NETWORK MATTERS March 2015

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1 HPHCURRENT EVENTS Eastern Harmony: A Review and 2015 Updates Harvard Pilgrim s innovative Eastern Harmony program is introducing some key changes for 2015, including acupuncture benefits and a visiting family benefit. Harvard Pilgrim s Eastern Harmony program combines Western medicine with traditional Eastern practices to provide a cross-cultural range of benefits. It is an allencompassing approach to wellness, complementing routine PCP visits and preventive care with alternative methods based in a rich history of Eastern health principles. In partnership with Healthways WholeHealth Networks, Harvard Pilgrim offers members up to 30% savings on alternative services from a variety of practitioners, including: Chiropractors Acupuncturists Ayurvedic practitioners Chinese herbal medicine Tai chi and qigong instructors Reiki and shiatsu practitioners Yoga and Pilates instructors What s new in 2015? Harvard Pilgrim now offers acupuncture benefits to most fully insured members of our Massachusetts, Maine, New Hampshire and Connecticut HMO, PPO, and POS products. Many of our members like to combine their regular treatments with acupuncture to help with a variety of conditions, such as headaches, low back pain, knee pain, osteoarthritis, and certain side effects of chemotherapy. As of 2015, up to 20 visits for the services of acupuncture specialists will be covered per year (copayments, deductibles, and coinsurance may apply). If your practice includes an acupuncturist who would like to participate, please visit the Healthways website (click on the Nominate a practitioner link at the bottom of the page) for information on the nomination and credentialing process. Harvard Pilgrim also introduced visiting family medical coverage. Recognizing that many Asian and South Asian Americans have family members overseas that may occasionally visit for extended periods of time, Harvard Pilgrim has partnered with IMG (International Harvard Pilgrim Health Care 1 Network Matters March 2015

2 Medical Group) to provide temporary medical coverage to international travelers visiting family and friends in the United States. IMG s customer service features include multilingual claims settlement and a secure website where members can search for providers, view the status of claims, and chat live with representatives. You may provide health care services to a visiting family member with IMG coverage if you are part of the IMG network; in this case, you can recognize these members by their IMG member ID card, which also includes claims submission information. For questions on the details of our visiting family health care coverage offerings, your patients should visit For questions about Harvard Pilgrim s Eastern Harmony program, please contact EasternHarmony@harvardpilgrim.org. *Harvard Pilgrim Health Care, through its affiliate HPHC Insurance Agency, Inc. makes referrals for travel medical insurance to International Medical Group (IMG). HPHC Insurance Agency receives a commission for each individual it refers to IMG who is subsequently enrolled into its plan. Harvard Pilgrim Health Care does not underwrite or bind individuals to coverage offered by IMG. Such coverage is not in any way connected to health coverage offered through Harvard Pilgrim Health Care or its affiliates. CLINICIAN CORNER Prior Authorization Required for Cosentyx Effective immediately, Harvard Pilgrim is now covering the medication Cosentyx with prior authorization on the Premium formularies. Cosentyx is a newly-approved IL-17A antagonist indicated for the treatment of moderate to severe plaque psoriasis. Cosentyx will be covered on the Premium formularies only, at the highest tier (i.e. Tier 3 on the 3-Tier and Tier 4 on the 4-Tier). Harvard Pilgrim is requiring prior authorization to ensure the safe and appropriate use of Cosentyx. Harvard Pilgrim's Cosentyx Clinical Coverage Criteria detail the requirements that must be met in order to obtain prior authorization, including: Patient is 18 years of age or older Diagnosis of moderate to severe plaque psoriasis Prescribed by (or in consultation with) a dermatologist Harvard Pilgrim Health Care 2 Network Matters March 2015

3 Patient has tried at least one course of systemic therapy for psoriasis including (but not limited to) acitretin, azathioprine, cyclosporine, hydroxyurea, methotrexate, mycophenolate mofetil, oral methoxsalen plus UVA light (PUVA), propylthiouracil, sulfasalazine, tacrolimus, or 6-thioguanine Patient has tried and failed therapy with, or has a contraindication to, Humira or Enbrel Approvals will be valid for 12 months. Harvard Pilgrim requires the following for a prior authorization to be renewed: the medication is prescribed by or in consultation with a dermatologist, the patient has been diagnosed with plaque psoriasis, and the patient's condition has improved while on therapy with Cosentyx. To request prior authorization, please complete the Cosentyx Medication Request Form and fax it to MedImpact Healthcare Systems at For more information, please refer to the Pharmacy Section of Harvard Pilgrim's provider website. New Quantity Limits for Select Opioid Agents Effective May 15th, 2015, the following medications will now have quantity limits: Exalgo, hydromorphone ER, Nucynta ER, Opana ER, and oxymorphone ER. Medication Quantity Limit Formularies Exalgo (hydromorphone ER) 60 tablets per 30 days Premium hydromorphone ER (generic) 60 tablets per 30 days Premium & Value Nucynta ER 60 tablets per 30 days Premium & Value Opana ER (oxymorphone ER) 90 tablets per 30 days Premium oxymorphone ER (generic) 90 tablets per 30 days Premium & Value This month, Harvard Pilgrim will send letters to members who have filled prescriptions for any of these agents in the past three months notifying them of the change. Harvard Pilgrim has determined that members with a cancer diagnosis will not be subject to the quantity limit. If your patient has cancer and is taking one of these medications, you may submit an exception request by completing a Formulary Exception Request Form and faxing it to MedImpact Healthcare Systems at Harvard Pilgrim Health Care 3 Network Matters March 2015

