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PRACTICESTM
MARCH/APRIL 2013
THIS NEWSLETTER CONTAINS INFORMATION THAT PERTAINS ONLY TO MVP-PARTICIPATING HEALTH CARE PROVIDERS.
in this issue
Healthy Practices delivered to your email
To reduce our impact on the environment and minimize the amount of mail that we send to our providers, MVP Health Care® is converting our printed newsletters to email. If you have an MVP online account, you are receiving Healthy Practices at the email address associated with that account. To receive communications at a different email address, or if you have not registered for an online account but would like to enroll in MVP e-communications, please complete this form: www.mvphealthcare.com/
providerpreferences. If you have any questions or choose to opt out at any
time, please email ecommunications@mvphealthcare.com.
Updates to Patient InformationAccessible Online .5 RADIOLOGY PROGRAM UPDATE
Financial Incentives Relating toUtilization Management Policy.6 Advanced imaging member scheduling program changes
MVP Health Care® implemented a member scheduling program in October, 2012. The program was a member advocacy program designed to assist members in scheduling their advanced imaging appointments. It also provided information to our members regarding the accreditationstatus of advanced imaging facilities and potential variation in out-of-pocket costs under their MVP health benefit plans.
MVP will modify the member scheduling program
•MVP received feedback from providers and members regarding the program. We listened to that feedback and, after careful consideration, •Effective Friday, January 25, the member scheduling program will be available to members on a voluntary basis only. Members may elect to initiate contact with CareCore National if they desire assistance with scheduling appointments. However, the member scheduling process will no longer be included in the advanced imaging prior authorization Provider site selection
•Effective Friday, January 25, the prior authorization process will be modified so that ordering providers are given information regarding the preferred status of MVP participating providers. MVP Health Care, Inc., Professional Relations Dept.
•Ordering providers may select any MVP participating provider to perform advanced imaging services for their patients. •This change will be incorporated into the existing telephonic and web-based authorization request processes. •Upon receipt of authorization, ordering providers will now be able to immediately schedule advanced imaging services for their patients. •CareCore National will no longer make outbound calls to members to MVP continues to believe that it is important to engage our members in active participation in their health care choices to ensure that they receivethe highest quality, clinically appropriate and cost effective services. We willcontinue to explore methods of educating our members about their health www.mvphealthcare.com
plan benefits, of promoting transparency as they MVP’s depression care program now managed
access health care services and of removing by ValueOptions®
unnecessary costs from the health care system.
MVP Health Care retired its depression care We thank you for your feedback regarding this management program as of January 1, 2013.
program and for your continued participation with Depression management services for MVP members are now offered by ValueOptions, a trusted partnerof MVP and a leader in behavioral health services.
POPULATION HEALTH
High-risk members that were enrolled in MVP’sDepression Care Program prior to January 1 are MANAGEMENT UPDATES
continuing their care management though MVP.
Members that were enrolled in MVP’s low-risk mailingprogram are now receiving information and support Improving asthma care for MVP members
from ValueOptions. Members may continue to self- MVP Health Care analyzed data on members refer by contacting the MVP Population Health with asthma who visited the emergency room (ER).
Management Department at 1-866-942-7966.
Our research shows that many members are non- Providers may continue to make depression care adherent with their asthma medications, or that referrals by calling that number. MVP will then their asthma is inadequately controlled on their work with ValueOptions for member outreach medications. MVP will begin outreach to health care and enrollment. This change is reflected in MVP’s providers in the coming months to address member updated Provider Resource Manual (June 2013). medication compliance, focusing on members of our Commercial and Medicaid health plans. PROFESSIONAL
If your patient’s asthma is not well controlled, MVP has Health Managers (Registered Nurse and RELATIONS UPDATES
Registered Respiratory Therapist) to work with yourMVP patients. A Certified Case Manager or WellnessCoach will offer information on lifestyle changes MVP requests your feedback: ICD-10 readiness
to help your patient minimize triggers, maintain MVP Health Care is preparing for the transition to an appropriate medication routine and more. Your ICD-10 in 2014. We are interested in our participating patient will receive helpful information by mail about health care providers’ progress toward ICD-10, also. managing asthma with follow-up phone calls to answer questions and offer support. To make a referral, about your ICD-10 readiness. Simply go to please call 1-866-942-7966, fax 1-866-942-7785 or
www.mvphealthcare.com/provider and click
email PHMReferrals@mvphealthcare.com.
