Prescription Drug Plan (PDP) Technology & Services by Sun Knowledge

Sun Knowledge provide the following services to PDP sponsors, Medicare Advantage organizations that offer MA-PDs (including local HMO plans, local, PPOs, regional PPOs, and Private Fee-for-Service plans), organizations with Cost Plans under section 1876 of the Social Security Act, Employer Groups, and PACE organizations.

• Enroll all eligible Medicare beneficiaries
• Administer the Part D benefit including providing coverage for drugs included in a CMS-approved formulary, administering appropriate deductibles and co-payments, managing the benefit using appropriate pharmacy benefit managerial tools, making discounts for applicable name brand drugs available to eligible enrollees at the point of sale, and operating effective oversight of that benefit
• Ensure that records are maintained in accordance with CMS rules and regulations and that both records and facilities are available for CMS inspection and audit
• Process claims
• Operate quality assurance, drug utilization review, and medication therapy management programs
• Administer coverage determinations, grievances, exceptions, and an appeals process consistent with CMS requirements
• Provide customer service to beneficiaries, including enrollment assistance, toll-free telephone customer service help, and education about the Part D benefits
• Protect the privacy of beneficiaries and beneficiary-specific health information
• Develop and/or maintain systems to support enrollment, provide claims-based data to CMS, coordinate benefits with secondary insurers (or primary insurers when Medicare is secondary) and support e-prescribing
• Health Plan Management System (HPMS) Data Entry
• Provide PDP / Claims Services for New Employer/Union-Only Group Waiver Plans (EGWPs)
• Automatic Enrollment of Full-benefit Dual Eligible Individuals
• System Access and Data Transmissions Support with CMS
• Abides by all applicable Federal laws, regulations and CMS instructions
• Performs adjudication and processing of pharmacy claims
• Operates an enrollee grievance and appeals process
• Performs customer service functionality
• Performs enrollment processing
• Complies with formulary guidance that is contained in the Prescription Drug Benefit Manual
• Provides for an appropriate transition for new enrollees into Part D plans following the annual coordinated election period, newly eligible Medicare enrollees from other coverage, individuals who switch from one plan to another after the start of the contract year, and current enrollees remaining in the plan affected by formulary changes prescribed Part D drugs that are not on its formulary
• Maintains policies and procedures to prevent over-utilization and under-utilization of prescribed medications
• Maintains methods to ensure cost-effective drug utilization management via Step therapy; Prior authorization (PA); Tiered cost-sharing
• Implements internal medication error identification and reduction systems
• Implements a Medication Therapy Management (MTM) Program designed to ensure optimum therapeutic outcomes for targeted beneficiaries through improved medication use & for targeted beneficiaries, reduce the risk of adverse events, including adverse drug interactions
• Has an appropriate MTM enrollment policy which enrolls targeted beneficiaries using an opt-out method of enrollment only
• Has an appropriate MTM enrollment policy which targets beneficiaries for enrollment at least quarterly during each year
• Supports and complies with electronic prescription standards relating to covered Part D drugs for Part D enrollees
• Complies with the CMS Enrollment and Disenrollment Guidance documents that are provided on the www.cms.gov
• Complies with CMS operational guidance on Creditable Coverage and the Late Enrollment Penalty
• Provides all current and newly enrolled individuals all required enrollment material and notices within the timeframes provided in the CMS PDP Enrollment and Disenrollment Guidance
• Operates a process for enrolling Medicare beneficiaries in the PDP that includes: communicating with beneficiaries who are requesting enrollment in the PDP within timeframes specified by CMS, including requirements for initiating appropriate follow up with beneficiaries who submit incomplete enrollment requests; and making enrollments effective according to the effective date requirements associated with the enrollment period in which the enrollment is received
• Accepts and processes voluntary disenrollment requests from beneficiaries, including providing all required notices and information to beneficiaries, communicating these requests to CMS, and establishing the disenrollment effective date according to the effective date requirements associated with the enrollment period in which the disenrollment request is received
• Provides advanced notice to all enrollees in the event of a contract termination, describing the implications of the termination and alternatives for obtaining prescription drug coverage under Part D in accordance with Part 423 regulations and CMS non-renewal instructions
• Implements policies and procedures (including appropriate notice and due process requirements) for optional involuntary disenrollment as permitted by CMS
• Ensures that information necessary to access all plan benefits, such as an ID card, is provided to new enrollees prior to the enrollment effective date, or no later than 10 days after receipt of the enrollment request, according to the timeframes described in the PDP Enrollment and Disenrollment Guidance
• Completes the reconciliation of all enrollment, membership and payment data, and submits requests for valid discrepancy corrections in compliance with the 45-day schedule to submit the monthly CEO certification of enrollment data for payment
• Monitors and documents complaint resolutions for complaints attributed to their contracts in the CMS’ Complaint Tracking Module in accordance with CMS’ Standard Operating Procedures for Part D sponsors