DOCSLIB.ORG

Structuring Physician-Pharmacy Ventures

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text

Load more

Presenting a live 90-minute webinar with interactive Q&A Structuring Physician-Pharmacy Ventures: Minimizing Regulatory Risks, Ensuring Reimbursement Navigating Corporate Practice of Medicine/Pharmacy, Anti-Kickback and Stark Laws, and State Regulation WEDNESDAY, MAY 3, 2017 1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific Today’s faculty features: Reesa N. Handelsman, Partner, Wachler & Associates, Royal Oak, Mich. Rick L. Hindmand, Member, McDonald Hopkins, Chicago Todd A. Nova, Shareholder, Hall Render Killian Heath & Lyman, Milwaukee The audio portion of the conference may be accessed via the telephone or by using your computer's speakers. Please refer to the instructions emailed to registrants for additional information. If you have any questions, please contact Customer Service at 1-800-926-7926 ext. 10. Tips for Optimal Quality FOR LIVE EVENT ONLY Sound Quality If you are listening via your computer speakers, please note that the quality of your sound will vary depending on the speed and quality of your internet connection. If the sound quality is not satisfactory, you may listen via the phone: dial 1-866-819-0113 and enter your PIN when prompted. Otherwise, please send us a chat or e-mail [email protected] immediately so we can address the problem. If you dialed in and have any difficulties during the call, press *0 for assistance. Viewing Quality To maximize your screen, press the F11 key on your keyboard. To exit full screen, press the F11 key again. Continuing Education Credits FOR LIVE EVENT ONLY In order for us to process your continuing education credit, you must confirm your participation in this webinar by completing and submitting the Attendance Affirmation/Evaluation after the webinar. A link to the Attendance Affirmation/Evaluation will be in the thank you email that you will receive immediately following the program. For additional information about continuing education, call us at 1-800-926-7926 ext. 35. STRUCTURING PHYSICIAN-PHARMACY VENTURES: MINIMIZING REGULATORY RISKS, ENSURING REIMBURSEMENT Reesa Handelsman Rick Hindmand Todd Nova Wachler & Associates, P.C. McDonald Hopkins LLC Hall Render [email protected] [email protected] [email protected] 248.544.0888 312.642.2203 414.721.0464 Agenda • Overview - Drivers of Increased Pharmacy Integration Chatter • State Law, AMA • Stark & Anti-Kickback • Risk Profile • Institutional Considerations • Pharmacy Management Agreements 5 Integration Drivers – Payment Systems • Current: PPS Model • Effective October 1983. • Today includes - Acute Care I/P (DRG); Outpatient (APC); FQHC (Visit PPS) • Some limited exceptions - RHC; Hospice; CAH; etc. • Future: Value-Based Purchasing (VBP) and Bundled Payments • Per CMS, current payment systems reward quantity, rather than quality • What is VBP? • Reward quality of care through incentives and transparency • Link payment more directly to the quality of care provided • May 6, 2011 VBP Regulation: • “The overarching goal of these initiatives is to transform Medicare from a passive payer of claims to an active purchaser of quality health care for its beneficiaries.” 6 Integration Drivers – Reimbursement Office-Based Professional Component • Physician Fee Schedule (“PFS”) RVU (non-facility) drug administration CPT codes • PFS E&M CPT Code (non-facility) Drug cost • Part B: ASP + 6% (was percentage of AWP) Hospital-Based Technical Component • APC Professional Component • PFS E&M and/or procedure CPT Code (facility) Drug cost • PPS - Part B: • ASP + 6 % (if drug cost greater than drug packaging threshold of $100 for 2016) • Bundled into APC (if drug cost lower than drug packaging threshold of $100 for 2016) • Limited subset of drugs with “pass-through” status (separate payment regardless of price) • Status indicator G – roughly 40 in 2016 OPPS Final Rule • CAH • 101% of reasonable costs Pharmacy • Part D ingredient cost plus dispensing fee (plan specific) • Part B reimbursement not available for any drug usually self-administered 7 Issues Impacting Drug Cost and Reimbursement Costs Revenues • Care coordination • Part A Reforms • ACO/Shared Savings • Site Neutral • Bundled Payments • Bundled Payments • VBP • Therapeutic substitutions • Part B Reforms • System-wide P&T Committees • From ASP + 6% to? • VBP • Advanced Practice Clinicians • Pharmacists as providers? • PBM Consolidation • MAC Transparency • 340B • DIR Fees • Rural to Urban Reclass • Contract Terms • Specialty Pharmacy Partnering & Development • Any willing provider laws • 340B Contract Pharmacy and Prescription Transfers • Patient Assistance Programs • Pricing Power via Provider Integration (Vertical and Horizontal) – GPO Considerations Other Factors • Price negotiations – Part D • Access 8 Integration Drivers –VBP… And Beyond CMS: Better Care. Smarter Spending. Healthier People: Paying Providers for Value, Not Volume (January 26, 2015) Consider – Role of pharmacy and other vertically integrated providers Source: Centers for Medicare and Medicaid Services – January 26, 2015. 