Issues for Part D Compliance
|
|
- Alyson Blanche Tate
- 6 years ago
- Views:
Transcription
1 HCCA- MEDICARE PRESCRIPTION DRUG PART D COMPLIANCE CONFERENCE Issues for Part D Compliance Craig Miner, RPh, JD Division of Drug Plan Policy Babette S. Edgar, Pharm.D., MBA Division of Finance and Operations
2 Topics Part D Drugs Exclusions The Formulary Review Process The Formulary Maintenance Process 2
3 Part D Drugs 3
4 What is a Part D Drug? ( ) Rx Only Drugs approved by FDA for safety and efficacy as described in 1927(k)(2) Biologicals as described in 1927(k)(2) Insulin and medical supplies associated with the injection of insulin Vaccines Used for Medically Accepted Indications 4
5 Medically Accepted Indications FDA Approved or Off-Label if supported by citation in either: AHFS USP-DI, or DRUGDEX 5
6 Exclusions 6
7 Exclusions Drugs or classes of drugs, or their medical uses, which may be excluded under 1927(d)(2) (except smoking cessation agents) Any drug for which, as prescribed and dispensed or administered to an individual, payment would be available under Medicare part A or part B for that individual 7
8 1927(d)(2) Exclusions Agents when used for anorexia, weight loss, or weight gain; Agents when used for cosmetic purposes/hair growth; Agents when used for symptomatic relief of cough & colds; Prescription vitamins & mineral products (except prenatal vitamins & fluoride preparations); Nonprescription drugs; Covered outpatient drugs when manufacturer seeks to require associated tests or monitoring as a condition of sale; Barbiturates; Benzodiazepines 8
9 1927(d)(2) Exclusions and Combination Products Commercially Available--Products that contain at least one Part D drug component are part D drugs when used for a "medically accepted" indication, unless CMS makes a determination that such product, as a whole, belongs in one of the categories of drugs excluded from coverage under Part D Extemporaneously Compounded--Only Part D components are Part D drugs 9
10 1927(d)(2) Exclusions State Medicaid Programs my continue to provide coverage and receive Federal Match Part D plans may provide supplemental coverage for excluded drugs (except OTCs) not subsidized by CMS 10
11 Medicare Parts A and B Medicare Part A (Hospital Insurance) Inpatient hospital, hospice, home health, SNF coverage Medicare Part B (Supplemental Medical Insurance) Physician and hospital outpatient services, some drugs and biologics, DME, glucose test strips, other medical services 11
12 Exclusions based upon Medicare Part B Coverage Drugs furnished incident to a physician s service Separately billable ESRD drugs (EPO) Durable Medical Equipment Supply drugs Drugs covered as supplies integral to a diagnostic or therapeutic service Drugs used in immunosuppressive therapy Certain Vaccines Parenteral Nutrition Oral Cancer Drugs Clotting Factors Antigens IVIG 12
13 Formulary Review 13
14 Pharmacy & Therapeutics Committee Requirements What is a P&T committee? All formularies must be developed and revised by a P&T committee Membership of the committee - Majority of members who are practicing physicians and/or practicing pharmacists - At least one practicing physician and at least one practicing pharmacist who are independent and free of conflict relative to sponsor, plan, pharmaceutical manufacturers - At least one practicing physician and one practicing pharmacist who are experts regarding care of elderly or disabled individuals 14
15 Formulary Review: Rationale MMA requires CMS to review Part D formularies to ensure: beneficiaries have access to a broad range of medically appropriate drugs to treat all disease states formulary design does not discriminate or substantially discourage enrollment of certain groups 15
16 Guiding Principles for Formulary Review Relying on Existing Best Practices Provide Access to Medically Necessary Drugs Flexibility Administrative Efficiency 16
17 Formulary Review: Approach Ensure the inclusion of a broad distribution of therapeutic categories and classes Utilize reasonable benchmarks to check that drug lists are robust Review tiering and utilization management strategies Identify potential outliers at each review step for further CMS investigation Obtain reasonable clinical justification when outliers appear to create access problems 17
