NewsBrief. AvMed Network. What's News. Administrative Updates. Health & Medical. AvMed's 2016 Achievement Highlights. Be Fluent

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1 AvMed Network NewsBrief Winter Issue February 2017 What's News AvMed's 2016 Achievement Highlights Administrative Updates Be Fluent Health & Medical J-Codes Requiring Prior Authorization A quarterly publication for AvMed Providers and Staff

2 our commitment to you Happy New Year! We are off to an exciting start in 2017 with the launch of new programs, tools, and resources to assist both our Members and Providers. This issue of Network NewsBrief features an article on Novologix, our new online Specialty Pharmaceutical Prior Authorization system, which is just a prelude to the many online capabilities to come with the launch of our upgraded Provider portal later this year. We also highlight our High Performance Network, and new benefits from Podiatry Network Solutions and Delta Dental. The flu season is in full swing, so be sure to take care of yourselves as well as your patients. Important flu facts can be found on page 3. Please remind your AvMed Members to take advantage of the many resources on our newly launched AvMed Member portal including our value-finding Cost Calculator and convenient Virtual Visits. And look for upcoming issues of Network NewsBrief to feature enhanced content, local stories and Provider profiles. Best wishes for good health, happiness, and success in 2017, Ann O. Wehr, MD, FACP Senior Vice President and Chief Medical Officer Population Health & Provider Alliances news you need to know For complete details on all the current news you need to know and to download forms, please visit our website at AvMed.org. Updated Forms & Web links: Revised 2017 forms, guidelines, and standards Please take a moment to review your Provider profile and make sure we have your current information including address in our records. Just click My profile when you log in to AvMed.org. Submit New Claims to: P.O. Box Miami, FL Claims Correspondence, Reviews, and Appeals to: P.O. Box Miami, FL Fax: Page 2 Network Newsbrief Winter Issue - February 2017

3 AVMED NETWORK NEWSBRIEF table of contents ADMINISTRATIVE UPDATES 6-7 Be Fluent High Performance Network Updates Podiatry Network Solutions 5 Delta Dental USA WHAT S NEWS AvMed's 2016 Achievement Highlights Novologix Prior Authorization System HEALTH & MEDICAL J-Codes Requiring Prior Authorization Formulary Update Network Newsbrief Winter Issue - February 2017 Page 3

4 administrative updates be FLUENT: Helpful Flu Facts: Peak of the flu season usually starts in January and lasts well into spring. Vaccinations are available at no cost to AvMed Members. CDC recommends a yearly flu vaccine for everyone 6 months and older. Now is a good time to get vaccinated. It takes about two weeks after a vaccination for protection to set in. Flu vaccination can reduce flu illnesses and prevent complications such as pneumonia: > CDC recommends use of the flu shot (inactivated influenza vaccine or IIV) and the recombinant influenza vaccine (RIV). > The nasal spray flu vaccine (live attenuated influenza vaccine or LAIV) should not be used during > The influenza vaccination recommendations are now available. > Source: CDC.gov/Flu/Index.htm Encourage your patients to get the flu shot, especially if at high risk. High Performance Network Updates Seven years ago AvMed created the High Performance Network (HPN) program in order to support consumer- conscious healthcare selection. The HPN designation provides AvMed Members a tool to identify Physicians most efficient in delivering quality care. Quality and cost efficiency benchmarks are set by specialty and Physicians and their practice earn the HPN designation when they meet or exceed them. Members can find designated Physicians in the Provider Directory identified by this HPN symbol (p). The HPN Network is reviewed and updated annually. These are the updates for 2017: Allergy/Immunology Specialty is no longer being evaluated for HPN Colorectal Surgery Specialty is no longer being evaluated for HPN It is AvMed s policy to apply HPN status to any Specialty for which evaluation criteria is not available, therefore the above specialties will be designated HPN in 2017 $40 copay for visit to Non-HPN Specialist $5 copay for visit to HPN Specialist in Miami-Dade county $10 copay for visit to HPN Specialist in Broward county Podiatry Network Solutions AvMed s Commercial and Medicare Members are served by Podiatry Network Solutions (PNS). No referral is needed for podiatric services and home visits are available, if medically authorized. Podiatry Network Solutions (PNS) has over 15 years of experience in podiatry and network management and is locally owned and operated in Miami. They have over 270 providers statewide. Since 2000, PNS solidified its stance in the health care market by providing proven value-added solutions. Their success is defined by how well they meet the needs of their customers, network providers, health plans and the members they service. You can find more details about PNS on the web at ProviderNetworkSolutions.com or, contact them directly, toll-free at (Fax ). Delta Dental USA Dental benefits are available to AvMed Medicare Members in Dade and Broward counties through Delta Dental USA. Members must select a contract dentist from the large Network of Delta Dental Providers but may change contract dentists within the network if they so desire. Benefits such as X-Rays, cleanings and complete dentures are covered at no cost to Members. Delta Dental has worked with Medicare Advantage Organizations for years to provide dental benefits to those who need them most. Headquartered in Alpharetta, GA, Delta Dental and its marketing affiliates provide dental insurance to five million enrollees in nine states. Since 1970, the private insurance company has offered innovative programs designed to control costs and ensure quality care. For more information about Delta Dental Insurance Company visit DeltaDentalIns.com. Page 4 Network Newsbrief Winter Issue - February 2017

