updatesm December 2016 Professional Injectable and Vaccine Fee Schedule updates effective January 1, 2017 page 8

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1 updatesm December out-of-pocket maximums for commercial HMO, POS, and PPO members page 7 Professional Injectable and Vaccine Fee Schedule updates effective January 1, 2017 page 8 Our prescription drug program and safe prescribing procedures page 14

2 Inside this edition Announcements Exciting changes coming to Partners in Health Update and the Provider News Center Administrative Upcoming HEDIS medical record review Required lead time when updating your provider information Easy to use online peer-to-peer request form Procedures for referring members for covered and non-covered services 2017 out-of-pocket maximums for commercial HMO, POS, and PPO members Billing Professional Injectable and Vaccine Fee Schedule updates effective January 1, 2017 NaviNet New NaviNet Claim Status Inquiry transaction delay Medical Reminder: Cost-sharing and billing requirements for Preventive colorectal cancer screening Reminder: $0 copays on preferred diabetic supplies for Medicare Advantage members Reminder: Neulasta : Updates to precertification requirements, sites of service, and coverage options Reminder: Upcoming changes to medical benefit specialty drug cost-sharing for 2017 Reminder: Upcoming changes to precertification requirements for 2017 View up-to-date policy activity on our Medical Policy Portal Pharmacy Our prescription drug program and safe prescribing procedures Benefits provided by BriovaRx Select Drug Program Formulary updates Prescription drug updates Products New value-based insurance design program Quality Management Clinical Practice Guideline Summary now available Member Wellness Guidelines available New Perinatal Guideline Summary now available Health and Wellness Behavioral health: Promoting provider communication and collaboration: Part 4 Second generation antipsychotic medications Health Coaches: Supporting your patients, our members Discussing end-of-life care with your patients Partners in Health Update SM is a publication of Independence Blue Cross and its affiliates (Independence) created to provide valuable information to the Independence-participating provider community that provides Covered Services to Independence members. This publication may include notice of changes or clarifications to administrative policies and procedures that are related to the Covered Services you provide in accordance with your participating professional provider, hospital, or ancillary provider/ancillary facility contract with Independence. This publication is the primary method for communicating such general changes. Suggestions are welcome. Contact information: Provider Communications Independence Blue Cross 1901 Market Street 27th Floor Philadelphia, PA provider_communications@ibx.com Models are used for illustrative purposes only. Some illustrations in this publication copyright All rights reserved. Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East, and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association. This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call Provider Services for the member s applicable benefits information. Members should be instructed to call the Customer Service telephone number on their ID card. The third-party websites mentioned in this publication are maintained by organizations over which Independence exercises no control, and accordingly, Independence disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs are presented for informational purposes only. Certain services/ treatments referred to in third-party sites may not be covered by all benefits plans. Members should refer to their benefits contract for complete details of the terms, limitations, and exclusions of their coverage. NaviNet is a registered trademark of NaviNet, Inc., an independent company. FutureScripts and FutureScripts Secure are independent companies that provide pharmacy benefits management services. CPT copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. For articles specific to your area of interest, look for the appropriate icon: Professional Facility Ancillary Articles designated with a blue arrow include notice of changes or clarifications to administrative policies and procedures. Keystone Health Plan East, Personal Choice, Keystone 65 HMO, and Personal Choice 65 SM PPO have an accreditation status of Commendable from the National Committee for Quality Assurance (NCQA).

3 ANNOUNCEMENTS Exciting changes coming to Partners in Health Update and the Provider News Center Beginning January 1, 2017, we will be making changes to the way you receive news and announcements from Independence. Partners in Health Update will be presented as an online, real-time newsletter posted directly to our Provider News Center: This allows us to provide you with notices of changes or clarifications to administrative policies and procedures, new products and programs, and other provider-specific information in a more timely manner. On the home page of the Provider News Center, the Latest News section will be renamed Partners in Health Update and it will feature the most recent articles posted. We will continue to include audience indicators (i.e., P, F, A) so you can easily find the articles that are pertinent to you and your staff. A complete archive of articles by topic is also available using the top navigation menu. We will continue to send an notification at the beginning of each month to highlight some of the recent articles that have been posted. If you do not currently receive our notifications, please sign up by selecting Sign up for from Provider Communications under Contact Us in the right-hand column of the Provider News Center. Note: This December 2016 edition will be the last consolidated publication of Partners in Health Update. We encourage you to visit the Provider News Center frequently to stay informed of important news and information from Independence. If you have any questions about this change, please us at provider_communications@ibx.com. ADMINISTRATIVE Upcoming HEDIS medical record review Letters will be sent later this month to some offices to advise that they may be selected to participate in an upcoming medical record review required by the National Committee for Quality Assurance (NCQA). During the first half of 2017, Independence will review the medical records of some of our members regarding services received. Independence is required to undertake this review to comply with regulatory and accreditation requirements. Once participants have been determined, Independence will contact each office to schedule an appointment for a nurse who is trained in analyzing medical records to perform an on-site review. We will review the records in accordance with the quality standards set by NCQA in its performance measurement tool known as the Healthcare Effectiveness Data Information Set (HEDIS ). Note: According to your Agreement with Independence, if your office is selected for this review, participation is mandatory. If you have any questions regarding this upcoming NCQA-required medical record review, please contact the Quality and Risk Management Department at December 2016 Partners in Health Update SM 3

4 ADMINISTRATIVE Required lead time when updating your provider information Independence would like to remind you about the importance of submitting changes to your provider information in a timely manner. Keeping your provider information current and up-to-date helps to ensure prompt payment of claims, delivery of critical communications, seamless recredentialing, and accurate listings in our provider directories. Per your Independence Professional Provider Agreement and/or Hospital, Ancillary Facility, or Ancillary Provider Agreement (Agreement), you are required to notify Independence whenever key provider demographic information changes. Professional providers As outlined in the Administrative Procedures section of the Provider Manual for Participating Professional Providers (Provider Manual), Independence requires 30 days advanced notice to process most updates, with the exceptions noted below: 30-day notice. Independence requires 30 days advanced notice for the following changes/updates to your practice information: updates to address, office hours, total hours, phone number, or fax number; changes in selection of capitated providers (HMO primary care physicians [PCP] only); addition of new providers to your group (either newly credentialed or participating); changes to hospital affiliation; changes that affect availability to patients (e.g., opening your panel to new patients). 60-day notice. Independence requires 60 days advanced written notice for closure of a PCP practice or panel to additional patients. 90-day notice. Independence requires 90 days advanced written notice for resignation and/or termination from our network. Submitting updates and/or changes* Professional providers can use the Provider Change Form, available at to quickly and easily submit most of the changes to their basic practice information. Please be sure to print clearly, provide complete information, and attach additional documentation as necessary. Mail your completed Provider Change Form to: Independence Blue Cross Attn: Network Administration P.O. Box Philadelphia, PA You can also fax the completed form to Network Administration at Please be sure to keep a confirmation of your fax. Note: The Provider Change Form cannot be used if you are closing your practice or terminating from the network. Refer to Resignation/termination from the Independence network in the Administrative Procedures section of the Provider Manual for more information regarding policies and procedures for resigning or terminating from the network. Facility and ancillary providers As outlined in the Administrative Procedures section of the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers, Independence requires 30 days advanced written notice to process updates to address, phone number, or fax number, as well as change in ownership. continued on the next page December 2016 Partners in Health Update SM 4

