Last revision date: 12.17.2020 Pharmacy Manual Supplemental Policies, Procedures and Regulations Prepared by: Elixir 800-361-4542 ELIXIRSOLUTIONS.COM 2181 E. Aurora Road, Suite 201 | Twinsburg, OH 44087 Copyright © 2020, Elixir. All rights reserved. Version 41 *This page was intentionally left blank* 1 Table of Contents PHARMACY MANUAL INTRODUCTION......................................................................................................................... 5 GENERAL INFORMATION ............................................................................................................................................. 5 PROPRIETARY AND CONFIDENTIAL .................................................................................................................. 5 ADVERTISING REQUESTS .............................................................................................................................. 6 CONTACT INFORMATION / WHERE TO GET HELP ...................................................................................................... 6 NETWORK ENROLLMENT FORM AND CREDENTIALING GUIDELINES ....................................................................... 6 APPLYING FOR PARTICIPATION ...................................................................................................................... 6 CREDENTIALING AND RECREDENTIALING GUIDELINES ....................................................................................... 7 PROVIDER AND MEMBER SERVICE STANDARDS ...................................................................................................... 7 NON-DISCRIMINATION CLAUSE ...................................................................................................................... 7 PROVIDER NETWORK – ACCESSIBILITY ........................................................................................................... 7 PHARMACY COMMUNICATIONS ....................................................................................................................... 8 NON-PREFERRED VS. PREFERRED STATUS ..................................................................................................... 8 QUALITY ASSURANCE ................................................................................................................................... 8 COMPLIANCE WITH LAWS .............................................................................................................................. 8 INVESTIGATIONS AND DISCIPLINARY ACTIONS .................................................................................................. 8 CHANGE OF INFORMATION ............................................................................................................................. 8 EXCLUDED PARTIES ..................................................................................................................................... 9 FRAUD, WASTE AND ABUSE TRAINING ............................................................................................................ 9 SUSPENSIONS AND TERMINATIONS ................................................................................................................. 9 PRICING AND REIMBURSEMENT QUESTIONS .......................................................................................................... 11 REIMBURSEMENT AND COST SHARE ....................................................................................................................... 11 MAXIMUM ALLOWABLE COST (MAC) ........................................................................................................................ 11 MAC LISTS ................................................................................................................................................. 11 MAXIMUM ALLOWABLE COST APPEALS ........................................................................................................... 12 VACCINES ................................................................................................................................................................... 12 RETAIL VACCINE PROCESSING INSTRUCTIONS............................................................................................... 12 VACCINE PROGRAM LIST ............................................................................................................................ 12 PART B VACCINE PROGRAM LIST ................................................................................................................. 14 COVID-19 VACCINES ................................................................................................................................ 15 PROCESSING A CLAIM ............................................................................................................................................... 16 BIN NUMBER AND PCN INFORMATION .......................................................................................................... 16 ELECTRONIC CLAIMS TRANSMISSIONS REQUIREMENT .................................................................................... 16 ACCURATE CLAIM SUBMISSION AND PRESCRIPTION RECORD ............................................................................. 17 AUDIT GUIDELINES ..................................................................................................................................................... 21 INTRODUCTION .......................................................................................................................................... 21 TYPES OF AUDITS ...................................................................................................................................... 21 REQUESTED DOCUMENTATION AND RECORDS ............................................................................................... 22 TYPICAL AUDIT PROTOCOL AND APPEALS PROCESS ...................................................................................... 22 WHOLESALER, MANUFACTURER AND DISTRIBUTOR INVOICES: REQUIREMENTS AND AUDITS ............................... 22 2 FREQUENTLY ASKED AUDIT QUESTIONS ....................................................................................................... 23 ACCEPTABLE AUDIT APPEALS ..................................................................................................................... 25 DEFINITIONS ............................................................................................................................................. 27 EDITS ........................................................................................................................................................................... 28 FRAUD WASTE AND ABUSE EDITS ................................................................................................................ 28 DRUG UTILIZATION REVIEW (DUR) EDITS ..................................................................................................... 28 POINT OF SALE (POS) OPIOID PATIENT SAFETY EDITS ...................................................................................... 29 COORDINATION OF BENEFITS (COB) .............................................................................................................. 31 MEDICARE PART D ..................................................................................................................................................... 31 MEDICARE COVERAGE GAP DISCOUNT PROGRAM ......................................................................................... 31 WHAT ARE “APPLICABLE” DRUGS? ............................................................................................................... 32 HOW WILL THE MEDICARE COVERAGE GAP DISCOUNT PROGRAM WORK? ....................................................... 32 HOW WILL MY PHARMACY KNOW WHICH MANUFACTURERS HAVE SIGNED A COVERAGE GAP DISCOUNT PROGRAM AGREEMENT WITH CMS? ...................................................................................................................... 32 MEDICARE AUDIT AND RECORD RETENTION REQUIREMENTS .......................................................................... 32 REJECTIONS .............................................................................................................................................. 33 PART D UNIQUE BIN REQUIREMENTS .......................................................................................................... 34 TRANSITION REQUIREMENTS ....................................................................................................................... 34 MEDICARE PRESCRIPTION DRUG COVERAGE AND YOUR RIGHTS – REVISED GUIDANCE FOR DISTRIBUTION OF STANDARDIZED PHARMACY NOTICE (CMS-10147) ........................................................................................ 35 MAIL ORDER PHARMACIES ........................................................................................................................... 36 HOME INFUSION PHARMACIES ...................................................................................................................... 36 HOME INFUSION PHARMACY NPPES REGISTRATION ......................................................................................... 36 PHARMACIES SERVICING LONG TERM CARE FACILITIES .................................................................................... 36 HOSPICE MEDICATIONS .............................................................................................................................