1. ORAP UPDATE Pharmacy Benefit Managers, Collections, PRC Rates and GAO
Terri Schmidt
Acting Director, Office of Resource Access and Partnerships
October 24,2017

2. Pharmacy Benefit Manager (PBM) Update
 BACKGROUND
- TSGAC requested IHS to provide assistance in resolving denials and non-payment from PBMs and Private Insurance collections
DHHS reached out to CVS/Caremark
CVS/Caremark verbally agreed to identify a point of Contact for Tribes/Tribal Organizations operating under and ISDEAA agreement with IHS
Claims submission process
Dear Tribal Leader Letter/Dear Urban Leader Letter
Outline process
Provide CVS/Caremark contact information
Depart. Reached out to one of the larger PBM’s and initiated discussions about these issues with representatives from CVS/Caremark’s HQ
Several discussions were required for CVS/Caremark to gain an understanding of the statutory right to recovery under 1621e
Earlier this month (October 2017) CVS/Caremark notified IHS they would like to discuss logistics to make sure that payments are being made accordingly to 1621e. They have verbally agreed to identify an internal POC for Tribes and Tos operating under an ISDEAA agreement with IHS, to discuss specific claims submission process with CVS/Caremark
Indian Health Service / Office of Resource Access and Partnerships

3. PRC RATE
PRC Rate regulation located at 42 CFR 136 Subpart I. Gives I/T/U’s the ability to cap payment rates to physicians and non-hospital providers and suppliers.
Mandatory for IHS and Tribes can opt-in
I/T/U’s can negotiate a higher rate of payment with providers
Must meet a reasonable pricing arrangement
Most Favored Customer Rate is a platform for negotiation
I/T/U’s are responsible for rate calculations
Payment amount is provider specific
Indian Health Service / Office of Resource Access and Partnerships

4. PRC RATES
In the absence of a contract or agreement with IHS or Tribes that have opt-in for a negotiated rate. The PRC Rate applies as follows
When a Provider accepts a referral/request for services from an I/T/U
When a Provider accepts a purchase order for services from an I/T/U
When a Provider files a claim for payment
When a Provider accepts payment
In these instances the Provider cannot balance bill the patient
Indian Health Service / Office of Resource Access and Partnerships

5. PRC SAVINGS
Currently all IHS Areas and 9 Tribes have opted-in
5 of the Tribes use the FI
Savings as of August 31, 2017 for IHS and Tribes that use the FI
$221,751,836 Million
Indian Health Service / Office of Resource Access and Partnerships

6. PRC/GAO Directors Workgroup on Improving PRC October 31 and November 1
GAO will meet with the Workgroup
GAO recommendations
PRC distribution methodology
Indian Health Service / Office of Resource Access and Partnerships