Download Physiciansplus

Physiciansplus
PROVIDER NEWSLETTER
Physicians Plus & Meriter Announce
Affiliation Agreement!
On October 10, Physicians Plus announced that, along with Meriter Health Services
and at the recommendation of our community Board of Directors, we have agreed to
formally affiliate with UnityPoint Health, a nationally recognized, integrated health
system based in West Des Moines, Iowa. The affiliation will allow Physicians Plus to
thrive in the changing health care landscape while maintaining our commitment to
you and this community.
There will be no disruption in members’ access to care. They can continue to see the
doctors they know today and receive care locally … just like now. Plans and benefits
will not change. We’ll continue to provide our members with access to our broad network of excellent providers and high-quality service.
UnityPoint Health is a growing, patient-centered health system. Like Physicians Plus
and Meriter, UnityPoint Health has a culture of patient-focused care and a community-minded spirit.
Physicians Plus will have access to resources that support and enhance what we already offer in this community. We expect to grow in strength and market coverage,
but our commitment to Dane County and south central Wisconsin does not change.
The affiliation requires state and federal regulatory approval, which is expected later
this year. In the meantime, the future is bright! Affiliation brings us strength and
new resources. All of us at Physicians Plus look forward to working with you to meet
the health care needs of our members for many years to come!
Physicians Plus Announces Changes
to Specialty Pharmacy Network
Effective January 1, 2014, there will be a change to the specialty pharmacy network
provided by Physicians Plus. Specialty drugs are usually high-cost drugs used to prevent, treat, or cure rare or complex diseases. They typically require clinical monitoring and management, special handling and storage.
Physicians Plus is partnering with Walgreens Specialty Pharmacy because they
provide improved access to medication and high quality case management support.
Walgreens Specialty Pharmacy, along with Meriter Outpatient Pharmacy, will comprise the Physicians Plus Specialty Pharmacy Network for 2014. Beginning January
1, 2014 all specialty medications must be filled at a Physicians Plus Specialty Network
pharmacy.
continued on p. 2
Fall 2013, Edition 47
In this issue
For Your Information
p. 2
ICD-10 Update
p. 3
Epocrates Upgrade
p. 3
Case Management
p. 4
Formulary Update
Insert
Editor
Scott Rabehl
E-mail: scott.rabehl@pplusic.com
The Provider Newsletter is dedicated
to informing P
­ hysicians Plus providers about our organization’s news
and developments.
Please Note: The content featured in this newsletter
was accurate at the time of printing. However, some
changes may have occurred since the printing date.
For the most current information, visit pplus.com.
P+ 3827-1113
02
For Your Information
Medical Management/ Utilization
Management Notice
making inpatient coverage determinations for the Plan. UM
criteria are available to practitioners upon request. You may:
Medical Management/Utilization Management (UM) decision
making is based only on appropriateness of care, type of service and member’s current coverage. Physicians Plus does not
specifically reward practitioners or other individuals for issuing
denials of coverage or care. Financial incentives are not provided to UM decision makers to encourage decisions that would
result in underutilization.
1. Obtain a copy of case-related criteria;
Medical Management/UM and Pharmacy staff is available
for inbound and outbound communication by phone between
the normal business hours of 8 a.m.–5 p.m., Monday–Friday
(excluding holidays), to discuss medical management/UM or
pharmacy issues with our members and providers. Voice mail,
fax and e-mail are available for UM and Pharmacy staff to
receive inbound communication regarding UM and pharmacy
issues after normal business hours. Members and providers
may obtain information on the medical management process
or authorization of care by calling Health Services at (608) 2828900 or (800) 545-5015. Pharmacy Services may be contacted
for medication questions or information at the same numbers.
Provider Manual Updates
Physicians Plus has made its annual updates to its Provider
Manual. The provider manual is a source of readily available
information regarding the administration of Physicians Plus
for participating providers and their office staff. The Provider
Manual can be found at pplus.com, “Providers,” “Provider
Manual & Forms.”
2. Discuss UM issues or the UM process with staff;
3. Discuss a UM denial or potential denial; or
4. C
ontact a UM reviewer by calling the Physicians Plus Health
Services department at (608) 282-8900 or (800) 545-5015.
Plan-developed criteria are also made available to practitioners
on our website at pplus.com.
Language Assistance
If you feel a Physicians Plus member needs language assistance for understanding benefits, sending us a complaint or
grievance, or wanting to discuss utilization management,
please have them contact Physicians Plus at (800) 545-5015
and we can assist them.
