June Newsletter

Reminders about Wellness Coverage

• Chlamydia screening is covered for all members without cost-sharing.
• Cholesterol and lipid screening (80061, 82465, 83718 and 83721) is covered without cost-sharing for:
  • Men 35 years and older – Once every 5 years
  • Men 20-35 years- Once every 5 years with diagnosis code V17.3–V17.4X, V81.0-V81.2
  • Women 45 years and older – Once every 5 years
  • Women 20-45 years Once every 5 years with diagnosis code V17.3–V17.4X, V81.0-V81.2
• Services performed outside these parameters, as well as other coded services, are covered according to the limits of the member’s medical benefits.

The wellness brochure, which lists services and procedure codes covered under the wellness benefit, is posted on the Forms and Resources page of Your Health Alliance. You can also contact your provider relations specialist for a copy.

No Preauthorization for CPAPs and BiPAPs

Effective immediately, CPAPs and BiPAPs do not need to be preauthorized and do not require reviews after 3 months.

Reminders Key to Colorectal Cancer Preventive Screening

Patients who visit their doctor for any reason were nearly 6 times more likely to get screened for colon cancer compared to those who didn’t visit their doctor, according to a study funded by the National Cancer Institute and published in the American Journal of Managed Care.

Kaiser Permanente conducted a study among 883 members who were overdue for a screening and had automated calls sent to members. 9 months after the automated calls, researchers examined the members’ medical records to see if they had completed any of the screenings either by sigmoidoscopy, colonoscopy, or the Fecal Occult Blood Test (FOBT), an annual at-home stool sample. More than 28% of the members completed screening within the year, most of them with the FOBT.

In another study published in Annals of Internal Medicine in March, people who were mailed a letter, a pamphlet and a FOBT kit completed the recommended screening twice as often and for less cost than those who were not reminded or who got an automated call.

The U.S. Preventative Services Task Force recommends that people 50-75 years old be screened for colon cancer in 1 of 3 ways:

• A home FOBT test every year
• Sigmoidoscopy every 5 years combined with a FOBT every 3 years
• Xolonoscopy every 10 years

Please discuss the options for colorectal cancer screenings with your patients, including the option of an annual FOBT.

New Process for Invalid Claims

You may have seen some changes with your critical error reports. Prior to March 2013, Relay Health would submit claims to us, and if the claim hit a critical error due to an invalid member number or date of birth, Relay Health would return the critical error to the provider or clearing house that sent it to them.

With the new process, the claim does not hit a critical error report, it loads the claim into our claims system under a bogus member number and the remittance advice states the claim was denied due to invalid member information. Please correct the information and resubmit electronically.

Pharmacy

Formulary Additions

• Linzess – For the treatment of chronic constipation.
  • Tier 3 with preauthorization (PA)
• Eliquis – To reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation.
  • Tier 3 with step edit
• Dymista – For the treatment of seasonal allergic rhinitis.
  • Tier 3 with PA
• Neupro – For the treatment of Parkinson’s disease and Restless Leg Syndrome
  • Tier 3
• Onmel – For the treatment of nail fungus.
  • Tier 3 with PA

Formulary Changes – Effective July 1, 2013

• Lovaza – For hypertriglyceridemia.
  • Moving from Tier 2 to Tier 3
• Finacea – For acne and rosacea.
  • Moving from Tier 2 to Tier 3
• Azelex for acne and rosacea.
  • Moving from Tier 2 to Tier 3
• Spiriva – For COPD.
  • Moving from Tier 2 to Tier 3

Preauthorization Criteria Updates

• Advair 500/50 –  Added  PA (500/50 strength only) requiring a diagnosis of asthma
• Butrans patch – Added PA for documentation of failure at maximum tolerated dose of fentanyl patch
• Suboxone film – Added step edit  for trial of generic tablets prior to coverage of brand film
• Testosterone topical, oral and IM products
  • Added PA criteria on all formulations to confirm diagnosis through lab values and document clinically important signs and symptoms of androgen deficiency
  • Androgel remains preferred topical
• Promacta – Updated PA criteria to include use in Hepatitis C treatment
• Lunesta and Silenor – Updated step-edit criteria to require 2 generic agents

Preauthorization Added to IV Oncology Agents – Effective May 1 2013

• IV injectable oncology drugs and oncology-related drugs require PA for new starts
  • Avastin (bevacizumab)
  • Erbitux (cetuximab)
  • Perjeta (pertuzumab)
  • Vectibix (panitumumab)
  • Herceptin (trastuzumab)
  • Rituxan (rituximab)
  • Neulasta (pegfilgrastim)
  • Neupogen (filgrastim)
  • Neumega (oprelvekin)
  • Leukine (sargramostim)
• All current users are grandfathered

New Partnership with CVS Caremark Specialty Pharmacy

Effective May 1, 2013, we have a new specialty pharmacy vendor, CVS Caremark. Specialty medicines must be filled at a CVS Caremark Specialty Pharmacy. Those filled at any other pharmacy after this date will be rejected as not covered.

CVS Caremark Specialty Pharmacy provides medications and personalized pharmacy care management, including:

• Access to an on-call pharmacist 24/7
• Coordination of care with members and their doctors
• Convenient delivery directly to members or their doctors’ offices
• Medicine and disease education and counseling
• Online support through CVSCaremarkSpecialtyRx.com, including disease-specific information and interactive areas to submit questions to pharmacists and nurses

Enrollment forms are available on our website.

Note: Medicare members can still use any in-network specialty pharmacy vendor.

If you have any questions, contact your provider relations specialist or call Specialty Customer Care at 1-800-237-2767, Monday through Friday, 6:30 a.m. to 8 p.m.

2013 Provider Manuals

The 2013 Provider Manuals are available on the Forms and Resources page of Your Health Alliance for providers and office personnel. Contact your provider relations specialist (PRS) with any questions.

New PRS Joins Team

CPS welcomed a new Provider Relations Specialist, Lori Mahorney, on May 6. Her service area is Springfield.

If you need more information, please contact her at Lori.Mahorney@healthalliance.org, 217-278-7868, or her manager, Patti Stolte, at Patti.Stolte@healthalliance.org, 217-337-8471.

Health Alliance Connect – New Plan, New Patients

Starting August 1, 2013, you might see patients with ID cards that say Health Alliance Connect. This is our new Medicaid coverage plan.

On July 1, Medicaid-enrolled Seniors and Persons with Disabilities (SPD) will be allowed to select us with an effective date of August 1, 2013. Those who do not select a plan will be assigned to plans with an effective date of October 1, 2013.

This is the first step for Health Alliance Connect, which will also begin covering Medicare-Medicaid Alignment Initiative (MMAI) members, or people who receive both Medicaid and Medicare assistance.

We will manage the care for these members in these counties:

• Champaign
• Christian
• DeWitt
• Ford
• Knox
• Logan
• Macon
• McLean
• Menard
• Peoria
• Piatt
• Sangamon
• Stark
• Tazewell
• Vermilion

Individuals will be allowed to select us January 1, 2014, or be assigned to one of the plans April 1, 2014.

We will coordinate the care for these members through an interdisciplinary care team comprised of the member, a Nurse Care Manager, a Member Resource Coordinator, the PCP and specialists, and the Long Term Support Services Coordinator. The goal will be to improve health outcomes and provide greater value and access to care while achieving reduced and predictable costs for the state Medicaid program.

As we move forward, we thank you for your continued quality care to all our members and your patients. If you have questions, please contact our Contracting & Provider Services.