PACE

PROVIDER BULLETIN

August 28, 2006

PACE Plus

 

Effective Friday September 1st, PACE will update over 150,000 PACE/PACENET cardholder files with Medicare Part D enrollment information from the seven (7) plans listed below.

Under the new PACE Plus Medicare Program, many PACE and PACENET cardholders will also be enrolled in Medicare Part D plans. 

    

For those cardholders:

·         PACE will pay the Part D plan premium, up to $32.59/mo.

·         Cardholders on PACENET, who are enrolled in one of the plans listed below, will no longer have a $40 deductible. Instead they will be billed for the monthly premium, up to $32.59 per month, by the Part D plan.

·         PACE will cover any Part D plan’s copay that exceeds the copay for PACE/PACENET.

·         PACE will be the secondary payer for drugs the Part D plan may not cover and will provide coverage during the Part D plan’s coverage gaps (i.e. the donut hole.)

 

Some PACE/PACENET cardholders have chosen not to be enrolled in a Part D plan. For these cardholders, PACE/PACENET  will continue to pay for their drugs as it has in the past.

 

Effective Friday September 1, 2006 PACE will edit claims for PACE/PACENET cardholders enrolled in the seven (7) Part D plans listed below.

 

These primary Part D plans must be billed before billing PACE/PACENET.

PLAN NAME

BIN

PHONE NUMBER

AmeriHealth Advantage (IBC) Option 1

012353

888-457-3007

First Health Premier

610029

800-588-3322

Highmark BlueRx Basic

610014

800-241-5704

Humana –Standard; Enhanced

610649

800-248-1133

MemberHealth Community Care Rx Basic

012304

866-684-5353

Ovations: United Medicare

Med Advance;  AARP Medicare RX

610652

888-288-9947

866-255-4835 (AARP Rx)

PacifiCare Saver

610097

800-947-9185

 

 

 

 

 

 

 

 

 

 

 

 

52% of all PACE/PACENET cardholders are newly enrolled in the 7 recommended Part D plans.

 

In addition, another 20% of PACE/PACENET cardholders have enrolled in MA-PD plans.

 

Please ask your PACE /PACENET patients if they have been notified of Part D enrollment.

 

PACE members should receive Plan D notification by September 1st. However, this information will also be available from PACE Cardholder Services (1-800-225-7223), Provider Services (1-800-835-4080), the Plan D Help Lines listed above or by the provider accessing the TrOOP Facilitator through their computer’s  E-1 Transaction.  

 

 

 

 

 

 

 

PACE also edits claims for the following Part D plans.  Claims denied for these plans do not have the cardholder’s Plan ID number returned in the response. To obtain the cardholder number providers must ask the cardholder, access the TrOOP Facilitator  (the E-1 transaction), or call the listed Help Desk number.

 

 

 

 

Plan

BIN

PHONE NUMBER

Aetna

610502

800-445-1796

Avalon

003858

877-234-3853

Elder Health

610014

800-291-0396

First Health Premier/Advantra RX & Advantra MAPD/Caremark

610029

800-588-3322

Geisinger

012353

800-631-1656

Health America / Health Assurance

610029

800-470-4272

Health Partners

012353

800-553-0784

HIGHMARK Freedom Blue

610014

800-935-2583

KHP East/ Keystone 65

004336

800-555-1514

Medco

610014

800-758-3605

Member Health

012304

866-684-5353

Pennsylvania Health Care

610468

850-432-1700

PSERS

003858

888-773-7748

RX America

012189

877-279-0370

Security Blue/KHP West

610014

800-935-2583

Senior Blue/ KHP Central

003858

800-990-4201

Silver Script

004336

866-552-6106

Unicare Life and Health

610053

800-928-6201

United  American

610014

866-524-4169

United Healthcare

610652

888-288-9947

UPMC

012353

877-381-3765

Wellcare

603286

888-423-5252


 

PROVIDER INFORMATION FOR SEPTEMBER 1ST

 

·         Claims billed to PACE/PACENET for cardholders enrolled in the 7 recommended Part D plans WILL DENY if the provider does not participate in the plan. If a PACE/PACENET cardholder is enrolled in one of the listed plans and the pharmacist does not participate in the Plan, the customer should be told they need to go to a pharmacy that does participate in their plan.

 

·         During the Part D coverage phase the Part D plan’s rules apply.  Note: in some instances, PACE, as the secondary payer, will deny claims from manufacturers refusing to participate in the Commonwealth’s rebate program. Some examples are: Vancocin HCl pulvules by Viropharma,    Vospire ER® tablets by DAVA Pharmaceutical, Qvar® by IVAX LABS and Mysoline® by XCEL Pharmaceuticals.

 

·          Claims denied by the 7 listed plans will have the Member’s Plan ID number, the plan’s name, BIN and PCN returned in the response. 

 

·         Claims denied by Part D plans for errors such as for “Prior Authorization Required,” “Product Not Covered,” or “Plan Limitations Exceeded” are to be submitted to PACE with the Primary’s deny code. PACE/PACENET will initiate the appropriate action on behalf of the cardholder.

 

·         Claims denied by Part D plans for non-formulary issues,  ( i.e., correctable errors) such as invalid day’s supply,  should be corrected to permit payment from the Part D plan.

 

·         Some listed plans have a $0 copay or a copay lower than the PACE copay. Therefore, some claims will not be submitted to PACE until the “donut hole” is reached.

 

·         Part D plans having a deductible should be submitted with the amount due from the cardholder entered in Field 433-DX, Patient Paid Amount and an Other Coverage Code of “4”.

 

·         90 Day Supply

 

o        RETAIL--Cardholders enrolled in Part D plans may choose to use a Plan’s “90 day supply at retail” option. Providers billing this 90 day supply to Part D may bill PACE as the secondary payer with “90” entered in the day’s supply. For those claims, the Program will calculate reimbursement based on three (3) PACE/PACENET copays.

 

o        MAIL ORDER PART D PROVIDERS-- Cardholders enrolled in Part D plans may choose to use the Part D Plan’s 90 day Mail Order option. This option will result in the Mail Order Provider billing this 90 day supply to Part D and billing PACE as the secondary payer. For those claims, the Program will calculate reimbursement based on three (3) PACE/PACENET copays. 

 

·         PACENET CARDHOLDERS WILL NO LONGER HAVE A $40 MONTHLY DEDUCTIBLE EFFECTIVE SEPTEMBER 1, 2006.

 

o        Those cardholders ENROLLED in a Part D plan will be billed by the Part D plan for the monthly premium. These cardholders will only pay the Part D plan copay or the PACENET copay, whichever is lower.

 

o        Those cardholders NOT ENROLLED in a Part D plan will continue to have a PACENET deductible collected at the point-of-sale. For these cardholders, their monthly deductible will decrease from $40.00 to $32.59. They must also pay the PACENET  copay(s).

 

IMPORTANT: No PACE/PACENET cardholder enrolled in Medicare Part D should be turned away without their medication as long as you participate in their Part D plan.

 

Questions may be directed to the Provider Services at

1-800-835-4080