November 8, 2018

EQuIPP: Plan Performance Display Update & Outlier Expansion

As more health plans and PBMs have been hosting performance information within EQuIPP and developing engagement and performance incentive programs with pharmacies, PQS has been working to create a new user‐friendly table making it easier for pharmacies to track specific program performance. EQuIPP will display a Quality Improvement Program (QIP) Table which will display a pharmacy's performance along with key details such as a percentiles for each program, starting with the Friday, October 16th release.

Also, additional outliers along with different outlier types are being displayed for some health plans within the dashboard. Pharmacies should be sure to view patient outliers, which are updated at least monthly with each refresh. Recent outlier additions are more often now updated weekly and in select circumstances they may be updated daily for the High Risk Medication Measure. Therefore, monitoring these patient outliers regularly provides our pharmacies with actionable opportunities for performance improvement to act upon. The different outlier types that may be displayed to pharmacies within EQuIPP are listed below:

Standard Outlier: These outliers represent members that are adversely impacting individual measure performance based upon calculations from the data provided to EQuIPP.

PDC outlier: A current outlier for adherence rates are patients whose PDC has dropped below 80%.

HRM outlier: Those patients who already received 2 fills of a HRM.

First Fill Outlier: These outliers apply to the High Risk Medication (HRM) measure and represent members who have filled one qualifying high risk medication (medication name is also listed). These outliers represent a potential opportunity to prevent a second fill of the medication. These outliers may be updated on a more frequent basis such as daily or weekly, depending on the data provider.

Priority Outlier: These outliers are determined by the health plan or PBM and may include those members that are not currently an outlier (e.g. non‐adherent) but are at the greatest risk for becoming an outlier throughout the year.

Prime Therapeutics: BCBS TX Star and Chip Medicaid Update

Prime released a Medicaid Update for BCBS TX Star and Chip plans in the Travis service area. Topics addressed include:

  • Eligibility Verification
  • 72 Hour Emergency Supply
  • Processing Requirements for Influenza Vaccinations
  • Processing Requirements for 340B
  • Pharmacy Processing updates

The complete Medicaid Update is available in the TriNet section of the PBA Health website.

Express Scripts: Reject 81 (Claim Too Old) Reminder

The Express Scripts Pharmacy Services Help Desk team no longer supports via phone call the processing of claims with a date of service beyond the standard 90-day processing window. These claims commonly reject with NCPDP Reject Code 81 (Claim Too Old). When a reject 81 occurs, the pharmacist should first reprocess the claim and enter the appropriate Delay Reason Code in field 357-NV. If the claim continues to reject, it will need to be submitted on the Pharmacist Resource Center (PRC) website using the following steps:

  • Log in to the PRC at
  • On the left side under Tools, select “Contact the Help Desk.”
  • Select the “Claim Too Old/Reversal Request” form.
  • Submit up to 10 claims for a single patient on one form.

The pharmacy will receive a response within 72 business hours of submitting the claim.

US Scripts: Buckeye Health Plan Preferred Drug List Update

Effective February 15, 2016, the preferred Albuterol MDI will be Ventolin HFA. ProAir HFA and Proventil will no longer be covered. Below is a list of the upcoming changes:

Therapeutic Class / Preferred / Non-Preferred
Short-Acting Beta
Agonist MDI / Ventolin HFA AER / ProAir HFA AER Proventil AER HFA

A full list of covered drugs can be viewed at:

Recall Notice:0.9% Sodium Chloride Irrigation by Baxter

Baxter recently announced a recall of one lot of 0.9% sodium chloride irrigation because of the presence of particulate matter, identified as an insect, in the solution of a single unit.

Per Baxter, use of irrigation solution with foreign material contamination may lead to complications, such as inflammatory reaction, foreign body reaction, and local infection. These complications are dependent in which anatomic location the irrigation is used.

If you have any questions, please call Baxter at 800-437-5176 (8:00 am – 5:00 pm CT,

Monday through Friday) for more information about this recall.

Affected Lot of 0.9% Sodium Chloride Irrigation Recalled by Baxter
Product Description / NDC / Lot # / Expiration
Date
0.9% Sodium Chloride Irrigation,
500 mL Plastic Pour Bottle / 0338-0048-03 / G120162 / 11/30/2018

Express Scripts: Provider Manual Update Reminder

REMINDER! The updated Express Scripts Provider Manual is available in the TriNet section of the PBA Health website.

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