9 Integration Drivers –VBP… And Beyond Source: Centers for Medicare and Medicaid Services – January 26, 2015. 10 Integration Drivers –VBP… And Beyond • CMS Bundled Payments for Care Improvement (BPCI) Initiative • Organizations to enter into payment arrangements that include financial and performance accountability for episodes of care • 4 Models (Participants as of April 2016): • Model 1 (1): Episode of care focused on the acute care inpatient hospitalization. Awardees provide a standard discount to Medicare from the usual Part A hospital inpatient payments • Separate TC and PC, but gainsharing permitted • Model 2 (649): Starting at inpatient admission, episodic care payments for a 30-, 60- or 90-day period • Model 3 (862): Starting at post-acute admission, episodic care payments for a 30-, 60-or 90-day period • Model 4 (10): Prospective bundled payment arrangement • Lump sum payment made to a provider for the entire episode of care includes PC and TC 11 Integration Drivers –VBP… And Beyond • In Models 2 and 3, bundle includes: physicians’ services, post-acute provider care, readmissions, and other related Part B services Including: • Clinical lab services; DMEPOS; and Part B drugs. • Part B Drugs include physician administered drugs. • CMS BPCI Initiative Models 2-4: Years 1 and 2 Annual Reports to CMS • 2015 • “…BPCI appears to have affected provider performance.” • “We observed statistically significant declines in SNF use and increases in HHA use…” • “Readmissions dropped more for BPCI Model 2 participants, although ED visits without a hospitalization increased…” • 2016 • “We remain limited in our ability to estimate the impact of the initiative under most Model and episode combinations because of insufficient sample size and the limited time the initiative has been underway.” 12 Integration Drivers –VBP… And Beyond • December 20, 2016 Episode Payment Model Final Rule: • Heart attacks; • Coronary bypass surgery; or • Surgical treatment of hip or femur fractures • Episode begins with inpatient admission and extends to 90 days after the date of discharge. The Medicare is automatically included in the applicable EPM. • Proposed that related items and services for EPM episodes would include the following items and services paid under Parts A and B: • Services: Physicians; I/P hospital; I/P psychiatric facility; LTCH; IRF; SNF; HHA; Hospital outpatient ; Independent outpatient therapy ; Clinical laboratory; and Hospice • Items: DME; and Part B drugs • Start date for the EPMs has been delayed for an additional three months, from July 1, 2017 to October 1, 2017 13 Integration Drivers - Impact • With shift to population health and cost reduction incentives, what are we to do? • Focus first on the clear quality and cost drivers through coordination (including pharmacy/specialty) • Highest cost patients are demonstrably concentrated 14 Integration Drivers – Drug Payment • 2016 CMS Proposed Part B Drug Payment Rule (Withdrawn) 15 Integration Drivers – Practical Issues • Consider: Role of physician, APC and pharmacist medication management in readmissions and HACs • Collaborative Practice Arrangements • Benefit has to be provided directly by Hospital or agent of hospital under hospital direction and control • Bedside delivery • Self-administered drugs (generally Part D) • Establishes refill relationship 16 Pharmacist Professional Practice • Various states (e.g., WA, VA, WI) • Wis. Stat. 450.033 (2014) • Incident-to billing for professional fees an option (in the office setting – not in the hospital setting) • Must meet direct supervision standards: “immediately available,” meaning at least in the office suite 17 PBM MAC Issues (Advocacy Opportunities) I. MAC Transparency Act (H. R. 244)(Introduced 1/9/2015): A. Would codify above (exists only in regulatory form now) and extend it to Tricare and Federal Employee Health Benefits Program B. Would amend Part D to require that PDP sponsor contracts obligate the PDP sponsor to include the following provision in PDP/PBM contracts: 1. “The PBM may not require that a plan enrollee use a pharmacy in which the PBM has an ownership interest or provide an incentive to an enrollee to encourage the use of such a pharmacy.” II. Since unlikely to be passed, carefully review your PBM agreements. PBM MAC Issues (Advocacy Opportunities) MAC Transparency – State Laws I. State Laws: A. 2015 1. Approximately 17 states have laws governing PBM MAC application 2. Wisconsin and Illinois not among them B. 2016 1. Approximately 31 states have
Recommended publications
  • Optumrx Mail Order Service

