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Carolina Care Benefit Plan Safety Initiatives

At Carolina Care Plan^®, Inc., the safety our member's care is vitally important. That's why we provide the following services and tools for our members and their physicians and pharmacists. After all, our members' health is at the heart of our plan.

24-Hour Nurse LineRegistered nurses are available, 24 hours a day, 7 days a week, to answer member questions and discuss treatment options. Nurse line also offers 400 pre-recorded health topics. Members may call 800-262-5155 anytime to speak to a registered nurse.

Carolina Care Plan's Pharmacy Management ProgramCarolina Care Plan employs an objective, clinically sound management philosophy and commitment to innovation and excellence. By applying operational and clinical expertise, we provide forward thinking pharmacy benefit consultation and management that effectively balances quality of care and cost containment. Decisions regarding Carolina Care Plan's Pharmacy Management Programs are made in conjunction with community physicians and pharmacists.

As a consultative partner, Carolina Care Plan works with clients to:

Improve the health of members
Reduce the cost of pharmacy benefit programs
Enhance the scope and quality of service

Concurrent DUR Edits. Concurrent drug utilization review (DUR) occurs while a claim is being processed at the pharmacy. Clinical alerts are communicated online, alerting the dispensing pharmacist of any safety issues, including drug interactions and therapeutic duplication. These alerts protect members from potential health problems. Typical concurrent edits include:

Drug-Drug Interactions	Identifies patients who are receiving two or more drugs, that when taken together, can cause unpredictable or undesirable effects. Additional criteria may be required to identify drug-drug interactions of higher severity (e.g., multiple doctors, multiple pharmacies, age, additional medications).
Drug-Disease Interactions	Identifies patients who are receiving drugs that may worsen or precipitate medical conditions. Drug markers are used to identify the medical conditions.
Over Utilization	Identifies patients who receive drugs at excessive dosage levels or for inappropriately extended periods of time. These patients are at elevated unnecessary risk for adverse drug reactions and drug-induced disease.
Under Utilization	Identifies patients who may be non-compliant with their maintenance medication. Under-utilization of drugs prescribed for the treatment of chronic conditions, such as hypertension, that places them at unnecessary risk for increased morbidity and mortality.
Drug-Pregnancy	Identifies patients who may be at risk for teratogenic effects or pregnancy complications from the use of certain drugs. We target women age 15-45 on prenatal vitamins, but not on oral contraceptives, and on Pregnancy Category D or X medications.
Addictive Substance	Identifies members receiving seven or more prescriptions for controlled substances from two or more physicians or three or more pharmacies during a 60-day interrogation period. Target medications: Controlled Substances (CII-IV), Tramadol, and Soma. Exclude member if they are receiving Chemotherapy agents, Fentanyl, Antiemetics, Antiretrovirals Lookback period: 60 days Exclusions: Unique physician/member combinations for six months Age range: N/A
Long-Term Hypnotics	Identifies members who have received more than a 90 cumulative day supply for hypnotics. Target medications- Benzodiazepine hypnotics, GABA-receptor modulators, Chloral hydrate Lookback period: 120 days Exclusions: Unique physician/member combinations for 6 months Age range: N/A
Duplicate Therapy	Include members who have two or more current prescriptions (drug A & drug B) within one of the following targeted therapy classes at time of interrogation. Prescriptions are considered current if (date of fill + day supply + 15 days > today's date). To prevent targeting of patients who merely switched therapy, the prescriptions must be filled on the same day or there must be a pattern of alternating prescriptions between the duplicative therapies, i.e. the most current claim (drug B) must have previous claim history prior to the most recent fill of drug A. If two unique physicians prescribed the duplicative therapies, both physicians will receive a mailing. Targeted Therapy Classes include: ACE inhibitor & combo products, ARB & combo products, Beta-blocker & combo products, CCBA & combo products, Estrogen, H2-blocker, HMG Co-A Reductase Inhibitors, Inhaled steroids, Nasal steroids, Non-sedating antihistamine & combo product, NSAIDs (including COX-2 inhibitors), PPIs, SSRIs, and Sulfonylureas. Lookback period: 120 days Exclusions: Unique physician/member combinations for six months Age range: N/A

Safety Management and Retrospective DUR. Carolina Care Plan and Express Scripts are committed to safety of medication use even after the prescription has been filled. Our Retrospective DUR notifies physicians of safety risks identified through this review and provides recommendations for management where appropriate. The logic of the program allows us to intervene on higher risk-related problems. This benefits the physician and the health care system by avoiding excessive paperwork on issues that are less critical in nature. Significant effort has been made to focus on edits/alerts that are the most clinically meaningful.