18 Formulary Review Checks Review of USP Categories and Classes Comparison to AHFS Categories and Classes Two Drugs per Category and Class USP Formulary Key Drug Types Tier Placement Widely Accepted Treatment Guidelines Therapeutic Categories or Pharmacologic Classes Requiring Uninterrupted Access Common Drugs for Medicare Population Quantity Limit Review Prior Authorization Review Step Therapy Review Insulin Supplies and Vaccines Review Long-Term Care Accessibility Review 18
19 Review of Categories and Classes USP categories and classes will satisfy a safe harbor. Available at: mg/finalmodelguidelines pdf Alternative classification structures will be compared to USP and other commonly used classification systems (AHFS or other) Two drugs in each category/class 19
20 USP Formulary Key Drug Types Review drug list for inclusion of at least one drug in each of the Formulary Key Drug Types identified by USP. Available at: Third column in USP document Most best practice formularies contain one or more of these agents 20
21 Tier Placement Review tier placement of drugs to ensure that access is not discriminatory Looking for at least one drug to be placed in a lower tier for each drug class Specialty tier is exempt from this requirement 21
22 Widely Accepted Treatment Guidelines Review drug list for inclusion of drugs/drug classes from widely accepted treatment guidelines - Inclusion based on best practice - Serves as a check, not an exhaustive list 22
23 Therapeutic Categories or Pharmacologic Classes Requiring Uninterrupted Access All or Substantially All Review certain drug classes to ensure that beneficiaries being treated with these classes have uninterrupted access to all drugs in that class via formulary inclusion, utilization management tools, or exceptions processes Antidepressants Antipsychotics Anticonvulsants Antiretrovirals Antineoplastics Immunosuppressants 23
24 Common Drugs for Medicare Population Review drug list for inclusion of the most commonly prescribed drug classes for the Medicare population in terms of cost and utilization 24
25 Utilization Tools Review: Checks Prior authorization Step therapy Quantity limitations 25
26 Insulin Supplies and Vaccines Review Formularies must include alcohol swabs, needles, syringes, and gauze Vaccines not covered under Part B must be covered under Part D 26
27 Drug List Review: Long Term Care Accessibility A review will be performed to ensure that all the medically necessary Part D covered products are included in the formularies. IV drugs, Compounded medications Alternate dosage forms, such as, but not limited to liquids, crushable etc. 27
28 Formulary Maintenance Categories and classes may only be changed at the beginning of each plan year unless new drugs or new uses appear Drug additions, deletions, or tier changes must be submitted within 30 days of P&T decision Negative formulary changes require a 60 day notification to CMS, affected beneficiaries, SPAPs, providers and pharmacy networks 28
29 October-December Formulary Additions Formulary additions No UM restrictions No new NDC codes of drugs already on formulary May be included in marketing materials Will not be reflected in the Plan Finder until January Submission date of December for effective January 1, 2006 date 29
30 New Generic Drugs Additions Options Add new generics following aforementioned process Add new generic and submit written notice to by 11/15/05 for effective date of 1/1/06 After 11/15, no changes to corresponding brand will be permitted until 60 days after the contract year begins 30
31 Provision of Notice Regarding Formulary Changes Prior to removing/changing drug from formulary Plan must: - Provide 60 days notice to CMS, SPAPs, prescribers, network pharmacies, and pharmacists - For enrollees, must provide either: Direct written notice at least 60 days prior to date the change becomes effective, or At the time a refill is requested, provide a 60 day supply of drug and written notice 31
32 QUESTIONS 32
Medicare Parts B/D Coverage Issues
2/14/2006 Medicare Parts B/D Coverage Issues This table provides a quick reference guide for the most frequent Medicare Part B drug and Part D drug coverage determination scenarios facing Part D plans
More information05/01/2014. Medicare has 4 parts A: Hospital coverage National Training Program. Session Objectives. The Basics. B: Outpatient medical coverage
2015 National Training Program Medicare Prescription Drug Coverage Parts A, B and D Session Objectives This session should help you Differentiate when/under what scenarios drugs are covered under the various
