NETWORK MATTERS April 2015

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1 HPHCURRENT EVENTS Harvard Pilgrim GIC Offerings Harvard Pilgrim and the Group Insurance Commission (GIC) are updating our product offerings for the plan year, which takes effect on July 1, We are replacing our PPO product with the Independence Plan POS product, and will continue to offer the Primary Choice HMO. The move to a POS plan supports our joint efforts to foster Centered Care and develop affiliations with Integrated Risk-Bearing Organizations (IRBOs). Centered Care is a collaboration among the GIC, Harvard Pilgrim, and provider organizations that emphasizes the principles of the patient-centered medical home, including improving care coordination and access to care, empowering patients to better manage their health, and using performance data to improve clinical outcomes. (For more on Centered Care, see previous Network Matters articles including those in our January and March 2014 issues.) POS product emphasizes the role of the PCP The move from a PPO product to a POS product brings with it a key change: all members of the POS product are required to identify a PCP. Similar to the previous PPO product, members who select the Independence Plan POS have a choice between in-network and out-of-network medical services. Harvard Pilgrim and the GIC are conducting outreach (through health fairs, mailings, etc.) to GIC members to educate them about their product options and inform them about the importance of working with a PCP to maintain or improve their health. Referrals for in-network care In keeping with Centered Care s emphasis on coordination of care between PCPs and specialists, referrals will be required for in-network coverage. It s important that GIC Independence Plan POS members and the clinicians who treat them ensure that the member s PCP makes referrals for specialist visits. In-network coverage and cost sharing applies for services obtained directly from the member s PCP or from other Harvard Pilgrim participating providers with the Harvard Pilgrim Health Care 1 Network Matters April 2015

2 appropriate referrals. Out-of-network coverage and cost sharing (i.e. deductible and coinsurance) applies if the member receives care from non-participating providers or from participating providers without a PCP referral. Certain services, such as routine eye exams and gynecological care, may be obtained without a referral. Referrals can be made electronically using the HPHConnect or NEHEN transaction services or by telephone, fax, or mail. Please visit the Referral, Notification, and Authorization page of our online Provider Manual for referral guidelines, and information on how to initiate the referral process. More detailed product information In-network benefits and cost sharing for the Independence Plan are similar to Primary Choice benefits and cost sharing. Both plans feature a deductible and a three tiered copayment structure for services obtained in the provider network. Copayments for specialist visits, inpatient hospital services, surgical day care, and prescription drugs will increase for both products on July 1, along with the per-member and per-family deductible amounts. The member s ID card includes copayment information. For information regarding specific benefits and/or copayments, use HPHConnect or call the Provider Service Center at For additional product details, please refer to the GIC Primary Choice HMO and GIC Independence Plan POS product pages in Harvard Pilgrim s online Provider Manual. For provider tiering information, please visit our provider GIC plan year webpage. ACA Update: Fluoride Varnish and Hepatitis B Screenings As part of the Affordable Care Act (ACA), effective May 1, 2015, two new preventive care benefits will be available to members without cost-sharing when the services are administered by an in-network provider. Fluoride Varnish* All children are at potential risk for tooth decay and may benefit from the application of fluoride varnish to their teeth. Beginning in May, the ACA requires health insurers to cover fluoride varnish applied to the baby teeth of all children ages five and younger at no cost to the member. This benefit applies to a maximum of four fluoride varnish applications per year provided by in-network primary care providers, including Harvard Pilgrim Health Care 2 Network Matters April 2015

3 pediatricians. Cost sharing may apply if the member goes to an out-of-network provider. This is a medical benefit and does not apply to services provided by a dentist. Hepatitis B Screenings* Also beginning in May, certain members at high risk for hepatitis B infection, who are not currently showing any symptoms of the condition, may receive screening for hepatitis B at no cost to them. Examples of people at high risk for hepatitis B infection include: People born in regions with a high prevalence of hepatitis B infection U.S.-born individuals not vaccinated as infants whose parents were born in regions with a very high prevalence of hepatitis B infection, such as sub-saharan Africa and central and Southeast Asia HIV-positive individuals Injection drug users Men who have sex with men Household members or sexual partners of people infected with hepatitis B For more information For more information on these benefit changes, including coding information, please refer to Harvard Pilgrim s updated Patient Protection and Affordable Care Act (Federal Health Care Reform) policy in our online Provider Manual. In addition, visit the U.S. Preventive Services Task Force (USPSTF) online for complete information on their recommendations for the application of fluoride varnish in children or hepatitis B screening. *Important Note: These changes do not apply to all employers and plans. Grandfathered plans may be exempt from certain provisions. Therefore, members should check with their employers to see if the benefits detailed here apply to their particular plan. CLINICIAN CORNER Prior Authorization of Select Surgical Procedures On an ongoing basis, Harvard Pilgrim reviews our medical policies to ensure that they reflect the most current evidence-based clinical guidelines and support care that is Harvard Pilgrim Health Care 3 Network Matters April 2015

