Accountable Care Organizations

  • Beginning January 1, 2013 ACOs are responsible for prescription benefits.
  • ACOs should be billed for pharmacy benefits for all drugs except for the following that have been carved out:
    • Hemophillia treatment drugs
    • Immunosuppresant drugs used for organ transplants
    • Pshycotherapeutic drugs as defined as:
    • Antipsychotics
    • Anti-depressants
    • Anticonvulsant/mood stabilizers
    • Anti-Anxiety Benzodiazepines
    • Attention deficit hyperactivity disorder Stimulants
    • Specific Addiction Therapy Drugs that include: Suboxone, naltrexone (Vivitrol), Revia, Methadone clinic therapy methadone, Campral, disulfiram (Antabuse).
  • Carved out drugs remain the responsibility of Medicaid.
  • Members who continue to receive pharmacy benefits directly from Medicaid Fee-For-Service include new enrollees for up to 3 months, Primary Care Network (PCN) members, and members who go into nursing homes for greater than 30 days.

ACO Websites:

Health Choice | Healthy U | Molina | SelectHealth

Any project documentation, FAQs, or general information that contains PHI or proprietary information will be shared with individual ACO using secure protocols.

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