1. Prior Authorizations (PAs, Prior Auth) Types of Medicaid “Extra Help”

2. Prior Authorization Training Non-covered dose not mean never covered, tricks and tips for successful prior authorizations.

3. Prior to starting your prior auth…. Get the facts. Here is what you will need to know: 1. The individual’s First and Last name and Date of Birth 2. The name of their prescription drug insurance i.e. Medicare Part D plan name, Medicaid HMO, Straight Ohio Medicaid, Private Insurance, ect, member ID #, and the phone number to call for the prior authorization

4. Prior to starting your prior auth continued… 3. The name and dose of the medication that needs a PA 4. Why the drug was denied coverage by the insurance and the covered alternatives (formulary drugs, covered doses) 5. Medications they have already tried and failed 6. Diagnosis for medication and ICD 9 code 7. The prescribing physician’s name NPI # and contact info

5. Where to get that information 1. The individual’s information- See Face Sheet- or Pharmacy 2. Insurance information- the pharmacy or the insurance card. This includes the name of the insurance, member ID # and phone number to call for the prior auth. Do not call member services.

6. Where to get info continued 3. Physician’s order information- pharmacy and/or prescriber, the pharmacy must initiate the claim before you can start the PA process. Include QTY (530ml in bottle, 30 for 30 days) 4. Info on why the drug was denied and covered alternatives- from the pharmacy (pharmacist). 5. Other drugs the person has tried and failed and their diagnosis- their medical records, the pharmacy Expense report. 6. Diagnosis for medication and icd9 code- physcian 7. Prescriber’s information-the prescription, your records or the pharmacy.

7. Essential Prior authorization terminology The Magic Words: Alternate drug(s) contraindicated or previously tried but with adverse outcome (toxicity, allergy, or therapeutic failure) All Alternative drugs are contraindicated Must be drug X because covered alternative drug(s) must be: taken on empty stomach, administered with apple juice, be swallowed whole, can not use MDI Tried and failed drug X (all covered alternatives) Allergic to covered alternative Covered alternative causes GI upset, mood or behavior symptoms

8. Essential Prior authorization terminology The Magic Words: Complex patient with 9 or more chronic conditions is stable on current drug(s); high risk of significant adverse clinical outcome with medication change. Is stable on current drug does not have to be a long time a trial of 3-7 days is usually enough, see if the physician's office can provide samples. Great for formulary changes Use complex patient with 9 or more chronic conditions wording with all PAs when applicable

9. Essential Prior authorization terminology The Magic Words: Anticipated significant adverse clinical outcome medical need for different dosage form and/or higher dose Explain they have tried and failed the covered dosage form or dose Explain the medical reason for the exception i.e. Swallowing difficulties, can not sit upright Noncompliant with multiple medication administration times

10. Essential Prior authorization terminology The Magic Words: Anticipated significant adverse clinical outcome medical need for different dosage form and/or higher dose Tried and failed covered dosage form or dose Swallowing difficulties Noncompliant with multiple medication administration times

11. Essential Prior authorization terminology The Magic Words: Formulary or preferred drug(s) contraindicated or tried and failed, or tried and not as effective as requested drug Show trial of preferred drug Explain why the ordering physician prefers the ordered drug

12. Essential Prior authorization terminology When all else fails Psychiatric Drugs: The order prescribed by a psychiatrist The person has been stable on the current medication Failure to provide this medication will result in adverse clinical outcomes including an exacerbation of symptoms which may lead to acute inpatient hospitalization Other Drugs: Failure to have this medication may result in hospitalization. Provide any examples of hospitalizations for diagnosis

13. Pick your poison….. Complete the Prior Authorization online Use covermymeds.com Will take at least 24 hours to get approval Call the Insurance Plan Directly for the Prior Authorization Will take between 15-60 minutes on the phone and may require paper documentation Allow the Physician’s Office or Pharmacy Complete the Prior Authorization Will require physician’s signature may get denied

14. http://www.covermymeds.com Create an account Log in Begin new request Complete the appropriate form as prompted by the site. Fill in the blanks with the information you obtained before starting the authorization Collect additional documentation as needed Create a Free Account Log in New Request

15. Phone Prior Authorizations When calling to complete a prior auth on the phone: You are calling from the physician's office. Give them the physician's address, your direct line phone number and your direct fax number. The member’s phone number and address is that of the ICF or waiver home be sure to not give out their cell phone, they use this number to inform the member if the request has been approved or denied. Be sure to emphasize covered alternatives are contraindicated. Most companies give authorization code and start and end dates over the phone.

16. Prior Authorizations Completed by the Physician’s office or Pharmacy Give them as much information as you can, you know the person best. Do not assume they know anything. Depending on the insurance, physicians must sign off on the PA if it is completed by the pharmacy. SilverScript is the worst offender. They often require a “statement of medical necessity” to be signed by the doctor to process the PA it is easier to do them yourself. Keep copies of everything including fax confirmations.

17. What now? Send the completed prior auth form to the plan or chose to send it to the prescriber for a signature then send it to the plan. Wait for a fax confirming the of approval or denial of the medication or call the insurance company to follow-up on the status of the prior authorization. Send the approval fax to the pharmacy or call them with the approval information. If the request is denied, find out why, and start an appeal.

18. Misc. You can back date a prior auth for a medication that has already been dispensed. Once the prior authorization has been approved the pharmacy must resubmit the claim, they need to be told to do this. Prescription Assistance Programs are available to persons with insurance as well as the uninsured. To process the application you need a statement from the pharmacy proving what the co-pay is and a copy of their proof of income as well as a physical prescription from the physician.

19. Examples See handouts

20. Types of Medicaid Currently there are 19 types of Medicaid in Ohio Applicable Medicaid types : Aged, Blind or Disabled (ABD)- spend down may apply Medicare Premium Assistance Program (MPAP) Medicaid Buy-In for Workers with Disabilities (MBIWD) Residential State Supplement (RSS)- For ICFs Long-Term Care or Waiver Services:

21. Medicaid can help to cover Medicare Expenses Medicare Premium Assistance Program (MPAP) Assistance covering the $104.90 Medicare premium automatically withdrawn from social security check Co-pay Assistance Income for 1 person QMB 981/month SLMB 1,177/month Medicaid Buy-In for Workers with Disabilities (MBIWD) Persons living in ICFs can keep social security payment instead of having to give money back to cover “cost of care”

22. Applying Medicaid coverage is separate from cash and food benefits, it also requires a redetermination annual, this is a separate process from food and cash benefits as well and may not fall at the same time. This is completed at the department of job and family services or online, see form. Applying for Medicaid to help to cover Medicare Expenses is done using a separate form and process from applying for Medicaid. It is not an automatic benefit. This is done at the department of job and family services, see form.

23. QUESTIONS