More informationPharmaceutical Management Medicaid 2019
Pharmaceutical Management Medicaid 2019 Toll-free Contact Number: (888) 327-0671 Pharmacy Administration: (810) 244-1660 Introduction Pharmaceutical Management promotes the use of the most clinically appropriate,
More informationPHARMACY Section 9. Overview. Preferred Drug List. Additions and Exceptions to the Preferred Drug List
Overview The management of outpatient prescription drugs is an integral part of the medical management program to improve the health and well-being of our members. Prescriber and member involvement is
More informationCARD/MAIL/PRE-APPROVAL/PREFERRED RIDER FOR PRESCRIPTION DRUG [INSURANCE] [Policy]holder: Group Policy No: Effective Date:
RIDER FOR PRESCRIPTION DRUG [INSURANCE] [Policy]holder: Group Policy No: Effective Date: CARD/MAIL/PRE-APPROVAL/PREFERRED The Prescription Drug Coverage under this Rider [replaces] [supplements] the Prescription
More informationFlexRx 6-Tier. SM Pharmacy Benefit Guide
FlexRx 6-Tier SM Pharmacy Benefit Guide Welcome to FlexRx The AllWays Health Partners FlexRx SM program is built for choice, savings, and convenience with benefits including: Low-cost drug tier for many
More informationPublic Health Service Breakout Session 1
CPE Information and Disclosures Public Health Service Breakout Session 1 LT Teisha Robertson and LT Emeka Egwim Centers for Medicare & Medicaid Services LCDR Ayana Rowley and LCDR Tina Smith Food and Drug
More information$250 (Deductible does not apply to Tier 1 and Tier 2) $500 (Deductible does not apply to Tier 1 and Tier 2)
Benefit Summary Outpatient Prescription Drug Illinois 5/50/100/250 Plan 455 Your Co-payment and/or Co-insurance is determined by the tier to which the Prescription Drug List (PDL) Management Committee
More informationTHE HEALTH PROFESSIONAL S ROLE IN FORMULARY MANAGEMENT OF MEDICARE PART D BENEFITS
THE HEALTH PROFESSIONAL S ROLE IN FORMULARY MANAGEMENT OF MEDICARE PART D BENEFITS Timothy Covington, MS, PharmD Bruno Professor of Pharmacy Executive Director, Managed Care Institute Samford University
More informationCoverage Period: Coverage for: Plans: This is only a summary of your GatorCare pharmacy benefits. Coinsurance: you your Dependent Copayment: you
This is only a summary of your GatorCare pharmacy benefits. If you would like detail about your coverage and costs, you can get the complete terms in the policy or plan document at gatorcare.magellanrx.com/member
More informationPharmacy benefit guide
FlexRx SM 5-Tier Pharmacy benefit guide 1 Welcome to FlexRx The NHP FlexRx SM program is built for choice, savings, and convenience with benefits including: Low-cost drug tier for many common medications
More informationCoverage Period: 01/01/ /31/2018 Coverage for: Individual and/or Family Plan: Healthy Rewards HSA
This is only a summary of your GatorCare pharmacy benefits. If you would like detail about your coverage and costs, you can get the complete terms in the policy or plan document at gatorcare.magellanrx.com/member
More informationCoventry Health Care of Georgia, Inc.
Coventry Health Care of Georgia, Inc. PRESCRIPTION DRUG RIDER (for High Deductible Health Plans) This Prescription Drug Rider is an attachment to the Coventry Health Care of Georgia, Inc. ( Health Plan
More informationGetting started with Prime
Getting started with Prime How does a pharmacy plan work? When you visit your doctor, he or she may prescribe medicine for you. Here's how the plan works: Take your prescription and member ID card to the
More informationAmy Larrick Chavez-Valdez, Director, Medicare Drug Benefit and C & D Data Group
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850 CENTER FOR MEDICARE TO: FROM: SUBJECT: All Part D Sponsors Amy Larrick
More informationUpdate to HMO Drug Formulary Tier Definitions. February 8, 2018
Update to HMO Drug Formulary Tier Definitions February 8, 2018 Agenda 1 Overview of Current Drug Tiers 2 Proposed Drug Tiers for 2019 3 Impact to SFHSS and SFHSS Members 4 How the Drug Formulary Works
More informationAnthem Blue Cross High HMO
Anthem Blue Cross High HMO HMO HIGH SELECT NETWORK Modified Premier HMO 10/100% This Summary of Benefits is a brief overview of your plan's benefits only. For more detailed information about the benefits
More informationPBMs: Impact on Cost and Quality of Pharmaceutical Care in the U.S.