the ICD-10 readiness survey link on the right side of the page. Your feedback will help us implement Raising antibiotics awareness
education and outreach to help our participating Antibiotics are not always the easy answer to providers as we all get ready for the October 2014 being well. MVP recently partnered with the Vermont adoption deadline set by CMS. We appreciate your Department of Health and Vermont-area insurers to promote the Get Smart About Antibiotics campaigncreated by the Centers for Disease Control and OrthoNet professional service claims audit
As communicated in the July/August 2012 issue of MVP’s focus is on urging all of our members Healthy Practices, MVP engaged OrthoNet to review (regardless of whether they live in Vermont) to the coding accuracy of certain surgical claims. That talk with their doctors about when an antibiotic review program was effective as of October 1, 2012.
will help their condition, or if their condition is most Claims with dates of service occurring on or after likely caused by a virus that cannot be treated by an October 1, 2012, may be subject to this review.
antibiotic. In addition to educational articles in all of OrthoNet will contact your office to request MVP’s spring 2013 member newsletters, we created additional information, if needed, to complete this a new web page to promote the campaign and link members to helpful information on the CDC website.
To visit this web page, go to www.mvphealthcare.com,
click Live Healthy at the top of the home page, then
click the Antibiotics link on the left side of that page.
H E A L T H Y P R A C T I C E S • 2
Radiation therapy management
Prior authorization for skilled nursing stays
As communicated in the July/August 2012 issue of As a reminder, all skilled nursing facility (SNF) stays Healthy Practices, MVP engaged CareCore National require prior authorization from MVP. Please complete (“CareCore”) to perform pre-service medical necessity a Prior Authorization Request form, available on our reviews of radiation therapy treatment plans.
website at www.mvphealthcare.com/provider/ny/
Prior Authorization: therapy plans initiated for
forms.html in the Prior Authorization, Referral and
services rendered on or after 10/29/12
Admissions section of the page. Forms may be Radiation therapy treatment plans initiated on or submitted by fax to 1-866-942-7826 or by mail
after October 29, 2012 require prior authorization to MVP Health Care, Utilization Management, from CareCore. Prior authorization requests can be 625 State Street, Schenectady, NY 12305. To submit initiated by calling CareCore at 1-866-665-8341.
a prior authorization request by phone, please call Radiation therapy prior authorization history and 1-800-999-3920.
status may be viewed at www.carecorenational.com.
Claims for radiation therapy initiated and rendered
MVP annual notices
on or after October 29, 2012 will be denied if prior As part of our commitment to the accreditation standards of the National Committee for Quality Registration: treatment plans initiated prior to
Assurance (NCQA), and to comply with state and 10/29/12
federal government regulations, MVP publishes an Radiation therapy treatment plans that were annual summary of important information for initiated prior to October 29, 2012 are required practitioners and providers. This notice includes to be registered with CareCore to ensure claim
payment. Claims for radiation therapy services •MVP’s recognition of members’ rights and initiated prior to October 29 (with continuation of services rendered beyond that date) will not be paid unless those cases are registered with CareCore.
•Confidentiality and privacy policies, including Registration of radiation therapy plans for services measures taken by MVP to protect oral, written that began before October 29 may be obtained by calling CareCore at 1-866-665-8341. When registering
such cases be certain to advise CareCore that the treatment plan was initiated prior to October 29, 2012. Audiologists required to be contracted
•Medical record standards and guidelines Effective July 1, 2013 MVP will require all •Information about MVP’s Quality Improvement audiologists that provide services to MVP members to be contracted and credentialed to •Reporting suspected insurance fraud and abuse remain participating with MVP. Audiologists who do not meet these requirements as of July 1 will •MVP’s stance on physician self-treatment and be considered non-participating providers. MVP will be sending out contractual agreements to all •MVP’s efforts to meet members’ special, cultural audiologists in our service area that have served MVP members in the past. If you have already signed To access MVP’s annual notices for health a contract with MVP for audiology services, no action is required on your part. If you have not received a www.mvphealthcare.com and click the Privacy and
copy of this contract, please contact your Professional Compliance link in the green bar at the bottom of the home page. If you would like to receive a printedcopy of this information, please call ProfessionalRelations at the phone number shown on the leftside of the this newsletter’s front page. H E A L T H Y P R A C T I C E S • 3
Access and availability standards
Obtaining provider data forms
The Department of Health (DOH) performs regular Provider data forms are available on the audits of MVP’s network of health care providers. MVP website. Go to www.mvphealthcare.com, click
The purpose of the survey is to assess the compliance on Providers, then Forms in the top green toolbar.
