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Products that have been covered with a transition fill using the DPA will no longer be covered starting April 1.  Please work with your patients and physicians to transition to CCRx formulary medications or initiate the Prior Authorization or exceptions process if your patient must continue on their current medication (request forms are available at CCRx.net).
 

The Pharmacy and Therapeutics Committee has established quantity limitations on certain medications to ensure patient safety and appropriate dosing. Quantity limits are generally based on manufacturers’ recommended dosing guidelines. To minimize disruption during the transition period, CCRx relaxed enforcement of quantity limits.  CCRx is in the process of activating formulary restrictions and edits to reflect our planned benefit design.

Beginning March 20, quantity limit edits will be restored for atypical antipsychotics, triptans, oxycodone SR tablets, and ketorolac. 

Pharmacists should work with physicians to change prescription quantities if needed.  The dynamic PA, which overrides ‘PRODUCT NOT COVERED’ rejects, can still be used until April 1 for initial prescriptions with quantity limits for patients who need a transition supply.

Physicians should request an exception if it is medically necessary to exceed the quantity limits.  The request form and a complete list of CCRx quantity limits are available for download at CCRx.net. Click on the link for ‘Providers/Physicians.’

Quantity Limits Per 30 Days

• Imitrex, Maxalt, Maxalt-MLT, Relpax, and Zomig tablets:  9 tabletsImitrex and Zomig spray:  8 sprays
• Imitrex injection:  3 kits or 6 vials (6 injections)
• ketorolac:  20 tablets; 20 mL of 15 mg/mL inj; or 10 mL of 30 mg/mL inj
• oxycodone 10, 20, 40 mg SR tablets:  90 tablets
• oxycodone 80 mg SR tablets:  60 tablets

• Abilify (2 mg, 5 mg, 10 mg, 15 mg, 30 mg ; 1 mg/mL solution) : Schizophrenia: 10-15 mg/day (max 30 mg/day)1,2 , Bipolar Disorder: 15-30 mg/day, Quantity Limit per 30 days is 30 tablets; 750 mL
• Zyprexa (2.5 mg. 5 mg. 7.5 mg, 10 mg, 15 mg, 20 mg): Schizophrenia:10-20 mg/day, Bipolar I (Mania-Mixed) 5-20 mg/day, Quantity Limit per 30 days is 30 tabs
• Risperdal (0.25 mg. 5 mg, 1 mg, 2 mg 3 mg, 4 mg; 1 mg/mL solution): Schizophrenia: 4-8 mg/day3, Bipolar Mania (Initial): 1-6 mg/day4, Quantity Limit per 30 days is 60 tabs; 120 mL
• Seroquel (25 mg, 50 mg, 100 mg, 200 mg, 300 mg, 400 mg): Schizophrenia: 300-800 mg/day, Mania: 400-800 mg/day, Quantity Limit per 30 days is 120 tabs
• Geodon (20 mg, 40 mg, 60 mg, 80 mg): Schizophrenia: 40-160 mg/day, Mania 80-160 mg/day, Quantity Limit per 30 days is 60 tabs

Antipsychotic Dosing Tips
The lowest effective dose should be utilized to decrease dose related side effects and improve patient compliance.

• Risperdal: Studies evaluating dose response relationship determined that 6 mg/day was the optimal dose for treating both positive and negative symptoms of treatment-resistant schizophrenia. Doses beyond the manufacturer’s recommended dose are associated with increased risk of extrapyramidal symptoms and hyperprolactinemia.
• Zyprexa: Doses beyond 20 mg/day may have increased efficacy but also increased incidence of headache and dizziness.
  
  • Seroquel: The optimal dose for chronic schizophrenia is 300 mg/day. Higher doses (600 mg/day) may be beneficial in patients with a partial response to conventional antipsychotics and in patients with comorbid cognitive dysfunction.
  • Geodon: Although the dose range is 40-160 mg/day, the optimal effective dose for maintenance treatment of schizophrenia is 40 mg/day. A dose related prolongation in QTc interval has been observed at higher doses.
  • Abilify: No dose response relationship has been observed across the range of 15-30 mg/day. An increased incidence of somnolence is observed at the higher doses.

The Medicare Part B durable medical equipment (DME) benefit covers inhalation drugs that require the use of a nebulizer “in the home.” Certain long-term care (LTC) facilities are not considered a “home” for this purpose. Inhalation solutions for residents in a facility that meets the following criteria are reimbursable under Part D (to the extent that they are not covered under Part A).