Speaker Brian K. Solow, MD, FAAFP Optum Life Sciences Irvine, CA, USA PBMs: Impact on Cost and Quality of Pharmaceutical Care in the U.S. Brian K. Solow, MD, FAAFP Chief Medical Officer, Optum Life Sciences
More informationRE: CMS-4130-P (Medicare Program; Policy and Technical Changes to the Medicare Prescription Drug Benefit)
Herb Kuhn, Acting Deputy Administrator Centers for Medicare & Medicaid Services Hubert H. Humphrey Building 200 Independence Avenue, S.W. Department of Health and Human Services Washington, D.C. 20201
More informationPharmacy Policy Bulletin
Pharmacy Policy Bulletin Title: Policy #: New Jersey Formulary Exception Policy Rx.01.193 Application of pharmacy policy is determined by benefits and contracts. Benefits may vary based on product line,
More informationAn Examination of Access to HIV/AIDS Medications in Exchange Plans United States Conference on AIDS. September 10,
An Examination of Access to HIV/AIDS Medications in Exchange Plans United States Conference on AIDS September 10, 2015 www.avalere.com Agenda PlanScape Methodology Key Takeaways Access to HIV/AIDS Medications
More informationMedicare Part D Opioid Policies for 2019 Information for Patients
CENTERS FOR MEDICARE & MEDICAID SERVICES Medicare Part D Opioid Policies for 2019 Information for Patients Introduction Prescription opioid pain medications like oxycodone (OxyContin ), hydrocodone (Vicodin
More informationLegislative & Regulatory Update Brad Young, RxPlus Government Affairs
Legislative & Regulatory Update 2018 Brad Young, RxPlus Government Affairs Disclosures Brad Young reports no actual or potential conflicts of interest associated with this presentation. 2 Learning Objectives
More informationHOSPICE INFORMATION FOR MEDICARE PART D PLANS
HOSPICE INFORMATION FOR MEDICARE PART D PLANS SECTION I -HOSPICE INFORMATION TO OVERRIDE AN HOSPICE A3 REJECT OR TO UPDATE HOSPICE STATUS A. Purpose of the form (please check all appropriate boxes) : Admission
More informationVaccine Coverage Requirements in the U.S.
Vaccine Coverage Requirements in the U.S. Richard Hughes IV and Emily Sobel 10.18.17 Avalere Health T 202.207.1300 avalere.com An Inovalon Company F 202.467.4455 1350 Connecticut Ave, NW Washington, DC
More informationPHARMACY BENEFITS MANAGER
PHARMACY BENEFITS MANAGER CU GME Benefits Office Prescriptions should be obtained at participating pharmacies using your Benefits ID card. A list of participating pharmacies may be obtained by calling
More informationAn Overview of Medicare Covered Diabetes Supplies and Services
News Flash - Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers serves as a resource on how to read and understand a Remittance Advice (RA). Inside
More informationAbout the PCTB Examination Assisting the Pharmacist in Serving Patients p. 1 Filling the Medication Order p. 3 Receiving the Medication Order p.
Preface p. ix About the PCTB Examination p. xii Assisting the Pharmacist in Serving Patients p. 1 Filling the Medication Order p. 3 Receiving the Medication Order p. 4 The Retail Medication Order p. 6
More informationPREFACE. Saskatchewan is participating in the Common Drug Review (CDR).
PREFACE OBJECTIVES The Drug Plan has been established to: provide coverage to Saskatchewan residents for quality pharmaceutical products of proven therapeutic effectiveness; reduce the direct cost of prescription
More informationGuidance for Industry DRAFT GUIDANCE. This guidance document is being distributed for comment purposes only.
Compounded Drug Products That Are Essentially Copies of a Commercially Available Drug Product Under Section 503A of the Federal Food, Drug, and Cosmetic Act Guidance for Industry DRAFT GUIDANCE This guidance
More informationPrincipal Benefits for Kaiser Permanente Traditional HMO (1/1/16 12/31/16)
Benefit Summary 128742, 35995 ACWA/JPIA Principal Benefits for Kaiser Permanente Traditional HMO (1/1/16 12/31/16) The Services described below are covered only if all of the following conditions are satisfied:
More informationPrincipal benefits for Kaiser Permanente Traditional Plan (10/1/15 9/30/16)
Disclosure Form SISC-SELF INSURED SCHOOLS OF CALIFORNIA Principal benefits for Kaiser Permanente Traditional Plan (10/1/15 9/30/16) The Services described below are covered only if all of the following
More informationChanges to the Eighth Edition
Pharmacy Practice and the Law, Eighth Edition Includes Navigate 2 Advantage Access By Richard R. Abood, BS Pharm, JD-Professor Emeritus Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences,
More information$"% & '( ) " * +, !"##!""$ !*$-!+*" % $&
! """# # $"% & '( ')&# '( ) " * +, '( )(*!*$-!+*"!"##!""$ % $& &. / 011 12 ' 32 3 456 3. 3 0 11 32! 71 829:1 1' 3,3 12/ 2 31:181' 337)1 / 111 3 : 39.21)2 231 1 1 13' 223 333 23) 3;3 2 1 1' 11 3 31 333
More informationAlabama Medicaid Pharmacy Override
