American Indian and Alaskan Native Medicare Drug Discount Card Program and $600 Credit

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American Indian and Alaskan Native Medicare Drug
Discount Card Program and 600 Credit

• Computer Sciences Corporation (CSC) and
  MemberHealth

Foxwoods, CT
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Agenda

• Introduction to CSC and MH
• CSC/MH Dedication to AI/AN Program
• Enrollment/Disenrollment
• Pharmacy Participation
• Discount Drug List
• Prescription Claim Submission
• Copayments
• Benefits to Providers
• Benefits to Beneficiaries
• Questions

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Introduction Criterion Advantage

• Criterion Advantage is a collaboration between
  Computer Sciences Corporation (CSC) and
  MemberHealth, Inc. (MH)
• CSC is the prime contractor under this initiative
  
• CSC and MH have partnered to provided the
  Medicare approved Criterion Advantage Discount
  Drug Card Program

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Sponsor Introduction Who is Computer Sciences
Corporation (CSC)?

• Founded in 1959, CSC is a leading global
  information technology (IT) services company
• Mission is to provide customers in industry and
  government with solutions crafted to meet their
  specific challenges and enable them to profit
  from the advanced use of technology
• Provides innovative solutions for customers
  around the world by applying leading technologies
  and CSCs own advanced capabilities
• Provides systems design and integration IT and
  business process outsourcing applications
  software development Web and application
  hosting and management consulting
• Headquartered in El Segundo, CA with
  approximately 90,000 employees worldwide CSC
  reported over 14 Billion in revenue for Fiscal
  Year 2004
• Major CMS projects include Common Working File,
  Managed Care Redesign, Program Safeguard
  Integrity, Medicaid Architecture

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Sponsor Introduction Who is MemberHealth (MH)?

• MemberHealth operates a number of national and
  state prescription benefit administration (PBM)
  programs, including insured, self-insured and
  discount prescription plans.
• MemberHealth is the PBM contractor for the CSC
  Medicare approved programs including Community
  Care Rx (CCRx), Criterion Advantage (CA), both
  nationwide programs, and the Golden Buckeye
  program in Ohio.
• Additionally, MemberHealth and CSC administer a
  growing list of state PAP/Medicare wraparound
  programs, including Connecticut, Ohio, North
  Carolina, and Mississippi.
• MemberHealth and CSC manage two Special Endorsed
  Medicare programs, for Long Term Care and I/T/U
  (AI/AN).
• MemberHealth is headquartered in Solon
  (Cleveland), Ohio

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Committed to the Success of the AI/AN Program

• Attended and participated in Medicare Tribal
  Technical Advisory Group (TTAG) meetings and
  conferences in Reno, NV, Orlando, FL and
  Washington, D.C.
• Participated in the May 28 Direct TV satellite
  broadcast, presenting an overview of the program.
• Worked closely with IHS and TTAG to ensure that
  the contracting language was appropriate for the
  Indian Health Service, Tribes and Tribal
  Organizations, and Urban Indian Organization
  (I/T/U) pharmacies
• Worked closely with IHS and TTAG to assure that
  pre-enrollment outreach and membership materials
  accurately describe the Medicare approved Drug
  Discount Card program as it relates to AI/AN
• Plan to attend every IHS regional training
  session to educate pharmacists, business managers
  and other stakeholders about the drug discount
  program and the 600 credit

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Enrollment

• Fill out and submit enrollment application
• There are two separate forms
• Enrollment form for the MedicareApproved Drug
  Discount Card
• Enrollment form for the MedicareApproved Drug
  Discount Card and 600 Credit in Paying for Your
  Prescription Drugs
• Make sure to complete and send in the correct
  form
• Only one form should be submitted do not submit
  both forms
• Do not omit or leave blank any fields of the form
  (ie member income, pharmacy NCPDP)

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Example Criterion Advantage Enrollment Forms for
600 Credit
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Example Criterion Advantage Enrollment Forms for
Discount Only

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Enrollment

• Enrollment fee is 30.00
• If applying for 600 Credit/Transitional
  Assistance (TA), Medicare will pay the enrollment
  fee
• If applying for discount drug card only, enrollee
  has to pay the enrollment fee
• Purchase Order (Voucher) will likely be issued
  for the payment of the enrollment fee
• Important to apply for 600 credit as soon as
  possible
• Beneficiaries who qualify for 600 credit and
  enroll in 2004 will receive 600 credit in 2004
  and 600 credit in 2005 to use towards their
  prescription drugs
• If do not enroll by end of December will lose the
  600 credit for 2004
• 600 credit will be prorated for anyone who
  enrolls after March 31, 2005 (losing 150 each
  quarter)

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Disenroll from a General Drug Card to Enroll in
an I/T/U Special Endorsed Drug Card

• If a beneficiary is currently enrolled in a
  general Drug Discount Card that does not have the
  I/T/U special endorsement, the beneficiary may
  elect to disenroll from the general card and
  enroll in a special endorsed card program at any
  time
• A Special Election Period (SEP) has been
  established for American Indian/Alaskan Natives
  (AI/AN) who want to disenroll from a general Drug
  Discount Card in order to enroll in an I/T/U
  special endorsed card.
• SEP is for the life of the Medicare Drug Discount
  Card Program
• To be eligible for the SEP, the AI/AN will need
  to disenroll from the general card in which s/he
  is currently enrolled and inform the sponsor that
  s/he qualifies for the SEP before the enrollment
  in the I/T/U special endorsed card can take place

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Pharmacies Network Pharmacies

