Express Scripts Canada

Transcription

1 Express Scripts Canada TRIAL RX PROGRAM NOTICE Effective January 1, 2014, Manulife Financial for ESI Canada will be implementing the Trial Rx Program for a national group. Program Overview The Trial Rx Program is designed to help determine if a plan member/patient can tolerate a specific drug without experiencing side effects. Providing a limited supply during the trial period eliminates unnecessary waste and provides the plan member/patient an opportunity for a discussion with the pharmacist (and physician, if necessary) before the remainder of the prescription is dispensed. If a plan member/patient requests a drug that qualifies for the Trial Rx Program, the system will reject the claim with the message, TP - PATIENT IS ELIGIBLE FOR TRIAL RX. If the pharmacist and plan member/patient agree to participate in a trial, the pharmacist must submit a claim to fill reduced initial trial drug quantity. A followup is requested by the pharmacist and if the pharmacist and plan member/patient determine the drug is well tolerated, the balance of the trial prescription is claimed and the prescription is filled. The pharmacists will NOT be eligible for the payment of cognitive fees if the claims are not submitted within 19 calendar days of the trial prescription. For audit purposes, pharmacists must document all relevant trial drug details on the prescription. Questions about this program should be directed to the Express Scripts Canada Provider Call Centre at , Monday to Friday from 6:30 a.m. to Midnight (ET) or Saturdays, Sundays and statutory holidays from 8 a.m. to Midnight (ET). Intervention codes when a patient does NOT agree to participate in the Trial Rx program If a patient, physician or pharmacist does NOT agree to participate in the Trial Rx Program, enter the respective intervention code, outlined in the table below, in the Rx Detail Third Party tab in PharmaClik Rx and resubmit the prescription for adjudication. No further action is required. Scenario Trial Rx refused by plan member/patient Trial Rx refused by physician Trial Rx refused by pharmacist Trial Rx refused by plan member / patient s agent Action Submit the intervention code VC Submit the intervention code VH Submit the intervention code VI Submit the intervention code VJ Page 1 of 6

2 Intervention codes when a patient agrees to participate in the Trial Rx program Scenario Action Response Plan member/patient, and physician agree to participate in the program Resubmit the code with a 14-day supply with the intervention code: MT-TRIAL RX PROGRAM Refer to the Resubmit the prescription for a 14-day supply and schedule a Followup section in this document. If the trial supply exceeds the duration allowed by the plan member/patient s plan, the pharmacy will receive the message: OF-INITIAL RX DAYS SUPPLY EXCEEDED. Express Canada will indicate how many days the patient plan allows in a free format message. The claim must be resubmitted with a reduced day s supply. If the Express Canada accepts the trial days supply that was entered, the pharmacy will receive the message: TJ-TRIAL CLAIM PROCESSED. Intervention codes when a patient tolerates the trial drug The pharmacist must call the patient after the initial day s supply is dispensed to determine if the drug is effective and tolerated. The appropriate action and response is outlined in the below table: Scenario Action Response Patient tolerates the trial drug Fill the balance of the prescription within 19 calendar days of the original prescription and submit with the intervention code: ND - TRIAL PRESCRIPTION BALANCE The pharmacy will receive a cognitive fee for the additional claim if the fee is submitted in the Special Services Fee (SSF) field and if it is an eligible benefit under the plan member/patient s plan. Refer to the Submitting a claim for the remaining balance section in this document. If the balance is accepted, the pharmacy will receive the message: TJ - TRIAL CLAIM PROCESSED If there is no record that this is a trial prescription, the pharmacy will receive the message: OD NO TRIAL RX ON RECORD, BALANCE REJECTED. The pharmacy will then need to resubmit the claim without the ND intervention code and it will be treated as a regular claim. If the trial balance is given too late, the pharmacy will receive the message: NZ - TRIAL BALANCE GIVEN TOO LATE. The pharmacy must then resubmit the claim without the ND intervention code and it will be treated as a regular claim. Page 2 of 6