4 medically necessary, clinically effective, and cost efficient. As a result of this review, Harvard Pilgrim is creating medical criteria for 7 surgical procedures. Effective for dates of service on or after July 1, 2015, Harvard Pilgrim will require prior authorization for the following procedures (please click on the links to see the detailed medical review criteria): Total knee arthroplasty Total hip arthroplasty Urinary incontinence surgeries Total hysterectomy Cholecystectomy Sinus surgeries Neurostimulators Our medical review policies provide detailed information on what Harvard Pilgrim covers, what documentation is necessary for prior authorization, and associated coding. These policies were developed after Harvard Pilgrim s medical management team conducted a rigorous analysis of the clinical literature with input from practicing specialists in the field. As we developed these policies, we collaborated with boardcertified practicing physicians in the community who had expertise in these areas, says Dr. Michael Sherman, Harvard Pilgrim s chief medical officer. Their input was invaluable in helping us draft surgical policies that ensure that care is effective and consistent with evidence-based medicine and established clinical guidelines. To request prior authorization, please enter the information about the procedure into our e-business web-based transaction tool HPHConnect or NEHEN and submit the appropriate prior authorization form (these will be posted on June 15) and medical documentation required (listed in the online medical review criteria) by fax to Harvard Pilgrim s utilization management team at Authorization requests will be reviewed by Harvard Pilgrim s trained nurse and physician reviewers. You can check the status of your prior authorization request through HPHConnect or NEHEN. Visit Harvard Pilgrim s provider website to register for HPHConnect. Harvard Pilgrim Health Care 4 Network Matters April 2015

5 Medical Policy for Esophagogastroduodenoscopy Based on a thorough clinical analysis and review of the competitive landscape, Harvard Pilgrim has developed a new medical policy for reimbursement of esophagogastroduodenoscopy (EGD), a test used to examine the lining of the esophagus, stomach, and duodenum. This medical policy identifies the conditions for which EGD is medically necessary, as well as the conditions and situations where EGD is not appropriate. Please refer to Esophagogastroduodenoscopy Medical Policy for a list of the non-covered diagnosis codes. Effective for dates of service on or after July 1, 2015, claims for EGD submitted with these non-covered diagnosis codes will be denied. Coverage for Reclast Harvard Pilgrim has established a medical policy for the injectable/intravenous medication Reclast (zoledronic acid) and will now cover the use of Reclast for the following medically necessary conditions, effective for claims processed as of April 1, 2015: Treatment and prevention of postmenopausal osteoporosis Treatment to increase bone mass in men with osteoporosis Treatment and prevention of glucocorticoid-induced osteoporosis Treatment of Paget s disease of bone in men and women Prevention or treatment of osteoporosis in men with prostate cancer during androgen deprivation therapy Prior authorization is not required for Reclast unless delivery of this drug is in the home setting by a homecare vendor. For more information on coverage of Reclast, including coding information, please refer to the Reclast Medical Policy. P&T Committee Updates At the March 2, 2015 meeting, the Harvard Pilgrim Pharmacy & Therapeutics Committee reviewed five medications and decided the following. P&T Committee Review and Decisions Name Description & Indication Decision Bunavail (buprenorphine Bunavail is a buccal film indicated for the maintenance Harvard Pilgrim Health Care 5 Network Matters April 2015