Additionally, we have pharmacists that are dedicated to monitoring for safety issues, new medications, and the overall pharmaceutical market. When a new issue of significant risk has been identified, it can be added to the Retro DUR program and letters can be mailed within the week. The Safety Management Retro DUR program is designed to reduce adverse drug events (ADEs) caused by drug-drug interactions, drug-disease interactions, over- utilization, under-utilization, therapeutic duplication, long-term use of hypnotics, and misuse of controlled substances. Physicians are retrospectively notified of these findings, along with patient profiling information.

DrugDigest.org. DrugDigest.org is an Express Scripts consumer health and drug information web site. The site allows members to access information provided by PharmDs (Doctor of Pharmacy) from leading academic institutions, staff physicians, medical editors, and professional editors. It encourages consumers to take an active role in their own health care by enhancing knowledge and stimulating overall interest in health and well being. DrugDigest.org gives members access to:

Drug interaction information
Drug efficacy and side effects
News and reviews
E-bulletins
Health condition information

Prior Authorization. For some drugs, it is best to require advance or prior authorization at the point-of-sale before prescription coverage is confirmed. A prior authorization (PA) program is designed to ensure appropriate use of prescription drugs when the potential exists for abuse or misuse.

Special Services. In an effort to meet the special requirements of some members, a variety of tools, training, and call routing techniques are used to help ensure the best customer service. These special requirements include:

Hearing Impaired
Visually Impaired
Elderly
Non-English Speaking

Additionally, we subscribe to the AT&T Language Line that provides interpretive services for more than 140 languages.

My Health Zone
My Health Zone is an interactive web site that can be customized to meet members' health and wellness needs, including personal nutrition, calorie counters, and managing weight and exercise goals. It also contains medical information, articles, and patient information for anyone who has asthma, allergies, diabetes, or high cholesterol. It provides members with the information they need to manage their health.

Carolina Pathways^SM Care Management and Wellness Programs
Carolina Care Plan offers programs to help members manage their health, ranging from asthma to pregnancy to diabetes.

Adult & Pediatric Asthma
Cardiovascular Programs for Congestive Heart Failure & Ischemic Heart Disease
Diabetes
Maternity Programs
- Baby Steps
- High-Risk Programs including ROSEBUD® Perinatal and Neonatal Case Management
Hypertension & High Cholesterol Program
Hepatitis C Program

All of these programs provide the member with educational materials. Some of the programs also include confidential counseling and emotional support. These programs encourage members to take an active role in managing their health. Additional information for each program is available on the Products & Services section at carolinacareplan.com.

URAC Accreditation
Carolina Care Plan received Full Health Plan Accreditation from URAC in 2003. URAC, a leading health care accrediting organization, has initiated a Patient Safety Advisory Committee that is responsible for developing standards of improving patient safety. Carolina Care Plan will work with URAC and develop additional patient safety initiatives as defined by URAC.

Credentialed Network Practitioners
All practitioners participating in the Carolina Care Plan network are approved through a credentialing process to ensure the quality of practitioners available to members. This process includes verifying the following information:

License to practice
Hospital privileges
DEA/DHEC certificate
Board certification or residency completion
Medical school graduation
Malpractice insurance
History of loss of license and/or felony convictions
Summary of malpractice claims history and/or adverse information

For more information about Carolina Care Plan, please visit our web site, carolinacareplan.com.

U.S. Office of Personnel Management 1900 E Street NW, Washington, DC 20415 | (202) 606-1800 | TTY (202) 606-2532