PROVIDER. Newsletter. WellCare Streamlines Authorization Rules. Provider resources

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1 medicare 2012 ISSUE II PROVIDER Newsletter WellCare Streamlines Authorization Rules The WellCare Group of Companies (collectively WellCare) has some good news to share with you about our authorization rules. We ve adjusted them to promote utilization management activities that ensure our members receive the right care at the right place and time. Many services performed in office and ambulatory surgery center (ASC) settings can be performed without an authorization. In addition, authorization requirements for durable medical equipment (DME) have been reduced. The following services will now require an authorization: 1. Inpatient confinements: 5. Home Health Care Elective Inpatient 6. Transplant Services Acute Inpatient Skilled Nursing Mental Health Rehabilitation Long-Term/Sub-Acute Care 2. Select Outpatient Surgical/ Diagnostic/Therapeutic Procedures 3. Select Durable Medical Equipment (DME) 4. Skilled Therapy Services (Occupational, Physical and Speech Therapy) 7. Non-Participating Provider and Facility Requests 8. Select Pharmaceuticals 9. Behavioral Health (Please refer to your Quick Reference Guide for authorization requirements related to these services.) 10. Advanced Radiological, Diagnostic Cardiac, Musculoskeletal (Pain) Management and Diagnostic Sleep Services (managed by CareCore National) WellCare will continue to partner with CareCore National, LLC, for clinical review of cases in all care settings related to Advanced Radiology, in addition to adding Diagnostic Cardiac, Musculoskeletal Management, and Diagnostic Sleep Services. For authorization requests related to these programs, go to or call CareCore National directly at You may access ProviderTraining to view additional information regarding new authorization requirements, including a searchable procedure code Look-Up Tool, Quick Reference Guides and CareCore Frequently Asked Questions. Provider resources You can find the following documents on Clinical Practice Guidelines Asthma Diabetes and more Provider Resources and Tools Diabetes Tool Kit Depression Tool Kit Prenatal and Postpartum Tool Kit ADHD Tool Kit and more HEDIS Information Provider Manuals Quality Improvement Program and Updates Member Rights and Responsibilities Electronic Claims Submissions ADDITIONAL CRITERIA AVAILABLE Please remember that all Clinical Coverage Guidelines, detailing medical necessity criteria for several medical procedures, devices and tests, are available via the provider resources link at com/provider/ccgs. WEB RESOURCES Visit to access our Preventive Health Guidelines, Clinical Practice Guidelines, EPSDT documents, Pharmacy Guidelines, Cultural Competency Plan and other helpful resources. If you would like to receive a hard copy of any of these documents, please contact your Provider Relations representative. continued on page 2

2 continued from cover We encourage you to always check eligibility and confirm benefits prior to rendering services to members. For questions regarding this notice, please contact your Provider Relations representative or Provider Services at the phone number located on your state-specific Quick Reference Guide. These changes are designed to help ease your day-to-day interactions with our Utilization Management activities, while allowing us to continue to exercise responsible stewardship over health care resources. We appreciate your continued participation and cooperation, and look forward to working with you to deliver the highest quality of care for our members. Provider Satisfaction Survey As mentioned in our last newsletter, WellCare Health Plans, Inc., has placed a renewed emphasis on the experiences of both our members and providers. In 2011, in order to fully understand our valued provider network, we conducted our first Provider Satisfaction Survey. The survey concentrated on a variety of subjects including: call center/member services, provider relations, continuity/coordination of care, provider network, utilization and quality management, finance issues, pharmacy and drug benefits, and overall satisfaction and loyalty. After extensively reviewing our 2011 survey results, the organization identified a number of actions for improvement including: enhancing provider services at the local level, claim processing improvement, enriching administrative tools/capabilities, assessment of our network composition, and a renewed emphasis on quality. The Provider Experience team has since been engaged with several cross-functional teams working on these initiatives, and others, that are aimed at better serving our providers. We anticipated incremental gains on several initiatives in 2012 and continued improvement beyond. Stay tuned as these efforts will be further communicated as the year progresses. In addition to these initiatives, the organization has made strides internally to improve our strategy and culture. We have engaged associates directly in both assessing awareness and promoting feedback on how they affect and can improve the experiences of our members and providers. We have also formed a Quality Council whose overall mission is to provide oversight and drive strategy relating to quality performance. These internal efforts will assist in the organization s continuing culture change toward improving the overall provider experience. Within the next month, WellCare will again conduct a Provider Satisfaction Survey. This follow-up survey will be used to measure progress from last year s baseline effort to better evaluate how we can become more effective and productive business partners. Your participation is encouraged and appreciated, as together we strive to positively impact our members overall quality of care. Lou Gianquinto Vice President, Provider Experience 2