5 ADMINISTRATIVE continued from the previous page Submitting updates and/or changes Per your Agreement, all changes must be submitted in writing to our contracting and legal departments at the following addresses: Independence Blue Cross Independence Blue Cross Attn: Vice President, Contracting and Reimbursement Attn: Deputy General Counsel, Managed Care 1901 Market Street, 27th Floor 1901 Market Street, 43rd Floor Philadelphia, PA Philadelphia, PA Authorizing signature and W-9 Forms Updates resulting in a change on your W-9 Form (e.g., changes to a provider s name, tax ID number, billing vendor or pay to address, or ownership) require the following signatures: For professional providers: Group practices: A signature from a legally authorized representative (e.g., physician or other person who signed the professional group provider agreement or one who is legally authorized to bind the group practice) of the practice is required. Solo practitioners: A signature from the individual practitioner is required. For facility and ancillary providers: Written notification on company letterhead is required. An updated copy of your W-9 Form reflecting these changes must also be included to ensure that we provide you with a correct 1099 Form for your tax purposes. If you do not submit a copy of your new W-9 Form, your change will not be processed. Independence will not be responsible for changes not processed due to lack of proper notice. Failure to provide proper advanced written notice to Independence may delay or otherwise affect provider payment. If you have any questions about updating your provider information, please contact your Network Coordinator. * To ensure appropriate setup in Independence systems, the timelines outlined above also apply to behavioral health providers contracted with Magellan Healthcare, Inc., an independent company, but they must submit any changes to their practice information to Magellan via their online Provider Data Change form at by selecting the Display/Edit Practice Info link or by contacting their Network Management Specialist at for assistance. Easy to use online peer-to-peer request form The online peer-to-peer process streamlines workflows, improves cost-efficiencies, and complies with accreditation requirements. The process was developed with input from the provider community and offers providers a streamlined process, along with opportunities to discuss decisions and resolve inquires prior to initiating a formal appeal. Visit to submit your requests electronically. In order to process peer-to-peer requests quickly and efficiently, please make sure to completely fill out the Peer-to-Peer Request Form, which includes: patient information (i.e., name, reference number/id number, and date of birth); Note: You can now add up to five patients in one submission. requesting physician s contact information (i.e., name and telephone number); inpatient information (i.e., facility name and telephone number, if applicable). If you have an urgent request, please call the Independence Medical Director s Office at For all out-of-area requests, please call All non-urgent calls will be returned within 24 hours. If you have questions regarding the submission process, please contact the Physician Support Team at December 2016 Partners in Health Update SM 5

6 ADMINISTRATIVE Procedures for referring members for covered and non-covered services Under the Independence Provider Agreement, for HMO and POS members, except in an emergency, providers are required to refer members only to participating providers for covered services. This includes, but is not limited to, ancillary services such as laboratory (i.e., members and/or their lab specimens) and radiology. Reminder: Specialists should ensure a referral is on file before rendering services. Services obtained without a referral, when one is required, will not be covered by Independence. If a participating provider is not available for referral or direction of the member, the ordering provider must obtain preapproval from Independence before referring/directing the member to a non-participating provider. If a provider is referring a member to a non-participating provider or provides/requests non-covered services to or for a member, the provider must inform the member in advance, in writing, of the following: a list of the services to be provided; Independence will not pay for or be liable for the listed non-covered services; the member will be financially responsible for such services. You can access the Independence Member Consent for Financial Responsibility for Unreferred/Non-covered Services Form at By signing this form, the member agrees to pay for non-covered services specified on the form. The form must be completed and signed before services are provided. If a member presents without a referral, the provider should request that the member completes a financial responsibility form. If a provider does not comply with the requirements as outlined above, the ordering provider is required to hold the member harmless. The ordering provider will be responsible for any and all costs to the member and shall reimburse the member for such costs or be subject to claims offset by Independence for such costs. If you have any questions, please contact your Network Coordinator. December 2016 Partners in Health Update SM 6

7 ADMINISTRATIVE 2017 out-of-pocket maximums for commercial HMO, POS, and PPO members Under the Patient Protection and Affordable Care Act, also known as Health Care Reform, members should not be charged any cost-sharing (i.e., copayments, coinsurance, and deductibles) once their annual limit for essential health benefits has been met. Essential health benefits include medical benefits, prescriptions, pediatric dental services, and pediatric vision services for those members whose benefits include these services. These limits are based on the member s benefit plan. While some member benefit plan limits may be lower, they currently cannot exceed the following amounts: Individual: $6,850 Family: $13,700 Beginning January 1, 2017, the annual limits will be changed to the following amounts: Individual: $7,150 Family: $14,300 Once members have reached their out-of-pocket maximum, providers should not collect additional cost-sharing for essential health benefits. Out-of-pocket maximum calculations embedded for each individual Please keep in mind that Health Care Reform regulations require an embedded in-network out-of-pocket maximum for each individual to limit the amount of out-of-pocket expenses that any one person will incur. This means that each member enrolled in an individual plan, or any person in a family plan, will only pay the in-network out-of-pocket maximum set for an individual and not be required to pay out of pocket to meet the family in-network out-of-pocket maximum for the plan. For a family plan, after one person meets the individual in-network out-of-pocket maximum for their plan, the other family members continue to pay out of pocket until the remaining in-network out-of-pocket maximum amount is met. To verify if members have reached their out-of-pocket maximum, providers should use the Eligibility and Benefits Inquiry transaction on the NaviNet web portal. Once on the Eligibility and Benefits Details screen, the member s current out-of-pocket expense will be displayed. December 2016 Partners in Health Update SM 7