    Optumrx Mail Order Service

    Mail Service Pharmacy Program OptumRx™ Mail Service Pharmacy makes ordering maintenance medications easy and saves you both time and money compared to a retail pharmacy. Using your mail order benefit entitles you to a 90-day supply at a discounted price, where through a retail pharmacy you receive a 30-day supply. Plus, shipping is at no cost to you — so you do not have to drive to your local pharmacy. • Save time • Save money • Convenient door-to-door service OptumRx uses generic products whenever possible to help reduce your medication costs. Generic medications are FDA approved equivalents to the more expensive brand-name version. If you or your physician prefers the brand-name, please indicate this on your order. Please be aware that the brand-name medication may be subject to a higher copay as determined by your Plan. Contact Customer Service for information about your copays. Mail Service Pharmacy Program Your Medication Safety Is Protected by Our Professional Staff Every prescription submitted to OptumRx is screened by our team of registered pharmacists for accuracy, drug interactions, allergies and appropriateness of therapy. OptumRx maintains a complete record of all of your current medications, regardless of where you had them filled.* If for any reason we believe your prescription needs clarification, we will contact you or your physician. If we are unable to resolve the issue and we anticipate a delay in shipping your order, we will contact you. • Professional staff • Accuracy • Quality • Medication screening Four Ways to Get Started Using Mail Service 1 Your Physician Can Fax Us If you would like to save mailing time to OptumRx, your physician can fax your prescriptions directly to our processing center at 1-800-491-7997, 24 hours a day, 7 days a week.
  • Geriatric Medicine and Why We Need Geriatricians! by Juergen H

    Geriatric Medicine and Why We Need Geriatricians! by Juergen H

    Geriatric Medicine and why we need Geriatricians! by Juergen H. A. Bludau, MD hat is geriatric medicine? Why is there a need for 1. Heterogeneity: As people age, they become more Wthis specialty? How does it differ from general heterogeneous, meaning that they become more and more internal medicine? What do geriatricians do differently when different, sometimes strikingly so, with respect to their they evaluate and treat an older adult? These are common health and medical needs. Imagine for a moment a group questions among patients and physicians alike. Many of 10 men and women, all 40 years old. It is probably safe internists and family practitioners argue, not unjustifiably, to say that most, if not all, have no chronic diseases, do not that they have experience in treating and caring for older see their physicians on a regular basis, and take no long- patients, especially since older adults make up almost half of term prescription medications. From a medical point of all doctors visits. So do we really need another type of view, this means that they are all very similar. Compare this physician to care for older adults? It is true that geriatricians to a group of 10 patients who are 80 years old. Most likely, may not necessarily treat older patients differently per se. But you will find an amazingly fit and active gentleman who there is a very large and important difference in that the focus may not be taking any prescription medications. On the of the treatment is different. In order to appreciate how other end of the spectrum, you may find a frail, memory- significant this is, we need to look at what makes an older impaired, and wheelchair-bound woman who lives in a adult different from a younger patient.
  • A Crisis in Health Care: a Call to Action on Physician Burnout

