Private/Commercial:

Authority: Pharmacists have mandated health plan coverage of services as a result of a bill passed in 2018 by CPS and can be found here: HB 18-1112.

• This gives pharmacists the authority to bill healthcare services (and requires payment) if the services are provided in a health professional shortage area (geographical or population based) AND the plan provides coverage for the same services if provided by physician or advanced practice nurse.

• The caveat is that this bill specifically does NOT require plans to contract with pharmacists which means that they are NOT required to enroll them into their medical networks. This has been a challenge for enrollment for pharmacists. However, once enrolled, pharmacists are entitled to payment for healthcare services.

• It is important to note that for any payer, both credentialing and contracting are essential steps.  Without a contract/agreement of some sort, it is unlikely that even if credentialed, pharmacists will have a clear path to payment from a health plan.

To date, there are no pre-determined covered services or billing codes. These will be determined as part of the contracting agreement process with an individual payer. No laws exist that limit the type of services that could be paid (as long as the healthcare services provided by the pharmacist would also be a paid service to another provider type).  This would open opportunities for chronic disease management, etc.

Important: Pharmacists need to push forward with discussions with health plans to identify opportunities to partner with payers and provide value to their patients. In this way, contracts can be made to enroll pharmacists and subsequently ensure that pharmacists are paid for the services. Once agreements are made to provide services as part of a contract, pharmacists can be internally credentialed with that payer.

Essential Steps: Enter your information into CAQH to have basic steps toward being credentialed with any payer; see the Colorado Pharmacist Services Billing Guide section for more details. 

Advocacy Asks: CPS continues to evaluate if a payment parity advocacy campaign is needed.  We also ask that any pharmacist/entity that gets rejected from a payer network notify CPS so we can take appropriate steps.