Medical Policy Update
Please review important medical policy updates. Go to
pplus.com, “Providers,” “Medical Policy Guidelines” for
further details on:
• Intratympanic Steroid • Orthopedic and Neuro-surgery
Injection
Referrals for ETF Members with
Low Back Pain
Coverage Update
Please review important coverage updates. Go to pplus.com,
“Providers,” “Updates & Regulations,” “Coverage Updates”
for further details on:
•Labiaplasty
•Vitiligo
•Lipomas
Utilization Review Criteria
Reminder: Coverage of Virtual Colonoscopies
Physicians Plus uses evidence-based criteria to assist in making utilization management (UM) review determinations.
Plan-developed criteria are created, adopted and reviewed with
the input of appropriate participating practitioners and specialists. InterQual is a nationally recognized criterion set used in
Physicians Plus does not cover virtual colonoscopies unless
medically necessary. Effective September 15, 2013, all virtual
colonoscopies must meet medical necessity for coverage and
require prior authorization. Go to pplus.com, “Providers,”
“Medical Policy Guidelines” for more information.
Network
continued from p. 1
Benefits of a dedicated specialty pharmacy network include:
• Access to a pharmacist 24 hours a day,
seven days a week.
• Case management and monitoring.
• Reliable, on-time medication delivery
to a location of your patient’s choice or
in-store pick-up.
In the next month, letters will be sent to
members affected by this change. In early
December, affected providers will receive a
list of their members currently on specialty medications to help facilitate a transfer
of these prescriptions to a Physicians Plus
Specialty Pharmacy Network pharmacy.
A FAQ sheet and list of specialty drugs
will also be available on the Physicians
Plus website at pplus.com.
For further information, please contact
Physicians Plus Pharmacy Services at
(608) 260-7803.
Physicians Plus Insurance Corporation Provider Newsletter: Fall 2013, Edition 47
Complex Case
Management continued from p. 4
2. M
ultiple chronic conditions involving
multiple specialists requiring coordination of care;
3. A
n acute, catastrophic condition/diagnosis resulting from trauma such as a
traumatic brain injury or catastrophic
diagnosis such as cancer;
4. Organ Transplant.
The Complex Case Management nurse
works together with you to achieve a
common goal: optimal care of the complex patient and their family in a way
that allows Physicians Plus to be a good
steward of our resources. The program
identifies and helps remove barriers
that may keep a patient from achieving
optimal healthcare outcomes through
a variety of ways, including: individualized education and support; proactive
management for their clinical symptoms
and needs; coordination of healthcare
services; assistance in the fulfillment of
advanced care plans; development of a
schedule for follow-up appointments; and
much more!
In this rapidly changing health care environment, it is important to have a working relationship with you — our network
physicians — to focus on supporting and
implementing your efforts to provide
quality medical care for your complex
patients. We look forward to working
together with you to make a difference
in the lives of your patients. For more information, please call (800) 545-5015 or
(608) 282-8900.
03
Physicians Plus ICD-10 Update
Physicians Plus would like to inform you that due to an effort to maintain compliance
with the Department of Health and Human Services’ final ruling for the modification
and standardization of medical code sets used for coding diagnoses and inpatient hospital procedures, Physicians Plus will be transitioning to the ICD-10 platform by the
compliance date of October 1, 2014.
As you may know, the Electronic Transaction and Code Set provision was designed to
reduce healthcare processing costs through the use of common transaction formats
and code set values. Some of the benefits of ICD-10 includes: fewer questionable or rejected claims; improvement in fraud and abuse detection; less requests for supporting
documentation; more accurate payments for new procedures and emerging technologies; and much more.
As the October 1, 2014, compliance date draws near, Physicians Plus would like to
partner with you to ensure the transition to ICD-10 is seamless. Please visit our web
site at pplus.com/providers to complete a survey regarding your ICD-10 readiness. We
would like to use this information to determine your ICD-10 status and establish any
testing that may need to be completed in anticipation of the 10/1/14 compliance date.
Please note: Any testing needs to be completed before August 15, 2014. Physicians
Plus reserves the right to create the testing time frame and schedule.
If you have any questions regarding the transition to the ICD-10 platform, please contact the Physicians Plus ICD-10 Help Group at ICD-10@pplusic.com.
Physicians Plus and Epocrates
Offer Upgrade Discount
Physicians Plus Pharmacy Services is helping providers upgrade their Epocrates
service by offering an exclusive 30% discount off any Epocrates product purchase.
Upgrade your current Epocrates subscription to get premium Epocrates content for
your mobile device and/or your internet-connected computer. The premium Epocrates
clinical references can guide you throughout the continuum of patient care — from
initial diagnosis, to evidence-based drug treatment plans, and even to extended patient
care with Patient Education materials.
Epocrates® provides healthcare providers with drug, disease and decision support tools
at the point of care. Epocrates can help improve patient safety by providing important
adverse event and drug interaction information. The content is continuously updated
so providers have the latest information at their fingertips.