Alabama Medicaid Pharmacy Override Therapeutic Duplication, Early Refill, Maximum Unit, Prescription Limit Switchover, Dispense as Written, Accumulation Edit, Maintenance Supply Opt Out, and Maximum Cost
More informationDrug Use Evaluation: Low Dose Quetiapine
Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119
More informationPhysician Injectable Drug List (PIDL) Department for Medicaid Services, HP, and Magellan Rx Management June 1, 2010
Physician Injectable Drug List (PIDL) Department for Medicaid Services, HP, and Magellan Rx Management June 1, 2010 Physician-Administered Drugs Physician-administered drugs are drugs, other than vaccines,
More informationPart D Formularies / Opportunities for Further FDA/CMS Collaboration
Part D Formularies / Opportunities for Further FDA/CMS Collaboration Authors: Jon Glaudemans Patti Manolakis, PharmD Christine Park Brian Bruen May 2008 This analysis is self-funded by Avalere Health,
More informationNew Medicare Part D Prescription Opioid Policies for 2019 Information for Prescribers
CENTERS FOR MEDICARE & MEDICAID SERVICES New Medicare Part D Prescription Opioid Policies for 2019 Information for Prescribers Background CMS understands the magnitude of the nation s opioid epidemic and
More informationPrincipal Benefits for Kaiser Permanente Traditional Plan (10/1/16 9/30/17)
Benefit Summary SISC-SELF INSURED SCHOOLS OF CALIFORNIA Principal Benefits for Kaiser Permanente Traditional Plan (10/1/16 9/30/17) The Services described below are covered only if all of the following
More informationDRUG PRODUCT INTERCHANGEABILITY AND PRICING ACT
c t DRUG PRODUCT INTERCHANGEABILITY AND PRICING ACT PLEASE NOTE This document, prepared by the Legislative Counsel Office, is an office consolidation of this Act, current to September 22, 2014. It is intended
More informationRe: Docket No. FDA-2009-N-0294 Regulation of Tobacco Products; Request for Comments
VIA Electronic Submission to http://www.regulations.gov September 29, 2009 Division of Dockets Management (HFA-305) Food and Drug Administration 5630 Fishers Lane, rm. 1061 Rockville, MD 20852 Re: Docket
More informationDiabetes Management, Equipment and Supplies
Coverage Summary Diabetes Management, Equipment and Supplies Policy Number: D-001 Products: UnitedHealthcare Medicare Advantage Plans Original Approval Date: 11/01/2006 Approved by: UnitedHeatlhcare Medicare
More informationMassachusetts Medicaid pediatric high-risk asthma bundled payment pilot
University of Massachusetts Medical School escholarship@umms Commonwealth Medicine Publications Commonwealth Medicine 9-28-2011 Massachusetts Medicaid pediatric high-risk asthma bundled payment pilot Katharine
More informationMEDICAL SCHEDULE OF BENEFITS
MEDICAL SCHEDULE OF BENEFITS Plan(s) 011 (F) All health benefits shown on this Schedule of Benefits are subject to the following: Lifetime and annual maximums, Deductibles, Co-pays, Plan Participation
More informationHARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES
Generic Brand HICL GCN Exception/Other BLOOD SUGAR DIAGNOSTIC DIABETIC TEST STRIPS 25200 NOTE: Requests for preferred blood glucose (diabetic) test strips manufactured by Abbott Diabetes Care (such as
More informationMedicaid in South Carolina. South Carolina Medicaid in /19/2018. > FY 2017 Appropriation: $7.2 billion > Full benefit Membership: 1.
Medicaid in South Carolina > FY 2017 Appropriation: $7.2 billion > Full benefit Membership: 1.04 million South Carolina Medicaid in 2018 Bryan Amick SC Chapter, American Academy of Pediatrics 2018 CATCH
More informationFLOWTUSS (hydrocodone bitartrate and guaifenesin) oral solution OBREDON (hydrocodone bitartrate and guaifenesin) oral solution
OBREDON (hydrocodone bitartrate and guaifenesin) oral solution Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit
More informationHow are Adult Immunizations paid for in the United States?
How are Adult Immunizations paid for in the United States? Litjen (L.J) Tan, MS, PhD Chief Strategy Officer, Immunization Action Coalition Co-Chair, National Adult and Influenza Immunization Summit February
More informationTHE GROWTH OF SPECIALTY PHARMACY
UnitedHealth Center for Health Reform & Modernization THE GROWTH OF SPECIALTY PHARMACY Current trends and future opportunities Issue Brief April 2014 Summary Innovative specialty drugs are providing important
More informationMemo. Implications of Proposed Rule on Medicare Part D Protected Class
Memo Implications of Proposed Rule on Medicare Part D Protected Class March 11, 2019 I. Introduction Since the implementation of Medicare Part D in 2006, six classes of drugs have been protected to ensure
More informationRegence HSA Individual Direct Plan Highlights
Plan Features Provider choice: Member coinsurance levels are lowest for In-Network providers. If a member chooses an Out-of-Network provider, the member may be required to pay costs above the allowed amount.