    A Crisis in Health Care: a Call to Action on Physician Burnout

    A CRISIS IN HEALTH CARE: A CALL TO ACTION ON PHYSICIAN BURNOUT Partnership with the Massachusetts Medical Society, Massachusetts Health and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute A Crisis in Health Care: A Call to Action on Physician Burnout Authors About the Massachusetts Medical Society Ashish K. Jha, MD, MPH The Massachusetts Medical Society (MMS) is the state- Director, Harvard Global Health Institute wide professional association for physicians and medical stu- Senior Associate Dean for Research Translation and dents, supporting 25,000 members. The MMS is dedicated Global Strategy to educating and advocating for the physicians and patients K.T. Li Professor, Dept. of Health Policy and Management, of Massachusetts both locally and nationally. As a voice of Harvard T.H. Chan School of Public Health leadership in health care, the MMS provides physician and Professor of Medicine, Harvard Medical School patient perspectives to influence health-related legislation Andrew R. Iliff, MA, JD at both state and federal levels, works in support of public Lead Writer and Program Manager, Harvard Global health, provides expert advice on physician practice manage- Health Institute ment, and addresses issues of physician well-being. Alain A. Chaoui, MD, FAAFP About the Massachusetts Health and President, Massachusetts Medical Society Hospital Association Steven Defossez, MD, EMHL The Massachusetts Health and Hospital Association Vice President, Clinical Integration, Massachusetts Health (MHA) was founded in 1936, and its members include and Hospital Association 71 licensed member hospitals, many of which are organized Maryanne C. Bombaugh, MD, MSc, MBA within 29 member health systems, as well as interested indi- President-Elect, Massachusetts Medical Society viduals and other healthcare stakeholders.
  • Guidelines for Developing a Team Physician Services Agreement in the Secondary School

    Guidelines for Developing a Team Physician Services Agreement in the Secondary School

    Guidelines for Developing a Team Physician Services Agreement in the Secondary School The following document has been developed by the NATA Secondary School Athletic Trainers’ Committee in an effort to assist secondary school athletic trainers in strengthening and formalizing the relationship with a team physician. The included components for such an agreement have been suggested by the American College of Sports Medicine (ACSM) and NATA (see resources). Guidelines for Developing a Team Physician Agreement in the Secondary School is intended to serve as an overview of those key components as they apply to the secondary school setting. It should be noted that while all components cited have merit, not all may be practical for all situations. Variability with state and local regulations must also be considered. DEVELOPED BY THE SECONDARY SCHOOL ATHLETIC TRAINERS’ COMMITTEE: Larry Cooper, MS, ATC, LAT, Chair Kembra Mathis, MEd, ATC, LAT Bart Peterson, MSS, ATC, Incoming Chair Lisa Walker, ATC Denise Alosa, MS, ATC Stacey Ritter, MS, ATC Casey Christy, ATC Chris Snoddy, ATC, LAT George Wham, EdD, ATC, SCAT Chris Dean, ATC Dale Grooms, ATC Cari Wood, ATC, NATA BOD Liaison Dan Newman, MS, ATC, LAT Amanda Muscatell, NATA Staff Liaison A SPECIAL THANKS TO TEAM PHSYICIAN SERVICES AGREEMENT SUBCOMMITTEE: George Wham, EdD, ATC, SCAT Dale Grooms, ATC Casey Christy, ATC Larry Cooper, MS, ATC, LAT, Chair Bart Peterson, MSS, ATC, Incoming Chair NATA Secondary School Athletic Trainers’ Committee 2016 Disclaimer: The materials and information provided in the National Athletic Trainers’ Association (“NATA”) “Guidelines for Developing a Team Physician Services Agreement in the Secondary School” (the “Guideline”) are educational in nature, and the Guideline is published as a resource for NATA members and is intended solely for personal use/reference in the manner described herein.
  • White and Brown Bagging Emerging Practices, Emerging Regulation

    White and Brown Bagging Emerging Practices, Emerging Regulation

    White and Brown Bagging Emerging Practices, Emerging Regulation Prepared By The National Association of Boards of Pharmacy White and Brown Bagging Emerging Practices, Emerging Regulation Published April 2018 Copyright 2018 National Association of Boards of Pharmacy 1600 Feehanville Drive Mount Prospect, IL 60056 USA 847/391‐4406 www.nabp.pharmacy Carmen A. Catizone, MS, RPh, DPh Executive Director/Secretary NABP Mission Statement NABP is the independent, international, and impartial Association that assists its member boards and jurisdictions for the purpose of protecting the public health. NABP Vision Statement Innovating and collaborating today for a safer public health tomorrow. ________________________________________________________________________ © 2018 by the National Association of Boards of Pharmacy. All rights reserved. No part of this publication may be reproduced in any manner without the written permission of the executive director/secretary of the National Association of Boards of Pharmacy. The terms “National Association of Boards of Pharmacy,” and “NABP,” are registered trademarks of the National Association of Boards of Pharmacy. Violation of the copyright will lead to prosecution under federal copyright laws. Table of Contents Overview……………………………………………………………………………………………………………………………..2 Results ………………………………………………………………………………………………………………………………..2 Results Background …………………………………………………………………………………………………………….3 Recommendations ………………………………………………………………………………………………………………5 References ………………………………………………………………………………………………………………………….6
  • Practitioner Acronym Table

