1.0 Scope
1.1 This
PMP is a quarterly review of all beneficiaries who
received prescriptions using TRICARE benefits.
The
goal of the program is to identify beneficiaries who may need additional
medical assistance by providing knowledge of resources and maintaining
compliance with the guidelines described within
32 CFR 199.4.
1.2 The contractors shall designate
a “reviewer”. The reviewer
shall be
a contractor’s Chief Medical Officer (CMO) or a person approved
by the CMO. The reviewer
shall have
the appropriate credentials to review all types of claims. The reviewer
shall review
individuals
on the quarterly list and
make determinations
based
upon the beneficiaries’ entire
profile regardless of individual providers seen over the duration
of the report. The reviewer
shall conduct
a medical review of the patient history to validate utilization
with medical diagnosis and appropriateness of care. The level of
review necessary is the breadth and depth needed to make an accurate
determination. It may include claims review, record review, or any
other relevant information as necessary to make an accurate determination.
Any inconsistencies with utilization and medical diagnosis and/or
over-utilization concerns for medical diagnosis noted by the reviewer
shall necessitate
the contractor to develop a support plan. A support plan
may be
restrictions only or include case management, pain management, behavioral
health, or any other contractually available services. If the plan
includes restrictions, the contractor
shall notify the
TRICARE
Pharmacy (TPharm
) contractor
and the TPharm contractor
shall begin
the process outlined in
paragraph 3.2.
2.0 Initial Review and SUPPORT
SERVICES
2.1 Each quarter, the TPharm contractor
shall generate for each of the contractors, a list of all beneficiaries
surpassing the current established parameters
, to
include the use of opioid potentiators. The parameters
are based
upon pharmacy’s commercial
best practices for identifying potential
Substance
Use Disorder (SUD) and doctor shopping. These parameters
may
evolve and
are not made publicly
available. The TPharm contractor
shall communicate the
parameters to the Government and identifying when changes are necessary.
The data provided to the contractor
s shall be
divided into subsets based
upon beneficiary’s
Primary
Care Manager (PCM
) assignment
(Prime or TRICARE Plus) or region location (e.g., residential address
of Select beneficiaries). The data
shall be
arranged in a two tiered report. One section
shall be
a summary of individuals included for the quarter and one page
shall be
claim level detail for the past 180 days. The report
shall contain
the latest status (see
paragraph 2.5) reported
by the contractor. The list
shall also
identify how many times within the past five years each beneficiary
has been identified on the report. The report
shall
be sent to the contractor for medical review.
2.2 During
the quarter, if concerns about controlled substance use are identified
by other entities such as private providers (physician, nurse practitioners,
etc.) or reviewers in the course of business, the TPharm contractor
shall refer the identified beneficiaries to the appropriate contractor.
Individuals identified by clinicians shall be put on 100% prepayment
review by the
Medical contractor and
shall be provided
a medical review by the contractor as received to determine final
status. These
shall be given priority
over the quarterly list and may be counted towards the minimum 20
cases per quarter
(see paragraph 2.4).
2.3 The
contractor shall coordinate efforts with other TRICARE contractors
as needed (change in PCMs, change in regions) to ensure the beneficiary’s
care is appropriately managed and benefits are not being abused.
The TPharm contractor shall coordinate
cases that need assistance from the Military Treatment
Facilities/Enhanced Multi-Service Markets (MTF/eMSMs).
2.4 The contractor shall prioritize
and review a minimum of 20 beneficiary cases per quarter from the
quarterly list. See
paragraph 2.5 for responses,
and
paragraph 2.6 for responses
that count towards the minimum review.
2.5 At
a minimum, each contractor shall review the data generated on the
quarterly report and provide a response in the following manner:
• No Action
(diagnosis supports utilization)
• Support plan with restrictions
• Support plan without restrictions
• Restrictions Only
• Further monitoring needed
• Not Reviewed
2.6 Each beneficiary documented
as no action, support plan with or without restriction, restrictions
only count towards for cases reviewed. The contractors shall provide
responses within 60 days after receiving the TPharm report identifying
at-risk beneficiaries and upload to the Performance Assessment Tracker
(PAT) tool (for details refer to DD Form 1423, Contract
Data Requirements List (CDRL),
located in Section J of the applicable contract) and provide a courtesy
copy to the Government’s designated pharmacy point of contact. The
responses shall be used by the TPharm contractor
in generating a new report for the next quarter and be documented
on future reports for trending across quarters.