6 and naloxone) Jublia (efinaconazole) Kerydin (tavaborole) Otezla (apremilast) treatment of opioid dependence. Jublia is a topical azole antifungal used to treat toenail fungus (onychomycosis) due to Trichophyton rubrum and Trichophyton mentagrophytes. Kerydin is a topical oxaborale antifungal used to treat toenail fungus (onychomycosis) due to Trichophyton rubrum and Trichophyton mentagrophytes. Otezla is a phosphodiasterase 4 (PDE-4) inhibitor indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. Tier 3 on the 4-Tier Value formulary Tier 4 on the 5-Tier Value formulary Tier 4 on the Medicare Advantage formulary Continued non-formulary status on 4-Tier Value formulary 5-Tier Value formulary Medicare Advantage formulary Continued non-formulary status on 4-Tier Value formulary 5-Tier Value formulary Medicare Advantage formulary Tier 5 on the Medicare Advantage formulary Continued non-formulary status on 4-Tier Value formulary 5-Tier Value formulary Harvard Pilgrim Health Care 6 Network Matters April 2015

7 Zubsolv (buprenorphine and naloxone) Zubsolv is a sublingual tablet indicated for the maintenance treatment of opioid dependence. Tier 3 on the 4-Tier Value formulary Tier 4 on the 5-Tier Value formulary Tier 3 on the Medicare Advantage formulary Posttraumatic Stress Disorder s Effect on Physical Health Posttraumatic stress disorder (PTSD) is a commonly misunderstood condition in the world of mental health. Beyond the obvious psychological challenges, PTSD may lead to a host of adverse effects to physical health that should not be overlooked. The challenges of PTSD are far from new, but this disorder is finding more relevance in the public eye lately. The 2014 film American Sniper brought the alarming reality of PTSD into the spotlight with its recounting of Navy SEAL and Iraq War veteran Chris Kyle s tragic life story, and recent catastrophic events like the April 2013 Boston Marathon bombings have evoked the symptoms in many victims and witnesses. Physical complications Yet the potential physical complications linked with the condition are just beginning to receive widespread attention. Whether symptoms are the result of active military service and the terrors of war, sexual assault, childhood abuse, a motor vehicle accident, or a natural disaster, people with PTSD are likely to have more physical health problems such as hypertension, metabolic syndrome, and obesity than those without the condition. It is unknown whether there is a direct causal relationship between PTSD and certain physical health issues or if other unhealthy behaviors such as smoking, drug and alcohol abuse, or poor diet and exercise habits play a role. Whether directly or due to related factors, recent research indicates a link between PTSD and an increased risk of hypertension, which could help explain the elevated rates of heart disease in those with PTSD. Additionally, PTSD has been found to be a potential risk factor for metabolic syndrome and obesity, which can lead to a laundry list of other health complications, including heart disease, diabetes, and stroke. Harvard Pilgrim Health Care 7 Network Matters April 2015

8 There is a lot left to learn about the mental and physical effects of PTSD, but it is clear that collaboration between PCPs and behavioral health clinicians is imperative in patients who may have been exposed to traumatic events. Veterans, victims of past sexual assault, etc. should be screened for PTSD, and the link between physical problems and such emotional trauma should be a consideration. For more on factors that may make an individual more susceptible to PTSD, as well as symptoms to watch for, see a previous Network Matters article on this condition. 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 OFFICE ASSISTANT Reminder: Appointment Availability Standards Harvard Pilgrim values our extensive network of providers and the outstanding care they deliver to our members. The organization is consistently ranked among the nation s best private health plans* because of the unsurpassed quality of this care. Like you, Harvard Pilgrim has high standards for the care administered. One of these standards is the expectation that members receive care in a timely fashion. For members who already have a scheduled appointment with their PCP, Harvard Pilgrim expects reasonably short office wait times (for example, wait times of less than 45 minutes for PCPs). The standards for expected wait times for scheduling appointments vary depending on the type of care being sought and the urgency of the visit for example, members who are symptomatic should be able to schedule office visits within 7 days, while an urgent visit should occur within 24 hours. For more details on Harvard Pilgrim s appointment availability standards, please refer to the Practice Site Standards in our online Provider Manual. * NCQA s Private Health Insurance Plan Rankings, , HMO/POS/PPO. NCQA s Health Insurance Plan Rankings Private. U.S.News/NCQA America s Best Health Insurance Plans (annual). America s Best Health Insurance Plans is a trademark of U.S.News & World Report. NCQA The State of Health Care Quality Harvard Pilgrim Health Care 8 Network Matters April 2015

9 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 9 Network Matters April 2015