8 BILLING Professional Injectable and Vaccine Fee Schedule updates effective January 1, 2017 Effective January 1, 2017, we will implement a quarterly update to our Professional Injectable and Vaccine Fee Schedule for all contracted providers. These updates reflect changes in market price (i.e., average sales price [ASP] and average wholesale price [AWP]) for vaccines and injectables and modifications to the percentage premium for the following: Drug Code Narrative Actemra J3262 Injection, tocilizumab, 1 mg Entyvio J3380 Injection, vedolizumab, 1 mg Inflectra TM Q5102 Injection, infliximab, biosimilar, 10 mg Orencia J0129 Injection, abatacept, 10 mg Remicade J1745 Injection, infliximab, 10 mg Simponi Aria TM J1602 Injection, golimumab, 1 mg, for intravenous use Stelara J3357 Injection, ustekinumab, 1 mg Allowance Inquiry transaction To look up the rate for a specific code, use the Allowance Inquiry transaction on the NaviNet web portal. To do so, go to Independence NaviNet Plan Central, select Claim Inquiry and Maintenance from the Independence Workflows menu, and then select Allowance Inquiry. For step-by-step instructions on how to use this transaction, refer to the user guide available in the NaviNet Resources section of our Provider News Center at Note: The Allowance Inquiry transaction returns current rates for professional providers only. The reimbursement rates that go into effect January 1, 2017, will be available through this transaction on or after this effective date. Provider payment allowances are for informational purposes only and are not a guarantee of payment. If you have any questions about these updates, please contact your Network Coordinator. December 2016 Partners in Health Update SM 8

9 NAVINET New NaviNet Claim Status Inquiry transaction delay As previously communicated, we will be introducing a new Claim Status Inquiry transaction on the NaviNet web portal. However, access to the new transaction will be delayed until January Check for updates regarding the release of this transaction and new user guides on the Provider News Center at Claim review As a reminder, all participating providers (including third-party supporting agents) are required to be enabled with NaviNet. As part of our self-service requirements, participating providers are required to use NaviNet when checking for claim status. Additionally, providers who are looking to request a claim review must submit those requests through the Claim Investigation transaction. We will continue to redirect those providers who submit paper claim review requests to the NaviNet provider portal to initiate the claim review. Please be specific when describing the reason for the claim review. Note: A number of providers are submitting claim review requests for lack of referral or authorization. If a claim is denied for lack of referral or authorization and one was required, you must submit a valid referral or authorization number in order for the claim to be reconsidered. The submission of medical records as a replacement for a required authorization or referral is not valid. If, however, you are experiencing an issue that affects a significant number of claims, we recommend that you contact your Network Coordinator for assistance rather than submit an adjustment request through NaviNet. For more information If you have any questions, please call the ebusiness Hotline at December 2016 Partners in Health Update SM 9

10 MEDICAL Reminder: Cost-sharing and billing requirements for Preventive colorectal cancer screening Independence is consistent with the requirements of the Affordable Care Act by covering certain colorectal cancer screening tests without member cost-sharing (i.e., copayments, coinsurance, and deductibles) when using an in-network provider.* Currently, the United States Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer in adults beginning at age 50 and continuing until age 75 using one of the following: fecal occult blood testing highly sensitive fecal immunochemical testing (FIT) CT colonography stool DNA testing (alone or combined with FIT) flexible sigmoidoscopy colonoscopy barium enema Reminder: $0 cost-sharing for related screening services No member cost-sharing is required for the following services when associated with a Preventive colorectal cancer screening procedure, when the criteria outlined in the Preventive Care Services policy are met: prescription bowel preparation medication for flexible sigmoidoscopy, colonoscopy, or CT colonography; pre-procedure consultation visit for flexible sigmoidoscopy, colonoscopy, or CT colonography; anesthesia associated with flexible sigmoidoscopy or colonoscopy; pathology associated with flexible sigmoidoscopy or colonoscopy. For members enrolled in a commercial plan, when the colorectal cancer screening tests identified above are billed, they will be processed as a Preventive service based on the frequency and age recommendations described by the USPSTF and outlined in Attachment A of Medical Policy # s: Preventive Care Services. This policy was posted as a Notification on November 1, 2016, and will become effective on January 1, Please note that colorectal cancer screening tests that are not included in the USPSTF recommendations will be subject to medical necessity and member cost-sharing, based on the terms of the member s benefit plan. Refer to Medical Policy # m: Colorectal Cancer Screening for more information. This policy is currently posted as a Notification and will become effective on January 1, Additionally, when a medically necessary esophagogastroduodenoscopy (EGD) is performed on the same day as a Preventive colorectal cancer screening test (e.g., colonoscopy), it is subject to applicable member cost-sharing. To access these policies, visit our Medical Policy Portal at and select Accept and Go to Medical Policy Online. Then select Commercial and type the policy name or number in the Search field. New billing requirement Beginning January 1, 2017, when billing for a colonoscopy or flexible sigmoidoscopy that converts from a screening to a diagnostic service, a PT modifier must be appended to the appropriate diagnostic CPT code to indicate the service turned into a diagnostic procedure. * Small group (1-50) and consumer commercial plans include a Preventive Plus feature that requires members to see a Preventive Plus provider and meet the Preventive criteria for colonoscopy screenings to be covered with $0 cost-sharing; cost-sharing will apply when members have colonoscopy screenings performed by in-network non-preventive Plus providers. Small group and consumer commercial members who live outside of our five-county service area (i.e., Bucks, Chester, Delaware, Montgomery, and Philadelphia counties) and contiguous counties (i.e., counties that surround the Independence five-county service area) may obtain a Preventive colonoscopy screening from any in-network provider at $0 cost-sharing. December 2016 Partners in Health Update SM 10

11 MEDICAL Reminder: $0 copays on preferred diabetic supplies for Medicare Advantage members In 2017, Independence Medicare Advantage members must use diabetic test strips and a glucose monitor from the preferred manufacturer brands Accu-Chek and OneTouch. These brands will be covered at $0 copayment. All other manufacturer brands will not be covered by Keystone 65 HMO plans. For Personal Choice 65 SM PPO, an out-of-network coinsurance will apply. If their current glucose monitor does not work with either of these brands, Medicare Advantage members can obtain a new glucose monitor at no additional cost. Please note that all other brands of test strips and glucose monitors will no longer be covered by Keystone 65 HMO plans. Diabetic members were sent a letter that outlines these changes. Test strips can be purchased from either a network pharmacy or durable medical equipment supplier. The $0 copay on Accu-Chek and OneTouch test strips will apply at both preferred and standard pharmacies. Note: These Medicare Advantage plans will continue to offer $0 copay on all brands of lancets and solutions. Reminder: Neulasta : Updates to precertification requirements, sites of service, and coverage options Effective January 1, 2017, Independence is changing how we manage the products Neulasta (pegfilgrastim) and Neulasta Onpro *. Currently, these drugs are covered under our members medical benefit and do not require precertification approval. Effective January 1, 2017, the following changes will take place: All requests for coverage for Neulasta under the medical benefit will require precertification approval from Independence prior to our members receiving the drug. As part of our Most Cost-Effective Setting Program, Independence will also review the setting where members enrolled in commercial plans receive Neulasta. Members enrolled in commercial plans whose pharmacy benefits are managed by FutureScripts, our independent pharmacy benefits manager, will also be able to obtain Neulasta under their pharmacy benefit. Note: For Medicare Advantage members, Neulasta is currently covered under the Part D benefit. Independence recently sent letters to notify affected providers about these changes. Precertification approval Independence requires precertification approval for many specialty drugs to ensure that the medical necessity criteria listed in our medical policies are satisfied. For dates of service on or after January 1, 2017, all requests for Neulasta under the medical benefit will require precertification approval from Independence for commercial and Medicare Advantage members. According to its U.S. Food and Drug Administration-approved label, Neulasta is given 24 hours after chemotherapy. Due to the time-sensitive nature of the drug, it is important for you to request precertification approval in advance of the member s scheduled treatment date. This allows Independence sufficient time to review the request. continued on the next page December 2016 Partners in Health Update SM 11