of PCPs and OB/GYNs participating in the NYS Once you click through to the Forms page, go to Medicaid managed care program with the medical the Provider Demographic Change Forms section.
appointment standards delineated in the Medicaid For a direct link to the provider data change and FHP contracts. Following is a list of these form, type the following into your web browser: access standards (also available in Section 4 of www.mvphealthcare.com/provider/documents/
the MVP Provider Resource Manual titled Provider contracted_provider_change_info.pdf.
Submitting provider data changes or registrations
Action requested
It is important for health care providers to submit Please fax Provider Registration forms, changes in participation or demographic information Contracted Provider Change of Information to MVP as outlined in this article. MVP also will forms or Mid-Level Practitioner Registration contact you to do our own internal access and forms to MVP’s Provider Data Management availability survey and to confirm your demographics. team at 518-388-2200.
MEDICAL HEALTH ACCESS STANDARDS
Type of Service
MVP Commercial
New York State DOH:
and all NH
MVP Option,
CMS: Medicare
Products
MVP Option Child and
Advantage
MVP Option Family
Products
Vermont Rule 10
Emergent Medical (Read further
for definitions of “emergency”)
Urgent Medical (Read further
for definitions of “urgent”)
PRIMARY CARE
Non-urgent “sick” visit
Routine symptomatic:
Non-urgent, non-emergent
with prompt F/Uincluding referralsas needed Routine asymptomatic: Non-urgent
& preventive care appointments
(NYSDOH) routine & preventive (CMS)
Preventive care, wellness visits
including routine physicals (CM, VT)
Adult (>21) baseline & routine
physical (NYSDOH)
Initial assessment
Well child care
Initial PCP OV for newborns
Within 2 weeks of discharge from hospital Wait in PCP office (max)
After-hours care
Other Medical Care
Initial prenatal visit:
1st trimester
2nd trimester
3rd trimester
Initial family planning
Specialist referrals
Routine lab, x-ray &
general optometry
H E A L T H Y P R A C T I C E S • 4
WEB UPDATE
CREDENTIALING UPDATE
Updates to patient information accessible
Hyperbaric Oxygen Therapy (HBOT)
credentialing criteria update
MVP is updating its online content for health care MVP Health Care now has credentialing criteria providers to ensure that the code descriptions we for hyperbaric medicine centers and for physicians display are consistent with codes that are used in providing hyperbaric oxygen therapy (HBOT). Facilities transmitting electronic (5010) transactions. These and physicians treating MVP members using HBOT updates are effective March 22, 2013 and will affect must fully comply with the requirements defined in the some of the information that you access when you MVP Organizational Credentialing and Recredentialing log in to your account at www.mvphealthcare.com.
