segment ID 11 M COMMENTS 409-D9 Ingredient Cost Submitted Value S Required for payment. 412-DC Dispensing Fee Submitted Value S Required for payment. 433-DX Patient Pay Amount Submitted Value S Required for payment. 477-BE Professional Service Fee Submitted Value Opt Not used at this time. 438-E3 Incentive Amount Submitted Value Opt Not used at this time. 478-H7 Other Amount Claimed Count Opt Submit only one (1) other amount claimed if applicable. Value=1 479-H8 Other Amount Claimed Qualifier 04 Opt Only Administrative costs allowed. 480-H9 Other Amount Claimed Submitted Value Opt Use only if requested by processor. 481-HA Flat Sales Tax Amount Submitted Value Opt Do not use if percentage tax (482) is submitted. 482-GE Percentage Sales Tax Amount Submitted Value Opt Do not use if flat tax (481) is submitted. 426-DQ Usual and Customary Charge Value S Required for payment. 430-DU Gross Amount Due Value S Required for payment. Coupon Segment: Not Used. Compound Segment: Not Used. Prior Authorization Segment: Not Used. Clinical Segment: Optional VALUE COMMENTS 111-AM Segment ID M 491-UE Diagnosis Code Count Value Opt 422-WE Diagnosis Code Qualifier 01 Opt ICD-9 only allowed. 424-DO Diagnosis Code Value Opt ICD-9 value if used. All Claims rejects will be identified using the standard NCPDP 5.1 or D.0 Error Codes. Additional descriptive text messages may accompany the reject code. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 63

64 Exhibit B Pharmacy Electronic Funds Transfer (EFT) Please click the form below for a printable version. Form is also available at the following PHARMACY ELECTRONIC FUNDS TRANSFER (EFT) ENROLLMENT FORM Prescription Solutions is improving service to you by offering electronic payments to contracted pharmacies. Use this form to enroll today! In order to sign up for this service, you must be able to accept HIPAA compliant 835 remittance advice electronically. Please note: you are not eligible for EFT if you are receiving your payments through a Pharmacy Services Administrative Organization (PSAO). PSAOs are eligible to receive EFT. After completing the enrollment form, please fax or mail to: Prescription Solutions PO Box 6104 Cypress, CA, Fax:(800) Enrollments are processed within 4 weeks of receipt. Please complete the following information: (all form fields required) ACKNOWLEDGEMENTS I acknowledge that I am required to receive electronic delivery of 835 remittance advice and will no longer receive paper remittance advice. I acknowledge that the pharmacy I am enrolling is not a member of a PSAO. I am authorized to complete the form for this pharmacy. ORGANIZATION INFORMATION Tax ID Number: NCPDP, NPI or Chain ID Number: Organization Name: Address: City: State: Zip Code: PRIMARY CONTACT INFORMATION First Name: Last Name: Title: Phone Number: Fax Number: Address: Password: DESIGNATION OF DEPOSITORY Bank Name: Account Name: Bank Contact Name: Bank Contact Phone Number: Bank Address: City: State: Zip Code: Checking Account Number: Routing Transit Number (RTN): Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 64

65 Exhibit C Network Pharmacy Provider Credentials (Please click the image below for a printable version you can fill out. *FORM MUST BE FILLED OUT COMPLETELY*) For Chain Pharmacies/PSAOs/GPOs Affiliation Credentialing Application Section A: Affiliation Information (DBA Name): Corporate Name: Other than the current name listed above, has pharmacy operated under any other trade or business name? Yes No If Yes, please provide details and name[s]: Street Address: City: State: Zip: Phone #: Fax #: State Tax ID: Website Address: Federal Tax ID: Affiliation Code(s) #: Pharmacy Help Desk #: Affiliation Type: Chain PSAO Franchise Combo Affiliation-owned/Franchise/PSAO Operate under a common d/b/a or banner name? Yes No If Yes, please provide details and name[s]: If a PSAO or Franchise, please provide a copy of the template agreement that Pharmacies must execute to join your organization. Payment Type: Source of Payment Check EFT * For EFT set-up, please complete the information located on our website at Payment Mailing Address (This address will also be used as the pharmacy s payment address) If mailing address is the same as the Affiliation corporate address, check here: Address: City: State: Zip: Phone #: Fax #: Does your Affiliation currently use a third party reconciliation service? Yes No If so, who? Pharmacy Notification/Communications Contact Information Send /Fax communications: Send directly to Pharmacy Chain/PSAO to distribute to Pharmacies If to chain/psao, send to: Fax #: Credentialing Application Chains/PSAOs 1 Rev. 8/22/11 Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 65