4 Members Rights and Responsibilities Harvard Pilgrim members receive a copy of the Members' Rights and Responsibilities upon enrollment, and all clinicians receive a copy at the time of contracting and credentialing and annually thereafter. Periodically, Harvard Pilgrim includes this information in Network Matters. Please take a moment to review. Because this information may vary among states, please be sure to read the full Rights and Responsibilities page of the Provider Manual. Members have a right to: Receive information about Harvard Pilgrim, its services, its practitioners, and providers, and members' rights and responsibilities Be treated with respect and recognition of their dignity and right to privacy Participate with practitioners in decision-making regarding their health care Engage in a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage Voice complaints or appeals about Harvard Pilgrim or the care provided Make recommendations regarding the organization s members' rights and responsibilities policy Members have a responsibility to: Provide, to the extent possible, information that Harvard Pilgrim and its practitioners and providers need in order to care for them Follow the plans and instructions for care that they have agreed on with their practitioners Understand their health problems and participate in developing mutually agreed-upon treatment goals to the degree possible. Caregiver Stress and Substance Abuse Providing around-the-clock care to a loved one in need can be a source of immense emotional strain; such caregiver stress sometimes results in a pattern of substance abuse by the caregiver. Harvard Pilgrim Health Care 4 Network Matters March 2015

5 Not only does stress-related substance abuse present a myriad of physical and emotional health problems for your patient it also prevents this patient from providing proper care to his/her loved one. If you are treating a patient who is a caregiver, it s important to watch for a possible occurrence of this type of selfmedication. Watching for signs A regular well visit with a caregiving patient is a good opportunity to gauge the potential for adverse emotional or physical effects of the role, and to check for signs of any worrisome coping behaviors. PCPs may want to ask some casual probing questions hinting at symptoms of caregiver stress or associated harmful reactive activities like abuse of alcohol or other drugs. These preventive measures can play a vital role in identifying and addressing stressdriven substance abuse before it becomes a full-blown addiction. Oftentimes, a problem of this nature starts out as something as simple as a drink to unwind after a long day of providing care before developing into a more serious dependency. Alcohol abuse could stem from depression or anxiety resulting from the stress of caregiving, or as a way to make up for the diminished opportunity for social interaction. Because caregivers tend to put the needs of their ill or aging loved one ahead of their own, they may internalize stress and turn to alcohol or prescription or psychotropic drugs, to deal with their feelings of helplessness or being overwhelmed. Coordinating with behavioral health specialists Patients exhibiting the signs of alcohol or drug abuse or other concerning behaviors triggered by caregiver stress should be referred to a behavioral health clinician for further treatment. How Optum/UBH can help your patients For complex clinical situations, Optum/UBH is available to provide consultative assistance. Practitioners can call the Optum/UBH Physicians Consultation Service at To refer a patient for behavioral health services and to facilitate the coordination of care, call Optum at Harvard Pilgrim Health Care 5 Network Matters March 2015

6 OFFICE ASSISTANT Harvard Pilgrim s E-Tools for Greater Efficiency Harvard Pilgrim s easy-to-use electronic tools offer valuable information to providers, and support a variety of online self-service functions to help you do business quickly and efficiently. These useful tools include HPHConnect (HPHC s own free, highly acclaimed web-based transaction service), EDI-Direct, NEHEN, and NEHENNet. HPHConnect is a user-friendly, HIPAA-compliant e-tool developed by Harvard Pilgrim to help provider practices run as smoothly as possible and deliver excellent care while saving time. With it, providers have access to a wealth of useful information, and have the ability to easily perform a number of transactions on their own. Among other things, the online self-service tool can be used to: Verify patient eligibility using flexible search options Find the status of a claim Submit claim batch files (HIPAA 837 Format) Submit notification and authorization requests and receive a timely status acknowledgement View a patient s personal health record Send specialty referrals and receive a timely response Also at providers disposal through HPHConnect is an array of information, including PCP membership reports, provider analytics, and more. Visit the HPHConnect webpage for more details. A collection of user guides is accessible via the provider section of Harvard Pilgrim s website to help familiarize providers with the tool s features and how to use them. If you are not yet registered, simply complete the easy online registration and see what HPHConnect has to offer. In addition to HPHConnect, Harvard Pilgrim supports other time-saving e-tools for online transactions EDI-Direct, NEHEN, and NEHENNet as detailed on the Harvard Pilgrim website. Harvard Pilgrim Health Care 6 Network Matters March 2015

7 Network Matters is a monthly newsletter for the Harvard Pilgrim provider network Eric H. Schultz, President and Chief Executive Officer Richard Weisblatt, Ph.D., Senior Vice President, Provider Network Annmarie Dadoly, Editor Joseph O Riordan, Writer Kristin Edmonston, Production Coordinator Read Network Matters online at For questions or comments about Network Matters, contact Annmarie Dadoly at annmarie_dadoly@harvardpilgrim.org or (617) Harvard Pilgrim Health Care 7 Network Matters March 2015