3.0 Restrictions
3.1 Based
upon 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
shall send
letters to the beneficiary. The beneficiary
shall be
asked to provide their primary provider preference and emergency
room preference per guidelines in
paragraph 3.2.1. 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 3.1.1)
is implemented unless the contractor chooses to specify more stringent
restrictions. See
paragraphs 3.1.1 to
3.1.3 for
available restriction options.
Note: The TPharm contractor system shall
have 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.
3.1.1 Default
Restriction Program For Purchased Care
3.1.1.1 Restrict pharmacy claim reimbursement
for controlled drugs and specific non-controlled drugs
(e.g., muscle relaxants, etc.) to cover
only those prescriptions written by a beneficiary’s designated provider(s).
3.1.1.2 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.
3.1.2 Default Restriction Program
For MTF/eMSM
3.1.2.1 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.
3.1.2.2 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 shall not
allow them to fill prescriptions at retail or mail order venues.
3.1.3 Highest
Level Of Restriction Available
Restrict all pharmacy claims
(not only Schedule II-V). Only those prescriptions written by designated
provider(s) shall be processed.
3.2 To
Add Beneficiary Restrictions
3.2.1 The
contractor and TPharm contractor
shall develop
a process to communicate the determinations. The contractor
shall notify
the TPharm contractor regarding which beneficiaries to add to the
restriction program. Notifications to the TPharm contractor to add
restriction
s may occur as the reviews
are completed.
The contractor may communicate with
the TPharm contractor at any time during the review process. Upon
notification, the TPharm contractor
shall then
start the following two letter process to refine the detail on the
restrictions:
3.2.1.1 The TPharm contractor
shall send
a letter to the beneficiary explaining the program and medical review
results. The letter
shall 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 shall be
provided to the appropriate contractor with jurisdiction to oversee
compliance.
3.2.1.2 A
notification letter shall 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.
3.2.2 The
beneficiary shall be given 14 calendar
days from the date the notification letter is sent to respond with
their selected options. The beneficiary shall be
notified in the initial letter that no payment shall 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 shall remain
in 100% prepay status review and shall 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.
3.2.3 Once
the beneficiary has made the appropriate selections,
the
beneficiary may request a re-review
for
previously pended or denied claims. The beneficiary
may
also request a list of all pended or denied claims.
The beneficiary request
s are not
required to
be in writing. The contractor
shall note
the date
requested and complete the review
(s) within
30 days. A request for re-review
shall be forwarded
to the other participating contractor within 24 hours to fulfill
the request.
Note: Due to
the real time environment, pharmacy claims are not pended.
Therefore, any previous claims that were subject to 100% copay may be
re-reviewed based upon additional information
and re-processed if necessary. An appeal is only necessary for claims
that have been re-reviewed and denied payment.
3.3 While
restricted, the beneficiary may need to
request overrides due to emergent need (illness while traveling)
or changing circumstances (moved, provider retired, etc.). The beneficiary
may request a temporary override (emergent need) or permanent change.
The TPharm contractor shall provide
in the initial notification letter an email address and phone number
to support those needs. This information shall also
be made available on the TPharm contractor’s web site. If the beneficiary requests
more than two overrides/changes during a six month period, the TPharm
contractor shall send the information
to the originating contractor for authorization to override.
3.4 To
remove a beneficiary from restrictions:
3.4.1 A
case manager, physician, or other provider may make
the request based upon a change in
clinical condition. This request shall be
reviewed by the originating contractor for concurrence. The contractor
shall respond in seven calendar days. The requestor shall be
notified of the results by originating contractor of the restriction.
If the request is received by the TPharm contractor they shall forward
within 24 hours of receiving to the contractor for resolution.