3 Intervention codes when a patient does NOT tolerate the trial drug Scenario Action Response Plan member/patient does not tolerate the trial drug The pharmacy will receive a cognitive fee if they submitted an EDI claim with a Product Identification Number (PIN or pseudo-din) of and if it is an eligible benefit under the plan member/patient s plan. Express Scripts Canada may conduct a post claim review of the cognitive fee payment to verify the validity of the claim. Refer to the Submitting a claim for the cognitive fee when the patient does NOT tolerate the medication section in this document. If there is a record of the first claim, the pharmacy will receive the message: TH - CURRENT CLAIM FOR UNFILLED BAL. PROCESSED Resubmitting the prescription for 14-day supply and scheduling a followup The prescription has been rejected with the response code, TP PATIENT IS ELIGIBLE FOR TRIAL RX. 1. In the Third Party tab in Rx Detail, press or click the Add button. A blank row is added to For Claim. 2. Select the intervention code, MT-TRIAL RX PROGRAM from the drop-down list. 3. Press or click the Rx New tab in Rx Detail. 4. Change the Qty and the DS fields to reflect a 14 day supply. 5. Press or click the Rx button. 6. Select Follow Up. The Follow Up window appears. 7. Enter a Follow Up Date (ex. 7 days from the current date). 8. Select the Consultation in the Follow Up Type drop-down list. 9. Press or click the OK button. 10. Press or click the Fill or the Queue button to resubmit the prescription as usual. If ESI Canada accepts the trial day s supply, the claim will be accepted with the response code, TJ TRIAL CLAIM PROCESSED. If the trial day s supply exceeds the duration allowed by the patient s plan, the claim will be rejected with the response code, OF INITIAL RX DAYS SUPPLY EXCEEDED. The appropriate days supply will be indicated in the claim response message. Press or click the More Info button in the Rx Detail Third Party tab to view the claim response message. The prescription must be resubmitted with the reduced quantity and days supply provided in the claim response message. Page 3 of 6

4 Processing the Followup on the scheduled date Contact the patient on the scheduled follow-up date to determine if the balance of the trial prescription should be dispensed. Complete the Prescription Followup activity. For audit purposes, pharmacists must document all relevant trial drug details on the prescription. To complete the Prescription Followup activity and documenting the follow-up: 1. Press or click the Activities tab on the Workbench. 2. Press or click the To Do tab, if it is not already displayed on the screen. 3. Highlight the Prescription Followup activity in the To Do tab. 4. Press or click the Process button. The patient s folder opens to the Consultation tab and the followup is highlighted. 5. Open the followup by pressing or clicking the Details button. 6. In the Service Dur dropdown, select the length of time used to perform the followup. 7. In the Service Lev dropdown, select the level of service that was provided. 8. In the Actual Follow-up field, enter the date that the followup was completed. 9. If necessary, update the Follow-up User. 10. Press the Add button located beside the Services section. The Consultation/Intervention Search window opens. 11. Highlight a row in the Category box (ex. Professional Service). 12. Highlight a row in the Type box (ex. Patient Monitoring and Followup). 13. In the Descriptions box, highlight one or more descriptions for the type of service (ex. Call back for trial Rx). 14. Press or click the Add button to add the selected options to the Selection box. 15. Repeat steps to document any additional categories and services for this consultation. 16. Press or click the OK button. The screen returns the Consultation/Intervention Form; the selected options are listed in the window. 17. Enter any comments in the Notes box. 18. Press or click the OK button. The screen returns to the Consultation tab. 19. Press or click the OK button in the Patient folder. The screen returns to the Workbench and a prompt asks if the activity is complete. 20. Press or click the Yes button. To complete the Prescription Followup activity without documenting the followup: 1. Press or click the Activities tab on the Workbench. 2. Press or click the To Do tab, if it is not already displayed on the screen. 3. Highlight the Prescription Followup activity in the To Do tab. 4. Press or click the Done button. Page 4 of 6