3 WellCare Introduces Star Advantage TM WellCare is pleased to introduce you to our new service, Star Advantage, offered by our business partner Inovalon (formerly MedAssurant). With the passage of health care reform, quality outcomes have become a key focus of the Centers for Medicare & Medicaid Services (CMS). Since 2007, CMS has utilized a proprietary Star Rating System to rate the quality performance of the individual Medicare Advantage health plans. This Star Rating System is based on a set of quality measures that pertain to a member s experience and quality of care. Inovalon s Star Advantage solution benefits providers by offering insight into the full patient profile, compiled from claims data, prescription drug data and laboratory data. Inovalon offers a unique approach through its ability to deliver to the provider both member-level insight and evidence-guided decision support. Targeted communications, which include member-specific letters, educational materials, and nurse telephonic outreach, facilitate member and provider encounters and awareness of potential CMS Star quality gaps. Additionally, select members may be targeted to receive In-Home Assessments, designed to help members identify barriers to care, enabling them to work with their PCPs more effectively. Aided by these Inovalon-directed outreach efforts, providers may improve their members documentation, clinical outcomes and overall satisfaction. In the coming months, you will receive correspondence from us that includes individually customized progress note forms (SOAP notes) that reflect your members historical health information and member-specific quality measure data. We ask that you update these SOAP notes, either online or via paper, with current information about your patients. Our goal is to support you in providing evidence-based care for your Medicare Advantage members. WellCare looks forward to your participation in this new service. If you have any questions or concerns, please contact WellCare Customer Service at the number listed on your state-specific Quick Reference Guide. WellCare Specialty Pharmacy is Now Exactus Pharmacy Solutions TM WellCare Specialty Pharmacy has changed its name to Exactus Pharmacy Solutions. What hasn t changed is our commitment to our members and our physician partners. As a WellCare company, Exactus is dedicated to providing you with the same excellent services we ve always offered: Specialty Pharmacy Our pharmacy team is highly skilled with medications that treat the following conditions and more: anemia, cystic fibrosis, Crohn s disease, hemophilia, hepatitis, HIV, multiple sclerosis, neutropenia, cancer, osteoarthritis and psoriasis. Preferred Mail-Service Pharmacy Members can enjoy the convenience and cost savings of having a 90-day supply of maintenance medications delivered right to their mail box. Diabetic Supplies Easy ordering and reliable delivery. Payment Plans Available to help members with their co-payments. Complete Inventory of Maintenance Medications in Stock Brands, generic, controlled substances and diabetic supplies. Refill Reminder Notices Sent when a member s medications may be running low. Orders Shipped in Tamper-Proof Packaging An extra measure of safety. Also know that whenever members use Exactus services, their orders are handled by a registered pharmacist. That way, they can be confident that their prescriptions will be filled accurately. And our pharmacists are available to answer questions 24 hours a day. As always, we re just a phone call away and ready to help. You can reach us at Monday Friday, 8 a.m. to 6 p.m. Eastern. TTY users may call Or us at exactus@wellcare.com. Exactus. New name. Same quality. Same convenience. Same care. Thank you for continuing to allow us to serve your pharmacy needs. 3

