# Presentation: 657841

## American Indian and Alaskan Native Medicare Drug Discount Card Program and $600 Credit

- Computer Sciences Corporation (CSC) and MemberHealth

***Foxwoods, CT****** ***

## Agenda

- Introduction to CSC and MH
- CSC/MH Dedication to AI/AN Program
- Enrollment/Disenrollment
- Pharmacy Participation
- Discount Drug List
- Prescription Claim Submission
- Copayments
- Benefits to Providers
- Benefits to Beneficiaries
- Questions

## Introduction: Criterion Advantage 

- Criterion Advantage is a collaboration between Computer Sciences Corporation (CSC) and MemberHealth, Inc. (MH)
- CSC is the prime contractor under this initiative
- CSC and MH have partnered to provided the Medicare approved Criterion Advantage Discount Drug Card Program

## Sponsor Introduction: Who is Computer Sciences Corporation (CSC)?

- Founded in 1959, CSC is a leading global information technology (IT) services company
- Mission is to provide customers in industry and government with solutions crafted to meet their specific challenges and enable them to profit from the advanced use of technology
- Provides innovative solutions for customers around the world by applying leading technologies and CSC’s own advanced capabilities
- Provides systems design and integration; IT and business process outsourcing; applications software development; Web and application hosting; and management consulting
- Headquartered in El Segundo, CA; with approximately 90,000 employees worldwide; CSC reported over $14 Billion in revenue for Fiscal Year 2004
- Major CMS projects include: Common Working File, Managed Care Redesign, Program Safeguard Integrity, Medicaid Architecture

## Sponsor Introduction: Who is MemberHealth (MH)?

- MemberHealth operates a number of national and state prescription benefit administration (PBM) programs, including insured, self-insured and discount prescription plans.
- MemberHealth is the PBM contractor for the CSC Medicare approved programs including Community Care Rx (CCRx), Criterion Advantage (CA), both nationwide programs, and the Golden Buckeye program in Ohio.
- Additionally, MemberHealth and CSC administer a growing list of state PAP/Medicare wraparound programs, including Connecticut, Ohio, North Carolina, and Mississippi.
- MemberHealth and CSC manage two Special Endorsed Medicare programs, for Long Term Care and I/T/U (AI/AN).
- MemberHealth is headquartered in Solon (Cleveland), Ohio

## Committed to the Success of the AI/AN Program

- Attended and participated in Medicare Tribal Technical Advisory Group (TTAG) meetings and conferences in Reno, NV, Orlando, FL and Washington, D.C.
- Participated in the May 28 Direct TV satellite broadcast, presenting an overview of the program.
- Worked closely with IHS and TTAG to ensure that the contracting language was appropriate for the Indian Health Service, Tribes and Tribal Organizations, and Urban Indian Organization (I/T/U) pharmacies
- Worked closely with IHS and TTAG to assure that pre-enrollment outreach and membership materials accurately describe the Medicare approved Drug Discount Card program as it relates to AI/AN
- Plan to attend every IHS regional training session to educate pharmacists, business managers and other stakeholders about the drug discount program and the $600 credit

## Enrollment

- Fill out and submit enrollment application
- There are two separate forms:
- Enrollment form for the Medicare–Approved Drug Discount Card
- Enrollment form for the Medicare–Approved Drug Discount Card _and_ $600 Credit in Paying for Your Prescription Drugs
- Make sure to complete and send in the correct form
- Only one form should be submitted; do not submit both forms
- Do not omit or leave blank any fields of the form (ie:  member income, pharmacy NCPDP#)

## Example  Criterion Advantage Enrollment Forms for $600 Credit

## Example  Criterion Advantage Enrollment Forms for Discount Only

## Enrollment

- Enrollment fee is $30.00
- If applying for $600 Credit/Transitional Assistance (TA), Medicare will pay the enrollment fee
- If applying for discount drug card only, enrollee has to pay the enrollment fee
- Purchase Order (Voucher) will likely be issued for the payment of the enrollment fee
- Important to apply for $600 credit as soon as possible
- Beneficiaries who qualify for $600 credit and enroll in 2004 will receive $600 credit in 2004 and $600 credit in 2005 to use towards their prescription drugs
- If do not enroll by end of December will lose the $600 credit for 2004
- $600 credit will be prorated for anyone who enrolls after March 31, 2005 (losing $150 each quarter)

## Disenroll from a General Drug Card to Enroll in an I/T/U Special Endorsed Drug Card

- If a beneficiary is currently enrolled in a general Drug Discount Card that does not have the I/T/U special endorsement, the beneficiary may elect to disenroll from the general card and enroll in a special endorsed card program at any time
- A Special Election Period (SEP) has been established for American Indian/Alaskan Natives (AI/AN) who want to disenroll from a general Drug Discount Card in order to enroll in an I/T/U special endorsed card.
- SEP is for the life of the Medicare Drug Discount Card Program
- To be eligible for the SEP, the AI/AN will need to disenroll from the general card in which s/he is currently enrolled and inform the sponsor that s/he qualifies for the SEP before the enrollment in the I/T/U special endorsed card can take place