5 what's news Novologix Prior Authorization System AvMed has implemented a new request process that impacts prior authorizations for certain pharmaceuticals. Effective February 1, 2017, we began using NovoLogix online Prior Authorization (PA) system to manage prior authorization requests for impacted medications administered in your office, participating facility, or in the home by a healthcare practitioner. Only self administered medication authorization requests need to be submitted using the form on AvMed's website. A matrix of all J-Code Drugs which currently require prior authorization by AvMed are on pages 6-7 and can be found at AvMed.org Achievement Highlights 2016 was a year of many tremendous successes for AvMed: A fifth straight J.D. Power recognition for Highest in Member Satisfaction among Commercial Health Plans in Florida Successful transition of Behavioral Health services to Magellan Healthcare, which delivers countless service enhancements to our Members Commitment to our brand purpose, a focus on helping our Members find the many riches delivered through happiness and health in the WELLfluent world we create* Highest rated plan among our direct competitors in CAHPS, for the twelfth straight year Maintained CMS Stars Rating of 4.0 for 2017 An outstanding report from our on-site NCQA Accreditation visit, achieving greater than 99% of all possible survey points Garnered seventh straight top provider satisfaction score as nine of ten Physicians said they would recommend us to their patients and peers Some of the benefits of NovoLogix web-based PA system are: A single, web-based site to enter all healthcare practitioner administered medication PA s for both Commercial and Medicare Members Ability to directly answer PA criteria questions specific to each type of medication Ability to receive automatic PA decisions for a significant number of medications Real-time tracking of authorization status for PAs requiring manual review by AvMed You can find Novologix linked from AvMed s website (AvMed.org). Though we will honor all authorizations issued on or before January 31, 2017, as of February 1, 2017, ICORE/MagellanRx is no longer managing AvMed s Commercial Pharmaceutical Prior Authorizations. Also online at AvMed.org you will find video training, a user manual, and FAQs for the new PA system as well as other convenient resources. Should you have any further questions or need additional assistance, feel free to call AvMed s Provider Service Center at , 8:30 am and 5 pm. * To learn more about WELLfluent(TM), watch our video on AvMed.org Network Newsbrief Winter Issue - February 2017 Page 5

6 health & medical J-Codes Requiring Prior Authorization HCPCS Drug Name Route of Medicare Commercial Admin PA PA J9264 ABRAXANE IV Y Y J3262 ACTEMRA IV Y Y J3262 ACTEMRA SC Y Y J0800 Acthar HP IJ y y J9042 ADCETRIS IV Y Y J7192 ADVATE IV y J9305 ALIMTA IV Y Y J2469 Aloxi IV Y Y J7186 Alphanate/ IV Y y VWF Complex/ Human J7193 AlphaNine SD IV Y y J0881 Aranesp IJ Y Y (Albumin Free) J0882 Aranesp IJ Y Y (Albumin Free) C9257 AVASTIN IV Y Y J9035 AVASTIN IV Y Y J7194 BEBULIN IV y J9032 BELEODAQ IV Y Y J7195 BeneFIX IV y J0490 BENLYSTA IV Y Y J1556 Bivigam IV Y Y J9039 BLINCYTO IV Y Y J0585 BOTOX IJ Y Y J1566 Carimune NF IV y y J1786 CEREZYME IV Y Y J9308 CYRAMZA IV Y Y J0586 DYSPORT IM Y Y J7205 ELOCTATE IV y J3380 ENTYVIO IV Y Y J0885 Epogen IJ Y Y J9055 ERBITUX y J1325 Epoprostenol IV Y Y Sodium J9019 ERWINAZE IJ y J7198 FEIBA IV y J7198 Feiba NF IV Y y J7198 Feiba VH IV Y y Immuno HCPCS Drug Name Route of Medicare Commercial Admin PA PA J1572 FLEBOGAMMA IV Y Y J1572 FLEBOGAMMA IV Y Y DIF J1325 Flolan IV Y Y J0641 FUSILEV IV y J1569 Gammagard IJ Y Y J1566 Gammagard IV Y Y S/D J1566 Gammagard IV Y Y S/D Less IgA J1561 Gammaked IJ Y Y J1557 Gammaplex IV Y Y J1561 Gamunex-C IJ Y Y J9301 GAZYVA IV Y Y J0257 GLASSIA IV y J1447 GRANIX SC y J9179 HALAVEN IV y J7192 Helixate FS IV Y y J7190 HEMOFIL M IV Y y J9355 HERCEPTIN IV Y Y HIZENTRA SC Y Y J1559 HIZENTRA SC Y Y J0800 HP Acthar IJ y y J7187 HUMATE-P IV y J1575 HYQVIA SC Y Y J0638 ILARIS SC y J9214 INTRON A IJ y y J7195 Ixinity IV y J9043 JEVTANA IV Y Y J9354 KADCYLA IV Y Y J9271 KEYTRUDA IV Y Y J7190 Koate-DVI IV y J7192 Kogenate FS IV Y y J7192 Kogenate FS IV Y y Bio-Set J2507 KRYSTEXXA IV Y Y J9047 KYPROLIS IV Y Y J0202 LEMTRADA IV Y Y J2820 LEUKINE IJ Y Y J2820 LEUKINE IV Y Y J1950 LUPRON DEPOT IM y y J9217 LUPRON DEPOT IM y y Page 6 Network Newsbrief Winter Issue - February 2017

