CLINICAL
SERVICES
Clinical Services
Quality Services That Protect Your Investment
Nowadays, increased drug spend and utilization of high-cost specialty medications are creating the need to deliver comprehensive, high-quality, and cost-effective healthcare services.
ProCare Rx's main objective is to implement aggressive, clinical-based utilization management programs and strategies for patients' well-being and the rational use of medications.
ProCare Rx's outstanding characteristic is its continuous client support through unique programs and services to achieve the following:
- Patient engagement to make better health decisions and maximize the use of their benefits
- Supporting healthcare providers through evidence-based care support and improving patient adherence to their treatment plan
- Partnering with specialty pharmacies to support patient safety, reduce errors, and improve the quality of life of patients
- Focusing on clinical outcomes, their corresponding economic savings, and value-based pricing
- Negotiating rebates and discounts from drug manufacturers and pharmacies
- Leveraging competition to reduce the cost of specialty medications and improve adherence
- Encouraging the use of generics and more cost-effective brand medications
Mail Order/Home Delivery
ProCare Rx PharmacyCare (PPC) is a mail order and specialty pharmacy that is patient and provider oriented, focused on optimizing drug therapies, and providing member health education. PPC believes timeliness and efficiency are synonymous to providing quality services.
In order to accomplish this goal, we have developed a state-of-the-art automated system that maximizes efficiency and accuracy. Multiple quality checks are performed by licensed professional pharmacists for every prescription. A barcoded shipping and manifesting system is in place to provide fast, reliable delivery. PPC ships to all fifty states and Puerto Rico.
ProCare Rx PharmacyCare maintains URAC accreditation for mail order services, with a fulfillment location in Miramar, FL. Our mail order facility is fully integrated with our Clinical department and oversees specialty medication management and fulfillment. Our web-based claims processing system operates in real-time, so every mail order prescription is evaluated with the members’ retail claims.
Every order is trackable and confidential, with standard shipping provided at no additional cost.
Refills may be easily ordered via ProCare Rx’s online Member Portal.
If your health plan includes the mail order option, there are a few ways to receive your medication:
- Call toll-free to our Customer Service Center for mail order medications at 1-800-662-0586
- Visit the Member Portal
- Visit the PPC Mail Order Patient Portal
- Print, complete, and send the registration form via fax to 1-800-662-0590
Mail Order Brochure
Specialty Pharmacy Program
Specialty Pharmacy and Home Delivery
ProCare Rx offers a coordinated approach to managing the proper use and the high-cost of complex therapies. Through our variable copay and cost-plus programs for specialty drugs, clients can receive low prices on some of the most expensive medications.
Our SpecialtyCare program combines medication distribution with utilization guidance to aid your members living with complex health conditions. ProCare Rx assures the integrity of the drugs we dispense, along with the appropriate ancillary supplies, and then follows up with excellent clinical assistance to help the patient most effectively manage their illness.
SpecialtyCare services included at no charge:
- Clinical monitoring and support to reduce potential health risks and possible serious side effects
- Dosage and quantity verification
- Free drug administration supplies
- Insurance verification and reimbursement support
- Coordination of Benefits for use with manufacturer coupons and vouchers
- Copay assistance programs
- Proactive outbound compliance and support calls
- Patient education
- Electronic medical billing with acceptance of assignment
Hospice Services
The vision of ProCare Rx HospiceCare (PHC) is to provide effective hospice medication management with cost efficiency solutions, while supporting the organization’s goals and objectives. We strive to meet this challenge seamlessly, with the highest possible level of clinical expertise and customer service. This places quality patient care at the forefront, with the necessary sense of urgency to access both medication and clinical support.
Our comprehensive program is the gold standard of hospice PBM services, incorporating professional pharmacy benefit management with 24/7/365 access to Help Desk technicians, assuring comprehensive medication management, excellence in patient outcomes, and proven cost abatement strategies.