• Hospital or skilled nursing facility bed that does not have part A coverage, whose part A coverage has run out or whose stay is not covered
• A nursing home that is dually-certified as both a Medicare SNF and a Medicaid SNF
• A Medicaid-only NF that primarily furnishes skilled care
• A non-participating nursing home (i.e., neither Medicare or Medicaid) that provides primarily skilled care
• An institution which has distinct part SNF primarily furnishing skilled care

For patients residing in their own home or in assisted living facilities coverage for solutions used in a nebulizer is under the DME benefit under Part B .

For albuterol, ipratropium, and cromolyn:  Prior authorization is not required for LTC pharmacies or pharmacies submitting claims for LTC residents with patient location code 03.  Medicare Part B should be billed for beneficiaries not residing in one of the facilities in the bulleted area above.

The following formulary medications require completion of a prior authorization form to determine medical necessity in addition to Medicare Part B vs. D coverage:

• Pulmicort Respules Prior Authorization Form:
  1 Determines if coverage is under Part B or D
  2 Assesses if being used for an FDA-approved indication, whether patient has ability to utilize a MDI, and if the patient has not received an appropriate response from maximally efficacious dose of corticosteroid inhalers
  
• Pulmozyme Prior Authorization Form:
  1 Determines if coverage is under Part B or D
  2 Assesses if being used for an FDA-approved indication and administered with an effective nebulizer as per the manufacturer’s recommendation

In less than two months the initial enrollment period for Medicare Part D will end on May 15. Eligible beneficiaries who miss the deadline will not be able to enroll in a Medicare Part D plan until the next open enrollment period which begins on November 15. Additionally, non-dual eligible or LIS beneficiaries who are enrolled in a plan will not be able to change plans until until November after the May 15 deadline.

You can help avoid the last minute enrollment crunch expected the first two weeks of May by educating your patients about the benefits of enrolling now in a Part D plan. Those who are eligible and don’t enroll by May 15 will begin to incur the 1 percent per month premium penalty unless they have other creditable drug coverage. At the very least, they will incur seven months of penalty; resulting in a premium 7 percent higher if they wait until November instead of enrolling now.

The CCRx plans-basic, choice, and gold-are designed to appeal to beneficiaries with a variety of medication needs and budgets. Enrollers from Community Care Outreach Services (CCOS) are available to come to your store and assist beneficiaries with choosing the CCRx plan that is right for them. Enrollers, who are licensed insurance agents, have facilitated more than 26 percent of all CCRx enrollments, making them a valuable resource for you and your patients. Think of the CCOS enrollment representative as a “free” employee for the day. To request an enroller, please call 888-868-5854 x172 or look for our online enroller request form launching in the near future.

CCRx encourages pharmacists to work with their patients and educate them about the value of enrolling in CCRx by mid-month to allow the systems ample time to process the enrollment and ensure that they have ID and group numbers in hand by their effective date on the first of the following month.

It is just past the middle of March. Beneficiaries may continue to enroll in CCRx through March 31 and have a benefit effective date of April 1, however, some beneficiaries may not receive letters by the time they begin using their benefit. If a patient presents at your store who enrolled in March but still hasn’t received a letter, please call the Pharmacy Tech Center (PTC) at 866-684-5395 for assistance if the eligibility transaction does not reflect current data.

CCRx will begin the national rollout of its medication therapy management (MTM) program in June. CCRx with its MTM program will expand the role of community pharmacy by demonstrating that the pharmacists, in addition to their important dispensing role, are also are also clinical service providers, risk managers, and financial advisors to the patients they loyally serve. Importantly, pharmacists deserve to be compensated for this valuable service.

Have you thought about how you will prepare your pharmacy for the CCRx MTM program? With only three months until rollout, it’s the perfect time to begin educating yourself and your staff about this new, vital opportunity.

Staffing and Time Management

MTM is an investment in your future and will require the pharmacist to move some time from dispensing to consulting. Evaluate your current staffing levels and determine if pharmacist dispensing can be made more efficient through increased use of technicians or automated dispensing systems, freeing up time for the pharmacist to conduct MTM sessions.

CCRx will utilize Community MTM Services, Inc. (CMTM), a web-based communications service that will facilitate the delivery of MTM and other patient care services by community pharmacists. CMTM will make it possible for pharmacists to deliver MTM efficiently and easily. Your CCRx MTM sessions are budgeted to reimburse pharmacists for a consultation that should last approximately 30 minutes. Evaluate traffic flow in your pharmacy as you decide when it is best to schedule MTM visits in your store.