7 health & medical HCPCS Drug Name Route of Medicare Commercial Admin PA PA J1950 LUPRON IM y y DEPOT-PED J9217 LUPRON IM Y Y DEPOT-PED J7190 MONOCLATE-P IV y J7193 MONONINE IV y J0587 MYOBLOC IM Y Y J2505 NEULASTA SC Y Y J2505 Neulasta Onpro SC y y J1442 NEUPOGEN IJ Y Y J7182 NOVOEIGHT IV y J7189 NovoSeven RT IV Y y J2796 NPLATE SC Y Y J7192 Nuwiq IV y J7188 Obizur IV y J1568 Octagam IV Y Y J9266 ONCASPAR IJ y J9299 OPDIVO IV Y Y J0129 ORENCIA IV Y Y J0129 ORENCIA SC Y Y J9306 PERJETA IV y J1459 Privigen IV Y Y J0885 Procrit IJ Y Y J7194 PROFILNINE IV y J7194 Profilnine SD IV Y y J0256 Prolastin IV y J0256 Prolastin-C IV y J9015 PROLEUKIN IV y Q2043 PROVENGE IV Y Y J7192 RECOMBINATE IV y J1745 REMICADE IV Y Y J3285 REMODULIN IJ y S0090 Revatio IV y J9310 RITUXAN IV Y Y J7195 Rixubis IV y J7200 Rixubis IV y J0596 RUCONEST IV Y Y J1602 SIMPONI ARIA IV y y J1300 SOLIRIS IV Y Y J3357 STELARA SC Y Y J9226 Supprelin LA SC y y J2860 SYLVANT IV Y Y SYNAGIS IM Y Y HCPCS Drug Name Route of Medicare Commercial Admin PA PA J9262 SYNRIBO SC Y Y J3315 TRELSTAR IM y J3315 Trelstar Mixject IM Y y J2323 TYSABRI IV Y Y J9303 VECTIBIX IV Y Y J1325 Veletri IV Y Y J1322 VIMIZIM IV Y Y J3385 VPRIV IV Y Y J7183 Wilate IV y J0588 XEOMIN IM Y Y J2357 XOLAIR SC Y Y J7185 XYNTHA IV y J7185 Xyntha Solofuse IV Y y J9228 YERVOY IV Y Y J9400 ZALTRAP IV Y Y Q5101 ZARXIO IJ y J0256 Zemaira IV y J1786 Cerezyme IV Y Y (Imiglucerase) J3060 Elelyso IV y (taliglucerase alfa) J7199 Eloctate IV y (antihemophilic factor) C9293 Mitoxantrone IV y (Novantrone) AML J1290 Kalbitor SC Y Y J1744 Firazyr SC Y Y formulary update To view the latest formulary list, copay levels and other pertinent pharmacy information, visit AvMed.org. Network Newsbrief Winter Issue - February 2017 Page 7

8 9400 S. Dadeland Blvd. Miami, FL We welcome your feedback. We are committed to having the best Provider Network available and encourage you to give us your feedback and suggestions. Let us know about your experiences with quality improvement studies, practice guidelines or any other AvMed practice or interaction. We are always looking for more efficient, effective and above all, quality-driven ways to service our Providers, Practitioners and Members. If you would like to participate more directly in our Quality Improvement Program or would like information about the program, including progress toward our goals, us at or call the Provider Service Center at , Monday-Friday, 8:30 am-5 pm, excluding holidays. You may write us at: AvMed Public Relations Department 9400 S. Dadeland Boulevard Miami, FL AVMED S WEBSITE: AvMed.org Online provider services: Claims Inquiry, Member Eligibility, Referral Inquiry, Provider Directory, Physician Reference Guide, Clinical Guidelines, Preferred Drug List Please note our address: Providers@AvMed.org Use our centralized toll-free number to reach several key departments at AvMed. PROVIDER SERVICE CENTER AvMed Link Line, press one (1). Use this option to verify Member eligibility and limited benefit information, or confirm and request authorizations. Claims Service Department, press two (2). Use this option to verify status of claims payment, reviews, and appeals. Provider Service Center, press three (3). Use this option for questions about policies and procedures, to report or GO GREEN! request a change in your panel status, address/phone, covering Physicians, hospital privileges, Tax ID and licensure, or any other service issue. Clinical Pharmacy Management, press four (4). AUDIT SERVICES AND INVESTIGATIONS UNIT (To refer suspect issues, anonymously if preferred) CARE MANAGEMENT CLINICAL COORDINATION (For authorizations that originate in the ER or direct admits from the doctor s office) MP-5705 (2/17)