Transition Plan and Requirements

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MRT#11 – Bundle Pharmacy into Managed Care

5/31/2011

Transition Policy

To ensure a smooth transition of benefits from the Medicaid fee–for–service pharmacy program to the managed care plans, utilizing implementation and transition plans designed to minimize the impact on beneficiaries, providers and prescribers.
TOPIC ACTION REQUIREMENTS
Transition Period Within the first 90 days of coverage after implementation, plans must provide a temporary fill in the event that the pharmacist´s inability to resolve a claim denial, results in the beneficiary not being able obtain needed medications. This would include denied claims for drugs that are on a plan´s formulary and/or require prior authorization or step therapy under a plan´s utilization management rules. This 90 day timeframe assists those beneficiaries who are attempting to obtain medications through their Medicaid Managed Care plan for prescriptions that had been previously covered by the Medicaid pharmacy fee–for–service program. Provide a detailed description of the plan´s process for handling requests for transition fills including but not limited to:
  • The process that will be used by the plan´s customer service/call center staff to triage requests for temporary fills.
  • The process that will be used by the plan´s customer service/call center staff to ensure that requests are handled appropriately during non–core hours (i.e. weekends and evenings).
  • How the plan will ensure that customer service/call center staff will be appropriately trained to handle requests for temporary fills during the transition period.
  • The monitoring process that will be used by the plans to ensure compliance, and that beneficiaries are getting needed medications.
Transition Fill/Quantity Provides a one–time, temporary fill of non– formulary drugs for up to a 30–day supply of medication, unless the prescription is written for less than 30 days. This would include drugs that are on a plan´s formulary but require prior authorization or step therapy under a plan´s utilization management rules.  

Pharmacy Claim Data Evaluation

Each plan should do a disruption analysis to identify (based on RX claim data) those beneficiaries that would experience "at the counter" disruption effective 10/1/11, and to develop a comprehensive action to address access issues.
TOPIC ACTION REQUIREMENTS
Pharmacy Network Issues Identify pharmacies currently providing pharmacy services but not included in the plan´s provider network.
  • Provide the results of the analysis, identifying the number of impacted claims and beneficiaries and if there are certain geographical areas, beneficiaries and/or pharmacies for which there should be targeted efforts.
  • Describe how the plan will ensure that beneficiaries currently using pharmacies that are not in the plan´s network will be able to continue to obtain their medications.
  • If the plan has determined that they will refer beneficiaries to alternative pharmacies, describe how access will be measured so that beneficiaries will not need to travel significantly longer distances to obtain their medication.
  • Describe how the plan will ensure access to medications when beneficiaries are attempting to obtain their medications from non–participating pharmacies.
Prescriber Issues
  • Identify if there are prescribers currently providing services that are not included in the plan´s provider network
  • Provide the results of the analysis, identifying the number of impacted claims and beneficiaries and if there are certain geographical areas and/or prescribers for which there should be targeted efforts.
  • Describe how the plan will ensure access to medications for beneficiaries using prescribers that are not in the plan´s network.
Formulary Issues Identify if there are beneficiaries currently using:
  • Non–formulary drugs
  • Drugs requiring prior authorization
  • Drugs with coverage limitations such as frequency, quantity, and duration limits
  • Drugs requiring step therapy
  • Provide the results of the analysis, identifying the number of impacted claims and beneficiaries and if there are certain areas for which there should be targeted efforts.
  • Describe how the plan will ensure access to medications (including targeted efforts identified in the bullet point above) for drugs where plan limitations will be imposed that have not previously been imposed under the Medicaid fee–for–service program.
  • Describe how the plan will monitor, to ensure that beneficiaries obtain needed medications.
  • Submit a formulary which notates plan limitations such as drugs requiring prior authorization, step therapy or frequency, quantity and duration limits.

Evaluation and Strategy for Special Populations

Each plan will be responsible for identifying subsets of populations that may have special transition needs beneficiaries, to ensure continued access to needed medications
TOPIC ACTION REQUIREMENTS
Limited Access Drugs
  • Identify limited access drugs and affected beneficiaries.
  • Identify corresponding pharmacies that are approved to dispense the product and ensure network access.
  • Provide the results of the analysis, identifying limited access drugs, the number of impacted claims and beneficiaries and if there are certain beneficiaries/ drugs for which there should be targeted efforts.
  • Describe how the plan will ensure access to medications (including targeted efforts identified in the bullet point above).
  • Describe how the plan will monitor, to ensure that beneficiaries obtain needed medications.
Specialty Pharmacy
  • Identify specialty pharmacy drugs and affected beneficiaries. Identify access issues.
  • Provide the results of the analysis, identifying specialty pharmacy drugs, the number of impacted claims and beneficiaries and if there are certain beneficiaries/drugs for which there should be targeted efforts.
  • Describe how the plan will ensure access to medications (including targeted efforts identified in the bullet point above).
  • Describe how the plan will monitor, to ensure that beneficiaries obtain needed medications.
Clinical Drug Review Program (CDRP)
  • Identify beneficiaries currently receiving CDRP drugs (i.e. growth hormones).
  • Information regarding CDRP can be found at: https://newyork.fhsc.com/providers/CDRP_about.asp
  • Review current criteria for coverage and coordinate for continued access.
  • Provide the results of the analysis, identifying beneficiaries for which there are "CDRP claims" where a prior approval has already been issued under the Medicaid fee–for– service program. Identify if there should be targeted efforts for certain drugs/beneficiaries,
  • Describe how the plan will ensure access to medications (including targeted efforts identified in the bullet point above).
  • Describe how the plan will monitor, to ensure that beneficiaries obtain needed medications.
Mandatory Generic Program
  • Identify beneficiaries currently receiving brand name medications for which there is an FDA A– rated generic equivalent.
  • Provide the results of the analysis, identifying beneficiaries for which there are brand name drug claims where a prior authorization has already been issued under the Medicaid fee– for–service program. Identify if there should be targeted efforts for certain drugs/beneficiaries.
  • Describe how the plan will ensure access to medications (including targeted efforts identified in the bullet point above).
  • Describe how the plan will monitor, to ensure that beneficiaries obtain needed medications.
Specific drug classes of concern The following represents drug classes that are of special concern to the Department:
  1. Antipsychotics
  2. Immunosuppressants (for prophylaxis of organ transplant rejection)
  3. Antiretroviral therapy
  4. Anticonvulsants
  5. Antidepressants
  • Identify beneficiaries currently receiving drugs in these classes
  • Identify coverage and access issues
  • Provide detail regarding any coverage or utilization management tools utilized for these classes
  • Describe in detail how the plan will ensure access to these medications and how formularies and/or utilization management tools were developed.
  • Provide the results of the analysis, identifying beneficiaries that are currently using drugs in these classes, for which there will be a plan limitation imposed on 10/1/2011. Identify areas of clinical concern and if there will be targeted efforts for certain drugs/beneficiaries.
  • Describe the appeal process for these classes and explain in detail how the plan will ensure access to needed medications and temporary supplies in urgent/emergent situations.
  • Describe how the plan will monitor, to ensure that beneficiaries obtain needed medications.

