CMS POINT OF SALE PILOT ‘

Michelle Juhanson, CHC, CHPC Director, Compliance & Quality PerformRx ‘

Shawn McHale, Pharm.D. Manager, Pharmacy Prior Authorization PerformRx

CMS PILOT GOALS & PERFORMRX PARTICIPATION

What options available to resolve certain point of sale (POS) claim rejections without the enrollee having to request a coverage determination from the plan?

CMS invited PerformRx

• Relationship

• Coverage determination policy excellence

• Stand-alone PBM

Other pilot participants

• Highmark BCBS

• CVS Caremark

• Martins Point Health Plan

CMS Pilot Goal

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CMS Expectations

Develop proactive process initiated without any action on the enrollee’s part in response to POS claim rejection – Exclude pharmacy-resolvable rejections

Identify 5 to 10 target drugs for the pilot

Meet with CMS throughout the testing period – Be creative

– Provide honest feedback and policy recommendations

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PILOT PROCESS & OUTCOMES

Initial development of process – Two weeks

Process refinement from CMS feedback & pilot experience – Four weeks

Time Investment Pharmacist: 30 min per case

Technician: 10 min per case

Research and reporting: 30 min per day

Administration: 4 hours per week

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CIQA (2)

Pilot administration & initial case review

Service Delivery (1)

Rejection report

Prior Authorization (5)

Casework

MTM/DTM (4)

Casework

Formulary/DUR (1)

Consultative support

Account Management & Marketing (2)

Client engagement

Executive Leadership

(7)

Vetting

Pilot Process & Outcomes

Selection considerations

Beneficiaries from one plan contract

Frequently rejected drugs between 6/1/15 - 8/31/15

Most requested drugs at coverage determination level

Products overturned on redetermination

*Intersection with Star Ratings goals high risk medications (HRM)

**Additional drugs added 10/1-10/4

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Lidocaine 5% Patch *NITROFURANTOIN

MONO-MCR 100 MG

Esomeprazole Magnesium DR

40MG *CYCLOBENZAPRINE

NEXIUM 40 MG CAPSULE

Patanol 0.1% eye drops

**NIFEDIPINE ER 60 MG TABLET

**Januvia (GCNS- 97399, 97398,

97400

Pilot Process & Outcomes Targeted Drug Selection

Simple workflow

Limited disruption to plan or beneficiaries

Calls to pharmacies to: confirm validity of claims

instruct pharmacies to stop submitting un-approvable claims

Calls to prescribers to: explain criteria

offer to initiate coverage process

determine medical necessity

*MTM processed HRM cases

PA processed all other cases

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Run reject report (daily)

Review rejections against claim HX for subsequent

paid claims

PA or * MTM consult with pharmacy and

Prescriber to determine medical

necessity

Notify prescriber of

outcome

Notify pharmacy of the outcome.

Instruct to either reprocess or cease claim

submission

Actions/ outcomes

documented for CMS report

Pilot Process & Outcomes

Average Case Processing Time - 5.38 days

CMS determined pilot eligibility

Approved: PerformRx confirmed member got a drug

Unapprovable: CMS/Plan rules prohibit coverage 9

Caseseligble forthe pilot

Cases thatbecame

coveragedetermin…

Caseswhere

coverageapproved

Unapprovable cases

Casesprescriberopted out

of…

Caseswhere

formularyalternativ…

Results 79% 16% 53% 47% 68% 37%

0%20%40%60%80%

100%

Tota

l Cas

es

Pilot Process & Outcomes

COMPARISONS, CHALLENGES, &

REWARDS

Comparisons Pilot v. Coverage Determinations

SIMILARITIES

Multiple and varied outreach attempts required to secure information from prescribers

PBM pharmacists making the ultimate decision on medical necessity

PerformRx PA platform (PerformPA) used to document and workflow process once cases transferred to the PA department

Professional resources, decision making process essentially the same

Underlying Part D formulary rules applied

DIFFERENCES

POS Pilot CD

Required multi-department approach

PA department only (prospective cases)

No decision letter to beneficiary required

Written and telephonic beneficiary notice required

Pharmacists notified of outcomes

Pharmacy not informed of decision or progress

Not subject to timeliness standards. No defined “exceptions” process

24/72 hour timeframes (excludes tolling for exceptions)