66 For Independent Pharmacies ***** Attention****** Credentialing Information Required: Contract cannot be implemented without the following documentation: Copies of the Original Following Licenses: Pharmacy License - Not to expire within 30 days Pharmacist in Charge License - Not to expire within 30 days DEA - Valid DEA Copies of the following: Wholesaler Invoice - Must include DEA and/or State Lic Number & legend drug on order Insurance Coverage Minimum 1million occurrence/ 3million annual aggregate - Valid Insurance Processing Time: The processing of the contract documents and implementation of the agreement may take up to 15 business days to complete once received. Delays will occur if contract documents are not completed and/or required credentialing information is not supplied. The processing time is subject to change without notice. Please contact the Prescription Solutions Pharmacy Contracting Dept. at option 3 should you have any questions. Thank you, Prescription Solutions Pharmacy Contracting Department Credentialing Attention Rev. 8/4/11 Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 66

67 Exhibit D State Medicaid Regulatory Requirements The following State Appendices set forth certain State Medicaid Regulatory Requirements that Network Pharmacy Providers shall comply with in their respective states, as applicable. State with linked documents denoted in bold. 1. Alabama (AL) Medicaid regulatory requirements. 2. Alaska (AK) Medicaid regulatory requirements. 3. Arizona (AZ) Medicaid regulatory requirements: a. Medicaid Regulatory Requirements b. Children s Rehabilitative Services Appendix A-2 c. Minimum Subcontract Provisions d. Evercare Select 4. Arkansas (AR) Medicaid regulatory requirements. 5. California (CA) Medicaid regulatory requirements. 6. Colorado (CO) Medicaid regulatory requirements. 7. Connecticut (CT) Medicaid regulatory requirements. 8. Delaware (DE) Medicaid regulatory requirements. 9. District of Columbia (DC) Medicaid regulatory requirements: a. Medicaid Regulatory Requirements b. Medical Subcontractor c. Appendix - Unison and/or UnitedHealth Network UHN Provider 10. Florida (FL) Medicaid regulatory requirements: a. Medicaid Regulatory Requirements b. Medicaid Regulatory Requirements Appendix Subcontractor version 11. Georgia (GA) Medicaid regulatory requirements. 12. Hawaii (HI) Medicaid regulatory requirements: a. Subcontractor 13. Idaho (ID) Medicaid regulatory requirements. 14. Illinois (IL) Medicaid regulatory requirements. 15. Indiana (IN) Medicaid regulatory requirements. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 67

68 16. Iowa (IA) Medicaid regulatory requirements (hawk-i): a. Iowa hawk-i Program Regulatory Requirements Appendix - Medical Subcontractor 17. Kansas (KS) Medicaid regulatory requirements. 18. Kentucky (KY) Medicaid regulatory requirements. 19. Louisiana (LA) Medicaid regulatory requirements. 20. Maine (ME) Medicaid regulatory requirements. 21. Maryland (MD) Medicaid regulatory requirements: a. Medicaid Regulatory Requirements 22. Massachusetts (MA) Medicaid regulatory requirements: a. MassHealth Senior Care 23. Michigan (MI) Medicaid regulatory requirements: a. Subcontractor 24. Minnesota (MN) Medicaid regulatory requirements. 25. Mississippi (MS) Medicaid regulatory requirements: a. Medicaid Regulatory Requirements b. CHIP Program c. Regulatory Requirements Appendix - Medical Subcontractor 26. Missouri (MO) Medicaid regulatory requirements. 27. Montana (MT) Medicaid regulatory requirements. 28. Nebraska (NE) Medicaid regulatory requirements: a. Nebraska Medicaid Regulatory Requirements Appendix b. AMC Medical Contractor 29. Nevada (NV) Medicaid regulatory requirements. 30. New Hampshire (NH) Medicaid regulatory requirements. 31. New Jersey (NJ) Medicaid regulatory requirements. 32. New Mexico (NM) Medicaid regulatory requirements: a. Medicaid Regulatory Requirements b. NM Medicaid Fill Time Survey c. Medicaid Pharmacy Dispensing Fees Pursuant to New Mexico Statute Section , all Company Pharmacies within the state of New Mexico dispensing Prescription Drug Services to New Mexico Medicaid Members will receive a dispensing fee of at least $3.65 per Prescription Drug Service when drug product selection is permitted by a pharmacist in accordance with New Mexico Statute Section (i.e., lower cost therapeutically-equivalent or multi-source drug is available). Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 68