5 Submitting a claim for the remaining balance If the patient tolerates the trial drug, the balance of the prescription must filled be within 14 days of the original trial prescription. If the patient does not tolerate the trial drug, submit a fee for service claim for the cognitive fee. To dispense the remaining balance when the patient tolerates the medication: 1. Open the refill prescription in Rx Detail as usual. 2. Update the quantity and days supply to reflect the balance of the prescription. 3. Press or click the Third Party tab. 4. Press or click the Add button. A blank row is added to For Claim. 5. Enter the intervention code ND TRIAL PRESCRIPTION BALANCE. 6. To submit a claim for the cognitive fee, enter the dispensing fee in the Special Srv Fee field. 7. Continue to fill the prescription as usual. If the trial prescription balance is valid, the claim will be accepted with the response code, TJ TRIAL CLAIM PROCESSED. The dispensing fee may or may not be paid, depending on the patient s drug plan. If ESI Canada does not have a record that this is a trial prescription, the claim will be rejected with the response code, OD TRIAL NOT ON RECORD, BALANCE REJECTED. Remove the ND intervention code and resubmit the claim. It will be treated as a regular claim. If the trial prescription balance is submitted too late (after 14 days from the original fill date), the claim will be rejected with the response code NZ TRIAL BALANCE GIVEN TOO LATE. Remove the ND intervention code and resubmit the claim. It will be treated as a regular claim. The pharmacy will not be eligible for any cognitive fees. Submitting a claim for the cognitive fee when the patient does NOT tolerate the medication The cognitive fee will be paid if it is submitted in the Special Services Fee field and if it is an eligible benefit under the patient s plan. The prescription will be flagged as a Fee For Service claim to indicate that the balance of the medication has not been provided to the patient. The patient s profile will indicate that no repeats are remaining on the prescription and the Fee for Service checkbox will be selected. The Audit History will indicate *Fee For Service* for the prescription. Inventory does not decrement when the Fee for Service claims are filled, as no stock is dispensed with the prescription. 1. Discontinue the prescription as usual for the remainder of the medication and enter the reason for discontinuing in the Prescription Note box. Note: You must document the reason for discontinuing. 2. To submit the cognitive fee, create a new prescription for the patient using the DIN Enter the pharmacist as the prescriber. 4. Enter 1 in the Qty Auth, Qty, and DS fields. 5. Enter the prescription number from the discontinued medication in the SIG field. 6. Press or click the Process button. The Rx: New window appears. 7. Press or click on the magnifying glass icon in the Cost box. The Requested Cost & Fee window appears. 8. Select the Fee for Service checkbox. The cost and markup is removed from pricing; the fee is still displayed. The Qty and DS fields are updated to reflect the remaining quantity authorized on the prescription. 9. Press or click the OK button. 10. Press or click the Fill or the Queue button. Page 5 of 6

6 If ESI Canada has a record of the first claim, the claim will be accepted with the response code TH CURRENT CLAIM FOR UNFILLED BAL. PROCESSED. The label set printed for the prescription only includes a file copy with *FEE FOR SERVICE* indicated in large bold letters. Attach all relevant documentation to this file copy and file it as usual. This must be retained for audit purposes. The Fee for Service Report can be generated at any time to identify the Fee For Service prescriptions that were filled during a selected time period. Check out the Reports > Help for more information about the Fee for Service Report: 1. Press or click the Help button in the Reports. The Help Topics: PharmaClik Rx Reports window appears. 2. Press or click on the Contents tab. 3. Press or click the Creating Reports topic. 4. Press or click the Types of Reports under the Creating Reports topic. The Types of Reports window appears. 5. Press or click the Prescription Reports. The Prescription Reports window appears. 6. Press or click the Fee For Service. A description of the report appears in the Fee for Service window, along with a sample report. 7. Press or click the Print tab to print this report. Page 6 of 6