1.0 Scope
1.1 This PMP
is a quarterly review of
all 300 beneficiaries
who received prescriptions using TRICARE benefits. The
goal
of the program
is aims 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 examine 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
a 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 300 beneficiaries
surpassing the current established parameters,
to
include including the use
of opioid potentiators. The parameters are based
upon
the 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 identify
ing when
changes are necessary. The data provided to the contractors shall be
divided into subsets based
upon
the 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
within the past five years.
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
s, 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 Markets/Military Treatment Facilities/Enhanced
Multi-Service Markets (MTFs/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 respond within 60
days after receiving the TPharm report identifying at-risk beneficiaries
and upload it 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
review’s 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, it may include other drugs. For
example, when a previously unscheduled drug is under review for
categorization of scheduling schedule,
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 schedule.
3.1.2 Default Restriction Program
For
Market/MTF
/eMSM3.1.2.1 Deny access to drugs from retail
and mail order sources and narrow access to include only specific Market/MTF/eMSM pharmacy(ies).
The Market/MTF/eMSM may
designate a purchased care venue and/or provider for drug(s) not
carried at the Market/MTF/eMSM.
3.1.2.2 This function may also be chosen
by the beneficiary who wants to fill their prescriptions solely
at the Market/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 restrictions 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
s on of 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 who prescribed to
the beneficiary in the past 180 days. The letter explains the concern
of over-utilization, and asks
for confirmation of prescribing, and
notification of future restrictions. Individual Market/MTF/eMSM providers
do not receive letters.
3.2.2 The beneficiary shall be given
14 calendar days from the date when 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 requests
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 in the initial notification
letter 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 clinical condition change in
clinical condition. This request shall
be reviewed by the The originating
contractor shall review this request for
concurrence. The contractor shall respond in seven calendar days.
The requestor shall be notified of the restriction’s results
by originating contractor of the restriction.
If the request is received by the TPharm
contractor receives the request, they shall
forward it within 24 hours of receiving it 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 the beneficiary
of the results. If the result is removal from the program, the letter
shall identify the date of removal date.
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
Market/MTF
/eMSMbased
restrictions, the TPharm contractor shall facilitate a resolution
with the appropriate
Market/MTF
/eMSM site.
The
Market/MTF
/eMSM has
final say whether they will re-review the case. Requirements in
paragraph 4.1 do
not apply to the
Market/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 Market/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 Markets/MTFs/eMSMs detailing Market/MTF/eMSM prescribers
that write for restricted beneficiaries that are not assigned to
them or Market/MTF/eMSM prescribers
writing a high volume of Schedule II-V prescriptions. The TPharm
contractor shall also provide summary statistics for Market/MTF/eMSM pharmacies
that bypass restriction requirements and dispense a prescription.
The TPharm contractor shall support the Market/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 Markets/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 a 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
Market/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.