Documentation and Billing

CCRx understands how busy pharmacists are. That’s why CCRx chose CMTM to deliver medication therapy management services. With CMTM pharmacists will access an online system that makes it simple to document findings of the consultation by utilizing check boxes, pull down menus, and brief fill-in boxes. Even the coding and claims submission will be handled for you. Pharmacists will simply verify that the patient’s and pharmacist’s data are correct and click the submit button.

CCRx will remit payment for MTM visits separately from dispensing payments on a monthly basis.

Patient Education Materials

CCRx wants pharmacists to have successful outcomes and patient compliance as a result of their time and effort spent on MTM. With the CMTM service pharmacists will have access to patient education materials at the touch of a button. You’ll be able to print materials for your patient at the time of the MTM session.

Private Consultation Area

To ensure patient privacy, designate a secluded area of your store for MTM sessions. Partitions can be used in a common area to make it private but make sure the area is quiet. Ideally, the area should have a computer with Internet access and a printer.

CMTM will deliver the names of those CCRx patients who qualify for MTM to you. It is up to you to demonstrate the importance of your role as not only one who dispenses medications but also that of a trusted clinician improving the overall health of your patients. MTM is only the beginning of the value-added services pharmacists will provide to the health care system, and CCRx is the first Medicare Part D program with the vision to recognize the valuable role community pharmacists will play in keeping patients healthy and compliant.

CMS is preparing to begin the Auto Facilitated Enrollment process for beneficiaries who are not full-benefit dual eligibles but who are eligible for the low income subsidy (LIS) and have not already enrolled in a plan. The population of beneficiaries who qualify for auto facilitate enrollment into a Part D plan consist of two subsets:

• Partial Duals, that are mostly Qualified Medicare Beneficiaries (QMB) only, Specified Low-income Beneficiary (SLMB), or Qualifying Individuals (QI), are the Medicare beneficiaries for whom Medicaid pays the Medicare Part B premium, or in the case of QMBs also the Medicare Cost Sharing. These individuals will be eligible for a continuous SEP and will be able to change Part D plans monthly, the same as full benefit dual eligibles.
• Social Security (SSI) only - beneficiaries who applied for and were approved for LIS through the Social Security Administration (SSA). These individuals will be eligible to change plans once if they are not satisfied with the plan to which they were assigned.

CMS will send auto facilitated enrollees a letter on green paper notifying them that they will be auto-enrolled into a plan effective May 1, 2006. The letters will reach these beneficiaries around the first week of April, and the beneficiaries will have until April 30 to change or opt out of their assigned plan. If no change is requested, their benefit will begin on May 1 in their assigned plan.

Please note-these beneficiaries are different from the auto-assigned, full-benefit dual eligibles (Medicare and Medicaid) who receive yellow letters.

The Centers for Medicare and Medicaid Services (CMS) has issued a warning to seniors and people with disabilities to be aware of a scheme that asks Medicare beneficiaries for money and checking account information the help them enroll in a Medicare Part D plan. The scheme is called “$299 Ring” for the typical amount of money Medicare beneficiaries are talked into withdrawing from their checking accounts to pay for a non-existent prescription drug plan.

Medicare has received complaints from Indiana, Michigan, Pennsylvania, Massachusetts, New Jersey, and Georgia about many different companies, but authorities believe these companies are the same and typically based outside the U.S. CMS is turning over all complaints to federal law enforcement authorities for investigation.

Pharmacists can help prevent scams by educating their patients that no Medicare drug plan can ask a person for bank account or other personal information over the phone. Beneficiaries should never provide that kind of information to a caller and should contact their local police department if they believe someone is trying to take money or collect information from them illegally.

Legitimate Medicare Part D plans NEVER ask a beneficiary for money over the phone or Internet. Patients are billed for their monthly premium or may elect for an automatic withdrawal from their Social Security checks.

CMS requests that Medicare beneficiaries heed the following advice when being solicited for a Part D plan:

• No one can come into your home uninvited.
• No one can ask for personal information during their marketing activities.
• Keep all personal information, such as a Medicare number, in a safe place as a person would do for a credit card or Social Security card.
• Call 800-Medicare if there is concern about an activity or if there is a question regarding Medicare.

If a beneficiary believes that they are being solicited for a scam, CMS encourages him/her to call the local law enforcement office or 877-7SAFERX.

You may still be receiving inaccurate eligibility information because the system might not be updated with the most current information. Please call the CCRx Pharmacy Tech Center at 866-684-5395 to verify eligibility if you are unsure of a patient’s status.