Please Note: This special offer is only valid during the month of November. Log-in
online at epocrates.com and enter the coupon code, PPLUSIC2013 during checkout.
For any questions about the discount or discount code, please contact Physicians Plus
Pharmacy Services at (608) 260-7803, (800) 545-5015 or pharmacyinfo@pplusic.com.
For Epocrates Customer Support, you may submit your questions to goldsupport@
epocrates.com or call (800) 230-2150.
Presorted Standard
U.S. Postage
PAID
Madison,WI
Permit #2675
2650 Novation Park way
Madison, WI 53713
Making an Impact: Physicians Plus
Complex Case Management
Complex Case Management is a program Physicians Plus offers at no cost to our
members to help them with challenging health conditions. Specially trained nurses
provide personalized assistance in finding the resources and care our members need
to attain the highest possible health and function.
To show you the how the program can directly affect a member’s health and well-being, we’d like to offer the following example of how the Complex Case Management
program successfully impacted a member’s life. (Please note: The initials used in the
following example were deliberately changed to protect the member’s PHI; however,
the situation is a real and typical example of the work Physicians Plus case managers
and our network physicians collaborate on to address complex member needs):
“TD” enrolled in the Physicians Plus Complex Case Management Program when
she experienced a sudden hearing loss along with extreme vertigo, loss of balance
& tinnitus. As a young wife and mother with two school-aged children, she was
struggling with how to deal with her symptoms as well as feeling overwhelmed at
the uncertainties that her future held. The Complex Case Management nurse established a relationship with her, listened to her to learn the details of her medical
condition from her perspective, worked with her to create a care plan, and provided
support/facilitation to ensure that she received the care/assistance she needed. “TD”
just recently accepted a job that she is very excited about and has been officially discharged from the Complex Case Management Program.
Stories like “TD’s” would not happen without you, the physician. It is your keen eye
to what your patient needs that assists in identifying and caring for patients that may
benefit from Complex Case Management.
Eligibility for Complex Case Management
This program is available for your patients that meet the following criteria:
Provider Network
Management Contacts
President & CEO
Linda Hoff
(608) 417-4577
E-mail: linda.hoff
@pplusic.com
Chief Medical Officer
Dr. Larry Kay
(608) 417-4503
E-mail: larry.kay
@pplusic.com
Director of
Managed Care
Sonja Petermann
(608) 417-4560
E-mail: sonja.
petermann
@pplusic.com
Credentialing
Supervisor
Leah Carini
(608) 417-4678
E-mail: leah.carini
@pplusic.com
Provider Service
Representatives
(608) 282-8900
(800) 545-5015
Provider Network
Management
Manager
Traci Schaefer
(608) 417-4680
E-mail: traci.schaefer
@pplusic.com
Provider Network
Management Liaison
Scott Penney
(608) 417-4673
E-mail: scott.penny
@pplusic.com
Kelly Gibson
(608) 417-4679
E-mail: kelly.gibson
@pplusic.com
Dana Horner
(608) 417-4576
E-mail: dana.horner
@pplusic.com
Provider Network
Management Fax
(608) 327-0329
Tell us how to
improve your
newsletter at scott.
rabehl@pplusic.com
1. High utilization of ED and/or inpatient services (including readmission);
Provider Network Web Site
continued on p. 3
www.pplusic.com/providers
Formulary Update
The Physicians Plus prescription
drug formulary is the preferred
list of prescription drugs developed
by our Pharmacy & Therapeutics
Committee and is continually updated through additions, deletions
and status changes. The abbreviated, comprehensive formulary and
pharmacy management procedures
are available at pplus.com/providers/
pharmacy with hard copies available upon request. The formulary
is also available at epocrates.com
and Physicians Plus MyChart.
Formulary drugs are covered under
all of our prescription drug plans.
Drugs not on the formulary are
covered only by our three-tier drug
plans. Prior Authorization (PA) medications require prescribers to submit
a PA request form to Physicians
Plus. The form must be submitted
before the prescription is filled at a
pharmacy. If PA is not obtained or
is denied, members with two-tier
coverage are responsible for 100%
of the medication cost, and members
with three-tier plans are responsible
for 50% coinsurance. In a­ ddition,
a change in formulary status may
affect a member’s out-of-pocket
expense. Please contact Pharmacy
Services at (608) 260-7803 with any
­questions or to receive a formulary
hard copy.
Key: Tier 1 Formulary low copay. Tier
2 Formu­lary moderate copay. Tier 3
Non-Formulary (prescription drugs
available at 50% coinsurance for some
benefit plans). PA Prior Authorization
required. QL Quantity Limits are in
place. TS Voluntary Tablet Splitting
Program medication. Members electing to use #15 tablets per month will
receive a half-copay or coinsurance
reduction depending on their drug
benefit.