Evaluation and Strategy for Supplies

Each plan will be responsible for identifying and addressing transition issues related to the provision of supplies.
TOPIC ACTION REQUIREMENTS
Diabetic Supplies
  • Identify where current meter and blood glucose test strips are provided in network.
  • Identify access issues
  • Process to obtain BG testing supplies
  • Identify where plan parameters and/or preferred networks or manufacturers will impact access effective 10/1/2011.
  • Provide the results of the analysis for each topic, identifying the number of impacted claims and beneficiaries and if there are certain areas for which there should be targeted transition efforts.
  • Describe how the plan will ensure a smooth transition and access to supplies. Include a description of targeted efforts identified in the bullet point above.
  • Describe how the plan will monitor, to ensure that beneficiaries obtain needed supplies.
Hearing Aid Batteries
  • Identify access issues
  • Process to obtain HA batteries
Enteral Products
  • Identify current member utilization
  • Identify prior authorization requirements
  • Process to obtain enteral formula
Medical supplies (bandages, gauze, etc.) MMC ONLY
  • Process to obtain supplies
  • Prior authorization requirements

Targeted Communication Plan

Establish a timeline for mailings. Communication plan should allow adequate time for providers and beneficiaries to take appropriate action and minimize "at the counter" issues.
TOPIC ACTION REQUIREMENTS
Timeline
  • Plans must communicate to all beneficiaries and providers regarding the benefit and limitations 45 to 60 days prior to implementation.
  
Notifications to Providers
  • Notification should explain change in coverage and actions required to ensure beneficiary access after 10/1.
  • Information regarding appeals and medical exceptions
  • Provide a description of the notification(s) to providers (pharmacies and prescribers) that will be used, with details regarding what topics will be included. Draft samples may be provided but are not required.
  • Provide a description of any targeted communications that will be utilized, with details regarding what topics will be included. Draft samples may be provided, but are not required.
Notifications to beneficiaries Notification should explain the changes to benefit, specific drug(s) that will require action by beneficiary/prescriber, and action required to continue access after 10/1.
  • New cases opened in August/September will need to have current language for pharmacy as well as information regarding the 10/1 change
  • Plan details including but not limited to: formulary, prior authorization requirements, step therapy program, mail order information.
  • Information regarding appeals and medical exceptions
  • Customer service information (Plans are encouraged to develop specific phone lines to respond to questions or conduct extensive training of member services staff to ensure accuracy of the information provided.
  • Provide a description of the notification(s) to beneficiaries with details regarding what topics will be included. Draft samples may be provided, but are not required.
  • Provide a description of how plans will provide beneficiaries access to information regarding formularies and participating pharmacies.
  • Provide a description of any targeted communications that will be utilized, with details regarding what topics will be included. Draft samples may be provided, but are not required,
Website Modifications
  • Update with relevant information
  • Provide a description of the website(s) that will be used, what information regarding the pharmacy program will be made available, and how the web site will be updated and incorporated into the overall communication plan.
  • Provide detail regarding the functionality of the web site. For example, will provider or member portals be utilized? If so, what functionality and/or services will they provide?

Provider Outreach and Education

Plans will be responsible for provider outreach that addresses issues identified in the disruption analysis.
TOPIC ACTION REQUIREMENTS
Outreach May include:
  • Face to face meetings
  • Telephone briefings
  • Web cast
  
Prescriber Identification of beneficiaries so that prescribers can initiate new prescriptions and/or appeals/requests for prior authorization.
  • Provide a description of the plan´s prescriber outreach strategy and how it will be incorporated into the overall communication.
  • Provide detail regarding how the plans will determine and/or target outreach activities and how these activities will be conducted.
Pharmacy
  • Identification of beneficiaries so that pharmacies can update beneficiary files with updated plan information
  • Provision of beneficiary information to enable pharmacies to request eligibility information via an "E1" transaction
  • Provide a description of the plan´s pharmacy outreach strategy and how it will be incorporated into the overall communication plan.
  • Provide detail regarding how the plans will determine and/or target outreach activities and how these activities will be conducted.
  • Provide detail regarding how the plans will work with pharmacies to ensure a smooth implementation. For example, will eligibility information be shared with pharmacies so that they can update their systems with appropriate plan information, bin number, etc. prior to 10/1? Will plans enable pharmacies to request eligibility information via an "E1" transaction?