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Texas
Pharmacy Business Council is an organization of
American Pharmacies and the Academy of Independent
Pharmacists-Texas.
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TDI pharmacy help
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The Texas
Department of Insurance has a Pharmacist Resource
Page that includes links to complaint forms and
advises when the next Pharmacy Outreach Conference
Call will be held.
Add this link to your online
"favorites"
list. |
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Texas legislation
success
list |
Regulation
of Rx discount
cards
PBM
transparency in state
contracts
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Calls continue to come
in about CVS Caremark business practices
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TPBC continues to receive
reports from members that CVS Caremark is asking
beneficiaries to use Caremark mail order or CVS
retail stores for maintenance
medications.
As
you become aware of instances where CVS Caremark
is telling your patients they must use Caremark
mail order or CVS retail stores, please note who
the employer is and e-mail or fax
(512.992.1391) the information to us at the Texas
Pharmacy Business Council so we can review
it.
Especially
when taxpayer money is at issue, we have a greater
chance of heading off Caremark by bringing it to
the attention of elected officials, public agency
staff and local news
media.
We recently
learned that the Houston ISD is working on an RFP
for hiring a PBM. An organization that
shares our concerns about CVS Caremark is Change
to Win, a coalition of American labor unions
originally formed in 2005 as an alternative to the
AFL-CIO, is tracking CVS/Caremark's actions around
the country as public agencies consider PBM
contracts. Change to Win is educating the public
and legislators about CVS Caremark's business
practices. Change to Win's letter to Houston ISD is available
here.
One of our
members faxed us this letter sent to his patient
who is covered by the Liberty County health plan
and we will encourage Liberty county pharmacists
to contact county officials. But our best
chance of impacting public health plans' decisions
in selecting a new PBM to administer their Rx
benefits is when they are out for bids or in the
Request for Proposal (RFP) process. We urge
you to talk to your city, county, school officials
or a significant local employer and ask them about
the status of their health plan contracts and
offer to be a resource for them on pharmacy
benefit managers.
Another one of our Council members alerted
us that Tarrant County is in the process now. You
can begin the process of educating them before a
decision has been made and a contract is signed.
The FTC and
several state attorneys general are investigating
the CVS/Caremark merger. However, we can't just
sit back in hopes the FTC rules any time soon. So
please share documents such as the one from
Liberty County or information like the Tarrant
County bid process. If you don't have a document,
at the least tell us the name of the employer,
whether public agency or private
business.
Stay
tuned! 
Richard E. Beck,
RPh
Executive Director, Texas Pharmacy Business
Council |
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TPBC/TDI
tip
Is Humana refunding your
adjudication fees?
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By
Amanda Gohlke Fields, General Counsel
Your
Texas Pharmacy Business Council representatives
continue our work with the Texas Department of
Insurance (TDI) that we initiated in July, 2009,
to assist our members with resolution of
complaints against health plans and
PBMs.
As part of the TPBC/TDI relationship,
we will send you occasional tips regarding
appropriate and timely reimbursements.
Today's
Tip
As you've reported to us,
Humana sent you written notification that the fee
will no longer be applied, and most importantly,
that Humana will issue a credit for all fees that
were assessed since the fee's effective date of
Dec. 8, 2009. The credit should appear on your
next electronic remittance, if it has not
already.
You will remember that TPBC submitted a
complaint on behalf of its members to TDI
against Humana, in response to the $0.25
adjudication fee it proposed. TPBC complained that
this adjudication fee violated a portion of the
Texas Insurance Code that applies to electronic
health care transactions, and states that a health
care plan may not directly or indirectly charge or
hold a health care professional, health care
facility, or person enrolled in a health benefit
plan responsible for a fee for the adjudication of
a claim. TDI representatives indicated to TPBC
that it agreed with the complaint and Humana may
not charge the adjudication fee. You can see TDI's
opinion of the complaint under the FAQ section of
the TDI pharmacy-specific webpage: http://www.tdi.state.tx.us/hprovider/pharmacy.html
If
you are directly charged an adjudication fee like
the one described above by a health maintenance
organization or insurer, please submit your
complaint to TDI. If you are indirectly charged by
a health maintenance organization or insurer, such
as through a PBM, please also submit your
complaint, but be sure to submit the complaint
against the health maintenance organization or
insurer (not the PBM), as the language of the
applicable law targets the health maintenance
organization or insurer that directly or
indirectly (through a PBM) charges the fee. Take
ten minutes today and submit a complaint to
eliminate your adjudication fees!
TDI's
enforcement of existing laws translates to more
money in your pocket, and we appreciate TDI being
so proactive and responsive. Utilizing TDI as your
dispute adjudicator can save you time and
money! Please submit your complaints
regarding HMOs, insurers or PBMs to TDI. They are
the agency charged with oversight of these issues,
and thanks to the work of APRx and TPBC staff and
consultants, are on standby to help you! If
they don't hear from you, they can't help you!
Remember, bookmark this page: http://www.tdi.state.tx.us/hprovider/pharmacy.html.
In addition to important information for you, it
also has a link to file an electronic
complaint. It couldn't be easier!
If you have questions or need
assistance with filing your complaint or TDI's
resolution of the complaint, please email Amanda
Gohlke Fields, General Counsel at afields@aprx.org.
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CMS terminates FOX
Insurance
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The Centers
for Medicare & Medicaid Services recently
terminated FOX Insurance from the Medicare Part D
program. In a directive that went into effect
March 1, pharmacists should be billing all
enrollees who were in the FOX program to the new
Part D Low Income (LI-NET) program administered by
Humana. The National Community Pharmacists
Association reports many pharmacies are not being
paid by FOX for prescriptions dispensed between
Feb. 16 and March 1, and that some claims being
billed to LI-NET are being rejected. CMS has asked
NCPA to provide them with examples of specific
claims that are at issue. Please fax any claim
information to NCPA (attention: Government
Affairs) at 703-683-6375 so we can provide them to
CMS.
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CMS suspends Aetna
Medicare Advantage Part D
coverage
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Regulators
have suspended Aetna Inc. from enrolling customers
in Medicare Advantage plans due to changes the
health insurer made to its Part D prescription
drug coverage.
The suspension starts April
21. It covers all Medicare Advantage plans as well
as plans that just provide Medicare's prescription
drug coverage. Aetna also cannot market the plans
under the suspension.
Medicare Advantage
plans are privately run versions of the
government's Medicare program, which provides
health coverage for the elderly and disabled. The
plans, subsidized by the government, offer basic
Medicare coverage topped with extras or premiums
lower than standard Medicare rates.
The
sanction stems from changes the insurer made from
2009 to 2010 when Aetna switched its Part D
prescription drug coverage from an open formulary
to a closed one, which involves payment tiers and
in some cases favors generic drugs over brand
names. | |
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Texas
Pharmacy Business Council
Ensuring patient access to
quality pharmacy care services,
the viability of
community pharmacy and the pharmacy
profession.
1001
Congress Ave., Suite 250, Austin, TX 78701
512.992.1219
Richard
E. Beck,
RPh, Executive Director
www.TxRxCouncil.org | | |
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