Program Implementation Notice

[PDF]Program Implementation Notice -

12 downloads 79 Views 235KB Size

Program Implementation Notice Effective January 1, 2013 US Script will be the Pharmacy Benefit Manager (PBM) for Sunflower State Health Plan (Sunflower). We are pleased to welcome you to the US Script Pharmacy Network Program and are happy to answer any questions you may have. Please refer below for frequently asked questions regarding Sunflower and the US Script Agreement. For any other additional questions, please contact the US Script Pharmacy Network Development Department at (800) 460-8988 or pharmacycontract[email protected]

Frequently Asked Questions: Is my pharmacy contracted with US Script for Sunflower members? US Script has existing contracts with the Kansas chains and Pharmacy Services Administration Organizations (PSAOs) listed below. If your pharmacy is associated with one of these groups, they are reviewing or have already executed a Sunflower Addendum. The contract Addendum must be completed before you are able to process prescriptions for Sunflower members. 39 43 97 110 207 229 246 758


139 307 490 496 540 603 605 630 651 712

Medicap Medicine Shoppe Balls Four B Corp A W G Pharmacy Network TriNet Leader Access Health605 Access Health630 Family Care Major Value

PSAOs 767 769 854 860 866 872 904 967 A87 A96

Rx Pride PPOK Third Party854 OK Area Indian Health Service Phcy Third Party866 Insty Meds GPPN H D Smith Third Party The University Of Kansas Hospital CIPN

What happens if the PSAO representing my pharmacy does not execute an Addendum? If your PSAO does not provide an executed Amendment US Script’s Pharmacy Network Development staff will contact you directly to execute an independent Agreement and Sunflower Addendum.

My pharmacy is not associated with the groups listed above. How can I contract with US Script? US Script identified most Kansas pharmacies not currently in our network and sent a contract packet to them in October 2012. If you did not receive a packet, you can call our offices at (800) 460-8988 or email us at [email protected] to request a copy. We can send via email, fax, or mail at your preference. NOTE: To participate in this program, you must be located in Kansas or within 50 miles of the State border AND you must have a Kansas Medicaid provider ID number.

Can I dispense DME and medical supplies to Sunflower members if I have a US Script contract? No. If you currently dispense DME products and diabetic supplies for Kansas Medicaid eligible patients, we hope you will choose to contract for these services with Sunflower State Health Plan for their members in the KanCare program. These items are not included in the US Script pharmacy benefit.

If you would like a contract, please reach out to Sunflower’s Network Development team at 1-877-644-4623 or via e-mail at [email protected]

Can I dispense medications to Sunflower members without a US Script contract? No. You must have either a current contract with US Script or execute a US Script Agreement and Sunflower Addendum, as well as submit a credentialing application before we can permit your pharmacy to process prescriptions for reimbursement.

How will I know if I’m not contracted? When you submit a claim for a member prescription, you will receive a point of service (POS) claim denial stating you are a “non-contracted pharmacy.” Call or email us to get your pharmacy contracted if you receive this denial. We will help to expedite a contract for you. If you submit a DME/Supply claim to US Script, your POS denial will indicate you need to contact Sunflower State Health Plan for reimbursement.

Page 27 of the US Script Agreement lists several Fee Schedules. Which Fee Schedule is for Sunflower members? These are the US Script Commercial Fee Schedules. You must participate in the Open Access network (at the top of the page) because it is our default network. The other networks are optional and/or do not apply in Kansas.

Where is the KS-Sunflower Fee Schedule indicating the $3.40 mandated dispensing fee? At the end of the Agreement (after page 61), you will find the Amendment for Sunflower signature page. It is followed by Exhibit A, which is the Sunflower Fee Schedule, and Exhibit B, which are the State regulatory requirements.

Who can answer other questions about the contract? You can contact Pharmacy Network Development staff at (800) 460-8988 or email questions to [email protected]

Our pharmacy provides Specialty medications. Does that require a special contract? No. Currently, specialty medications are reimbursed at the same rates as non-specialty items and any willing provider with a Kansas Medicaid ID and an executed US Script Agreement with Sunflower Addendum can dispense specialty medications after securing required prior authorizations.

If a member does not have their ID card, how can I determine eligibility?

The patient’s Medicaid ID number is our primary system ID number. If that is not known, you can use the member’s Social Security number, case number, or Amysis number as an alternate ID.

I heard about a “Spend Down” process. What is that? The KanCare program includes coverage for certain family cases where the members must meet a predetermined amount of their health care costs before being eligible for program benefits. Their case managers determine the spend down amount and it is tracked as the member/family incurs covered costs. Within the pharmacy point of service (POS) claims system, any spend down needing to be applied to the members’ prescription will be identified within the copayment field. Although US Script is receiving daily updates for the State’s spend down file, you may be notified post claim adjudication by the State that the member’s spend down was already met. In that instance, you will need to reverse the original claim and reprocess. Any excess copayment made by the member must be refunded to the member in a timely manner. Questions by the member about the amount or accuracy of the spend down amount calculated as their copayment should be directed to the State’s spend down program unit at: (800) 792-4884.

When the reimbursement amount for medication is “too low” can I choose not to dispense? No. Your contract requires you to provide the medication. US Script will review any pricing questions and will adjust pricing and approve reprocessing when appropriate. The pricing inquiry form is available on the US Script website at Fax or email the completed form with a copy of your purchase invoice as directed on the form. It usually takes 7-10 business days to complete this process. However, if you have an unusual situation, please call our Pharmacy Network Services team at (800) 460-8988 to discuss your concerns. In no instance is it OK it deny the member their covered medication(s) or require them to pay for it instead of processing the US Script/Sunflower claim.