Effective January 1, 2017, CMS will require Medicare plan sponsors to limit the daily cumulative dose of opioid products a member may obtain at Point of Sale (POS). The daily limit is referred to as the Morphine Equivalent Dose (MED) limit. The cumulative limit is based on a combination of drug strength and a product’s Morphine Milligram Equivalency (MME). The cumulative total daily MED value will be calculated based on the number of opioid drugs prescribed over a period of time which includes incoming claims and active claims history. Depending on the plan, there may be multiple MED limits with varying response levels (Soft or Hard reject). 

 Effective November 1, 2016, Prime will begin providing prescription drug services to members of the Texas Medicaid Program for State of Texas Access Reform Kids ("STAR Kids"), a program administered by Blue Cross and Blue Shield of Texas. In addition, there will be reimbursement changes to the 340B claims under the Texas Medicaid Network.

BlueCross BlueShield of South Carolina, BlueChoice HealthPlan of South Carolina and CVS/caremark^® are introducing the new Advanced Choice Network^TM. This network is exclusive for all BlueCross and BlueChoice^®Health Insurance Marketplace (Exchange) plans.  CVS/caremark is an independent company that provides pharmacy benefit management and pharmacy services on behalf of BlueCross and BlueChoice.

Beginning Oct. 1, 2016, Blue Essentials^SM (BlueCross Exchange) and Blue Option^SM (BlueChoice Exchange) members must use pharmacies in the Advanced Choice Network. If members fill prescriptions at a non-participating pharmacy after Oct. 1, 2016, they will be required to pay the full retail price.  APNS is participating in the Advanced Choice Network.  This is a limited network. 

Attached please find a listing that shows a claim count by zip code  where there are excluded pharmacies.  Your pharmacy has the opportunity to pick up some of these claims by being in network.

Members have already received a notification advising them of this change, which also includes a list of participating pharmacies closest to their homes.

Effective 9/15/2016, APNS pharmacies will no longer participate in ProCare Rx discount card programs. Discount card programs are intended for uninsured patients.  APNS pharmacies are able to offer better discounts to their patients without being used as the "middle" man for pharmacy benefit managers.

Attached please find payer sheet information that will assist you in identifying  patients that may be using the ProCare discount card programs at your pharmacy.

Please see attached PDF for more information.