4 CASE AND DISEASE MANAGEMENT PROGRAMS 4 WellCare s Case Managers support you and your hectic schedules, freeing you to spend more time with your patients by: Collaborating with providers and physicians to create a targeted assessment and treatment plan for the patient s condition Maintaining communication between the patients and their families, and the team of physicians Identifying opportunities for interventions such as ineffective treatment plans or lack of financial resources to meet the needs Assisting with patient transition when discharged from the program The types of cases targeted by our Case Management program include, but are not limited to, the following types of patients: Complex case needs requiring coordination of multiple outpatient services Transplants Frequent inpatient admissions and readmissions Prolonged or debilitating illness or injuries WellCare s Disease Managers support you and your hectic schedules too, freeing you to spend more time with your patients by: Educating them on how to deal with the challenges of their disease Documenting progress in clinical notes and alerting their patients of significant changes or findings Our Disease Management program targets the following conditions: Asthma Coronary Artery Disease (CAD) Congestive Heart Failure (CHF) Chronic Obstructive Pulmonary Disease (COPD) Diabetes HIV Hypertension Our Case and Disease Management programs identify potential candidates based on available data and referrals from multiple sources: Claims or encounter data Pharmacy Laboratory data Utilization Management, Case Management, Disease Management and Discharge Planner referrals Practitioner and member referrals Behavioral health vendors If you would like to refer your WellCare patients to either or both of these programs, please call the Case and Disease Management Referral Line at Monday through Friday, from 8 a.m. to 5 p.m. Eastern.

5 WellCare s Quick Access Guide to Provider Services The WellCare Group of Companies (WellCare) is dedicated to providing customer satisfaction and operational excellence in the communities that we serve. We understand patient care is the priority, and your time is important. You may contact Provider Services directly by calling the state-specific toll-free Provider Services telephone number provided on your state-specific Quick Reference Guide. To bypass our menu options and more quickly gain access to the answers you need, use the following prompts: To use our automated interactive voice response (ivr) system For: Member eligibility and co-pay information, claims status and/or a list of participating providers or pharmacies Authorization status To reach a live representative for: Authorization requests for medical services such as: Automated authorization status requests Inpatient-related services including: Obstetrics (OB) Deliveries Urgent requests Requests after business hours Outpatient services Durable medical equipment or therapy services Disease management (does not apply to IL or OH Medicaid) Case management (only applies to IL, MO and OH Medicaid) Direct extension for inquiries regarding a Medicaid member Direct extension for inquiries regarding a Medicare member Pharmacy inquiries Provider portal Web support and inquiries EDI inquiries EDI-Master@wellcare.com For all other inquiries, or to be connected to Provider Services, including: Claims Eligibility Authorization status n/a WellCare also offers online tools via our secure provider portal such as: Member eligibility and co-pay information; Authorization requests; Claims status and inquiry; Your own inbox, with specific messages from WellCare; Provider news; and More To register, refer to any Provider How-To Guide located on our corporate website at job_aids, or on your applicable state website. 5