Key capabilities include:
- A la carte and tailored service options
- Traditional and pass-through pricing models
- ProCarePrescribe - Integrated electronic prescribing platform
- ADT and medication interfacing with EMRs to reduce administrative burdens
- In-house claims processing eliminates the middle man
- Medication access with strong local pharmacy footprint
- URAC-accredited mail order delivery and customized CarePaks
- Unlimited and customizable benefit plan design, formulary
- Customized ad hoc and scheduled reporting capabilities
- Reporting for CoPs, QAPI, and CMS (CR8358)
- The highest level of customer service in the industry
- Education and training programs, ANCC-accredited
Workers' Compensation
Learn MoreTo address the full scope of workers’ compensation claims with stringent controls for safety and cost optimization, ProCare Rx offers an end-to-end PBM solution that reduces cost, increases program penetration, and achieves greater operational efficiencies across the injured worker continuum.
Our WON Card Delivers Maximum Value
Introducing the WON Card! An innovative one-ID-card solution for collectively managing both workers' compensation and group health programs—providing the capability to prospectively flag dispensing and prescription conflict through analytical data management tools. Designed to help control pharmacy spend and provide comprehensive patient care, the WON Card is a unique product—created with ProCare Rx’s software development and maintenance, plus full contract ownership.
Cost Management Program
Designing for a Win-Win Relationship
At ProCare Rx, we focus on the rational use of medications, with the goal of optimizing clinical processes while reducing cost.
We offer the following cost-containment programs:
- Pharmacy Network Development
- MAC List Development and Management
- Pharmacy Auditing Program
- Fraud, Waste, and Abuse Program
- Rebate Management Program
- Value-Based Rebates
- Mail Order Program
Medicaid ADAP
HIV / AIDS Patients Program
The HIV / AIDS Patients Program was established between the Health Insurance Administration of Puerto Rico (ASES) and the Ryan White Program Part B / ADAP of the Department of Health of Puerto Rico. Under this program, eligible HIV / AIDS patients are able to access medications included on the ADAP formulary that are not included on the ASES medication list to manage their condition.
The Drug Assistance Program provides drugs approved by the FDA for the treatment of HIV / AIDS, side effects of the conditions, and opportunistic diseases, and is available for people with HIV / AIDS residing in Puerto Rico who have little to no pharmacy coverage and whose income does not exceed 200% of the federal poverty level.
The ADAP medication formulary classifies drugs into three categories:
- Category I: Drugs for HIV / AIDS
- Category II: Opportunistic conditions, Hepatitis C
- Category III: Drugs to counteract side effects of HIV / AIDS and reinforcement therapies
Visit the following links to learn about the participating pharmacies and physicians and the list of drugs available through them:
Also visit:
- Ryan White Program
- Department of Health of Puerto Rico
Pharmacy Services Call Center
MC-Rx's Pharmacy Services Call Center is staffed with knowledgeable, bilingual pharmacists and pharmacy technicians to effectively assist you during your call. Our Pharmacy Services Call Center is equipped with state-of-the-art telecommunications systems that provide all the necessary features to maintain our customer service operations performing at optimum capacity 24/7/365. Our Call Center Support Representatives can address questions regarding a member's benefit plan, including information about eligibility, copays, deductibles or co-insurance, and alert message interpretation, as well as other details required for claims management.
Pharmacy Services Call Center: 24/7/365
Toll-Free Numbers: 1-888-311-6001 / 1-866-411-6001
TTY Numbers: 711
Fax Number: 1-787-653-2814
Prior Authorization Call Center
Receive support and assistance when processing a prescription for a medication requiring authorization prior to dispensing. Designed to offer personalized services, well-staffed with bilingual representatives, equipped with the latest technologies, and available 24/7/365, our Prior Authorization Call Center provides exceptional service. Operations are continuously monitored and evaluated to maintain the quality of standards that our providers expect and deserve.
Prior Authorization Call Center: 24/7/365
Toll-Free Numbers: 711
TTY Number: 1-800-850-6682
Pharmacy Network
MC-Rx provides its Pharmacy Network members with administrative support to ensure compliance with applicable policies, regulations, laws, and contractual agreements. This is a continuous, collaborative process that promotes sound business practices and ensures the utmost quality service standards for our clients’ members.
Our Pharmacy Network Support Staff will assist you with any questions regarding Pharmacy Network contracts, requisites for becoming a member of the Pharmacy Network (Credentialing), and requisites for renewing Pharmacy Network membership (Re-credentialing), among other Pharmacy Network needs.