    Practitioner Acronym Table

    Practitioner Acronym Table AAP American Academy of Pediatrics ABAI American Board of Allergy and Immunology ABFP American Board of Family Practitioners ABO American Board of Otolaryngology ABPN American Board of Psychiatry and Neurology AK Acupuncturist (Pennsylvania) AOBFP American Osteopathic Board of Family Physicians American Osteopathic Board of Special Proficiency in Osteopathic Manipulative AOBSPOMM Medicine AP Acupuncture Physician ASG Affiliated Study Group BHMS Bachelor of Homeopathic Medicine and Surgery BSN Bachelor of Science, Nursing BVScAH Bachelor of Veterinary Science and Animal Husbandry CA Certified Acupuncturist CAAPM Clinical Associate of the American Academy of Pain Management CAC Certified Animal Chiropractor CCH Certified in Classical Homeopathy CCSP Certified Chiropractic Sports Physician CRNP Certified Registered Nurse Practitioner CRRN Certified Rehabilitation Registered Nurse CSPOMM Certified Specialty of Proficiency in Osteopathic Manipulation Medicine CVA Certified Veterinary Acupuncturist DAAPM Diplomate of American Academy of Pain Management DABFP Diplomate of the American Board of Family Practice DABIM Diplomate of the American Board of Internal Medicine DAc Diplomate in Acupuncture DAc (RI) Doctor of Acupuncture, Rhode Island DAc (WV) Doctor of Acupuncture, West Virginia DACBN Diplomate of American Chiropractic Board of Nutrition DACVD Diplomate of the American College of Veterinary Dermatology DC Doctor of Chiropractic DDS Doctor of Dentistry DHANP Diplomate of the Homeopathic Academy of Naturopathic
  • Important Pharmacy Information There Is No Copay When Your Primary Care Provider (PCP) Or Unitedhealthcare Community Plan Specialist Writes You a Covered Prescription

    Important Pharmacy Information There Is No Copay When Your Primary Care Provider (PCP) Or Unitedhealthcare Community Plan Specialist Writes You a Covered Prescription

    Important Pharmacy Information There is no copay when your Primary Care Provider (PCP) or UnitedHealthcare Community Plan Specialist writes you a covered prescription. But you can get many over-the-counter (OTC) medicines free when you have a prescription. You can get the medications listed on the following pages when they are medically necessary and you get a written prescription from your UnitedHealthcare Community Plan doctor and take it to a UnitedHealthcare Community Plan pharmacy. To get your medicine: • Take your prescription to a UnitedHealthcare Community Plan pharmacy. To find a pharmacy, call 1-800-903-5253 or go to UHCCommunityPlan.com. • For your safety, we urge you to select a single pharmacy from which to get your drugs. • Get to know the pharmacist and build a relationship. If the UnitedHealthcare Community Plan pharmacy says they cannot fill your covered prescription or you have to pay more than your copay: Do not leave the pharmacy. Do not pay for it yourself. Ask the pharmacy why they cannot fill your prescription. Response Your Solution Not Covered • Ask them to call OptumRx right away to find out which medicine is covered. • Ask them to call your doctor to see if you can get the covered medicine instead. Prior • Ask them to call your doctor for a prior authorization. Authorization • You can call your doctor and ask that a prior authorization be sent to: Needed UnitedHealthcare Pharmacy Prior Notification Service Fax 1-866-940-7328 Phone 1-800-310-6826 Refill Too Soon • Ask what day it can be filled. • Pick your prescription up the day it can be filled.
  • Introduction to Hospital and Health-System Pharmacy Practice 59 Tients with a Specific Disease State Or for Activities Related to Self Governance Diagnosis