More informationPrincipal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/15 9/30/16)
SISC - SELF-INSURED SCHOOLS OF CALIFORNIA Principal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/15 9/30/16) The Services described below are covered only if all of the following
More informationNews & Views. Antipsychotics on Maryland Medicaid PDL and Coverage of a 30-day Emergency Supply of Atypical Antipsychotics
Maryland Medicaid Pharmacy Program News & Views February 2011 Maryland Department of Health and Mental Hygiene /Office of Systems, Operations and Pharmacy Antipsychotics on Maryland Medicaid PDL and Coverage
More informationBruce Wilkinson. Formulary & Benefit (F&B) Copay Summary Recommendation
Bruce Wilkinson Formulary & Benefit (F&B) Copay Summary Recommendation F&B Summary Copay Usage Goal: Use the Summary Copay files in a consistent manner with other F&B file types, specifically formulary
More informationMedicare Preventive Services. Disclosure Statement
Medicare Preventive Services LCDR Tunesia Mitchell CMS/Region 2 Disclosure Statement The planners and presenters do not have any financial arrangements or affiliations with any commercial entities whose
More informationPrescription Drugs North Carolina Policies. Carol Steckel, MPH Medicaid Director
Prescription Drugs North Carolina Policies Carol Steckel, MPH Medicaid Director March 19, 2013 Pharmacy Services Optional service provided each year to about 1.5 million beneficiaries by 2,200 pharmacy
More informationSchedule of Benefits - CENTRAL HMO Group CITY OF MARSHFIELD Benefit Year: January 1st through December 31st Effective Date: 01/01/2017
Security Health Plan certifies that you and any covered dependents have coverage as described in your Certificate and Schedule of Benefits as of the effective date shown on the letter you received with
More informationPROLIA: Medical Coverage Policy Denosumab (Prolia and. Xgeva) EFFECTIVE DATE: POLICY LAST UPDATED:
Medical Coverage Policy Denosumab (Prolia and Xgeva) EFFECTIVE DATE: 11 01 2016 POLICY LAST UPDATED: 12 19 2017 OVERVIEW Prolia (denosumab) is indicated for the treatment of postmenopausal women with osteoporosis
More informationAn Overview of One Formulary Making Decision Process
An Overview of One Formulary Making Decision Process Disclosure Statement & Speaker s Non- Commercialism Agreement Rodney J. Gedey Presenter has no conflict of interest to disclose. This presentation was
More informationIOWA MEDICAID DRUG UTILIZATION REVIEW COMMISSION 100 Army Post Road Des Moines, IA (515) Fax
IOWA MEDICAID DRUG UTILIZATION REVIEW COMMISSION 100 Army Post Road Des Moines, IA 50315 (515) 725-1287 Fax 1-866-626-0216 Bruce Alexander, R.Ph., Pharm.D., BCPP Larry Ambroson, R.Ph. Casey Clor, M.D.
More informationJanuary 16, Dear Administrator Verma:
Ms. Seema Verma Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMMI New Direction P.O. Box 8011 Baltimore, MD 21244-1850 Re: (CMS-4182-P) Medicare
More informationTrending Determinations by Measure
TO: Interested Parties FROM: Cindy Ottone, Director, Policy DATE: February 2018 RE: HEDIS 1 2018 Measure Trending Determinations This memo communicates trending determinations for measures in the HEDIS
More informationPHARMACY COMPLIANCE RISK AREAS FOR 2014
PHARMACY COMPLIANCE RISK AREAS FOR 2014 2014 San Juan Puerto Rico Regional Compliance Conference Darrell W. Contreras, Esq., LHRM, CHC-F, CHPC, CHRC 5 Risk Areas 1. Overbilling of Herceptin 2. Quality
More informationISSUING AGENCY: Regulation and Licensing Department - NM Board of Osteopathic Medical Examiners.
Code of New Mexico Rules Title 16. Occupational and Professional Licensing Chapter 17. Osteopathic Medicine and Surgery Practitioners Part 5. Prescribing and Distribution of Controlled Substances 16.17.5.
