5.1 Based on
the outcome of the review, the contractor may place the beneficiary
on restrictions. In cases where restrictions are appropriate and
the TPharm contractor has been notified, the TPharm contractor will
send letters to the beneficiary. The beneficiary will be asked to
provide their primary provider preference and emergency room preference
per guidelines in
paragraph 5.2.1. The contractor does not need
to pick specifics (individual providers, individual drugs, or emergency
room) of the restrictions, but may designate at that level if deemed
appropriate. The default option (
paragraph 5.1.1) is implemented unless the
contractor chooses to specify more stringent restrictions. See
paragraphs 5.1.1 to
5.1.3 for
available restriction options.
Note: The TPharm contractor
system has adjudication edits in place to prevent multiple fills
with overlapping days’ supply at the same or multiple pharmacies;
therefore, pharmacy restrictions are not necessary but may be added
when appropriate.
5.1.1
Default
Restriction Program For Purchased Care
5.1.1.1 Restrict
pharmacy claim reimbursement for controlled drugs and specific non-control drugs
(e.g., antidepressants, antipsychotics, muscle relaxants, etc.)
to cover only those prescriptions written by a beneficiary’s designated
provider(s).
5.1.1.2 The default
drug restriction list is Schedule II-IV drugs but when necessary
may include other drugs. For example, when a previously unscheduled
drug is under review for categorization of scheduling, it may be
added to the list during the interim between the Drug Enforcement
Agency’s (DEA’s) Notice of intent to schedule and the “effective
date” of scheduling.
5.1.2 Default Restriction Program
For MTF/eMSM
5.1.2.1 Deny access to drugs from retail and mail order
sources and narrow access to include only specific MTF/eMSM pharmacy(ies).
The MTF/eMSM may designate a purchased care venue and/or provider
for drug(s) not carried at the MTF/eMSM.
5.1.2.2 This function
may also be chosen by the beneficiary who wants to fill their prescriptions solely
at the MTF/eMSM regardless of their PCM assignment. The narrow access
would not allow them to fill prescriptions at retail or mail order
venues.
5.1.3
Highest
Level Of Restriction Available
Restrict all
pharmacy claims (not only Schedule II-V). Only those prescriptions
written by designated provider(s) will be processed.
5.2
To
Add Beneficiary Restrictions
5.2.1 The
contractor and TPharm contractor will develop a process to communicate
the determinations. The contractor will notify the TPharm contractor
regarding which beneficiaries to add to the restriction program.
Notifications to the TPharm contractor to add restriction can occur
as the reviews are completed. Communication does not have to wait
until the minimum cases are reviewed or the due date for report
responses. Upon notification, the TPharm contractor will then start
the following two letter process to refine the detail on the restrictions:
5.2.1.1 The TPharm
contractor will send a letter to the beneficiary explaining the
program and medical review results. The letter will ask the beneficiary
to select a single provider for pain management and a primary emergency
department.
• Additional
providers may be added by beneficiary request and Government concurrence.
• The emergency department
choice will be provided to the appropriate contractor with jurisdiction
to oversee compliance.
5.2.1.2 A
notification letter will be sent to all individual commercial providers
that prescribed to the beneficiary in the past 180 days. The letter
explains the concern of over utilization, asks for confirmation
of prescribing, and notification of future restrictions. Individual
MTF/eMSM providers do not receive letters.
5.2.2 The beneficiary
will be given 14 calendar days from the date the notification letter
is sent to respond with their selected options. The beneficiary
will be notified in the initial letter that no payment will be made
after 14 days on Schedule II-V drugs or medical service claims associated
with obtaining those drugs until selections are made. A beneficiary
who chooses not to participate will remain in 100% prepay status
review and will be responsible for the costs of medical services
and pharmaceuticals (not to include claims where the contractor
has established medical necessity) until selections have been provided.
The beneficiary may respond in writing (fax, email, or letter) or
may call the designated phone number in the notification letter
to provide the selections.
5.2.3 Once the beneficiary has made
the appropriate selections, a re-review can be requested by the
beneficiary for previously pended or denied claims. The beneficiary
can request a list of all pended or denied claims. The beneficiary
request does not have to be in writing. The contractor must note
date requested and complete the review in 30 days. A request for
re-review will be forwarded to the other participating contractor
within 24 hours to fulfill the request.
Note: Due to the real time environment, pharmacy claims
cannot be pended. Therefore, any previous claims that were subject
to 100% copay can be re-reviewed based on additional information and
re-processed if necessary. An appeal is only necessary for claims
that have been re- reviewed and denied payment.
5.4 To remove a beneficiary from
restrictions:
5.4.1 A case manager, physician, or other provider
can make the request based on change in clinical condition. This
request will be reviewed by the originating contractor for concurrence.
The contractor shall respond in seven calendar days. The requestor
will be notified of the results by originating contractor of the
restriction. If the request is received by the TPharm contractor
they will forward within 24 hours of receiving to the contractor
for resolution.
5.4.2 The TPharm contractor shall
monitor the Morphine Equivalent Dose (MED) for opioid based restrictions.
When the TPharm contractor detects that the MED has dropped below
30mg for 180 consecutive days, the TPharm contractor will notify
contractor and the beneficiary will be removed from program in 30
days unless the contractor indicates otherwise. The contractor may
request to maintain the restriction.
5.4.3 The contractor will provide
written notification to beneficiary of the results. If the result
is removal from the program, the letter will identify the date of
removal. If the result is the not to remove, the letter will identify
the next date a review can be requested. A courtesy copy of the
result will be provided to the Government’s TPharm point of contacts.