Process policy and meet the criteria outlined here. PCP Specialty/Taxonomy Code Description
•All Hyperbaric Medicine Centers (“facilities”) PCP Details on the Patient Information page will providing HBOT services will be required to display the HIPAA-compliant Taxonomy Code provide proof that they have submitted an Description for the provider’s specialty. application for accreditation to the Undersea and Hyperbaric Medicine Society (UHMS) no Benefit Summary
later than July 1, 2013 and must achieve UHMS After searching for and selecting a member, the member’s benefits on the Benefit Details page willdisplay Service Type descriptions. •After July 1, 2013, facilities that have not achieved UHMS accreditation or cannot submit proof that Claim Status
they have applied for UHMS accreditation will The claims summary status will display a HIPAA- no longer meet MVP criteria and may not submit claims for services provided to MVP members. Examples of revised claim status language: •The final deadline for HBOT facility accreditation “Completed” will now read “Finalized” •After July 1, 2014, facilities that have not achieved UHMS accreditation will no longer meet MVP “In process” will now read “Pending/In Process” criteria, and may not submit claims for services Deductible Amounts
A member’s remaining deductibles will reflect Effective July 1, 2013, physicians providing HBOT HIPAA-compliant language and format changes. services must attain and provide proof of: •Board certification in Undersea and Hyperbaric Medicine by the American Board of Preventive Family deductible can include a Family Members Required option. In this type of deductible, once Emergency Medicine (ABEM) OR
the stated number of members has met their •Completion of a 12-month fellowship in Undersea deductible, it is considered to have been met, and Hyperbaric Medicine. The fellowship must be even if the total dollar amount for the family accredited by a program recognized by MVP OR
•Documented proof of eligibility to take the ABPM examination OR
•Affiliation with a Clinical Hyperbaric Facility In this example, once three family members accredited by or in the accreditation process with have met their $100 deductible requirement, the Undersea and Hyperbaric Medical Society benefit payment will begin, even though the $350 As a reminder, the following interim facility and
entered as being the family amount has not been physician criteria are now in effect. Please note that
met. The deductibles will also be considered as these criteria will no longer apply as of July 1, 2014.
satisfied when deductibles for all family members reach $350. For example, Family Members #1, •Be accredited as a Level 1, 2, or 3 Hyperbaric #2 and #3 have each accumulated $90 toward Hyperbaric Medical Society OR
accumulated $80, for a total of $350. No further •Be part of an acute inpatient medical-surgical charges will be applied to deductibles.
hospital fully credentialed by MVP per the MVP
"Hospital Criteria" and the MVP "Credentialing of
Organizational Providers" administrative policy AND
•Engage at least one physician who meets one of the approval pathways noted on the MVP H E A L T H Y P R A C T I C E S • 5
“Credentialing Criteria for Physicians Providing CARING FOR
Physicians must provide documented proof of the OLDER ADULTS
•Completion of a 40-hour course approved by the American College of Hyperbaric Medicine or the Your impact on patients’ Health Outcome
Undersea and Hyperbaric Medical Society AND
Survey (HOS) responses
•One year of active practice in Hyperbaric The Centers for Medicare & Medicaid Services Medicine with a minimum of 25 percent of the (CMS) requires health plans to monitor the care our time or 10 hours per week (whichever is greater) members receive from their health care providers. As spent in Hyperbaric Medicine AND
we have discussed in previous editions of this •Documentation of a minimum of 100 cases newsletter, the CMS Star Ratings include many treating the disease specific indications approved measures that are associated with care given by by Medicare and currently approved by the MVP physicians who care for MVP Medicare Advantage To request a credentialing packet or if you have Some of the measures are self-reported by your questions about this change, please contact your patients through a survey called the Health Outcome MVP Professional Relations or Facility Representative.
Survey (HOS). The HOS assesses each MA plan’sability to maintain or improve the physical and UTILIZATION
mental health functioning of its beneficiaries over atwo-year period. The initial survey is sent to get MANAGEMENT UPDATE
baseline information on the patient’s perception oftheir health. The survey is sent to the same patients (if possible) Financial incentives relating to utilization
after two years to assess changes in their physical management policy
health status. The survey includes questions that ask your patients if their PCP has talked to them It is the policy of all of the operating subsidiaries about physical activity, about their risk of falls and of MVP Health Care, Inc. to facilitate the delivery about urinary incontinence. CMS is expecting that an
of appropriate health care to our members and to assessment of these issues is completed and that a
monitor the impact of the Plan's Utilization treatment plan is in place to improve the quality of
life for your patients if any issues are identified.
potential under- and over-utilization of services.
The HOS also includes questions about their MVP’s Utilization Management Program does not physical and mental well-being. Several questions provide financial incentives to employees, providers are asked about their physical and mental health that or practitioners who make utilization management compares results to how these patients responded to decisions that would encourage barriers to care and the survey done two years earlier. Assessment of a patient’s physical and mental health is a critical part Utilization management decisions are based only on appropriateness of care and the benefits The CMS star rating for these measures for the provisions of the member's coverage. MVP does not last reporting period are in the chart below.
specifically reward practitioners, providers, or staff,including Medical Directors and UM staff, for issuing MVP has developed some tools to assist physicians and their office staff that can be utilized for theabove assessments. They can be found in the Financial incentives, such as annual salary reviews Provider QI Manual on our website.
and/or incentive payments do not encouragedecisions that result in underutilization.