    Introduction to Hospital and Health-System Pharmacy Practice 59 Tients with a Specific Disease State Or for Activities Related to Self Governance Diagnosis

    Part II: Managing Medication Use CHAPTER 4 Medication Management Kathy A. Chase ■■ ■■■ Key Terms and Definitions Learning Objectives ■■ Closed formulary: A list of medica- After completing this chapter, readers tions (formulary) which limits access should be able to: of a practitioner to some medications. 1. Describe the purpose of a formulary A closed formulary may limit drugs to system in managing medication use in specific physicians, patient care areas, or institutions. disease states via formulary restrictions. 2. Discuss the organization and role of the ■■ Drug formulary: A formulary is a pharmacy and therapeutics committee. continually updated list of medications 3. Explain how formulary management and related information, representing works. the clinical judgment of pharmacists, 4. List the principles of a sound formulary physicians, and other experts in the system. diagnosis and/or treatment of disease 5. Define key terms in formulary manage- and promotion of health. ment. ■■ Drug monograph: A written, unbi- ased evaluation of a specific medica- tion. This document includes the drug name, therapeutic class, pharmacology, indications for use, summary of clinical trials, pharmacokinetics/dynamics, ad- verse effects, drug interactions, dosage regimens, and cost. ■■ Drug therapy guidelines: A document describing the indications, dosage regi- mens, duration of therapy, mode(s) of administration, monitoring parameters and special considerations for use of a specific medication or medication class. ■■ Drug use evaluation (DUE): A process used to assess the appropriate- ness of drug therapy by engaging in the evaluation of data on drug use in a given health care environment against predetermined criteria and standards. ◆■ Diagnosis-related DUE: A drug use evaluation completed on pa- INTRODUCTION TO HOSPITAL AND HEALTH-SYSTEM PHARMACY PRACTICE 59 tients with a specific disease state or for activities related to self governance diagnosis.
  • Team Physician Consensus Statement

    Team Physician Consensus Statement

    Team Physician Consensus Statement SUMMARY QUALIFICATIONS OF A TEAM PHYSICIAN The objective of the Team Physician Consensus Statement is to provide The primary concern of the team physician is to provide physicians, school administrators, team owners, the general public, and the best medical care for athletes at all levels of participa- individuals who are responsible for making decisions regarding the medical tion. To this end, the following qualifications are necessary care of athletes and teams with guidelines for choosing a qualified team physician and an outline of the duties expected of a team physician. for all team physicians: Ultimately, by educating decision makers about the need for a qualified • Have an M.D. or D.O. in good standing, with an team physician, the goal is to ensure that athletes and teams are provided unrestricted license to practice medicine the very best medical care. • The Consensus Statement was developed by the collaboration of six Possess a fundamental knowledge of emergency care major professional associations concerned about clinical sports medicine regarding sporting events issues: American Academy of Family Physicians, American Academy of • Be trained in CPR Orthopaedic Surgeons, American College of Sports Medicine, American • Have a working knowledge of trauma, musculoskeletal Medical Society for Sports Medicine, American Orthopaedic Society for injuries, and medical conditions affecting the athlete Sports Medicine, and the American Osteopathic Academy of Sports Med- icine. These organizations have committed to forming an ongoing project- In addition, it is desirable for team physicians to have based alliance to “bring together sports medicine organizations to best clinical training/experience and administrative skills in serve active people and athletes.” some or all of the following: • Specialty Board certification EXPERT PANEL • Continuing medical education in sports medicine • Formal training in sports medicine (fellowship train- Stanley A.
  • First Fill Temporary Pharmacy Card Making It Easy to Get Your Workers’ Compensation Prescriptions Filled

    First Fill Temporary Pharmacy Card Making It Easy to Get Your Workers’ Compensation Prescriptions Filled