12 MEDICAL continued from the previous page Setting approval During precertification review, each member s medical needs and clinical history are evaluated to determine if the drug for which coverage is requested satisfies the coverage criteria. As part of this precertification process, Independence will also review the provider s request for treatment setting for certain drugs covered under the medical benefit to ensure that our members receive treatment in a setting that is both cost-effective and safe. Effective January 1, 2017, Neulasta will be added to the Most Cost-Effective Setting Program for all commercial plans. Cost-effective settings for Neulasta include: A physician s office, where you can either buy the drug and request reimbursement from Independence, or order the drug via the Independence Direct Ship Drug Program and incur no cost for acquiring the drug. The member s home, where the injection is administered by an in-network home infusion provider. An ambulatory (freestanding) infusion suite, not owned by a hospital or health system in our network. A hospital outpatient facility is the most costly setting in which to administer Neulasta ; and coverage in such a setting will be considered for those members who are receiving their initial dose of Neulasta or for members whose condition requires the intensive monitoring and access to emergent care uniquely available on a hospital campus. Independence will require submission of relevant medical records identifying the specific reason the hospital outpatient setting is requested for ongoing administration of Neulasta. This information will be reviewed and a coverage determination on setting will be made. For more information Providers can find additional information about Neulasta in the following Independence medical policies, which are currently posted as Notifications and will become effective on January 1, 2017: Commercial: # : Pegfilgrastim (Neulasta ) Medicare Advantage: #MA08.082: Pegfilgrastim (Neulasta ) To access medical policies, visit our Medical Policy Portal at Select Accept and Go to Medical Policy Online, then select Commercial or Medicare Advantage under Active Notifications. If you have questions about any of these changes, contact your Network Coordinator. *All mentions of Neulasta are inclusive of Neulasta Onpro. FutureScripts is an independent company that provides pharmacy benefits management services. Coverage for Neulasta under the pharmacy benefit for commercial members Offering coverage for Neulasta under either the medical or pharmacy benefit gives our commercial members more options and greater convenience. The terms, conditions, and cost-sharing provisions (including copay, deductible, and coinsurance) in their benefit contracts may vary between medical and pharmacy benefits, so members may compare both benefits to determine the coverage option that is more advantageous for them. If members choose to obtain Neulasta under the pharmacy benefit through FutureScripts, they will require a prescription. At your professional discretion, Neulasta may be prescribed for self-administration or may be physician-administered. In the event your office administers a dose of Neulasta, this service is eligible for reimbursement with submission of a claim. For members who do not have pharmacy benefits with FutureScripts but who have pharmacy benefit coverage with another vendor and are interested in self-administering Neulasta, you should encourage them to contact their pharmacy benefits manager to determine if Neulasta is available for coverage under their prescription drug plan. December 2016 Partners in Health Update SM 12

13 MEDICAL Reminder: Upcoming changes to medical benefit specialty drug cost-sharing for 2017 Effective January 1, 2017, Independence will update its list of specialty drugs that require member cost-sharing (e.g., copayment, deductible, and coinsurance). Cost-sharing applies to select medical benefit specialty drugs for members who are enrolled in Commercial FLEX products and other select plans. The member s cost-sharing amount is based on the terms of the member s benefit contract. Individual benefits should be verified. The updated list will include approximately 130 drugs, including new additions for Cinqair (reslizumab), Inflectra TM (infliximab)*, Nucala (mepolizumab), and Probuphine (buprenorphine). The updated list is available on our website at The current 2016 cost-sharing list can be accessed through this link until December 31, * For members enrolled in Commercial FLEX products, cost-sharing applies to all biosimilars of infliximab approved by the U.S. Food and Drug Administration. Reminder: Upcoming changes to precertification requirements for 2017 Effective January 1, 2017, new precertification requirements will apply to our commercial and Medicare Advantage HMO and PPO members for the following service and drugs eligible for coverage under the medical benefit. Service As of January 1, 2017, insulin pumps will require precertification approval from Independence. Drugs As of January 1, 2017, the drugs listed below will require precertification approval from Independence: Cinqair (reslizumab) Cubicin (daptomycin) Darzalex TM (daratumumab) Erwinaze (L-asparaginase) Exondys 51 TM (eteplirsen) Hymovis (high molecular weight viscoelastic hyaluronan) Inflectra (infliximab)* Neulasta (pegfilgrastim)* Neulasta (pegfilgrastim) Onpro * Sandostatin LAR (octreotide acetate) Faslodex (fulvestrant) Tecentriq (atezolizumab) In addition, the following drugs are currently pending approval from the U.S. Food and Drug Administration (FDA). Once they receive FDA approval, they will also require precertification approval from Independence: Cingal (sodium hyaluronate/triamcinolone hexacetonide) Ocrevus TM (ocrelizumab) Remune (HIV-1 immunogen) These changes will be reflected in an updated precertification requirement list, which will be posted to our website at later this month, prior to these changes going into effect. *Precertification requirements apply to all biosimilars of infliximab and pegfilgrastim approved by the FDA. December 2016 Partners in Health Update SM 13

14 MEDICAL View up-to-date policy activity on our Medical Policy Portal Changes to Independence medical and claim payment policies for our commercial and Medicare Advantage Benefits Programs occur in response to industry, medical, and regulatory changes. We encourage you to view the Site Activity section of our Medical Policy Portal in order to keep up to date with changes to our policies. The Site Activity section is updated in real time as changes are made to the medical and claim payment policies. Topics include: Notifications New Policies Updated Policies Reissued Policies Coding Updates Archived Policies For your convenience, the information provided in Site Activity can be printed to keep a copy on hand as a reference. News & Announcements In addition to the information posted in our Site Activity section, articles related to our website and medical and claim payment policies are periodically posted within the News & Announcements section. Simply select the appropriate link (Commercial, Medicare Advantage, or MAPPO Host) under the News & Announcements header on the Medical Policy Portal homepage to stay informed of the latest information. To access the Site Activity section, go to our Medical Policy Portal at and select Accept and Go to Medical Policy Online. From here you can select Commercial or Medicare Advantage under Site Activity to view the monthly changes. To search for active policies, select either the Commercial or Medicare Advantage tab from the top of the page. To access medical policies from Independence NaviNet Plan Central, select Medical Policy Portal under Provider Tools in the right hand column. PHARMACY Our prescription drug program and safe prescribing procedures Independence has contracted with FutureScripts, an independent pharmacy benefit manager, to manage the administration and claims processing of our prescription drug programs. FutureScripts provides mail-order services and works with community pharmacies to provide medications to our members. Medication claims are generally processed directly with the pharmacy provider when the member obtains the prescription. In order to oversee our pharmacy policies and procedures and to promote the selection of clinically safe, clinically effective, and economically advantageous medications for our members, Independence formed the Pharmacy and Therapeutics Committee. This Committee is a group of local physicians and pharmacists who meet quarterly to review, evaluate, and update the medications included in our formularies to ensure their continued effectiveness, safety, and value. continued on the next page December 2016 Partners in Health Update SM 14

