IHS Pharmacies using VA CMOP for Central Fill Mail-Out

1. IHS Pharmacies using VA CMOP for Central Fill Mail-Out May 2011

2. Definitions • VA CMOP – Consolidated Mail Outpatient Pharmacy • Central Fill –prescription refill information is sent to the VA CMOP for preparing and packaging; completed prescriptions either delivered back to the originating pharmacy or mailed directly to the patient. • Host CMOP Facility – for IHS, VA CMOP Leavenworth • Remote Facility = local IHS site

3. Reasons for Considering Mailing Prescriptions • Customer service – patients/tribe have requested service; reduces wait time in clinic (access to care). • Improves Adherence/Compliance • Reduces the number of Return to Stock prescriptions • Expand delivery of direct patient care activities – Clinical Pharmacy programs.

4. Adherence

5. Timeline • NDF patch released monthly • CMOP software - Pharmacy Patch 1009 – in production • New suspense functionality – Pharmacy Patch 1010 – production • BEX (Audiocare) modification for mail – in alpha test • Alpha Test Site • Rapid City – implemented CMOP transmissions June 2010 • Averaging 2,000 Rx/month • Beta Test Sites • PIMC – FY2011 – has station number, started local mailout Feb 2011 • Claremore – FY2012 – implemented local mailout • Yakama FY2012 – planning stages

6. Key Preparation – Best Practice • CEO support of mail out program • Consider site visit to local VA-CMOP • CEO support of pharmacists’ clinical work/clinics. • Local and Area IT support • Pharmacy Preparation

7. Key Preparation – Pharmacy • Good communication and support within pharmacy department • Regular Staff meetings • All staff involved in new processes • Site visit to local VA – review mail processes • Clinical Pharmacy programs expanding or in development; medical staff support. • Implement local/internal mail-out program • Refill system (Interactive Voice Response - IVR) implemented - maximized

8. Patient Outreach • Efforts to improve compliance by making it easier for patients to obtain medication refills. • Implement local mail-out. • Outreach several months in advance to tribal communities. • Update mailing address (Patient Registration package or Outpatient Pharmacy package) • Educate on delay from the time of the refill request to receipt of mailed prescriptions. • Process changes using IVR – option of mail versus window pick-up

9. RPMS/IT Preparation • Infrastructure - potentially 6-12 month project • Station code – coordinate with Area IT/OIT • Use of suspense (manual) – Outpatient Pharmacy patch 8 • Drug File – populate appropriate “warning label” field.

10. Rx Volume Using CMOP • The VA processes approximately 75-80% of refills through CMOP. • Tribal sites that have implemented mail-out are mailing from 50-75% of refills after 2-3 years. • IHS sites process 10-30% of refills using IVR.

11. Costs • Cost of CMOP prescription cost of service and includes personnel, operating and mailing costs. • Current cost per prescription is drug cost + $3.12 per prescription • NSSC – will still collect 0.7 % of CMOP drug costs. • Coordinate IHS requests for CMOP to stock a product.

12. Visits • A patient requests a refill via IVR which is reviewed by the pharmacist. • The suspended prescription is transmitted on the appropriate day to VA CMOP for filling and mailing. • This is considered a Pharmacy visit (39) with primary provider being the pharmacist. • The pharmacy visit is billable.

13. Finance • IHS will IPAC payments to VA in a timely manner. • Leaning towards 30 day estimate of usage paid in advanced. • CMOP invoices monthly • September (end of Fiscal year), estimate of bill is provided and reconciled at the end of the FY.

14. Controlled Substances • Should IHS mail controlled substances? • National, Area or Local policy? • No CII’s or diversion drugs (determined locally) will be mailed, i.e. Vicodin • Chronic meds, IV & V’s (i.e. seizure) – mailing may be considered • Would require modifications to CSM report. • If patient is “missing” mailed prescription, change to window pick-up. • Status – will need to work with VA to obtain a waiver from the DEA.

15. Local Mail • Sites will need to determine how they will process prescriptions that are: • Returned by CMOP, i.e. not in stock; clarification/editing of prescription. • Refill request for non-CMOP drug when others in the request are filled by the VA CMOP. • Eg. Non-formulary drug is not stocked at CMOP and will be filled/mailed locally. Remaining drugs will be filled/mailed by CMOP. • Local site will need the capacity to mail meds locally.

16. Addresses • Sites will need to ensure patient mailing address is current. • Will need to coordinate among departments that update this information. • Pharmacy has access to update and maintain mailing addresses via Outpatient Pharmacy package. • Pharmacy can also enter temporary address.