• To obtain a discount or use the 600 credit
  beneficiaries must have their prescriptions
  filled at a network pharmacy
• The pharmacy network includes
• Indian Health Service, Tribes and Tribal
  Organizations, and Urban Indian Organization
  pharmacies that are under contract with Criterion
  Advantage
• Retail pharmacies that are under contract with
  Criterion Advantage
• Tribal Accupax mail service pharmacy
• Become a network pharmacy by signing a network
  pharmacy contract as soon as possible
• All IHS pharmacies are contracted with Criterion
  Advantage
• Tribal and Urban Indian contract has been
  approved by CMS your packet includes a copy.
  Each pharmacy must sign the contract in order to
  provide services

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Pharmacies Mail Service Pharmacy

• Beneficiaries can send written prescriptions to
  the pharmacy
• I/T/U pharmacies in rural areas who do not have a
  drug in stock and do not have access to CHS
  contracted retail pharmacies can fax written
  prescriptions to the mail service pharmacy to be
  filled
• Prescriptions should be written for a minimum of
  60 to 90 days supply
• Normal service cycle is a maximum of three days
  to process the order in the pharmacy
• Complete reviews of the ordered prescriptions
  against the users medical, prescription, and
  allergy profile are conducted
• Please allow for 14 days from the date the
  beneficiary sent the prescriptions to the
  pharmacy for the processing and mailing of
  prescriptions
• Shipping is through the U.S. Postal Service and
  is free

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Discount Drug List

• I/T/U sites will keep the Federal Supply Schedule
  as their formulary
• Open Formulary for retail and mail pharmacies
• ALL brand and generic drugs are covered under the
  program except those federally excluded (next
  slide)
• The Discount Drug List is to be used when having
  prescriptions filled at pharmacies that are not
  operated by the Indian Health Service, Tribes and
  Tribal organizations, or Urban Indian
  organizations (I/T/U)
• The Discount Drug List is to be used when having
  prescriptions filled at retail pharmacies

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Discount Drug List Federally Excluded Drugs

• Drugs not covered under the Medicare Discount
  Card are
• Anorexia, weight loss, or weight gain
• Fertility Drugs
• Cosmetic purposes or hair growth
• Drugs to relieve coughs or colds
• Prescription vitamins and mineral products
  (except prenatal)
• Nonprescription drugs (Over-the-counter drugs)
• Barbiturates
• Benzodiazepines
• Drugs that could be covered under Medicare Part B

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Example Criterion Advantage Card
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Prescription Claim Submission

• Pharmacies with electronic billing capability
  will submit claims electronically and they will
  be adjudicated online
• Pharmacies without electronic billing capability
  will submit paper claims
• Pharmacy calls the helpdesk to obtain the
  transitional assistance balance remaining
• If a balance remains, pharmacy faxes a Universal
  Claim Form to MemberHealth for reimbursement
• MemberHealth will enter the claim online upon
  receipt of the claim form during hours of
  operation (M-F 800am-500pm EST)
• Pharmacy may also call the helpdesk to provide
  the claim information by phone for online entry,
  but will still be required to fax a Universal
  Claim Form to MemberHealth
• Payment is not guaranteed until the online claim
  has been successfully processed

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Copayments Prescription Filled at I/T/U Pharmacy

• If beneficiary has qualified for the 600 credit
  and has prescriptions filled at an I/T/U network
  pharmacy, then s/he likely will not pay a
  coinsurance at the pharmacy for each prescription
  drug (presuming the facility has agreed to waive
  the copay)
• The drug cost will be applied toward the 600
  annual credit

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Copayments Prescription Filled at Retail
Pharmacy (Non-I/T/U)

• If beneficiary has qualified for TA and
  self-refers to have prescriptions filled at a
  retail pharmacy, s/he will pay a coinsurance at
  the pharmacy for each prescription drug, until
  the credit of up to 600.00 is used, based on the
  income level as follows
• American Indian
• Single, 12,569 or less, 10 copay (up to
  135 FPL)
• Single, 9,310 or less, 5 copay (up to
  100 FPL)
• Married, 16,862 or less, 10 copay (up to
  135 FPL)
• Married, 12,490 or less, 5 copay (up to
  100 FPL)
• Alaskan Native
• 135 FPL, Family size of 115,701
• 135 FPL, Family size of 221,074
• 100 FPL, Family size of 111,630
• 100 FPL, Family size of 215,610
• If beneficiary has an authorized Contract Health
  Services (CHS) referral and has prescriptions
  filled at a retail pharmacy, CHS will cover the
  cost of the prescriptions and the coinsurance
  amount

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Benefits to I/T/U Providers

• Up to 600 paid to network I/T/U pharmacies to
  reimburse for prescriptions that they fill for
  each eligible beneficiary
• Estimated 20,000 eligible AI/AN beneficiaries
• 12 million in federal available
• Saves Contract Health Services funds
• If beneficiary has an authorized Contract Health
  Service referral and has prescriptions filled at
  a retail pharmacy, the 600 credit will be used
  to pay for the drugs at the retail pharmacy
• Positions AI/AN to be a part of 2006 Part
  DProgram

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Benefits to AI/AN Beneficiaries

• Beneficiaries who qualify for 600 credit and
  enroll in 2004 will receive 600 credit in 2004
  and 600 credit in 2005 to use towards their
  prescription drugs
• Any unused portion of the 600 credit that is not
  used in 2004 will roll over to 2005
• Beneficiaries who do not qualify for the 600
  credit will receive prescription drug discounts,
  especially if prescriptions are being filled at a
  retail pharmacy
• Ability to obtain prescriptions through Tribal
  Accupax mail service pharmacy at deeper discount

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Contact Information

• Scott G. Hughes R.Ph. Louis Hogan
• MemberHealth Inc. Computer Sciences Corp
• 888-868-5854 443.436.6620
• shughes_at_mhrx.com lhogan2_at_csc.com

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Questions?