15 PHARMACY continued from the previous page Select Drug Program The Select Drug Program is a formulary-based drug benefits program that is maintained by the Pharmacy and Therapeutics Committee and includes all generic drugs and a defined list of brand-name drugs that have been reviewed for medical effectiveness, safety, and value and approved by the U.S. Food and Drug Administration (FDA). This program is set up with a three-tiered cost-sharing structure: Tier 1 Generic: Includes most generic medications. Drugs are covered at the lowest formulary level of cost-sharing. Tier 2 Preferred Brand: Includes preferred brand medications. Drugs are covered at a higher formulary level of cost-sharing. Tier 3 Non-Preferred Drug: Includes non-preferred medications. Drugs are covered at the highest non-formulary level of cost-sharing. Coverage for drugs is based on the member s prescription drug benefits. You can download the latest Select Drug Program Formulary at or call ASK-BLUE to request a printed copy. Mail-order services FutureScripts provides mail-order services as an option for Independence members to receive their medications. Most of the time, medication requests are processed upon receipt of a prescription from a physician; however, there may be times when the physician will need to contact FutureScripts for medication coverage, such as when formulary management limitations exist. See the Prescribing safety section on the next page for more details. Generic medications According to the FDA, generic drugs are equivalent to their brand-name originator in active ingredients, dosage, safety, strength, and performance and are held to the same strict standards as their brand-name counterparts. The only noticeable difference between a generic drug and its brand-name counterpart may be the shape and/or color of the drug. Generic drugs are just as effective as the corresponding brand-name drugs; however, they may cost up to 70 percent less, helping to reduce health care costs for members. The generic option is generally the lowest cost for the member. Please note that FutureScripts does not determine when a generic medication will be provided at the pharmacy. In accordance with state laws, generic medications may be provided by the pharmacist at the point of sale, if available, unless the physician indicates dispense as written or brand medically necessary on the prescription. However, if brand medications are prescribed in place of a generic medication, prior authorization may be needed before the drug is dispensed. Exceptions When necessary, consideration for an exception can be requested for a non-preferred medication to be covered at the formulary level of cost-sharing. Physicians may request coverage on behalf of a member when the following conditions are met: All formulary alternatives have been exhausted or there are contraindications to using them. A completed Formulary/Cost Share Exception Request form has been faxed to FutureScripts at and contains at least the following information: diagnosis for the drug requested medication history supporting medical information for the requested medication continued on the next page December 2016 Partners in Health Update SM 15

16 PHARMACY continued from the previous page The request form can be found at authorization/prior_auth_commercial/prior_comm_selectform.html. If the non-formulary exception request is approved, the physician will receive written notification and the drug will be processed at the appropriate formulary level of cost-sharing. If the request is denied, the physician and member will receive a denial letter. Prescribing safety As part of formulary management, Independence implements safe prescribing procedures that are designed to optimize the member s prescription drug benefits by promoting appropriate utilization. These procedures are based on FDA guidelines, and the approval criteria were developed and endorsed by our Pharmacy and Therapeutics Committee. FutureScripts continuously monitors the effectiveness and safety of drugs and drug prescribing patterns. Several procedures support safe prescribing patterns for our prescription drug programs, such as prior authorization and age, gender, and quantity limits. Prior authorization Prior authorization is required for certain covered drugs to review whether the drug is medically necessary, appropriate, and prescribed according to FDA guidelines. The approval criteria for these medications may include that the physician order a trial of a different drug, such as a generic or a therapeutic alternative. Clinical pharmacists evaluate the information submitted by the member s prescribing physician, including available prescription drug therapy history. The clinical pharmacists determine whether there are any drug interactions or contraindications, that the dosing and length of therapy are appropriate, and that other drug therapies, if necessary, were utilized where appropriate. The prior authorization process may take up to two business days once completed information from the prescribing physician has been received. The prescriber will be notified if an approval has a defined time frame, such as 12 months. Once the approval time period elapses, the physician will need to request consideration for a new prior authorization. Physicians should fax the appropriate prior authorization form and all supporting medical information to FutureScripts at The prior authorization forms are available on the FutureScripts website at comm_selectform.html. Age limits Upon approval of a drug, the FDA indicates specific safety limitations that govern prescribing practices. Age limits are designed to prevent potential harm to members and to promote appropriate use. Pharmacists have access to up-to-date information regarding FDA guidelines. If a member s prescription falls outside of the FDA guidelines, it may not be covered until prior authorization is obtained. The prescribing physician may request consideration for prior authorization of these medications when medically necessary by completing the General Pharmacy form, available at prior_comm_selectform.html. The member should contact the prescribing physician to request that he or she initiate the prior authorization process. Quantity limits Certain drugs have a limit on how many doses a member can receive per month. Quantity limits are based upon FDAapproved maximum daily doses and/or length of therapy of a particular drug. If medically necessary, a physician can request consideration for a quantity limit exception by completing the General Pharmacy form, available at comm_selectform.html. For additional information on pharmacy policies and programs, go to FutureScripts is an independent company that provides pharmacy benefits management services. December 2016 Partners in Health Update SM 16