    First Fill Temporary Pharmacy Card Making it easy to get your workers’ compensation prescriptions filled. Employer: Print this page immediately upon receiving notice of injury, fill in the information below and give it to your employee. Injured Employee: 1. If you need a prescription filled for a work-related injury or illness, go to a Tmesys network pharmacy. 2. Give this page to the pharmacist. 3. The pharmacist will fill your prescription at no cost. Attention Pharmacists: Call 800.964.2531 to establish First Fill benefit eligibility and obtain the ID# for online adjudication Prescription Card of approved benefits for the injured worker. CARRIER/TPA EMPLOYER/OTHER ENTITY Tmesys is the designated PBM for this patient. Sedgwick CLIC INJURED WORKER NAME Tmesys Pharmacy SOCIAL SECURITY NUMBER DATE OF INJURY Help Desk 800.964.2531 Please provide directly to Pharmacist Notice to Cardholder: This card should be presented to your pharmacy to receive NDC Envoy medication for your work-related injury. It is only valid within 30 days of your date of injury. RxBin 004261 or 002538 For information regarding the program or to find nearby pharmacies call 866.599.5426. RxPCN CAL or Envoy Acct. # (To create a card for your wallet, cut along outer line and fold in half.) Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at 800.964.2531. 2. Provide the information listed above. 3. The Help Desk will provide an ID number for adjudication. Finding a Network Pharmacy Use one of these easy methods to find a network pharmacy: ■ Visit one of the following pharmacy chains: Walgreens Walmart Duane Reade Publix Rite Aid CVS Kroger Safeway ■ Use our pharmacy locator online: www.pmsionline.com/pharmacy-center.
  • Specialty Pharmacy Drug List

    Specialty Pharmacy Drug List

    Specialty Pharmacy Drug List Our Specialty Pharmacy provides patients with comprehensive support services and coordinated delivery related to high-cost oral, inhaled or injectable specialty medications, used to treat complex conditions. We are your single source for high-touch patient care management to control side effects, patient support and education to ensure compliance or continued treatment, and specialized handling and distribution of medications directly to the patient or care provider. Specialty medications may be covered under either the medical or pharmacy benefit. Please consult your insurance documentation to determine which benefit covers these medications. We offer a broad specialty medication list containing nearly 500 drugs, covering 42 therapeutic categories and specialty disease states. This list is updated with new information each quarter. Characteristics of Specialty Medications “Specialty” medications are defined as high-cost oral or injectable medications used to treat complex chronic conditions. These are highly complex medications, typically biology-based, that structurally mimic compounds found within the body. High-touch patient care management is usually required to control side effects and ensure compliance. Specialized handling and distribution are also necessary to ensure appropriate medication administration. Medications must have at least one of the following characteristics in order to be classified as a specialty medication by Magellan Rx Management. High Cost High Complexity High Touch High-cost medications
  • Prescription and Over-The-Counter Medication; Language Assistance

    Prescription and Over-The-Counter Medication; Language Assistance

    PRESCRIPTION AND OVER-THE-COUNTER MEDICATON PRESCRIPTION MEDICATION OVER-THE-COUNTER MEDICATION LANGUAGE ASSISTANCE PRESCRIPTION AND OVER-THE-COUNTER MEDICATION PRESCRIPTION MEDICATION New York City Administrative Code: Title 20 § 20-712. Definitions. § 20-713. Display of Prescription Drug Prices. § 20-713.1. Display of Information Relating to Emergency Contraception. § 20-714. Regulations. § 20-715. Penalties. Rules of the City Of New York: Title 6 § 5-121. Posting of Prescription Drug Prices. § 5-122. Display of Information Relating to Emergency Contraception. New York Education Law § 6826. Drug Retail Price Lists. OVER-THE-COUNTER MEDICATION New York City Administrative Code: Title 20 § 20-821. Definitions. § 20-822. Prohibited Conduct and Violations. § 20-823. Enforcement. LANGUAGE ASSISTANCE New York City Administrative Code: Title 20 § 20-620. Definitions. § 20-621. Provision of Interpretation Services Required. § 20-622. Provision of Translation Services Required. § 20-623. Notification Relating to Language Assistance Services. § 20-624. Penalties. § 20-625. Hearing Authority. Rules of the City Of New York: Title 6 § 4-11. Content and Form of Language Assistance Sign. PRESCRIPTION MEDICATION Note: New York City businesses must comply with all relevant federal, state, and City laws and rules. All laws and rules of the City of New York, including the Consumer Protection Law and Rules, are available through the Public Access Portal, which businesses can access by visiting www.nyc.gov/consumers. For convenience, sections of relevant New York State Law and/or New York City Law and Rules are included as a handout in this packet. The New York City Law and Rules are current as of March 2011.