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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
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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
plan benefits, of promoting transparency as they
MVP’s depression care program now managed
access health care services and of removing
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.
High-risk members that were enrolled in MVP’sDepression Care Program prior to January 1 are
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
medication compliance, focusing on members of our Commercial and Medicaid health plans.
If your patient’s asthma is not well controlled,
MVP has Health Managers (Registered Nurse and
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
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
, 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
in the Prior Authorization, Referral and
services rendered on or after 10/29/12
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
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
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
and click the Privacy and
copy of this contract, please contact your Professional
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
The purpose of the survey is to assess the compliance
, 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
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
the MVP Provider Resource Manual
Submitting provider data changes or registrations
It is important for health care providers to submit
Please fax Provider Registration
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
New York State DOH:
and all NH
MVP Option Child and
MVP Option Family
Vermont Rule 10
Emergent Medical (Read further
for definitions of “emergency”)
Urgent Medical (Read further
for definitions of “urgent”)
Non-urgent “sick” visit
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
Well child care
Initial PCP OV for newborns
Within 2 weeks of discharge from hospital
Wait in PCP office (max)
Other Medical Care
Initial prenatal visit:
Initial family planning
Routine lab, x-ray &
H E A L T H Y P R A C T I C E S • 4
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”)
on the Patient Information
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
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
•After July 1, 2013, facilities that have not achieved
UHMS accreditation or cannot submit proof that
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
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
•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
Physicians must provide documented proof of the
•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
mental health functioning of its beneficiaries over atwo-year period. The initial survey is sent to get
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
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.
East Region HMO
East Region PPO
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
and then Provider Quality Improvement Manual
the Quality Programs
section of that web page.
The direct link is www.mvphealthcare.com/provider/
Reports from MVP help enhance patient
The MVP Adult
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
•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
or Sarah Ghent,
and how they can take care of themselves.
Professional Liaison, at firstname.lastname@example.org
•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
wallet card. It is available on
our website at www.mvphealthcare.com
. Click onMedicare 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 updates effective June 1, 2013
Electrical Stimulation Devices & Therapies
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
will continue to
inform your office about new and updated medical
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)
. 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
. The Current Updates
page of the BIM
lists all medical policy updates. If you have questions
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.
The first 5 digits identify the drug manufacturer.
Bone Growth Stimulator
The next 4 digits identify the specific drug and
The Indications/Criteria for the Ultrasound Bone
Growth Stimulator now lists the types of bone
The last 2 digits are indicative of the package
•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);
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:
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
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:
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
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.
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
•New indication and criteria for the use in post-
herpetic neuralgia was added. Criteria is the same as Gralise.
Therapeutic class changes
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
•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)
•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.
Qvar will be added to the formulary. Flovent will be
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.
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
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
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
•Formulary language updated for Option/
•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.
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
New drugs (recently FDA approved, prior
authorization required, Tier 3, non-formulary
for MVP Option/MVP Option Family)
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
H E A L T H Y P R A C T I C E S • 1 1
Patient Category Recommended Therapy Contained Casualty Setting Adults Preferred choices Gentamicin, 5 mg/kg IM or IV once daily or 2 mg/kg loading dose followed Alternative choices Doxycycline, 100 mg IV twice daily or 200 mg IV once daily Chloramphenicol, 25 mg/kg IV 4 times daily§ Children\Preferred choices Streptomycin, 15 mg/kg IM twice daily (maximum daily dose, 2
University of Wisconsin Research Subject Information and Consent Form A Randomized, Double-Blind, Placebo-Controlled Trial of Spironolactone versus Eplerenone in Patients with Mild to Moderate Heart Failure Investigator: [name and contact information] INVITATION/SUMMARY You are invited to participate in a research study about medications used to treat heart failure. You