17 PHARMACY Benefits provided by BriovaRx Independence s specialty pharmacy provider, BriovaRx (administered by FutureScripts, our independent pharmacy benefits manager) offers access to such things as experienced clinicians and refill reminders. Through BriovaRx, Independence members will have access to: 24/7 video consultations. Through the secure web video consultation program, called BriovaLive TM, pharmacists are available anytime to answer questions, provide self-administration medication training, and help members follow personalized treatment plans. Ongoing patient education and support. Members will receive educational materials on their specific medications. BriovaRx staff communicates with the member s other health care providers regarding follow-up, when appropriate, in order to help them manage their condition more effectively. BriovaRx clinicians will counsel patients on how the medication works, how to administer and store the drug, how to manage any side effects, and answer any questions or concerns the member may have. Confidential, convenient ordering and delivery. Members can order medications by phone for delivery anywhere in the U.S. with no shipping charges. Refill reminders. Members will receive a phone call before their medication refill date to schedule the next delivery and help them adhere to their treatment without disruption. Mandatory specialty pharmacy benefit Some Independence members have a mandatory specialty pharmacy benefit where they must obtain their specialty drugs from BriovaRx. As of January 1, 2017, for those members with this benefit, the first prescription fill must be obtained through BriovaRx. The member may call the number on their identification card to find out the details of their plan. For more information on specialty drugs, visit For more information Members can reach BriovaRx to have a prescription filled by calling BRIOVA ( ) or by visiting If you have any questions regarding the BriovaRx or the mandatory specialty pharmacy benefit, please contact Customer Service at ASK-BLUE. FutureScripts is an independent company that provides pharmacy benefits management services. December 2016 Partners in Health Update SM 17

18 PHARMACY Select Drug Program Formulary updates The Select Drug Program Formulary, which is available for commercial members, is a list of medications approved by the U.S. Food and Drug Administration that were chosen for formulary coverage based on their medical effectiveness, safety, and value. The list changes periodically as the Pharmacy and Therapeutics Committee reviews the formulary to ensure its continued effectiveness. The most recent changes are listed below. Generic additions These generic drugs recently became available in the marketplace. When these generic drugs became available, we began covering them at the appropriate generic formulary level of cost-sharing: Generic drug Brand drug Formulary chapter Effective date armodafinil* Nuvigil 3. Pain, Nervous System, & Psych June 6, 2016 clindamycin phos-tretinoin 1.2% % gel clindamycin-benzoyl peroxide 1% - 5% gel w/ pump Veltin 1.2% % gel or Ziana 1.2% % gel 5. Skin Medications July 11, 2016 benzaclin pump 5. Skin Medications May 9, 2016 dofetilide Tikosyn 4. Heart, Blood Pressure, & Cholesterol June 13, 2016 doxycycline hyclate 50 mg Doryx 50 mg and 200 mg dr tablet 1. Antibiotics & Other Drugs Used for Infection May 30, 2016 ethacrynic acid Edecrin 4. Heart, Blood Pressure, & Cholesterol July 11, 2016 miglitol Glyset 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones May 23, 2016 nilutamide Nilandron 2. Cancer & Organ Transplant Drugs July 25, 2016 omeprazole-sodium bicarbonate 20 mg - 1,680 mg and 40 mg - 1,680 mg packet* Zegerid 20 mg - 1,680 mg and 40 mg - 1,680 mg packet 8. Stomach, Ulcer, & Bowel Meds July 25, 2016 pramipexole er 3.75 mg Mirapex ER 3.75 mg 3. Pain, Nervous System, & Psych July 18, 2016 *Generic requires prior authorization. Brand additions Effective October 1, 2016, these brand drugs were added to the formulary and covered at the appropriate brand formulary level of cost-sharing: Brand drug Simponi Stelara Formulary chapter 9. Bone, Joint, & Muscle 9. Bone, Joint, & Muscle Covered under pharmacy and medical benefit. Brand deletions Effective January 1, 2017, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing: Brand drug Generic drug Formulary chapter Edecrin ethacrynic acid 4. Heart, Blood Pressure, & Cholesterol Mirapex ER 3.75 mg pramipexole er 3.75 mg 3. Pain, Nervous System, & Psych The generic drugs for the above brand drugs are on our formulary and available at the generic formulary level of cost-sharing. continued on the next page December 2016 Partners in Health Update SM 18

19 PHARMACY continued from the previous page Generic deletions Effective January 1, 2017, these drugs will be covered at the appropriate non-preferred level of cost-sharing: Non-preferred drug Formulary therapeutic alternative Formulary chapter Apexicon E betamethasone dipropionate, fluocinolone acetonidem, triamcinolone acetonide 5. Skin Medications Clodan clobetasol propionate 5. Skin Medications frovatriptan almotriptan malate, sumatriptan, zolmitriptan 3. Pain, Nervous System, & Psych metformin ER (generic Glumetza ) omeprazole-sodium bicarbonate metformin ER (generic Glucophage XR and Fortamet ) omeprazaole, lansoprazole, pantoprazole sodium 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones 8. Stomach, Ulcer, & Bowel Meds oxiconazole econazole nitrate, ketoconazole 5. Skin Medications Trianex betamethasone dipropionate, fluocinolone acetonide, triamcinolone acetonide 3. Pain, Nervous System, & Psych For additional information on pharmacy policies and programs, please visit Prescription drug updates For commercial members enrolled in an Independence prescription drug program, prior authorization and quantity limit requirements will be applied to certain drugs. The purpose of prior authorization is to ensure that drugs are medically necessary and are being used appropriately. Quantity limits are designed to allow a sufficient supply of medication based upon the maximum daily dose and length of therapy approved by the U.S. Food and Drug Administration for a particular drug. The most recent updates are reflected below. Drugs requiring prior authorization The prior authorization requirement for the following non-formulary drugs was effective at the time the drugs became available in the marketplace: Brand drug Generic drug Formulary chapter Effective date Afstyla Not available 4. Heart, Blood Pressure, & Cholesterol June 13, 2016 Bevespi aerosphere Not available 12. Allergy, Cough & Cold, Lung Meds July 11, 2016 Briviact Not available 3. Pain, Nervous System, & Psych May 23, 2016 Cabometyx Not available 2. Cancer & Organ Transplant Drugs May 2, 2016 Epclusa Not available 1. Antibiotics & Other Drugs Used for Infection July 4, 2016 Nuplazid Not available 3. Pain, Nervous System, & Psych May 16, 2016 Nuvigil armodafinil* 3. Pain, Nervous System, & Psych June 6, 2016 continued on the next page December 2016 Partners in Health Update SM 19

