Last revision date:  12.17.2020 
                                                                                                        
                                                                                                        
                                                                                                        
                                                                                                        
                                                                                                        
                                                                                                        
                                                                                                        
                                                                                                        
                                                                                                        
                                                                                                        
                                                                  Pharmacy Manual 
                                      Supplemental Policies, Procedures and Regulations 
                                                                                                        
                                                                                                        
                                                                                          Prepared by: 
                                                                                                  Elixir 
                                                                                           800-361-4542 
                                                                                                        
                                                                                 ELIXIRSOLUTIONS.COM 
                                     
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                                                     
                                                                                                        
                                                                    2181 E. Aurora Road, Suite 201 | Twinsburg, OH 44087  
                                                                            Copyright © 2020, Elixir. All rights reserved. 
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                                   Table of Contents 
          PHARMACY MANUAL INTRODUCTION......................................................................................................................... 5 
          GENERAL INFORMATION ............................................................................................................................................. 5 
                PROPRIETARY AND CONFIDENTIAL .................................................................................................................. 5 
                ADVERTISING REQUESTS .............................................................................................................................. 6 
          CONTACT INFORMATION / WHERE TO GET HELP ...................................................................................................... 6 
          NETWORK ENROLLMENT FORM AND CREDENTIALING GUIDELINES ....................................................................... 6 
                APPLYING FOR PARTICIPATION ...................................................................................................................... 6 
                CREDENTIALING AND RECREDENTIALING GUIDELINES ....................................................................................... 7 
          PROVIDER AND MEMBER SERVICE STANDARDS ...................................................................................................... 7 
                NON-DISCRIMINATION CLAUSE ...................................................................................................................... 7 
                PROVIDER NETWORK – ACCESSIBILITY ........................................................................................................... 7 
                PHARMACY COMMUNICATIONS ....................................................................................................................... 8 
                NON-PREFERRED VS. PREFERRED STATUS ..................................................................................................... 8 
                QUALITY ASSURANCE ................................................................................................................................... 8 
                COMPLIANCE WITH LAWS .............................................................................................................................. 8 
                INVESTIGATIONS AND DISCIPLINARY ACTIONS .................................................................................................. 8 
                CHANGE OF INFORMATION ............................................................................................................................. 8 
                EXCLUDED PARTIES ..................................................................................................................................... 9 
                FRAUD, WASTE AND ABUSE TRAINING ............................................................................................................ 9 
                SUSPENSIONS AND TERMINATIONS ................................................................................................................. 9 
          PRICING AND REIMBURSEMENT QUESTIONS .......................................................................................................... 11 
          REIMBURSEMENT AND COST SHARE ....................................................................................................................... 11 
          MAXIMUM ALLOWABLE COST (MAC) ........................................................................................................................ 11 
                MAC LISTS ................................................................................................................................................. 11 
                MAXIMUM ALLOWABLE COST APPEALS ........................................................................................................... 12 
          VACCINES ................................................................................................................................................................... 12 
                RETAIL VACCINE PROCESSING INSTRUCTIONS............................................................................................... 12 
                VACCINE PROGRAM LIST ............................................................................................................................ 12 
                PART B VACCINE PROGRAM LIST ................................................................................................................. 14 
                COVID-19 VACCINES ................................................................................................................................ 15 
          PROCESSING A CLAIM ............................................................................................................................................... 16 