CMS Measure*
Rochester HMO
Rochester PPO
East Region HMO
East Region PPO
Members Results
Members Results
Members Results
Members Results
Monitoring physical activity (discussed physical
activity & PCP advised to start, increase or
maintain level of exercise or physical activity)
Reducing Fall Risk (assess patient’s risk
of falling & development of a plan to
reduce risk of falls)
Improving Bladder Control (assess patient
for urinary incontinence & received treatment)
Improving or maintaining physical health
Improving or maintaining mental health
*Scores are rated 1 to 5 stars with 5 stars being the highest or best rating.
H E A L T H Y P R A C T I C E S • 6
Go to www.mvphealthcare.com, click Provider
QUALITY UPDATE
and then Provider Quality Improvement Manual in
the Quality Programs section of that web page.
The direct link is www.mvphealthcare.com/provider/
Reports from MVP help enhance patient
qim/caring_for_older_adults.html. The MVP Adult
management
Preventive Care Guideline includes a matrix ofpreventive services recommended for care of offers primary care quality reports (produced atthe practice site level) that can help you manageyour patient population. Talk to patients about avoiding hospital
readmission
•The prospective Gaps in Care report identifies members who have not had preventive screenings, In an effort to decrease readmission rates after well care visits or immunizations. If a member is a hospital stay, MVP is educating its Medicare lacking services in multiple areas, the information Advantage plan members on how to be prepared is consolidated on one row to make it easier for for a smooth transition from hospital to home.
you to ensure that all services are provided in Members who are better prepared before their visit a timely fashion. This report is produced three will have a lower chance of having to be admitted back into the hospital because of a problem.
•MVP also produces two emergency room (ER) Providing continuity and coordination of care for utilization reports. One provides detailed a patient as they transition from the hospital setting information on members who have utilized the to outpatient is also crucial in reducing hospital ER in the past month for care. The other report readmission rates. Health care providers can help provides a list of members who have utilized the by obtaining hospital discharge summaries in a ER two or more times in the past month for care.
timely manner and documenting any changes in These reports are produced monthly and are medical/surgical history and medications. Often, usually available around the 20th of each month.
after a hospital stay, a patient may have additional •The Inpatient report provides a list of members specialists involved in their care. It is important for who were discharged from the hospital during the primary care providers (PCPs) and specialists to previous month. The report lists the discharging communicate relevant information to ensure a hospital, the length of stay and diagnosis. This coordinated approach to the patients care.
report also is produced monthly and is available We encourage physicians to speak with MVP Medicare plan members about this important MVP’s reports are provided in an electronic format topic. Some helpful tips that members should (Excel), allowing you to work with the data based on your particular need or interest. All of the reports that •Bring a complete list of medications to the you request will be sent to you via MVP’s secure email service (ZixMail) to ensure the protection of PHI.
•Work with the discharge planning staff to If you would like to begin receiving these reports or have questions about any of the reports that you •Take an active role in discharge and treatment Nicole Gadziala, Professional Liaison, at •Learn any important details about the condition ngadziala@mvphealthcare.com or Sarah Ghent,
and how they can take care of themselves.
Professional Liaison, at sghent@mvphealthcare.com.
•Schedule a follow-up appointment within seven •Bring hospital discharge plan along with a list of medications to follow-up appointment(s).
•Carry important information at all times about the condition, medications, doctor and pharmacycontact information. To help members keep important information with them at all times, MVP has created the My Hospital
Discharge Checklist wallet card. It is available on
our website at www.mvphealthcare.com. Click on
Medicare Members, select the county in which your
patient lives, then click on Live Well and Useful Tips
After a Hospital Stay.
