WellCare NC Program

The WellCare program has been renewed. The amended SOW is available below.
Pharmacies must re-enroll in the program in order to participate in the 2024-2025 contract year. Email lrhodes@cpesn.com for assistance.
As part of the new contract, CPESN is requiring the following:
- - Pharmacies must actively engage in the program by submitting at least one care plan per quarter.
  - Pharmacies must document at least two A1c measurements per engaged patient per program year.
  - Each pharmacy must submit at least one patient success story per quarter using this online form.
If a pharmacy is not engaged for 3+ months, the pharmacy may:
- Submit a performance improvement action plan to network staff that describes how they will engage in the program
- Notify network staff that they wish to voluntarily unenroll from the program
- Be involuntarily unenrolled from the program if the pharmacy does not respond to network staff within 3 outreach attempts (via at least 2 methods

Diabetes Management and Education Service

The pharmacist or pharmacy staff will work with the member and member’s health provider to obtain the most recent HgA1c test result.
If there are no recent results available, the pharmacist or pharmacy staff will refer the member for HgA1c test or conduct a point of care test at the pharmacy.
The pharmacy staff will ensure a diagnosis of diabetes and will consult with the member’s provider to make recommendations and identify opportunities. This should be detailed on a care plan, including any communications between CPESN and the member’s health provider.
The pharmacist or pharmacy staff will work directly with the member to make it easier for them to take their medications, often trying adherence packaging or aligning medications to be refilled on a consistent day each month.
The pharmacist and pharmacy staff will identify and close any diabetes-related care gaps, such as an eye exam, statin use, RAAS use, and immunizations.
The pharmacist and pharmacy staff will document the care provided in a care plan, which will be provided to WellCare of North Carolina.

CareSync Service

The pharmacist or pharmacy staff will screen for and enroll members with multiple chronic medications into an appointment-based model of care.
The pharmacist or pharmacy staff will work directly with the member to optimize their adherence to prescribed medications by aligning the member’s medication to be refilled on a consistent day each month. Adherence packaging will be offered to members in order to improve adherence.
A medication reconciliation will take place to ensure all medications are correct during the onboarding of the member. Intervention codes will be provided in a care plan which will identify a med rec has taken place. The pharmacist will include details in the notes.
The members’ provider(s) will be engaged as needed to verify and discuss medications, lab results, etc.
Pharmacy staff will offer hand delivery of medications to the member.
The pharmacist and pharmacy staff will identify, and close care gaps related to the member's health conditions, including but not limited to immunizations. Details of this will be provided to WCNC via codes included in the Care plan and details in the notes.
The pharmacist or pharmacy staff will provide the member with transitions of care supports, including assessing and reconciling medication lists from care settings with the pharmacy list. Details of this will be provided to WellCare of North Carolina.

Payment Structure

The pharmacist and pharmacy staff will document the care provided in a care plan (must include payer code WCNC).
The pharmacy can earn $55 per engaged member per month (PEMPM). Engaged members are defined as members/patients who have received services outlined in the SOW, and resulted in at least one HL7 Pharmacist Electronic Care plan in a calendar month.

WellCare NC Program Overview