Paying for MedicationsPrior Authorizations (PAs, Prior Auth)

Types of Medicaid“Extra Help”

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

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

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

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.

Where to get info continued3. 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- physcian7. Prescriber’s information-the prescription, your

records or the pharmacy.

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 contraindicatedMust 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 alternativeCovered alternative causes GI upset, mood or

behavior symptoms

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 changesUse complex patient with 9 or more chronic

conditions wording with all PAs when applicable

Essential Prior authorization terminology

The Magic Words:Anticipated significant adverse clinical

outcome medical need for different dosage form and/or higher doseExplain they have tried and failed the

covered dosage form or doseExplain the medical reason for the exception

i.e. Swallowing difficulties, can not sit uprightNoncompliant with multiple medication

administration times

Essential Prior authorization terminology

The Magic Words:Anticipated significant adverse

clinical outcome medical need for different dosage form and/or higher doseTried and failed covered dosage form or

doseSwallowing difficultiesNoncompliant with multiple medication

administration times

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 drugShow trial of preferred drugExplain why the ordering physician

prefers the ordered drug

Essential Prior authorization terminology

When all else failsPsychiatric Drugs: The order prescribed by a psychiatristThe person has been stable on the current medicationFailure 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

Pick your poison…..Complete the Prior

Authorization online

Usecovermyme

ds.com•Will take at least 24 hours to get approval

Call the Insurance

Plan Directly for

the Prior Authorizati

on•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

http://www.covermymeds.comCreate 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 authorizationCollect additional documentation as needed

Create a Free Account

Log in

New Request

Phone Prior AuthorizationsWhen 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.

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.

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.

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.

ExamplesSee handouts

Types of MedicaidCurrently there are 19 types of Medicaid in

OhioApplicable 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 ICFsLong-Term Care or Waiver Services:

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”

ApplyingMedicaid 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.

QUESTIONS