©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry Health Care® California Medical Bill Reviewer Re-Certification Unit 5: Pharmacy Fee Schedule Module 1: Pharmacy Guidelines

March 2011CA Regulations Training – Pharmacy Guidelines Overview Lets start by discussing the basics of the pharmacy guidelines... Pharmacy Guidelines Pharmacy Reimbursements Simple Prescriptions Compound Prescriptions Other Pharmacy Services Brand Name Drugs Generic Drugs Hi! In this module, you will learn about pharmacy guidelines. You will learn how simple and compound prescriptions are reimbursed and how to look up their reimbursement values. Then, you will learn how other types of pharmacy services are reimbursed. Pharmacy Guidelines

March 2011CA Regulations Training – Pharmacy Guidelines Pharmacy Guidelines Pharmacological services are listed in a separate fee schedule, much like med-legal, ambulance, and DMEPOS services. The pharmacy fee schedule includes reimbursement for: Simple prescriptions Compound prescriptions

March 2011CA Regulations Training – Pharmacy Guidelines Pharmacy Reimbursement The maximum reasonable fee for pharmacy services rendered after March 1, 2007 is 100% of the fee prescribed in the relevant Medi-Cal payment system. You may access the current reimbursement rates at the following link: Workers' compensation pharmacy fee schedule There, you will access the Medi-Cal pharmacy rates by clicking on a link to a zip file. If you click on the above link now, you will see the here link, which will route you to the current pharmacy rates.here

March 2011CA Regulations Training – Pharmacy Guidelines Pharmacy Reimbursement As you know, there are two types of prescriptions for which there are reimbursement guidelines in the pharmacy fee schedule, which are: Simple PrescriptionsCompound Prescriptions Lets take a look…

March 2011CA Regulations Training – Pharmacy Guidelines Simple Prescription Reimbursement On the Workers Compensation Pharmacy website you will also find a calculator that allows you to look up the current price for simple prescriptions.

March 2011CA Regulations Training – Pharmacy Guidelines Simple Prescription Reimbursement As you can see, using the calculator to look up the price for simple prescriptions requires a few pieces of information that you can locate on a pharmacy bill. The required information is: NDC number Metric decimal number of units U & C price or Billed Charge Date of Service

March 2011CA Regulations Training – Pharmacy Guidelines Simple Prescription Reimbursement Now lets look at an example... If you key... The example NDC code in the NDC number field 100 units in the Units field $12.48 in the U & C field Date of Service: February 2, the calculator provides you with the payment price for the prescription.

March 2011CA Regulations Training – Pharmacy Guidelines Compound Prescription Reimbursement As you might expect, calculating the reimbursement value for compound prescriptions is more complex than calculating reimbursements for simple prescriptions. To calculate the reimbursement value for compound prescriptions, you must fill out a different form. Lets take a look… You can navigate to the form by clicking the here link above the simple calculation table.here Full instructions are provided on the website!

March 2011CA Regulations Training – Pharmacy Guidelines Compound Prescription Reimbursement The first step in calculating the reimbursement for a compound prescription is keying the total number of separate ingredients that make up the compound prescription. For example, suppose a compound prescription is composed of 5 separate ingredients. If you key 5 in the Count field, and click Continue, a calculation table appears. Lets take a look…

March 2011CA Regulations Training – Pharmacy Guidelines Compound Prescription Reimbursement Notice that there are more data elements for the compound prescription reimbursement calculation. The data elements are: Count Usual & Customary Price Date of Service Dosage Form Dosage Units Route of Administration Number of Containers Sterility Fee Note that not all of the fields are required!

March 2011CA Regulations Training – Pharmacy Guidelines Compound Prescription Reimbursement You will also notice that below the calculation form, you must key each ingredients NDC code and the associated number of units of each ingredient. Now lets take a look at an example...

March 2011CA Regulations Training – Pharmacy Guidelines Compound Prescription Reimbursement Suppose you need to calculate the price for Vicodin ES, with a billed charged of $ Vicodin ES is is composed of two ingredients. As before, you key... Count: 2 U & C: $91.25 Date of Service: 10/01/2006 Dosage Form: Powder Dosage Units: 2 Route of Administration: Oral Number of Containers: 1 Sterility Fee: optional Remember, you must key the NDC # & Number of Units of each ingredient.

March 2011CA Regulations Training – Pharmacy Guidelines Why is the dosage form Powder? It is important to use the appropriate NDC code. Since the compound is powder-based, the NDC codes must be for the powder form of each ingredient. Why is the Dosage Metric Decimal Units 2? Vicodin is made of 2 powders. Compound Prescription Reimbursement As compound drugs are mixed, they must be Powder or Liquid.

March 2011CA Regulations Training – Pharmacy Guidelines Compound Prescription Reimbursement As before, the calculator provides you with the payment price for the prescription.

March 2011CA Regulations Training – Pharmacy Guidelines Other Pharmacy Services In some instances, specific pharmacy services are not covered by the Medi-Cal payment system. Under these circumstances, the maximum reasonable payment shall not exceed the fee specified in the OMFS The reimbursement calculation differs for brand name and generic drugs. Lets take a look…

March 2011CA Regulations Training – Pharmacy Guidelines Drug Reimbursement To calculate the reimbursement value for brand name drugs, use the following equation: Drug Reimbursement AWP x.83 + $7.25 dispensing fee = Total Reimbursement AWP: Average Whole Sale Price For Example: If the AWP = $25.00 AWP = $25.00 Dispensing Fee = $7.25 Total Reimbursement = $28.00 Percentage of AWP =.83

March 2011CA Regulations Training – Pharmacy Guidelines Summary Pharmacy Reimbursement Guidelines How pharmacy services are reimbursed. How to calculate simple prescription reimbursements. How to calculate compound prescription reimbursements. How drugs are reimbursed per the OMFS 2007.