Retail pharmacies exploring the option to provide long-term care pharmacy services at home must be aware of additional requirements that apply. In 2005, CMS provided guidance to Part D plans on requirements for performance and service criteria regarding pharmacies servicing LTC facilities. More recently, this guidance has been applicable to pharmacies servicing LTC Pharmacy at Home patients. The expectation from payors (particularly those that recognize/reimburse for it) is that these criteria are also applicable to pharmacies servicing qualified patients residing in their home, helping to ensure they receive the same level of care, medication management and safety oversight as those in long-term care facilities.

Expanding your pharmacy services is a great option to provide additional care for your current patients and potentially attract new ones. GPO and LTC contracts can result in enhanced dispensing fees and potential margin expansion compared to retail agreements. The enhanced dispensing fees, in part, are in recognition of the additional costs associated not only with providing special packaging and home delivery, but also ensuring the pharmacy is meeting these CMS defined performance and service criteria.

During audits, PAAS National^® has seen OptumRx and Humana require pharmacies to complete an LTC Pharmacy Attestation/Credentialing form. These forms list each of the CMS performance and service criteria that pharmacies must meet. As a traditional community pharmacy, pharmacies may not fully understand that operating as a “combo shop” (with an LTC NPI and LTC contracts) obligates you to comply with these standards.

The Alliance for Long-Term Care @ Home has published guidelines for pharmacies providing LTC Pharmacy at Home Services regarding these performance and service criteria. While some of these standards may not seem applicable for your setting/patients, pharmacies must be prepared to demonstrate they have the ability to meet all criterion, upon request.

Performance and Service Criteria for Network LTC Pharmacies:

1.  Comprehensive Inventory and Inventory Capacity
2. Must have a comprehensive inventory of plan formulary drugs commonly used in the LTC setting
3. Includes OTC medications dispensed and reflected in the patient’s medical record
4. Pharmacy Operations and Prescription Orders:
5. DURs to screen for allergies, drug interactions, adverse drug reactions and inappropriate drug usage in the LTC population
6. Software systems able to meet the needs of prescription drug ordering and distribution to an LTC facility
7. A Policy and Procedure Manual for the pharmacy and the patient’s home or LTC facility
8. For LTC at home patients, pharmacy must have policy and procedures for PBM review that may include information sheet with how to contact pharmacy, when to expect deliveries, community resources, safe medication disposal, medication refrigeration, how to solve problems with medication, delivery, etc.
9. Special Packaging
10. LTC at home patients must receive compliance packaging for all meds in 30-day supply or less, except products required to be dispensed in original containers
11. Options may include punch or bingo cards, multiple dosage cards, pouch or pillow packages with one or multiple medication in each package
12. IV Medications
13. Capacity to provide IV medications as ordered (may be subcontracted)
14. Arrangement with a vendor to provide special equipment and supplies
15. Compounding/Alternative Forms of Drug Composition
16. Provide specialized drug delivery formulations
17. If residents can’t swallow or ingest through normal routes
18. May require split or crushed tablets
19. Suspension or gel formulations
20. Pharmacist On-Call Services
21. Provide 24/7 service with a qualified pharmacist available after hours to provide medication dispensing outside normal hours of operation (may be subcontracted)
22. Delivery Services
23. Facilitate timely delivery of medication
24. Emergency delivery services must be available 24/7
25. Emergency Boxes
26. Able to provide in compliance with state requirements
27. May want readily available, even if not engaged in facility-based care (for audit purposes)
28. Emergency Logbooks
29. Necessary if utilizing emergency box
30. Have template available for general audit purposes
31. Miscellaneous Reports, Forms and Prescription Ordering Supplies
32. Special instructions for patients based on drug regimen and medications
33. Forms for patient monitoring (e.g., blood pressure, glucose, heart rate, etc.) or tracking (e.g., controlled substance utilization)
34. How to order/track PRN medications

PAAS analysts are frequently asked about compounding, IV medication, and emergency box standards—and whether the pharmacy is obligated if only billing LTC at Home patients. The answer is “YES”, you must have a plan in place to comply with LTC agreements.

By Trenton Thiede, PharmD, MBA, President at PAAS National^®, expert third party audit assistance, FWA/HIPAA and USP 800 compliance.

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