69 d. Generic Substitution Form e. CLTS 33. New York (NY) Medicaid regulatory requirements: a. Medicaid Regulatory Requirements b. Medicaid Pharmacy Dispensing Fees For purposes of doing business in New York, the Prescription Drug Services Agreement, as amended, ( Agreement ) with Prescriptions Solutions, Inc. is contracted through RxSolutions NY IPA, Inc. 34. North Carolina (NC) Medicaid regulatory requirements. 35. North Dakota (ND) Medicaid regulatory requirements. 36. Ohio (OH) Medicaid regulatory requirements. 37. Oklahoma (OK) Medicaid regulatory requirements. 38. Oregon (OR) Medicaid regulatory requirements. 39. Pennsylvania (PA) Medicaid regulatory requirements: a. Medicaid Regulatory Requirements b. Government-Sponsored Programs Addendums c. CHIP 40. Rhode Island (RI) Medicaid regulatory requirements: a. Medicaid Regulatory Requirements 41. South Carolina (SC) Medicaid regulatory requirements: a. Medicaid Regulatory Requirements b. Medicaid MCO Program and Healthy Connections Kids Program 42. South Dakota (SD) Medicaid regulatory requirements. 43. Tennessee (TN) Medicaid regulatory requirements. 44. Texas (TX) Medicaid regulatory requirements. 45. Utah (UT) Medicaid regulatory requirements. 46. Vermont (VT) Medicaid regulatory requirements. 47. Virginia (VA) Medicaid regulatory requirements. 48. Washington (WA) Medicaid regulatory requirements. 49. West Virginia (WV) Medicaid regulatory requirements. 50. Wisconsin (WI) Medicaid regulatory requirements. 51. Wyoming (WY) Medicaid regulatory requirements. Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 69

70 Exhibit E NCPDP Submission Clarification Code 420-DK Submission Clarification Code Definition of Field Code indicating that the pharmacist is clarifying the submission Values: Field Format 9(2) T, P, A Standard/Version Formats Field Limitations Code Description 0 Not Specified, Default 1 No Override 2 Other Override 3 Vacation Supply - The pharmacist is indicating that the cardholder has requested a vacation supply of the medicine 4 Lost Prescription - The pharmacist is indicating that the cardholder has requested replacement of medication that has become lost 5 Therapy Change - The pharmacist is indicating that the physician has determined that a change in therapy was required; either that the medication was used faster than expected, or a different dosage form is needed, etc. 6 Starter Dose - The pharmacist is indicating that the previous medication was a starter dose and now additional medication is needed to continue treatment. 7 Medically Necessary - The pharmacist is indicating that this medication has been determined by the physician to be medically necessary. 8 Process Compound for Approved Ingredients 9 Encounters 10 Meets Plan Limitations - The pharmacy certifies that the transaction is in compliance with the program s policies and rules that are specific to the particular product being billed. 11 Certification on File - The supplier s guarantee that a copy of the paper certification, signed and dated by the physician, is on file at the supplier s office. 12 DME Replacement Indicator - Indicator that this certification for a DME item replacing a previously purchased DME item. 13 Payer-Recognized Emergency/Disaster Assistance Request - The pharmacist is indicating that an override is needed based on an emergency/disaster situation recognized by the payer. continued next page Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 70

71 Code Description 14 Long Term Care Leave of Absence - The pharmacist is indicating that the cardholder requires a short-fill of a prescription due to a leave of absence from the Long Term Care (LTC) facility. 15 Long Term Care Replacement Medication - Medication has been contaminated during administration in a Long Term Care setting. 16 Long Term Care Emergency Box (kit) or automated dispensing machine - Indicates that the transaction is a replacement supply for doses previously dispensed to the patient after hours. 17 Long Term Care Emergency supply remainder - Indicates that the transaction is for the remainder of the drug originally begun from an Emergency Kit. 18 Long Term Care Patient Admit/Readmit Indicator - Indicates that the transaction is for a new dispensing of medication due to the patient s admission or readmission status. 99 Other Prescription Solutions by OptumRx Pharmacy Manual: 5th Edition 71