TR589Managed Health Services MHS Pharmacy Presentation

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Managed Health Services
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Managed Health Services
Who Are We

• MHS Indiana
• Centene Corporation
• Betty Brinn Foundation
• Centene Foundation for Healthcare Quality

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Agenda

• MHS Overview
• Preferred Drug List
• Prior Authorization
• Contingency Protocol
• 72 Hour supply
• Synagis
• Pharmacy Network
• Questions and Answers

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Managed Health Services
Our Guiding Principles

• Physician Directed
• Nurse Mediated
• Member Empowered

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Managed Health Services
Mishawaka
Indiana Office Locations

Merrillville
Fort Wayne
Muncie
Indianapolis
Indiana counties with MHS membership
MHS Indiana office locations
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Managed Health Services
Member Empowerment

• Nursewise
• 24/7 toll free nurse advice line
• Bi-lingual staff
• Member Services
• CONNECTIONS Program
• Transportation
• Statewide vendor reached through toll-free number
• Health Education in the Community
• Participation in local health fairs

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Managed Health Services
Coordinated Care

• Preventive Care
• Disease / Care Management
• OB Programs
• Immunization Initiatives
• Asthma/Diabetes Initiative
• Focused Utilization Management
• Team Concept (Physician, Nurse,
  Social Worker, Coordinator)
• Work in Partnership with Doctors

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Managed Health Services
Provider Empowerment

• Physician Committees
• Compensation
• Pharmacy and Therapeutics
• Quality Management
• Provider Driven Programs
• Pharmacy Gold Card Program
• Member Restricted Card Program
• Practicing Physicians in Key MHS Roles
• Access to Key MHS Leadership

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Managed Health Services
Whats New for 2007

• Behavioral Health Carve-In
• Members Pick-A-Plan
• Pay For Performance
• Member Initiatives
• E Health
• Enhanced Web Portal

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• PHARMACY

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Managed Health Services
Preferred Drug List

• What is a Preferred Drug List?
• A PDL is a continually updated list of
  medication and related information, representing
  the clinical judgment of physician, pharmacists
  and other experts in the diagnosis and/or
  treatment of disease and promotion of health.

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Preferred Drug List

• Why does MHS utilize a PDL?
• To promote rational, clinically appropriate,
  safe and cost effective drug therapies to best
  serve the health
• interest of the MHS Members.

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PDL Prior Authorization Process

• Most drugs do not require prior authorization
• Contact Pharmacy Benefit Manager (PBM) US Scripts
  for approval for drugs that require a PA
• Phone [phone]
• Fax [phone]
• Telephonic Process with immediate determination
• Confirmation via Fax
• Denials only made by Medical Director

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Contingency Protocol for Drugs

• Several drugs on PA list have contingency
  protocols to decrease the number of instances
  when the PBM must be contacted. This makes for a
  more user friendly process
• Example Advair a soft edit in the system looks
  for a claims history of Serevent and Flovent. If
  present, the prescription automatically approves,
  bypassing PA requirement.

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Medical Necessity Approvals

• Providers MUST provide medical necessity
  documentation for certain medications if
• The medications that are on the PA list, but a
  first line has not been used
• Medications that are not on the PDL
• Medications that are not indicated for use in the
  manner that they are being prescribed for
• Substance abuse treatment medications
• Example Methadone

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72 Hour Supply

• A 72 hour supply may be given to a Member if
• A PA is required and the physician is not
  available
• Medication can not be abruptly discontinued
• Comes in a non-dividable container (i.e. MDI,
  creams, etc.) in these cases the full container
  must be filled
• Note Narcotics that are not completely filled
  within 72 hours will require a new prescription
  under IC. Certain meds should not be abruptly
  discontinued for the safety of the member, thus
  warrant getting full approval for the
  prescription before filling is the better
  solution.

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Synagis

• MHS, effective 10/30/06 for patients that meet
  MHS criteria centered around American Academy of
  Pediatrics will approve 5 doses through March
  31, 2007
• Doses to be given after March 31, 2007 will be
  required to be authorized by MHS
• Synagis (Billed as J Code)
• Cost per dose 1400 - 1500 (average) and
  available through Caremark only
• Contact Caremark at 1-800-237-2767

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Injectables

• Office
• Pharmacy
• Caremark

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Pharmacy Network

• Pharmacy Network over 800 pharmacies
• CVS
• Walmart
• Walgreens
• Independent Pharmacies
• Do Not Leave Pharmacy Without Your Medication
  Campaign
• Members
• Providers
• Pharmacists

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Questions and Answers