More information2016 OPEN ENROLLMENT RETIREE HEALTH PLANS
2016 OPEN ENROLLMENT RETIREE HEALTH PLANS SERVICES Inpatient Hospital (Part A) COMPANIONCARE/Medicare Supplement Plan BENEFIT SUMMARY (Based on Calendar Year) MEDICARE 2016 Benefits Pays all but first
More informationMedicare Coverage of Mental Health Services
Medicare Coverage of Mental Health Services Medicare Coverage of Diabetic Services and Supplies July 2015 For Those Who Counsel People With Medicare What is Diabetes? Chronic disease in which your body
More information08/10/2015. Medicare Coverage of Diabetes Services and Supplies. What is Diabetes? 2015 National Training Program
2015 National Training Program Medicare Coverage of Diabetes Services and Supplies July 2015 For Those Who Counsel People With Medicare What is Diabetes? Chronic disease in which your body can t make or
More informationPQS Summary of Pharmacy/ Medication-Related Updates in the CY 2020 Final Call Letter
Managing Performance Information in a Quality Driven World PQS Summary of Pharmacy/ Medication-Related Updates in the CY 2020 Final Call Letter REGULATORY UPDATE PQS Summary of Pharmacy/ Medication-Related
More informationCoventryHealthandLife Insurance Company IndividualPolicyPPOScheduleof Benefits
State(s) of Issue: Oklahoma PPO Plan: OI C05020 20 CoventryHealthandLife Insurance Company IndividualPolicyPPOScheduleof Benefits Covered Services ReceivingServicesfrom Participating Providers(In- Network)
More informationCALIFORNIA. When I Fill a Prescription, How Much Medication Do I Receive? What Is My Schedule of Benefits? How Do I Use My Prescription Drug Benefit?
CALIFORNIA HMO PHARMACY SCHEDULE OF BENEFITS Summary of Benefits Retail Pharmacy Copayment (per Prescription Unit or up to 30 days) Mail Service Pharmacy Copayment (up to 3 Prescription Units or up to
More informationUSING MTM TO IMPROVE STAR RATINGS : CASE STUDIES
USING MTM TO IMPROVE STAR RATINGS : CASE STUDIES Sept 13, 2015 Amanda Applegate, PharmD, BCACP Disclosures Nothing to disclose Learning Objectives Describe how MTM can improve star ratings Discuss strategies
More informationMassachusetts Department of Developmental Services Medication Review
University of Massachusetts Medical School escholarship@umms Commonwealth Medicine Publications Commonwealth Medicine 8-7-2012 Massachusetts Department of Developmental Services Medication Review Alexandra
More informationMARYLAND MEDICAL ASSISTANCE PROGRAM Pharmacy Transmittal No Maryland Pharmacy Assistance Program Transmittal No. 39 February 22, 1999
1 PT17-99 MARYLAND MEDICAL ASSISTANCE PROGRAM Pharmacy Transmittal No. 160 Maryland Pharmacy Assistance Program Transmittal No. 39 February 22, 1999 TO: FROM: NOTE: RE: Physicians Pharmacists Martin P.
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Invega) Reference Number: CP. PMA.10.11.19 Effective Date: 10.06.16 Last Review Date: 04.18 Line of Business: CenpaticoMedicaid Revision Log See Important Reminder at the end of this
More informationPrincipal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19)
Disclosure Form SISC - Self Insured Schools Of California Home Region: California Principal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19) Accumulation Period The Accumulation Period
More informationTools for Targeting High Risk Patients in Your Practice. Statement of Disclosure
Tools for Targeting High Risk Patients in Your Practice Joseph Vande Griend, PharmD, BCPS, CGP Assistant Professor, University of Colorado Departments of Clinical Pharmacy and Family Medicine Skaggs School
More informationContractor Name: Novitas Solutions, Inc. Contractor Number: Contractor Type: MAC B. LCD ID Number: L34834 Status: A-Approved
LCD for Blood Glucose Monitoring in a Skilled Nursing Facility (SNF) (L34834) Contractor Name: Novitas Solutions, Inc. Contractor Number: 12502 Contractor Type: MAC B LCD ID Number: L34834 Status: A-Approved
More informationMedicare Part D Prescription Opioid Policies for 2019 Information for Pharmacists
CENTERS FOR MEDICARE & MEDICAID SERVICES Medicare Part D Prescription Opioid Policies for 2019 Information for Pharmacists Background Opioid medications are effective at treating certain types of pain,
More informationClinical Policy: Clozapine orally disintegrating tablet (Fazaclo) Reference Number: CP.PMN.12 Effective Date: Last Review Date: 02.