17. VA drugs versus IHS drugs • Mailed prescriptions will initially be CMOP drugs that the VA stocks. • NSSC will coordinate with VA to add drugs to CMOP (i.e. national or high use by IHS sites). • VA pre-pack drugs generate a new NDC. There may be delay from First Data Bank, then to payer. • The NSSC is liaison with McKesson (regions) for CMOP implementation timeline.

18. Temperature • USP did an extensive review - mailing a range of products to the hottest parts of the US during the heat of summer and all products still met pharmacy standards.  • CMOPs do use freezer packs for select products with overnight shipping on select products to protect the integrity of the products. • the newest insulin products are all shipped in coolers • List of refrigerated items on the national CMOP web: https://vaww.apps.cmop.va.gov/CMOPRefrigerated/Refrig.aspx • In general, these items are mailed in cold storage packs. • Formoterol is the only one on the list that only gets mailed in coolers seasonally (from June 15-Sept 15).

19. https://vaww.apps.cmop.va.gov/CMOPRefrigerated/Refrig.aspx

20. Training • Sites will need to consider training programs for both pharmacists and technicians, especially if roles change. • Pharmacists may need more training as clinical role expands. • Develop needs assessment for pharmacy staff.

21. Chapter 7 - Mailed Prescriptions • d. Mailed Prescriptions • Prescriptions may be mailed to patients provided that IHS pharmacists can meet the IHS Pharmacy Standards of Practice (Sections 3-7.3B and 3-7.3C. The facility’s policy will define patients eligible to receive prescription refill mail-out service, including restrictions on medications mailed and how the pharmacy will meet the IHS Pharmacy Standards of Practice. • Schedule II controlled substances will not be mailed. Facilities can determine locally if Schedule III through V controlled substances will be mailed, taking into consideration clinical necessity and potential for diversion, i.e.hydrocodone. • Mailing prescription refills is intended to be a service provided to eligible patients with regular appointments and living within the health service delivery area. The pharmacist will review medication orders for appropriateness of therapy and by consultation will verify patient understanding of their drug therapy. • New or first time prescriptions are expected to be processed locally. • In locations where a pharmacist is not physically available for medication counseling, resources such as telepharmacy or trained community health aids can be utilized.

22. Incorporating POS Pharmacy Billing Suspense file transmitted to CMOP RPMS CMOP Message returned to initiating site includes NDC dispensed. Prescription filled and mailed to patient. Prescription released; calls POS package for e-billing.

23. Pharmacy Billing • Documenting receipt of prescription, in lieu of signature log – USPS delivery • CMOP web site – package tracking: https://vaww.apps.cmop.va.gov/

24. Access to Web Site - Security • Users will need access to a VA account in order to log on to the web sites. Access potentially needed for these three sites: • http://vaww.national.cmop.va.gov/default.aspx- CMOP web site used for order look up , package tracking, and product look ups • http://vaww.national.cmop.va.gov/CostReports/default.aspx - where monthly drug cost bills are posted for medical centers to pickup • https://vaww.apps.cmop.va.gov/PBMOnlineProductDatabase/  - online product look up web site for the PBM.

25. CMOP Portal Options

26. CMOP Products

27. CMOP Portal

28. PARCELite tracking

29. Leavenworth

30. Stats – Leavenworth

31. VA CMOP manuals

32. Mapping Products • Insulin, inhalers and eye ointment • Routine in Outpatient Pharmacy v7 p9 to prevent dispense unit from being over-ridden when marking a CMOP drug. • NSSC to coordinate with VA CMOP Leavenworth • VA CMOP Hines – back-up for Leavenworth • Will eventually need ensure they have Leavenworth mapping set up at Hines.

33. Go-Live • Pharmacy information to include on the prescription label – send to: sheila.volski@va.gov • VA CMOP contacts on SharePoint • Provide VA with list of IHS contacts (Area and remote/local site)

34. IHS representation • Monthly VISN-CMOP-DoD-IHS call, Tuesday, 2:00pm CT • NSSC represents IHS on monthly calls. • VA Formulary – process to request addition of drugs

35. Training –https://vaww.apps.cmop.va.gov/CMOPNationalWebApplicationv2/

36. Things that are working great: • Payment process with Finance and VA • RPMS POS billing • Reduces RTS • VA communication • Daily communication with site • Bi-weekly conference calls with – project • Monthly VA Leavenworth/ Calls - NSSC • Mapping process