3.4.2 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 shall notify the contractor
and the beneficiary shall be removed
from the program within
30 days unless the contractor indicates otherwise. The contractor may
request to maintain the restriction.
3.4.3 The
contractor shall provide written notification
to beneficiary of the results. If the result is removal from the
program, the letter shall identify
the date of removal. If the result is the not to remove, the letter shall identify
the next date a review may be requested.
A courtesy copy of the result shall be provided
to the Government’s TPharm points of
contact.
4.0 RE-REVIEWS TIMELINES
4.1 The
beneficiary
shall be offered an opportunity
to request a re-review of the initial decision to restrict the beneficiary
and informed that his/her attending provider(s) may discuss the
case with the reviewer. The beneficiary
shall have
90 days from the date of the original notification letter (
paragraph 3.2.1.2)
to request an initial re-review
. The
contractor
shall respond to the beneficiary’s
request for a re-review
within 30 days.
If there is no initial request for a re-review, the procedures in
paragraph 4.2 are applicable.
Being placed on the PMP restriction program is not appealable but
claims denied due to restrictions in place may be appealable.
4.2 The
beneficiary may request an annual review or anytime they have documentation
from their provider about a clinical condition which substantiates
utilization. If the request goes to the TPharm contractor, they shall forward
within 24 hours to the appropriate contractor for medical review.
The contractor shall respond to the
beneficiary on annual reviews within 30 days.
4.3 As appropriate, the requirement
for 100% prepayment review or restrictions may be removed in the
face of new or updated information about the beneficiaries’ clinical
condition.
4.4 If a beneficiary needs assistance
with MTF/eMSM based restrictions, the TPharm contractor
shall facilitate
a resolution with the appropriate MTF/eMSM site. The MTF/eMSM has
final say whether they will re-review the case. Requirements in
paragraph 4.1 do
not apply to the MTF/eMSM.
5.0 REPORTS
5.1 Monitoring Reports
5.1.1 TPharm
contractor shall provide to the Government a quarterly activity
report on individuals currently restricted which includes date restricted,
restrictions in place, source of restriction, and any other notes
necessary for monitoring compliance (number of emergent override
request, compliance with restrictions, etc.). A copy of this report shall be
provided to the respective contractor and MTF/eMSM. (For details
refer to DD Form 1423, CDRL, located in Section J of the applicable contract.)
5.1.2 The
TPharm contractor shall provide a monthly report at summary level
to the MTFs/eMSMs detailing MTF/eMSM prescribers that write for
restricted beneficiaries that are not assigned to them or MTF/eMSM
prescribers writing a high volume of Schedule II-V prescriptions.
The TPharm contractor shall also provide
summary statistics for MTF/eMSM pharmacies
that bypass restriction requirements and dispense a prescription.
The TPharm contractor shall support
the MTF/eMSM by providing detail reports when requested. (For details
refer to DD Form 1423, CDRL, located in Section J of the applicable
contract.)
5.2 Summary Reports
5.2.1 The
contractor (excluding MTFs/eMSMs) shall provide to the Government
an annual summary status report of all beneficiaries currently in
the restriction program and summary of the case history to include
summary of the clinical review, the support services being provided,
beneficiary restrictions, and beneficiary compliance. (For details
refer to DD Form 1423, CDRL, located in Section J of the applicable
contract.)
5.2.2 The TPharm contractor shall
provide a monthly report to the Government office (
Managed Care
Support Program Section (MCSPS)), program office
(i.e., dental), or MTF/eMSM
a list
of beneficiaries
to whom restrictions have been applied in their area. (For details
refer to DD Form 1423, CDRL, located in Section J of the applicable
contract.) A courtesy copy
shall be
provided to the contractor for their region.
5.2.2.1 Contractors
with physician portals shall be required
to maintain a searchable database of patients currently on restriction
in their secured website and make available to their network providers. These
physician portals shall be compliant with Health Insurance
Portability and Accountability Act (HIPAA) Privacy
standards, HIPAA Electronic Transaction standards, and any other
applicable Federal regulations.
5.2.2.2 Prior
to initial posting, the contractor shall provide
a preview of the location and validate the site has appropriate
access restrictions.