H E A L T H Y P R A C T I C E S • 7
MEDICAL POLICY
Medical policy updates effective June 1, 2013
Electrical Stimulation Devices & Therapies
(NEW POLICY)
The policy follows Medicare’s National and Local The MVP Quality Improvement Committee (QIC) Coverage Determination. Coverage is allowed for approved the policies summarized below during the TENS for chronic low back pain when criteria in the January meeting. Some of the medical policies may policy are met. Medicare does not allow coverage of reflect new technology while others clarify existing Healthy Practices and/or FastFax will continue to inform your office about new and updated medical CLAIMS UPDATE
policies. MVP encourages your office to look at all of the revisions and updates on a regular basis in the Benefit Interpretation Manual (BIM) located on National Drug Codes (NDCs)
www.mvphealthcare.com. To access the BIM, log in
Health care providers have asked how to bill NDC to your account, visit Online Resources and click BIM codes. What follows are answers to your most-asked under Policies. The Current Updates page of the BIM lists all medical policy updates. If you have questions NDC Formatting
regarding the medical policies, or wish to obtain a •A valid NDC is submitted as an 11-digit code paper copy of a policy, contact your Professional •However, you will usually not see just 11 numbers Medical policy updates effective April 1, 2013
package. This is because the 11 digits of an Bone Density Study for Osteoporosis (DEXA)
There are no changes to the medical policy. ᔢ The first 5 digits identify the drug manufacturer.
Bone Growth Stimulator
ᔢ The next 4 digits identify the specific drug and
The Indications/Criteria for the Ultrasound Bone Growth Stimulator now lists the types of bone ᔢ The last 2 digits are indicative of the package
Compression Stockings
•In some cases, you may see a “5 digit-4 digit-2 The following codes are not covered under MVP Option products: surgical stockings (A4495, A4500); ᔢ In this situation, you will simply remove the
gradient compression stockings (A6530, A6533 – A6541, A6544; and A6549; miscellaneous DME •You also may see other formats for NDCs, since supply or accessory, A9999, not otherwise specified). many manufacturers omit leading zeros in one Speech Generating Devices
Communication boards have been added under •For a claim to be paid, any leading zeros must be accessories covered for speech generating devices. added back into the appropriate place within the Please refer to the coding section on the policies NDC to create an 11-digit NDC number that matches to identify any code changes (e.g., new, deleted) or the Medispan and/or First Databank databases.
codes no longer requiring prior authorization for a Choosing the applicable NDC:
specific policy. Each policy grid defines the prior •Drug manufacturers are currently not allowing authorization requirements for a specific product.
NDCs found on the inside packaging to be published.
This means that the outermost NDC (on a box)should always be used for billing rather than the NDC found on an individual syringe or vial.
HERE’S HOW TO CONVERT YOUR NDC INTO THE “5-4-2” FORMAT AND HOW TO KEY IT ONTO THE
CLAIM FORM BY ADDING THE N4 QUALIFIER:
Packaging NDC Format
Add leading zero(s) to the:
Conversion Examples
and is keyed as
H E A L T H Y P R A C T I C E S • 8
NDCS ON CMS-1500 CLAIM FORMS
Instructions for filling out a CMS-1500 form
• NDC should be entered in the shaded area of fields 24A – 24G for the corresponding procedure code • The following should be included in order ᔢ Report the N4 qualifier (left justified) followed immediately by:
ᔢ 11 digit NDC (no hyphens)
ᔢ One space followed immediately by:
ᔢ Unit of measurement qualifier:
• F2 – International Unit• GR – Gram• ML – Milliliter• UN - Unitfollowed immediately by: ᔢ Unit Quantity
Quantity is limited to eight digits before the decimal and three digits after the decimal. If entering a wholenumber, do not use a decimal.
Examples:• 1234.56• 2• 99999999.999 NDCS ON UB-04 FORMS AND ELECTRONIC CLAIM SUBMISSIONS
Instructions for filling out a UB-04 form
• The following should be included in order ᔢ Report the N4 qualifier (left justified) followed immediately by:
ᔢ 11 digit NDC (no hyphens) followed immediately by:
ᔢ Unit of measurement qualifier:
• F2 – International Unit• GR – Gram• ML – Milliliter• UN - Unit • Unit Quantity (floating decimal, limited to three digits to the right of the decimal) Instructions for electronic claim submissions
Complete the drug identification and drug pricing segments in Loop 2410 following the instructions below.