Tier 2 or Biopharmaceutical with Prior Authorization Required
Tecfidera
(dimethyl
fumarate)
A newly approved oral agent indicated for the treatment of patients with relapsing
forms of multiple sclerosis (MS). The mechanism by which Tecfidera exerts its action
is not known but may activate the nuclear factor (erythroid-derived 2)-like 2 (Nrf2)
pathways. The Nrf2 pathway is involved in cellular response to oxidative stress and has
demonstrated both anti-inflammatory and cytoprotective effects within in vivo studies.
Tecfidera is dosed twice per day and its most common adverse events are flushing
and gastrointestinal effects. If approved, this agent would be covered at Tier 2 or the
Biopharmaceutical/Specialty Tier of $100–$250 depending upon the benefit plan. There
is a quantity limit of 2 capsules per day and prior authorization criteria are: (1) Diagnosis
of relapsing forms of MS, (2) Prescribed by a neurologist, (3) Failure of both Avonex and
Copaxone.
Erivedge
(vismodegib)
QL-30
A new first-in-class small molecule inhibitor of the hedgehog signaling pathway; mutations in this pathway have been implicated in basal cell carcinoma (BCC) as well as other
cancers. Vismodegib is indicated in metastatic basal cell carcinoma (MBCC) or with
locally advanced basal cell carcinoma that has recurred following surgery or in which patients are not candidates for surgery. If approved, this agent would be covered at Tier 2
or the Biopharmaceutical/Specialty Tier of $100–$250 depending upon the benefit plan.
There is a quantity limit of one capsule per day and prior authorization criteria are: (1)
Diagnosis of MBCC or BCC, (2) Prescribed by oncologist or dermatologist, (3) Patient
contraindicated for surgical or radiological treatment, (4) Approval limited for 3 months
with re-approval if demonstration of stability at baseline or improvement.
Tier 3 Copay / Coinsurance with Prior Authorization Required
H.P. Acthar
Gel
(Repository
Corticotropin)
ACTH repository gel (H.P. Acthar) is a porcine derived adrenocorticotropin hormone
approved in 1952 with many corticosteroid responsive indications including: rheumatoid
arthritis, collagen disorder, dermatologic diseases, allergic states, ophthalmologic diseases,
respiratory diseases, and edematous states. There are a lack of comparative trials between ACTH gel and corticosteroids in most of the FDA approved indications. According
to the Society of Child Neurology guideline, ACTH gel is the standard of care for infantile
spasms (West Syndrome) which is a rare neurologic illness with the goal of stopping the
spasms. The recommended one-month treatment regimen with taper costs approximately $87,779. The prior authorization criteria for coverage at Tier 3 are: (1) Prescribed by
a neurologist, (2) Diagnosis of infantile spasms (West Syndrome), (3) Initial approval for a
duration of one month only.
Medical Benefit with Prior Authorization Required
Elelyso
(taliglucerase
alfa)
A hydrolytic lysosomal glucocerebroside-specific enzyme used as a long-term enzyme
replacement infusion for the treatment of Type I Gaucher Disease. Gaucher disease is an
autosomal recessive lysosomal storage disorder which results in accumulation of glucocerebroside in the lysosomal compartment of macrophages. Anemia, thrombocytopenia,
and liver and spleen organomegaly are the most common clinical manifestations. The
prior authorization criteria are: (1) Prescribed by an endocrinologist or hematologist,
(2) Symptomatic disease state (moderate to severe anemia, thrombocytopenia, bone
disease, hepatomegaly, or splenomegaly).
Xylocaine
(lidocaine
infusion)
Lidocaine is a class 1B antiarrhythmic agent which also has analgesic effects. Lidocaine
stabilizes neuronal membranes which produces direct analgesia without complete
anesthetic block. Moderate pain relief was demonstrated in small randomized studies of
20 to 30 people in limited diagnoses of neuropathic pain (trauma, diabetes) and central
pain. Lidocaine is a short-term modality with pain relief lasting approximately one to
three weeks. The most common side effects reported were metallic taste, tremor, dry
mouth, insomnia, allergic reactions and tachycardia. The prior authorization criteria are:
(1) Prescribed by a pain specialist, (2) Diagnosis of one of the following: (a) peripheral or
central neuropathic pain, (b) complex regional pain syndrome (CRPS), or (c) persistent
post-surgical pain, (3) Documentation of other failed treatments, (4) Initial approval
duration of three infusions, (5) Re-approval with documentation of safety and efficacy
for up to six months, (6) Conditions considered experimental/investigational include:
chronic headache, fibromyalgia and persistent post-surgical pain.