TR594Molina Healthcare, Inc', Pharmacy Presentation

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Molina Healthcare of Indiana www.molinahealthcare.
com 1-800-642-4509
450 E. 96th St., Suite 5006 Indianapolis, IN. 46
240 8001 Broadway, Suite 400, Merrillville, IN.
46410
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Marcia Palmer, PharmD, MBA Director of
Pharmacy Molina Healthcare of Indiana
September 2006
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AGENDA
Welcome

• Pharmacy Benefit Manager

• Pharmacy Claims

• Prior Authorization Process

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PHARMACY BENEFIT MANAGER
RxAmerica 221 Charles Lindbergh Drive Salt Lake
City, Utah 84116
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PHARMACY CLAIMS

• Molina Healthcare of Indiana
• Pharmacy Claims Statistics
• April 2005 5,122 Paid claims processed
• August 2005 15,945 Paid claims processed
• April 2006 23,374 Paid claims processed
• August 2006 44,974 Paid claims processed

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PHARMACY CLAIMS

• Drug Utilization Review - Member Safety
• On-Line edits/alerts are sent to pharmacies
  regarding
• Drug-Drug Interaction
• Drug - Age
• Drug-Gender
• Refill-Too-Soon
• Quantity Limits Day Supply

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PHARMACY CLAIMS
On-Line Messaging has been implemented to improve
communication to pharmacies and administration of
the pharmacy program Default messaging for
drugs that require a Prior Authorization
Includes plan fax number Default messaging
for drugs that have a generic available Quantity
Limits included by medication Formulary
Alternative Messaging included by medication
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PHARMACY CLAIMS

• Additional Procedures implemented
• After-hours Procedure to allow pharmacies to
  dispense emergency medications after-hours,
  weekends and holidays
• Out-of-Area Procedure implemented to provide
  claims processing
• Direct Member Reimbursement Procedure implemented
  for members who fill prescriptions out-of-service
  area

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PHARMACY CLAIMS

• RxAmerica calls are tracked by Member, Pharmacy,
  Physician and Healthplan to improve Member
  Service
• 2nd Quarter
• Member Calls 115 (2005) 213 (2006)
• Pharmacy Calls 429 (2005) 1520
  (2006)
• Physician Calls 73 (2005)
  356 (2006)
• Health Plan Calls 18 (2005)
  9 (2006)

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PHARMACY CLAIMS

• RxAmerica calls are tracked by type of call to
  improve Member Service
• 2nd Quarter
• Prior Authorization Calls 32.38 (2005)
  21.78 (2006)
• Plan Information 14.96 (2005) 8.10
  (2006)
• Eligibility 11.50 (2005) 5.24
  (2006)
• Drug Utilization Review
  10.71 (2005) 11.96 (2006)
• Plan Limits Exceeded (Day Supply) 10.39 (2005)
  15.44 (2006)
• All other types less than 4 of calls

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PRIOR AUTHORIZATION PROCESS

• To Expedite the Prior Authorization (PA) Process
  Molinas PBM, RxAmerica, implemented a
  value-added system called the RxApprover
• Its a fax server
• A paperless environment
• RxApprover recognizes where PA request came
  from and automatically, once the PA has been
  approved/denied sends a reply to that same fax
  number

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PRIOR AUTHORIZATION PROCESS

• Once a Prior Authorization is approved,
  RxApprover will put an authorization number into
  the pharmacy system so patient can receive the
  medication
• RxApprover also allows us to inform the physician
  if there are any alternative medications that can
  be substituted than what was requested
• Ultimate goal for RxApprover system is to allow
  our physicians the ability to request a Prior
  Authorization from their office and get an
  immediate answer

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PRIOR AUTHORIZATION PROCESS
Prior Authorization Request is needed when

• Medication is not included on Molina of
  Indianas Preferred Drug List (PDL)
• Medication is considered medically necessary
• Formulary alternatives have demonstrated
  ineffectiveness

When these exceptional situations occur,
physicians office may fax a completed
medication prior authorization form to Molina
at 1-877-581-7145
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THE MOLINA MISSION

• Molina Healthcare is an innovative health care
  leader providing quality care and
• accessible services in an
  efficient and caring manner.
• Core Values
• We strive to be an exemplary organization
• We provide quality service
• We are healthcare innovators and respond
  quickly to change
• We respect each other and value ethical
  business practices
• We are careful in the management of our
  financial resources
• We care about the people we serve.
• This is the
  Molina Way