Element Name
Information
Use qualifier N4 to indicate that entry of the 11 digit National Drug Code in 5-4-2 format in LIN03 Include the quantity for the NDC billed in LIN03 For the NDC billed in LIN03, include the unit or basis for measurement code using the appropriate code qualifier:• F2 – International Unit• GR – Gram• ML – Milliliter• UN – Unit H E A L T H Y P R A C T I C E S • 9
PHARMACY UPDATES
Horizant
•New indication and criteria for the use in post- herpetic neuralgia was added. Criteria is the same as Gralise.
Therapeutic class changes
Hypnotics (select)
Upon review of select therapeutic classes, the •Intermezzo was added to the policy with quantity Pharmacy & Therapeutics committee approved the following changes. These changes do not apply to •Select Medicare language was removed as new MVP Medicare, Option or Option Family business. All impacted members and providers will receive a letter if further action is required.
Inhaled Corticosteroids and Combinations (NEW)
Antidiabetic agents
•New policy requiring prior authorization for Janumet XR will be added to the formulary.
non-formulary Alvesco, Flovent and Advair.
Onglyza and Kombiglyze XR will be removed from the formulary and require prior authorization •Criteria includes FDA approved dosing and age requirements as well as failure on all otherformulary covered drugs.
Inhaled corticosteroids
Qvar will be added to the formulary. Flovent will be Mepron (NEW)
removed from the formulary. Prior authorization New policy establishing prior authorization will be required for non-formulary agents Alvesco and Flovent effective April 1, 2013.
Migraine Agents
Inhaled corticosteroids/LABA combinations
•Clarified prior authorization requirements on Dulera will be added to the formulary. Advair will be removed from the formulary and require Overactive Bladder (Oral) Treatment (NEW)
prior authorization effective April 1, 2013.
•New policy requiring prior authorization for Urinary anticholinergics/antispasmodics
non-formulary Sancture/XR and Enablex.
Toviaz and Vesicare will be added to the •Criteria include failure on formulary agents.
formulary. Prior authorization will be required Pain Medication
for non-formulary agents effective April 1, 2013.
•Language referring to the new REMS Program Policy updates (effective April 1, 2013)
for Tansmucosal Immediate Release Fentanyl was added.
Antipsychotics for Depression
•Step edit requirement language was clarified.
•Use of buprenorphine in combination with Compounded (Extemporaneous) Meds
•Language clarified that self-administered Pharmacy Programs Administration
compounds must process through the PBM.
•Prescriber prevails provision added for atypical antipsychotics, for Option and Option Family •All compounds, medical or pharmacy, over Prescribers Treating Self and Family Members
Cox-2 Inhibitors
•Formulary language updated for Option/ Provenge
•Prostate cancer stats were updated. No changes DPP4 Inhibitors (NEW)
•New policy requiring prior authorization for non-formulary Onglyza and Kombiglyze XR.
•Criteria includes failure on formulary DPP4 agents.
•Use with alcohol added as an exclusion.
Erivedge (NEW)
The following policies were reviewed and approved
•New policy establishing prior authorization without any changes to criteria:
criteria that includes but is not limited to diagnosis of locally advanced or metastatic basal cell carcinoma, prescribed by an oncologist or dermatologist and age 18 or older.
H E A L T H Y P R A C T I C E S • 1 0
Formulary updates for Commercial and
Option members
New drugs (recently FDA approved, prior
authorization required, Tier 3, non-formulary
for MVP Option/MVP Option Family)
Drug Name
Indication
Generic drugs added to Formulary (Tier 1)
oxymorphone (Opana ER –old formulation) Drugs removed from the Formulary
(effective April 1, 2013)*
*Affected members will receive a letter if further action is required (i.e. contacting the prescriber for a formulary alternative) Drugs removed from prior authorization
(all medications are non-formulary, Tier 3 unless
otherwise noted)
H E A L T H Y P R A C T I C E S • 1 1
healthypractices

Source: http://www.mvma.net/yahoo_site_admin/assets/docs/mvma_HealthyPractices_MarApr2013.83104709.pdf