20 PHARMACY continued from the previous page Brand drug Generic drug Formulary chapter Effective date Ocaliva Not available 15. Diagnostics & Miscellaneous Agents June 6, 2016 Stelara Not available 9. Bone, Joint, & Muscle October 1, 2016 Vonvendi Not available 4. Heart, Blood Pressure, & Cholesterol July 11, 2016 Xiidra Not available 11. Eye Medications July 25, 2016 Xtampza ER Not available 3. Pain, Nervous System, & Psych May 16, 2016 Zinbryta Not available 1. Antibiotics & Other Drugs Used for Infection July 11, 2016 *Generic requires prior authorization. Covered under pharmacy and medical benefit. Effective January 1, 2017, the following non-formulary drugs will be added to the list of drugs requiring prior authorization: Brand drug Generic drug Formulary chapter Abilify aripiprazole 3. Pain, Nervous System, & Psych Beyaz Not available 10. Female, Hormone Replacement, & Birth Control Capex Not available 5. Skin Medications Clobex clobetasol propionate 5. Skin Medications Cloderm clocortolone pivalate 5. Skin Medications Cordran flurandrenolide 5. Skin Medications Crestor rosuvastatin calcium 4. Heart, Blood Pressure, & Cholesterol Cuprimine Not available 9. Bone, Joint, & Muscle Cutivate fluticasone propionate 5. Skin Medications Derma-Smoothe FS fluocinolone acetonide 5. Skin Medications Dermasorb HC, TA Not available 5. Skin Medications Desonate Not available 5. Skin Medications Desowen desonide 5. Skin Medications Dibenzyline phenoxybenzamine* 4. Heart, Blood Pressure, & Cholesterol Diclegis Not available 8. Stomach, Ulcer, & Bowel Meds Dymista Not available 6. Ear, Nose, Throat Medications Ecoza Not available 5. Skin Medications Effexor XR venlafaxine er 3. Pain, Nervous System, & Psych Ertaczo Not available 5. Skin Medications Exelderm Not available 5. Skin Medications Extina ketoconazole 5. Skin Medications continued on the next page December 2016 Partners in Health Update SM 20

21 PHARMACY continued from the previous page Brand drug Generic drug Formulary chapter Glumetza metformin er* 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones Halog Not available 5. Skin Medications Kenalog triamcinolone acetonide 5. Skin Medications Lexapro escitalopram oxalate 3. Pain, Nervous System, & Psych Locoid [lipocream] hydrocortisone butyrate/emoll 5. Skin Medications Loprox ciclopirox 5. Skin Medications Luxiq betamethasone valerate 5. Skin Medications Luzu Not available 5. Skin Medications Minastrin FE Not available 10. Female, Hormone Replacement, & Birth Control Olux [E] clobetasol propionate/emoll 5. Skin Medications Oxistat oxiconazole nitrate 5. Skin Medications Pandel Not available 5. Skin Medications Psorcon diflorasone diacetate 5. Skin Medications Rayos Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones Safyral Not available 10. Female, Hormone Replacement, & Birth Control Synalar fluocinolone acetonide 5. Skin Medications Syprine Not available 15. Diagnostics & Miscellaneous Agents Topicort desoximetasone 5. Skin Medications Ultravate halobetasol propionate 5. Skin Medications Valtrex valacyclovir hcl 1. Antibiotics & Other Drugs Used for Infection Vanos fluocinonide 5. Skin Medications Vusion Not available 5. Skin Medications Xartemis XR Not available 3. Pain, Nervous System, & Psych Xolegel Not available 5. Skin Medications Zoloft sertraline hcl 3. Pain, Nervous System, & Psych *Generic requires prior authorization. Drugs with quantity limits Quantity limits were/will be added or updated for the following drugs as of the date indicated below: Brand drug Generic drug Quantity limit Effective date Denavir Not available 1 tube per 30 days January 1, 2017 Xtampza ER Not available 60 caps per 30 days May 16, 2016 continued on the next page December 2016 Partners in Health Update SM 21

22 PHARMACY continued from the previous page Drugs no longer requiring prior authorization Effective January 1, 2017, the prior authorization requirement was removed for the following drugs: Brand drug Generic drug Formulary chapter Invokamet Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones Invokana Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones PegIntron, Pegasys Not available 3. Pain, Nervous System, & Psych various ribavirin 1. Antibiotics & Other Drugs Used for Infection For additional information on pharmacy policies and programs, please visit PRODUCTS New value-based insurance design program Beginning January 1, 2017, Independence will introduce a new voluntary program called the Vital Care Program for Keystone 65 Select HMO and Keystone 65 Preferred HMO members who have been diagnosed with both congestive heart failure and diabetes. The Vital Care Program is a Value-Based Insurance Design (VBID) model, which is part of a new initiative that the Centers for Medicare & Medicaid Services is conducting and regulating through the Center for Medicare & Medicaid Innovation. It is designed to help members improve their overall health and well-being and will test whether it can improve health outcomes and lower expenditures for Medicare Advantage enrollees. Specific to this program is a reduced copayment for eligible members when they visit their cardiologist, endocrinologist, or podiatrist. The lower cost-share can help make these visits more affordable, encouraging members to see their specialists more regularly to help better manage their care. Under the Vital Care Program, the 2017 reduced copays for specialists office visits are as follows: Endocrinologist and Cardiologist: $10 copay Podiatrist: $5 copay; $5 copay also applies to both Medicare-covered and six routine podiatry visits per year Eligible members will be automatically enrolled into the program, but they will have an opportunity to opt out if they choose to do so. There are no additional participation requirements. Since both Keystone 65 Select HMO and Keystone 65 Preferred HMO are HMO plans, referrals will still be required from the primary care physician for a specialist visit. Identifying Vital Care Program members Eligible members will receive a new ID card that indicates they are enrolled in the Vital Care Program as well as a written summary of benefits (the Notice of VBID Benefits ). The copayment amount for specialists will be listed as varies on the member s new ID card as shown. Please be sure to verify the member s eligibility and benefit information via the NaviNet web portal at the time of service to ensure the correct copay is being collected. If you have any questions about this program, please contact your Network Coordinator. December 2016 Partners in Health Update SM 22

23 QUALITY MANAGEMENT Clinical Practice Guideline Summary now available We recently posted the Clinical Practice Guidelines Summary, which replaces the previous version. The revised Summary includes a listing of all Clinical Practice Guidelines adopted by Independence that are considered the accepted minimum standard of care in the medical profession. Adherence to these guidelines may lead to improved patient outcomes. Guidelines are available for the following medical and behavioral health conditions: asthma chronic obstructive pulmonary disease (COPD) coronary heart disease diabetes heart failure obesity renal disease attention deficit hyperactivity disorder (ADHD) autism spectrum disorders depression substance abuse disorders Changes in the Clinical Practice Guidelines Summary include updates to the current guidelines, as well as the addition of the following guidelines: Asthma. Global Initiative for Asthma (GINA). URL for Appendix to 2016 Report; At-A-Glance Asthma Management Reference for adults, adolescents, and children 6 11 years. COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD Diagnosis and Management At-A-Glance Desk Reference. Coronary Heart Disease. AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk. Diabetes. Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus. Renal Disease. Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic Kidney Disease. Individual clinical decisions should be tailored to specific patient medical and psychosocial needs. As national guideline recommendations evolve, please update your practice accordingly. The Summary provides the reference for each condition and links directly to the guidelines. We update the guidelines annually based on changes made to nationally recognized sources. Changes are reviewed by internal and external consultants, as appropriate, and by the Independence Quality Committee, which is comprised of network physicians. You can access the Clinical Practice Guidelines Summary at Paper copies can be ordered by submitting an online request at or by calling the Provider Supply Line at December 2016 Partners in Health Update SM 23