Ability to make and provide decision over the phone in real time

Verbal and written decisions made after

Process is time and labor intensive with limited automation

Getting clinical information from prescribers in a reasonable amount of time

Allotting extra time for pilot participants because not in current staffing model

Value limited in the 4th quarter because of low volume of rejections

Challenges

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Rewards

Coordinate & confirm care for 10 of 19 members

Demonstrating a benefit to beneficiaries and plans when pharmacies know our decisions

Working directly with CMS – ― Getting immediate feedback from leadership

― Innovation encouraged & our ideas taken seriously

― Flexibility to apply new techniques & timelines

Opportunity to present findings to more than 800 from CMS Central Office

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Rewards CMS Feedback

“You deserve the highest praise for the work you did on this Point of Sale Pilot. Your reports and presentations were an outstanding example of professionalism. Your efforts went beyond our expectations, developing new creative approaches in aid of our collaborative goal. The Part D program will benefit from this work, most particularly our beneficiaries. Your enthusiastic advice was always appreciated; and I learned a great deal from our interactions”

- Jeffrey Kelman, MMSc MD, Chief Medical Officer, Center for Medicare, CMS “We believe there will be a significant level of interest in the presentation of your findings ...You presented thoughtful and valid concerns about potentially implementing this type of a change across the program, while highlighting valuable lessons learned and offering a number of suggestions on how we might address certain POS issues, including leveraging related program areas such as MTM, e-prescribing and rejected claims review, and through improved plan/PBM communication with prescribers at the point of prescribing”

- Beckie Peyton, Division of Appeals Policy, CMS

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PUBLIC POLICY IMPACT

Investigate programs to increase prescriber accountability to prevent unnecessary POS rejections

Apply greater emphasis on point of care coordination to lessen the need for a retrospective POS process.

Enforce adoption of existing e-prescribing standards (NCPDP Formulary Benefits 1.0) with prescribers and point of care software vendors

Monitor rejections at the prescriber level to identify gaps in formulary awareness

Public Policy Impact What PerformRx Recommended

An ounce of prevention

is worth a pound of cure

-Benjamin Franklin

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What type of Program do we recommend?

Voluntary

Which drugs should be included?

• Allow plan choice of drugs and disease states (like MTM)

• Drugs that prevent hospitalization • “Clinically fragile” drugs • Not necessary for HEP C and other high-cost specialty drugs

When would this have the greatest benefit?

• When beneficiaries are new to a plan or benefit design

• If applied year-round some prescribers may expect Medicare plans to initiate all coverage determinations

Who else should be included?

Pharmacy involvement critical to success of our pilot and missing link in

coverage determinations

Who is best-suited to do the work?

Organization(s) that process coverage determinations and contract with network pharmacies

Will this save Part D money versus coverage determinations?

No. Plan costs likely increase- staffing and drug utilization

Plan size, member composition, and marketing strategy would define ROI

Public Policy Impact What PerformRx Recommended

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Policy Impact What CMS decided

CMS position and call for comment released in Draft 2017 Part C & D Call Letter

Policy Impact What CMS decided

Some of the areas CMS may explore based on the pilot experience 1. How CMS and Part D plans could reduce the volume

of rejected claims on the front end by resolving certain issues before the prescription is sent to the pharmacy, such as:

Encouraging electronic prescribing, particularly electronic prior authorization, or other efficiencies in the PA process for a subset of drugs where the information needed to satisfy the PA may be obtained in a streamlined manner;

Making formularies more accessible to prescribers earlier in the process

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Policy Impact What CMS decided

2. How plans could employ proactive processes to resolve certain POS issues without the enrollee having to request a coverage determination, such as:

Identifying an appropriate subset of rejected claims to target proactive outreach efforts;

Designing outreach processes in a way that maximizes value while managing plan, pharmacy and prescriber resources, and program costs.

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Final Thoughts

CMS still considering policy –

– look to final 2017 Call Letter and beyond

– Potential for increased program costs with flexibility for plan/member composition

PerformRx prepared to collaborate with plans, CMS, prescribers, & pharmacies

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Questions?

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