Clinical Policy: Clozapine orally disintegrating tablet (Fazaclo) Reference Number: CP.PMN.12 Effective Date: 08.01.15 Last Review Date: 02.18 Line of Business: Medicaid Revision Log See Important Reminder
More informationMedicare Part D Overutilization Monitoring System
Medicare Part D Overutilization Monitoring System Lisa Thorpe, Division of Part D Policy Gary Wirth, Division of Clinical and Operational Performance Medicare Drug Benefit and C&D Data Group July 17, 2013
More informationNo An act relating to health insurance coverage for early childhood developmental disorders, including autism spectrum disorders. (S.
No. 158. An act relating to health insurance coverage for early childhood developmental disorders, including autism spectrum disorders. (S.223) It is hereby enacted by the General Assembly of the State
More informationBLOOD GLUCOSE METER TEST STRIP STEP THERAPY CRITERIA
BLOOD GLUCOSE METER TEST STRIP STEP THERAPY CRITERIA Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan.
More informationTest Bank for Basic Pharmacology for Nurses 14th edition by Clayton, Stock and Harroun
Test Bank for Basic Pharmacology for Nurses 14th edition by Clayton, Stock and Harroun Link download full: https://digitalcontentmarket.org/download/testbank-for-basic-pharmacology-for-nurses-14thedition-by-clayton-stock-harroun
More informationTexas Vendor Drug Program Specialty Drug List Process. February 2019
Texas Vendor Drug Program Specialty Drug List Process February 2019 Table of Contents Table of Contents...1 1 About the Specialty Drug List...2 1.1 Information for Pharmacies... 2 1.2 Information for Managed
More informationSUMMARY TABLE OF MEASURES, PRODUCT LINES AND CHANGES
Summary Table of Measures, Product Lines and Changes 1 SUMMARY TABLE OF MEASURES, PRODUCT LINES AND CHANGES General Guidelines for Data Collection and Reporting Guidelines for Calculations and Sampling
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Transmucosal Immediate Release Fentanyl Products Reference Number: CP.HNMC.211 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Medicaid Medi-Cal Revision Log See Important
More informationEvaluation of a Medicaid Psychotropic Drug Management Program in Utah
Evaluation of a Medicaid Psychotropic Drug Management Program in Utah Dominick Esposito James M. Verdier 2008 SAMHSA/CMS Invitational Conference on Medicaid and Mental Health Service/Substance Abuse Treatment
More information2016 OPEN ENROLLMENT RETIREE HEALTH PLANS
2016 OPEN ENROLLMENT RETIREE HEALTH PLANS SERVICES Inpatient Hospital (Part A) COMPANIONCARE/Medicare Supplement Plan BENEFIT SUMMARY (Based on Calendar Year) MEDICARE 2016 Benefits Pays all but first
More informationClinical Policy: Olanzapine Orally Disintegrating Tablet (Zyprexa Zydis) Reference Number: CP.PMN.29 Effective Date: Last Review Date: 02.
Clinical Policy: (Zyprexa Zydis) Reference Number: CP.PMN.29 Effective Date: 08.01.15 Last Review Date: 02.19 Line of Business: Medicaid See Important Reminder at the end of this policy for important regulatory
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Aimovig) Reference Number: CP.PHAR.128 Effective Date: 07.10.18 Last Review Date: 08.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this policy
More informationA nation in pain: Focus on Medicaid
DATA INSIGHTS A nation in pain: Focus on Medicaid Opioid pain medications have become one of the most controversial classes of prescription therapy. While they provide great benefits in controlling both
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Ajovy) Reference Number: CP.PHAR.## Effective Date: 10.30.18 Last Review Date: 02.19 Line of Business: Commercial, TBD HIM*, Medicaid Revision Log See Important Reminder at the end of
More informationFamily Coverage Self-Only Coverage Amounts Per Accumulation Period (a Family of one Member) or more Members
Benefit Summary 128742 & 35995 ACWA JPIA Principal Benefits for Kaiser Permanente Traditional HMO Plan (1/1/18 12/31/18) Accumulation Period The Accumulation Period for this plan is 1/1/18 through 12/31/18
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Tagrisso) Reference Number: CP.PHAR.294 Effective Date: 12.01.16 Last Review Date: 08.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this
More informationREQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Fax Number: Anthem Blue Cross Cal MediConnect Plan 1-844-493-9213 Medicare Prior Authorization
More informationPreventive Services Update: Fall Prevention Services and Intimate Partner Screening and Intervention
Date: April 29, 2013 Market: All Preventive Services Update: Fall Prevention Services and Intimate Partner Screening and Intervention Overview On August 1, 2011 HHS published an amendment to the September
More information