24 QUALITY MANAGEMENT Member Wellness Guidelines available Member Wellness Guidelines are a user-friendly version of evidenced-based wellness recommendations for the average-risk person. We encourage you to review these recommendations with your Independence patients to determine which screenings would be appropriate based on specific patient medical and psychosocial needs. Wellness guidelines are available for the following age groups: Pediatric guidelines (ages birth to 17) Adult guidelines ages Adult guidelines ages 65 and older You can access the Member Wellness Guidelines on our website at Paper copies can be ordered by submitting an online request at or by calling the Provider Supply Line at Note: Member Wellness Guidelines should not be confused with Preventive Care Benefits as provided under the Affordable Care Act. These recommendations are not a statement of benefits and some of these services may require cost-sharing. New Perinatal Guideline Summary now available The Perinatal Guideline Summary is a new comprehensive resource available for our OB/GYN and primary care providers. The Summary outlines perinatal care from preconception care through postpartum care with an emphasis on patient and family counseling, and laboratory work and testing. It also details perinatal care throughout each stage of pregnancy from the patient s initial OB/GYN visit through subsequent visits over 40 weeks. Risk factors to pay close attention to throughout each trimester are also identified. For providers located in New Jersey New Jersey law mandates that health care providers include family members, as appropriate, in prenatal and postpartum counseling, especially as it relates to postpartum depression. It also mandates that new mothers be screened for postpartum depression symptoms prior to discharge from the birthing facility and at the first few postpartum check-up visits. Although the Edinburgh Postnatal Depression Scale is the most commonly used postpartum screening method, the New Jersey law does not specify which screening tool should be used for the screening. To assist providers, Independence has identified a variety of depression screening tools available, which is included within the Perinatal Guidelines Summary. Information provided includes the number of items in the survey, time to complete, and sensitivity and specificity for each screening tool. You can access the Perinatal Guideline Summary on our website at Paper copies of the Summary can be ordered by submitting an online request at or by calling the Provider Supply Line at December 2016 Partners in Health Update SM 24

25 HEALTH AND WELLNESS Behavioral health: Promoting provider communication and collaboration We are pleased to continue our short series of articles in Partners in Health Update that is designed to explore potential barriers and opportunities to facilitate communication and collaboration between primary care physicians and behavioral health providers and to achieve optimal outcomes for your patients. Part 4 Second generation antipsychotic medications Independence and Magellan Healthcare, Inc. (Magellan) have been encouraging all primary care physicians and behavioral health providers to communicate with each other about their patients. This is one example of a crucial need to make sure ongoing communication occurs. Second generation antipsychotic (SGA) medications, also known as atypical antipsychotic medications, have been used in psychiatry since 1990 when clozapine (Clozaril ) was approved for treatment-resistant schizophrenia. Today, these medications are being prescribed by providers of many specialties, not just psychiatry. As more medications for this class of drugs are being developed, we expect use of these medications to continue. Use of these medications is prompted by their association with fewer anticholinergic and movement side effects than the typical antipsychotic medications such as haloperidol (Haldol ). These side effects are very uncomfortable for patients. However, SGAs have presented other side effects, known as Metabolic Syndrome. 1 Metabolic Syndrome includes hyperglycemia, hyperlipidemia, hypertension, and increase in weight. Current literature does not show that Metabolic Syndrome is dose- or time-related, 2 so all providers who prescribe an SGA need to monitor for Metabolic Syndrome. Monitoring for Metabolic Syndrome The current SGA medications approved by the U.S. Food and Drug Administration include: aripiprazole (Abilify ) asenapine (Saphris ) clozapine* (Clozaril ) iloperidone (Fanapt ) lurasidone (Latuda ) olanzapine (Zyprexa ) olanzapine/fluoxetine (Symbyax ) paliperidone (Invega ) quetiapine (Seroquel ) risperidone (Risperdol ) ziprasidone (Geodon ) The chart below shows monitoring protocols that are recommended by the American Diabetes Association and American Psychiatric Association. 3 More frequent assessments may be warranted based on clinical status. Baseline Week 4 Week 8 Week 12 Quarterly Annually Every 5 years Medical History X X Weight (BMI) X X X X X Waist Circumference X X Blood Pressure X X X Fasting Glucose/hemoglobin A1C X X X Fasting lipids X X X continued on the next page December 2016 Partners in Health Update SM 25

26 HEALTH AND WELLNESS continued from the previous page All prescribing providers should explain the need for this monitoring as well as the potential side effects when they discuss treatment with their patients and request their informed consent. Independence and Magellan have collaborated to provide practitioners with information on atypical antipsychotic medication management, including a patient handout to educate your patients on antipsychotic medication management and potential risks. You can access this information on our website at *Alert: Clozapine is also associated with agranulocytosis and in order to dispense this medication, the pharmacy must have an Absolute Neutrophil Count (ANC) on file. 4 When a provider prescribes clozapine, not only do they need to monitor for Metabolic Syndrome as recommended but the ANC must be drawn weekly for the first 6 months, then every 2 weeks for the next 6 months. If the patient is taking the medication for one year, the ANC only needs to be drawn monthly. 1 DeHert, M., et al (2012). Metabolic and cardiovascular adverse effects associated with antipsychotic drugs. Nature Reviews Endocrinology. Vol 8: Liao, T.V. & Phan, S.V. (2014). Acute hyperglycemia associated with short term use of atypical antipsychotic medication. Drugs. 74:2, American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care, 2004; 27: Clozaril REMs Program: A single shared system for Clozapine. May 20, Magellan Healthcare, Inc., an independent company, manages mental health and substance abuse benefits for most Independence members. Health Coaches: Supporting your patients, our members Independence recognizes that the physician-patient relationship is at the heart of patient care. Through health coaching from our Registered Nurse Health Coaches, the following programs are offered to enhance your ability to provide coordinated care for your patients and promote integration of care among members and their families, physicians, and community resources: 24/7 Health Information Line. Your Independence patients can call ASK-BLUE anytime to speak with a Registered Nurse Health Coach about general health questions and concerns. Case management. Case management provides support to members who are experiencing complex health issues or challenges in meeting their health care goals. Condition management. Condition management is available to eligible members for specific chronic conditions such as asthma, diabetes, COPD, hypertension, and congestive heart failure. Baby BluePrints maternity program. Your expecting Independence patients can self-enroll in this free program to receive support from an experienced Registered Nurse Health Coach throughout their pregnancy. Please encourage your expecting Independence patients to enroll by calling BABY. Independence also offers obstetrical Registered Nurse Health Coach support to expecting Independence patients who have been identified as high-risk to facilitate the best possible outcome. If you would like to refer an Independence patient to one of the programs listed above, complete the online physician referral form, available at or call December 2016 Partners in Health Update SM 26