## Pharmacies: Network Pharmacies

- To obtain a discount or use the $600 credit beneficiaries must have their prescriptions filled at a network pharmacy
- The pharmacy network includes:
- Indian Health Service, Tribes and Tribal Organizations, and Urban Indian Organization pharmacies that are under contract with Criterion Advantage
- Retail pharmacies that are under contract with Criterion Advantage
- Tribal Accupax mail service pharmacy
- Become a network pharmacy by signing a network pharmacy contract as soon as possible
- All IHS pharmacies are contracted with Criterion Advantage
- Tribal and Urban Indian contract has been approved by CMS; your packet includes a copy. Each pharmacy must sign the contract in order to provide services

## Pharmacies: Mail Service Pharmacy

- Beneficiaries can send written prescriptions to the pharmacy
- I/T/U pharmacies in rural areas who do not have a drug in stock and do not have access to CHS contracted retail pharmacies can fax written prescriptions to the mail service pharmacy to be filled
- Prescriptions should be written for a minimum of 60 to 90 days supply
- Normal service cycle is a maximum of three days to process the order in the pharmacy
- Complete reviews of the ordered prescriptions against the user’s medical, prescription, and allergy profile are conducted
- Please allow for 14 days from the date the beneficiary sent the prescriptions to the pharmacy for the processing and mailing of prescriptions
- Shipping is through the U.S. Postal Service and is free

## Discount Drug List

- I/T/U sites will keep the Federal Supply Schedule as their formulary
- Open Formulary for retail and mail pharmacies
- ALL brand and generic drugs are covered under the program except those federally excluded (next slide)
- The Discount Drug List is to be used when having prescriptions filled at pharmacies that are not operated by the Indian Health Service, Tribes and Tribal organizations, or Urban Indian organizations (I/T/U)
- The Discount Drug List is to be used when having prescriptions filled at retail pharmacies

## Discount Drug List: Federally Excluded Drugs

- Drugs not covered under the Medicare Discount Card are:
- Anorexia, weight loss, or weight gain
- Fertility Drugs
- Cosmetic purposes or hair growth
- Drugs to relieve coughs or colds
- Prescription vitamins and mineral products (except prenatal)
- Nonprescription drugs (Over-the-counter drugs)
- Barbiturates
- Benzodiazepines
- Drugs that could be covered under Medicare Part B

## Example Criterion Advantage Card

## Prescription Claim Submission

- Pharmacies with electronic billing capability will submit claims electronically and they will be adjudicated online
- Pharmacies without electronic billing capability will submit paper claims
- Pharmacy calls the helpdesk to obtain the transitional assistance balance remaining
- If a balance remains, pharmacy faxes a Universal Claim Form to MemberHealth for reimbursement
- MemberHealth will enter the claim online upon receipt of the claim form during hours of operation (M-F 8:00am-5:00pm EST)
- Pharmacy may also call the helpdesk to provide the claim information by phone for online entry, but will still be required to fax a Universal Claim Form to MemberHealth
- Payment is not guaranteed until the online claim has been successfully processed

## Copayments: Prescription Filled at I/T/U Pharmacy

- If beneficiary has qualified for the $600 credit and has prescriptions filled at an I/T/U network pharmacy, then s/he likely will not pay a coinsurance at the pharmacy for each prescription drug (presuming the facility has agreed to waive the copay)
- The drug cost will be applied toward the $600 annual credit

## Copayments: Prescription Filled at Retail Pharmacy (Non-I/T/U)

- If beneficiary has qualified for TA and self-refers to have prescriptions filled at a retail pharmacy, s/he will pay a coinsurance at the pharmacy for each prescription drug, until the credit of up to $600.00 is used, based on the income level as follows:
**American Indian**
- Single, $12,569 or less, 10% copay       (up to 135% FPL)
- Single, $ 9,310 or less, 5% copay          (up to 100% FPL)
- Married, $16,862 or less, 10% copay     (up to 135% FPL)
- Married, $12,490 or less, 5% copay       (up to 100% FPL)
**Alaskan Native**
- 135% FPL, Family size of 1:$15,701
- 135% FPL, Family size of 2:$21,074
- 100% FPL, Family size of 1:$11,630
- 100% FPL, Family size of 2:$15,610
- If beneficiary has an authorized Contract Health Services (CHS) referral and has prescriptions filled at a retail pharmacy, CHS will cover the cost of the prescriptions and the coinsurance amount

## Benefits to I/T/U Providers

- Up to $600 paid to network I/T/U pharmacies to reimburse for prescriptions that they fill for _each eligible beneficiary_
- 		Estimated 20,000 eligible AI/AN beneficiaries
- 		       =   $12 million in federal $$ available
- Saves Contract Health Services’ funds
- If beneficiary has an authorized Contract Health Service referral and has prescriptions filled at a retail pharmacy, the $600 credit will be used to pay for the drugs at the retail pharmacy
- Positions AI/AN to be a part of 2006 Part DProgram

## Benefits to AI/AN Beneficiaries

- Beneficiaries who qualify for $600 credit and enroll in 2004 will receive $600 credit in 2004 and $600 credit in 2005 to use towards their prescription drugs
- Any unused portion of the $600 credit that is not used in 2004 will roll over to 2005
- Beneficiaries who do not qualify for the $600 credit will receive prescription drug discounts, especially if prescriptions are being filled at a retail pharmacy
- Ability to obtain prescriptions through Tribal Accupax mail service pharmacy at deeper discount

## Contact Information

- Scott G. Hughes R.Ph.			Louis Hogan
- MemberHealth Inc.			Computer Sciences Corp
- 888-868-5854				443.436.6620
- _[shughes@mhrx.com](mailto:shughes@mhrx.com)_			lhogan2@csc.com

## Questions?