PACE
PROVIDER BULLETIN
January, 2010
2010 Medicare Part D Partner Plans
PACE is conducting its annual assignment of cardholders into Part D partner plans. Although 2 of the 3 partners are the same, some cardholders may have been moved into a plan that better serves their needs. As before, we are providing lists of cardholders that frequent your pharmacy with the primary plan’s information to assist you in updating your files.
Additionally, if a provider bills PACE as the primary payer and the claim rejects for error 7C –“M/I other payer ID” or 41- “Bill Primary Payer,” the primary’s BIN, PCN, GROUP, Cardholder ID and Plan name is returned in field 504-F4 as part of the denied response.
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Part D Partner Plans
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BIN
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PCN
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Mail Order
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Prem
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Deduct
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Tier 1
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Tier 2
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Tier 3
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Tier 4
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Generic
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Preferred Brand
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Non-Pref’d Brand
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Specialty
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Community CCRx Basic
(Pennsylvania Life Insurance Company MemberHealth)
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610211
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PDP
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NO Mail Order—
90 day supplies available at retail
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$20.60
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$310
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$0
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30%
90 day = 3x copay
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65%
90 day = 3x copay
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N/A
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AARP Medicare Rx Saver
(Ovations -- United Health Group)
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610097
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9999
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$27.10
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$310
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$6
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$25.00
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$82.75
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25%
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|
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Rx Solutions
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|
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$4 90 day
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$60 90 day
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$233.25 90 day
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25%
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All other mail order pharmacies
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3 x copay
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3 x copay
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3 x copay
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3 x copay
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Part D Partner Plan
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BIN
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PCN
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Mail Order
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Deduct
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Tier 1
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Tier 3
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Tier 4
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Tier 5
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Fox Value Plan
(Fox Insurance )
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Preferred Generic
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Other Generic
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Pref’d Brand
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Non-Pref’d Brand
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Specialty
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014194
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MEDD
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$30.90
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$310
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$0
Retail 30 day
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50%
Retail 30 day
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40%
Retail 30 day
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60%
Retail 30 day
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25%
Retail 30 day
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|
|
|
|
|
|
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$0
Retail 90 day
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50%
Retail 90day
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40%
Retail 90 day
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60%
Retail 90 day
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N/A
Retail 90 day
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|
|
|
|
|
|
|
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|
|
|
|
|
|
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ProCare RX
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|
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$0
Mail Order
30 day
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50%
Mail Order
30 day
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40%
Mail Order
30 day
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60%
Mail Order
30 day
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25%
Mail Order
30 day
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|
|
|
|
|
|
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$0
Mail Order
90 day
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50%
Mail Order
90 day
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30%
Mail Order
90 day
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50%
Mail Order
90 day
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N/A
Mail Order
90 day
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CARDHOLDER INFORMATION
PACE Cardholders:
· The PACE Program will pay the Part D premiums for PACE cardholders enrolled in one of the program’s 3 partner Part D plans.
· IF PACE has secured an agreement with a non-partner plan to pay the Part D plan premium, PACE will pay up to the regional benchmark of $32.09. (2010).
· Cardholders enrolled in a plan with a premium higher than $32.09 must pay the difference to the plan.
· Catastrophic Coverage: Copay = the greater of $2.50 generic; $6.30 brand or 5%.
PACENET Cardholders:
- Cardholders not enrolled in any Part D plan will have the 2010 Benchmark premium of $32.09 assessed (deducted) at the point of sale. Note: This is the same procedure currently in place.
- PACENET cardholders enrolled in one of the 3 partner plans will have the plan’s premium collected (deducted) by including it in the amount due from the cardholder plus the lower of the plan’s or PACENET’s copay.
- NOTE: This is the same process used for PACENET cardholders not enrolled in a Part D plan. The only difference is that instead of the benchmark of $32.09 plus the copay being returned in the response, the partner’s plan premium plus the applicable copay will be returned in the response.
- PACENET cardholders in non-partner Part D plans will be billed by the plan. The cardholder will pay the premium directly to the plan and will pay only copays at the pharmacy.
· Catastrophic Coverage: Copay = the greater of $2.50 generic; $6.30 brand or 5%.
The most current PACE/PACENET information can be found on the PACE Cares website at pacecares.fhsc.com.
Cardholder Inquiries should be directed to 1-800-225-7223.
Provider questions may be directed to Provider Services at 1-800-835-4080.