Changes in pharmacy benefit management

• Centralized services
• Integrated claims processing
• Prior Authorization (PA)
• Self-service on the Web 

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Centralized services

Electronic Data Systems (EDS) will administer the following pharmacy benefit management (PBM) functions for DHS:

• Prior Authorization Help Desk
• Help Desk that supports all system components of the overall PBM program including for Pharmacy Point-of-Sale (POS) and Coordination of Benefits assistance
• Pro-DUR program operation, edits processing and error resolution
• State Maximum Allowable Cost (SMAC) list updates
• Drug reference file maintenance
• Medicaid Drug Rebate program operation

Integrated claims processing

All pharmacy claims will be processed through the replacement MMIS. Pharmacies will have the following options for submitting claims:

• Point of Sale (POS) interactive claim: Real-time NCPDP 5.1 claim transaction
• Web claim: Real-time NCPDP 5.1 transaction through the Provider Web Portal
• Paper claim: The UCF 5.1 paper claim will process through the DHS Electronic Document Management System (EDMS) like other standard DHS claims.

Prior Authorization (PA)

With the replacement MMIS, you will have two enhancements to existing PA processes:

• Automated PA: Some pharmacy claims will go through the DUR+ automated PA system as part of regular processing. DUR+ will automatically review the drug claim for PA based on pre-defined criteria and the client’s claim history. DHS will utilize this as fully as possible wherever the appropriate clinical criteria can be linked to drugs requiring PA.
• Web PA: Prescribing providers will be able to submit PA requests through the Provider Web Portal. For more information about this and other Web portal benefits, go to this link.