                BIN NUMBER AND PCN INFORMATION .......................................................................................................... 16 
                ELECTRONIC CLAIMS TRANSMISSIONS REQUIREMENT .................................................................................... 16 
          ACCURATE CLAIM SUBMISSION AND PRESCRIPTION RECORD ............................................................................. 17 
          AUDIT GUIDELINES ..................................................................................................................................................... 21 
                INTRODUCTION .......................................................................................................................................... 21 
                TYPES OF AUDITS ...................................................................................................................................... 21 
                REQUESTED DOCUMENTATION AND RECORDS ............................................................................................... 22 
                TYPICAL AUDIT PROTOCOL AND APPEALS PROCESS ...................................................................................... 22 
                WHOLESALER, MANUFACTURER AND DISTRIBUTOR INVOICES: REQUIREMENTS AND AUDITS ............................... 22 
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                FREQUENTLY ASKED AUDIT QUESTIONS ....................................................................................................... 23 
                ACCEPTABLE AUDIT APPEALS ..................................................................................................................... 25 
                DEFINITIONS ............................................................................................................................................. 27 
          EDITS ........................................................................................................................................................................... 28 
                FRAUD WASTE AND ABUSE EDITS ................................................................................................................ 28 
                DRUG UTILIZATION REVIEW (DUR) EDITS ..................................................................................................... 28 
                POINT OF SALE (POS) OPIOID PATIENT SAFETY EDITS ...................................................................................... 29 
                COORDINATION OF BENEFITS (COB) .............................................................................................................. 31 
          MEDICARE PART D ..................................................................................................................................................... 31 
                MEDICARE COVERAGE GAP DISCOUNT PROGRAM ......................................................................................... 31 
                WHAT ARE “APPLICABLE” DRUGS? ............................................................................................................... 32 
                HOW WILL THE MEDICARE COVERAGE GAP DISCOUNT PROGRAM WORK? ....................................................... 32 
                HOW WILL MY PHARMACY KNOW WHICH MANUFACTURERS HAVE SIGNED A COVERAGE GAP DISCOUNT PROGRAM 
                   AGREEMENT WITH CMS? ...................................................................................................................... 32 
                MEDICARE AUDIT AND RECORD RETENTION REQUIREMENTS .......................................................................... 32 
                REJECTIONS .............................................................................................................................................. 33 
                PART D UNIQUE BIN REQUIREMENTS .......................................................................................................... 34 
                TRANSITION REQUIREMENTS ....................................................................................................................... 34 
                MEDICARE PRESCRIPTION DRUG COVERAGE AND YOUR RIGHTS – REVISED GUIDANCE FOR DISTRIBUTION OF 
                STANDARDIZED PHARMACY NOTICE (CMS-10147) ........................................................................................ 35 
                MAIL ORDER PHARMACIES ........................................................................................................................... 36 
                HOME INFUSION PHARMACIES ...................................................................................................................... 36 
                HOME INFUSION PHARMACY NPPES REGISTRATION ......................................................................................... 36 
                PHARMACIES SERVICING LONG TERM CARE FACILITIES .................................................................................... 36 
                HOSPICE MEDICATIONS .............................................................................................................................. 38 
                PRESCRIBER VERIFICATION......................................................................................................................... 38 
                LONG TERM CARE PHARMACY (LTC) ........................................................................................................... 39 
                SHORT CYCLE DISPENSING ......................................................................................................................... 39 
                REQUIREMENTS FOR CODING PATIENT RESIDENCE AND PHARMACY SERVICE TYPE ON CLAIM TRANSACTIONS ..... 41 
                DAILY COST SHARING REQUIREMENTS ......................................................................................................... 41 
                MEDICARE PART D AUTO REFILL ................................................................................................................... 42 
                ADDITIONAL MEDICARE PART D REQUIREMENTS ........................................................................................... 42 
          STATE SPECIFIC PROVISIONS ................................................................................................................................... 43 
                CALIFORNIA – MANAGED HEALTH CARE ....................................................................................................... 43 
                MICHIGAN MEDICAID HEALTH PLAN DISPENSING FEE ....................................................................................... 44 
                NEW HAMPSHIRE - MEDICAID LINE OF BUSINESS ........................................................................................... 44 
                NEW JERSEY - COMMERCIAL LINE OF BUSINESS ............................................................................................ 48 
                NORTH CAROLINA – FULLY-INSURED COMMERCIAL AND HMO LINE OF BUSINESS ................................................. 49 
                TEXAS - NETWORK ADMINISTRATION TECHNOLOGY FEE (NATF) ..................................................................... 50 
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