Stephanie Morrissey, Provider Network Specialist

• Automates electronic and paper payments to reduce costs and errors.
• Helps providers transition from paper to electronic methods of payment and explanation of benefits (EOB) in an efficient and secure manner.
• Allows providers to manage the receipt of payments and EOBs more efficiently.
• Provides a secure web site to providers to obtain copies of EOBs and to update payment instructions

In 2008, we started reporting on a new pharmacy metric, called "the hassle factor". This metric measures the number of prescriptions that reject at the point of sale. Since there are many different reasons why prescriptions reject, they have been consolidated into two major categories - clinical rejections and administrative rejections. Here are the highlights:

Time period - 07/01/08 to 09/30/08 (3 months)
Total Rxs - 44,315
Our Total Rx Cost - $2,217,294

Clinical Rejections
Definition - Clinical rejections are defined as prescriptions which reject after the first adjudication attempt as a result of a clinical edit.  Clinical edits include prior authorization (PA), step therapy, quantity limit or formulary issues.

Administrative Rejections
Definition - Administrative rejections are defined as prescriptions which are rejected after the first adjudication attempt as a result of an administrative edit. Administrative edits include refill-too-soon, vacation supply, lost medications, NDC not covered (OTCs), eligibility/enrollment, wrong DOB/ID #, non-contracted pharmacy, etc.

Pharmacy Benefits Changes
Over the past three years since the inception of the Medicare Part D benefit, Commonwealth Care Alliance's pharmacy program has endeavored to offer an array of flexible coverage policies that are generally not found in other Medicare Part D options in order to reduce "hassle". However, regulatory requirements and increasing financial constraints are making it increasingly difficult to continue some of these policies. What follows are changes that we are making to our pharmacy benefit, effective January 1, 2009.
 
I. Erectile Dysfunction (ED) Medications
Effective January 1, 2009, we will no longer cover ED medications and/or devices, thereby aligning our policy with MassHealth and Medicare Part D which do not cover ED therapies.
 
II. Multi-Source Brand Medications
Historically, Commonwealth Care Alliance has allowed network clinicians the flexibility to continue to prescribe brand name medications in instances where generic equivalents are available, as a convenience to those patients and clinicians who are reluctant to switch to a generic equivalent for a variety of reasons. However, we can no longer justify this "convenience," given the substantial increase in expenditures inherent in this policy and the lack of evidence of quality compromise when "generics" are substituted for brand name medication (e.g. simvastatin for Zocor). Therefore, effective January 1, 2009, we will only cover the generic equivalent of multi source branded medications. 

III. Anti-Tussive Medications
Effective January 1, 2009, Commonwealth Care Alliance will substantially limit over-the-counter and/or prescription only anti-tussive medications that we will cover to only:
a)      Generic Robitussin (guaifenesin);
b)      Generic Tessalon Perles (benzonatate), and;
c)      Generic Cheratussin AC (guaifenesin/codeine)
All other, anti-tussive medications (OTC and/or prescription only) will no longer be covered. Neither Medicare Part D nor MassHealth cover any anti-tussive medications.
 
IV. Anorexiant Medications
Effective January 1, 2009, Commonwealth Care Alliance will no longer cover any anorexiant (weight loss) medications. Neither Medicare Part D nor MassHealth cover this class of medication.

Commonwealth Care Alliance will honor and continue to cover all previously approved benefit exceptions for these classes of medication. However, upon the expiration of these benefit exception approvals, we will not renew ED medications, multi-source brands, anti-tussives, and all anorexiants.

 

Questions? Contact Basem Shebli, Pharmacy Director, at 617.426.0600 ext. 225 or bshebli@commonwealthcare.org

My Life, My Health is a Stanford Chronic Disease Self-Management program, where participants learn to live better with long-term conditions. 

 

 

Casenet trainings will be conducted for staff in Springfield on February 26 & 27. Trainings will be held in Boston on March 3, 4 & 5.

 

Before Casenet, Commonwealth Care Alliance utilized a number of different software applications for the varied activities associated with managing membership. With the implementation of this new software, staff will have a single data source for thorough and up-to-date patient information to facilitate more accurate and efficient decision-making. By integrating the claims payment system and replacing care management systems with Casenet, Commonwealth Care Alliance will benefit from a centralized, cross-disciplinary design that increases efficiencies and collaboration, thereby improving care recommendations and overall health outcomes, and better managing healthcare costs.

 

Questions? Please contact Janet Norton, SCO Nurse Clinical Coordinator, at 617.426.0600 ext. 280 or jnorton@commonwealthcare.org