Pharmacy Network: Monday - Friday, 8:00am – 5:00pm
Telephone Number: 1-787-286-6032, Ext. 3147
TTY Number: 711
Fax Number: 1-787-653-2856
Email: PharmacyContracting@mc-rx.com
Pharmacy Provider Manuals
Pharmacy Auditing Program
Learn MoreThe Pharmacy Auditing Program is a unique, encompassing program and the key component for the adequate management and utilization of prescribed medications:
Ensures compliance with applicable laws and regulations
Ensures compliance with contractual terms between MC-Rx and participating pharmacies
Identifies, avoids, and prevents fraud, waste, and abuse
Ensures the validity and accuracy of the claims processed and invoiced to our customers and to CMS
Educates participating pharmacies on the submission of electronic claims and proper documentation
Pharmacy Forms
For your convenience, you may fill out most of these forms online.
- Electronic Funds Transfer (EFT) Request
- Guidelines for Adequate Medication Processing & Dispensing
- Notification CMS 10147
- Pharmacy Profile Update
- Prior Authorization Request Form
- Request to Dispute a Claim - Report discrepancies regarding an un-paid prescription or particular adjudication situations
- Request to Reverse a Pharmacy Claim
- Request for Reimbursement
- Universal Claim Form (UCF)
- PRX Maryland Generic Pricing Appeal Form MD GPA 2021a
- MC-Rx MD MC-Rx GPA 2021
- Disclosure Statement
- TN Standard Pharmacy Reimbursement Form for Actual Cost Appeals
Fraud, Waste, and Abuse (FWA)
MC-Rx is committed to prevent, reduce, and control incidences of fraud, waste, and abuse in accordance with federal and local laws. Our goal is to guarantee that all MPD pharmacy providers comply with instructions for prescriptions billing and dispatch, as established by the Centers for Medicare & Medicaid Services (CMS).
CMS has removed its own published Medicare Advantage and Part D General Compliance and FWA training modules from its website; however, compliance training is still required, and MC-Rx remains obligated to conduct routine monitoring, auditing, and oversight of their FDRs. Therefore, the Participating Pharmacy Providers must continue to conduct General Compliance and Fraud, Waste, and Abuse training and provide MC-Rx with an annual attestation to that effect. For your benefit, we have developed a training course tailored for pharmacies that serve Medicare Part D beneficiaries.
Who must complete the FWA training?
Every person that participates in the administration or delivery of Medicare Part D benefits must complete this training.
When must the training be completed?
No later than December 31st of each year.
- FWA Training Course – Use our customized training course to educate your staff
- FWA Attestation Forms – Once training is completed, print and fill out the Training Attestation Forms and send them to MC-Rx.
Email: pharmacycontracting@mc-rx.com
Fax: 1-787-653-2856
Mail: MC-Rx, Pharmacy Services Department, P.O. Box 4908, Caguas, Puerto Rico 00726
TTY Number: 711
For more information on FWA training requirements, contact MC-Rx’s Pharmacy Services Department at 787-286-6032, Ext. 3147 or 3122.
Pricing Review Processes
Actual Cost Appeal (TN)
ProCare Rx accepts appeals from pharmacies asserting that they have not received reimbursement for at least actual cost for all prescription drugs, drug products, and devices paid for by ProCare Rx.
A pharmacy must submit its Actual Cost Appeal to ProCare Rx within seven (7) business days of its submission of the initial claim for reimbursement.
ProCare Rx has seven (7) business days from the date it receives all required documentation for processing an Actual Cost Appeal to make a final decision to grant or deny the pharmacy’s appeal.
If a pharmacy decides to appeal ProCare Rx’s denial of its Actual Cost Appeal to the TN Insurance Commissioner, the pharmacy must submit their appeal within thirty (30) days of receipt of ProCare’s appeal denial notice.
Tennessee Pharmacy Actual Cost Appeals Policy
TN Department of Commerce & Insurance Standard Pharmacy Reimbursment Appeal Form
Please address all questions regarding this process to reimbursement@procarerx.com
MPD MAC List Application – Review the cost of a prescription drug included in the Medicare MAC List. Search by name and/or date.
MAC Price Review Request Application – Access MC-Rx’s Price Review Request Application to ensure an agile and effective management of your request for the revision of a generic drug price.
Pharmacy Communications
Pharmacy PA Status Tool
Complaints
Pharmacy member complaints or grievances are a means of continually improving the quality of our services.
If you have a complaint regarding our services, please complete the Complaints Form.
All complaints will be handled in a timely manner.
Payer Sheets