District of Columbia Pharmacy Benefit Management (PBM)

1. District of Columbia Pharmacy Benefit Management (PBM) Provider Training

2. Implementation Information

3. District of Columbia Pharmacy Benefit Management (PBM) • On December 19, 2015, Magellan Medicaid Administration, Inc. (part of the Magellan Rx Management Division of Magellan Health, Inc.) will assume the responsibility for the District of Columbia Pharmacy Benefit Management (PBM). The PBM will perform the following functions: • Claims Processing • Operations support for the Pharmacy Benefit Management (PBM) system • Call Center Operations for Providers and Members • Clinical Consultation Services • Education and Outreach for Providers

4. Effective Date for Transition Implementation • On December 18, 2015, the current PBM vendor, Xerox State Healthcare, will shutdown claims processing at 11:59 p.m. • On December 19, 2015, Magellan Medicaid Administration will begin claims processing at 6:00 a.m. • Providers should hold ALL claims from 11:59 p.m. – 6:00 a.m.

5. Availability • The point-of-sale (POS) system will be available for submitting claims 24/7 • When needed, routine maintenance may occur: • Saturday at 11:00 p.m. – 6:00 a.m.

6. Readiness Documents and Resources • Provider Manual • Payer Specification Sheet • Forms • Frequently Asked Questions • User Administration Console (UAC) and Web Prior Authorization (WebPA) information for the prescriber community will be forthcoming All documents and resources are located on the District of Columbia Pharmacy Benefit Management (PBM) Website: www.dc-pbm.com

7. POS Technical Readiness

8. Technical POS Submission Readiness Transaction Header Segment • All transactions require the following values: • NEW - BIN Number: 018407 for all District pharmacy programs • Version/Release Number: D0 • NEW - Processor Control Number (PCN): • District Medicaid: DCMC018407 • District Alliance: DCAL018407 • District ADAP: TROOP • Group ID: • District Medicaid: DCMEDICAID • District Alliance: ALLI • District ADAP: DCADAP

9. Technical POS Submission Readiness NEW • Unit of Measure is required. • Values: • EA = Each • GM = Grams • ML = Milliliters

10. POS Operational Readiness

11. POS Operational Readiness The following transactions will be processed: • Claim Type • Original Claims B1 • Reversals B2 • Re-bills B3

12. POS Operational Readiness HIPAA Compliance There are requirements for privacy regulations regarding the use of claim data elements. Data element conditions are detailed in the Payer Specification Sheet including: • Mandatory (NCPDP designation – required at all times); or • Required; and • District Program requirements • Qualified Requirement • “Required when” • All submitted fields will be edited for valid format. • All submitted fields will be edited for valid values. • If optional data is sent, the values must be valid and any supporting and associated fields must be sent as well.

13. Co-Pay Structure • District Medicaid Fee-for-Service (FFS) co-pay is $1.00 per prescription. • Exceptions include the following : • Pregnant women (when pregnancy indicator is submitted) • Long-Term Care (LTC) resident • Beneficiary under 21 years of age • All contraceptives • DC Healthcare Alliance and DOH ADAP have no co-pay

14. Coordination of Benefits • Providers are required to fully pursue all third-party coverage before billing Medicaid. • Providers must comply with all policies of a beneficiary's insurance coverage including, but not limited to prior authorization (PA), quantity, and days’ supply limits. • Reimbursement will be calculated to pay the lesser of the Medicaid allowed amount or the Other Payer Patient Responsibility as reported by the primary carrier, less than the third-party payment. • Medicaid co-payments will also be deducted for beneficiaries subject to Medicaid co-pay. • In some cases, this may result in the claim billed to Medicaid being paid at $0.00. • Co-pay Only Claims, Other Coverage Code (OCC) = ‘8’, are not allowed.

15. Early Refills • Early refill tolerance periods: • 80 percent of the previous fill must be used for all drugs • NCPDP Response code for early refill error = “88” • For non-controlled drugs, the system will automatically check for an increase in dose and if found, based on the current and historical claims for the same GSN, the system will not deny the current claim for early refill.

16. Remittance Advices and Payment • Payments and remittance advice (RA) will still come from Xerox State Healthcare.

17. POS Claim Processing

18. District of Columbia Pharmacy Benefit Management (PBM) Contact Information • Clinical Contact Center Phone: 1-800-273-4962 • Clinical Contact Center Fax: 1-866-535-7622 • Pharmacy Contact Center Phone: 1-800-272-9679 • ADAP Beneficiaries and Physicians Phone: 1-202-671-4900

19. www.dc-pbm.com • The District of Columbia Pharmacy Benefit Management (PBM)Website will become active on November 19, 2015. • Primary sources for Pharmacy Program information and resources are: • Provider communication (letters, notices, etc.) • Forms • Provider Manual • Payer Specification Sheet • Contact Information • Links Note: User Administration Console (UAC) and Web Prior Authorization (WebPA) information for the prescriber community will be forthcoming.

20. ADAP • Key program elements remain the same: • Closed formulary available in the Provider Manual found at www.doh.dc.gov/node/299012 • Co-pays and deductibles are covered when other insurance payments apply • Prior authorization may be required for : • Certain CII drugs • A single drug claim exceeding $1,200 • Claims in excess of $10,000 annual cumulative amount per client

21. DC Healthcare Alliance • Key program elements remain the same: • Closed formulary can be found at www.dc-pbm.com • Antiretrovirals are not part of the DC Healthcare Alliance formulary. These are covered through the Department of Health’s AIDS Drug Assistance Program (ADAP). • Other non-formulary drugs must be submitted to the beneficiary’s Managed Care Organization for consideration and authorization

22. Medicaid FFS • Key program elements remains the same: • A preferred drug list is utilized and can be found at www.dc-pbm.com • Claims submitted for drugs that are not on the preferred drug list will require prior authorization • Non-PDL PA Request Form can be found at www.dc-pbm.com • $1.00 co-pay applies

23. Prior Authorizations • New in all programs • A beneficiary’s medical claim history is examined for diagnosis codes or procedure codes that will allow the system to automatically override a prior authorization requirement. For example: • The prior authorization requirement for a CII medication intended for long-term use will be systematically waived when a diagnosis of ADD, ADHD, narcolepsy, or cancer is found within the past six months in the beneficiary’s medical history.

24. Questions and Answers

25. Thank You