6 2012 Q2 PROVIDER FORMULARY UPDATE - MEDICARE Generic drug News The generic drugs listed below are now available to WellCare s Medicare members usually at a lower costsharing benefit: BRAND NAME GENERIC NAME THERAPEUTIC CLASS Combivir 150mg/300mg tablet Derma-Smoothe/FS body oil Derma-Smoothe/FS scalp oil DermOtic Oil ear drop Lamivudine-Zidovudine 150mg/300mg tablet Fluocinolone Acetonide 0.01% body oil Fluocinolone Acetonide 0.01% scalp oil Fluocinolone Acetonide Oil 0.01% ear drop Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors Glucocorticoids/ Mineralocorticoids Glucocorticoids/ Mineralocorticoids Otic Agents Entocort EC 3mg capsule Budesonide EC 3mg capsule Glucocorticoids Epivir 150mg and 300mg tablets Felbatol 600mg/5mL oral suspension Fortamet ER 500mg tablet Fortamet ER 1,000mg tablet Lamivudine 150mg and 300mg tablets Felbamate 600mg/5mL oral suspension Metformin HCl ER 500mg tablet (QL: 124 tablets/31 days) Metformin HCl ER 1,000mg tablet (QL: 62 tablets/31 days) Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors Glutamate Reducing Agents Antidiabetic Agents Antidiabetic Agents Levaquin I.V. 25mg/mL vial Levofloxacin 25mg/mL vial Quinolones Primaxin I.V. 250mg and 500mg vials Surmontil 25mg, 50mg and 100mg capsules Imipenem-Cilastatin Sodium 250mg and 500mg vials Trimipramine Maleate 25mg, 50mg and 100mg capsules Beta-Lactam, Other Tricyclic Antidepressants Zyprexa 10mg vial (QL: 6mL/31 days) Olanzapine 10mg vial (QL: 6mL/31 days) Atypical Antipsychotics Zyprexa 2.5mg, 5mg, 7.5mg, 10mg, 15mg and 20mg tablets (PA, QL: 31 tablets/31 days) Zyprexa Zydis 5mg, 10mg, 15mg and 20mg orally disintegrating tablets (PA, QL: 31 tablets/31 days) Olanzapine 2.5mg, 5mg, 7.5mg, 10mg, 15mg and 20mg tablets (PA, QL: 31 tablets/31 days) Olanzapine 5mg, 10mg, 15mg and 20mg orally disintegrating tablets (PA, QL: 31 tablets/31 days) Atypical Antipsychotics Atypical Antipsychotics 6 PA = Prior Authorization required QL = Quantity Limit Not covered on the 2012 Medicare formulary (continued on next page)

7 (continued from previous page) The following additions have been made to the WellCare Medicare Formulary: ADDITIONS Antara 43mg and 130mg capsules Boostrix vaccine vial Calcium Acetate 667mg tablets Caprelsa 100mg and 300mg tablets (PA) Ceftazidime/dextrose solution 1gm/50mL; 5%, 2gm/50mL; 5% Complera TM tablet Creon delayed release capsules 15,000 units; 3,000 units; 9,500 units Cyclobenzaprine HCl 7.5mg tablets (PA, QL: 93 tablets/31 days) Diltiazem HCl ER 180mg, 360mg capsules Emoquette TM 28 day tablet Erivedge 150mg capsule (PA, QL: 31 capsules/31 days) Erwinaze 10,000 units vial (PA) HalfLytely and Bisacodyl Bowel Prep Kit Halobetasol Propionate 0.05% cream and ointment Incivek TM 375mg tablet (PA, QL: 504 tablets/365 days) Jakafi TM 5mg, 10mg, 15mg, 20mg and 25mg tablets (PA) Juvisync TM 100mg/10mg, 100mg/20mg and 100mg/40mg tablets (QL: 31 tablets/31 days) Kalydeco 150mg tablet (QL: 62 tablets/31 days) Ketoconazole Foam, 2% Levocetirizine Dihydrochloride 2.5mg/5mL solution Levothyroxine 100mcg vial Livalo 1mg, 2mg and 4mg tablets Lumizyme TM 50mg vial (PA) Lupron Depot 45mg 6 month kit (PA) Nulojix TM 250mg vial (PA) Orsythia TM 28 day tablet Pegasys 180mcg/0.5mL syringe (PA) Pegasys ProClick TM 135mcg/0.5mL and 180mcg/0.5mL syringes (PA) Prenatal Plus Iron tablet Primaxin I.V. ADD-Vantage 250mg and 500mg vials Ranitidine HCl 50mg/2mL solution Rotarix suspension Sandimmune 50mg/mL ampule (PA) Seroquel XR 150mg and 200mg tablets (QL: 31 tablets/31 days) Seroquel XR 50mg, 300mg and 400mg tablets (QL: 62 tablets/31 days) Sucraid oral solution (PA) Sumatriptan succinate solution 6mg/0.5mL (QL: 8mL/31 days) Tamiflu 6mg/mL for oral suspension Tasigna 150mg capsule (PA) Tenivac TM syringe and vial Victrelis TM 200mg capsule (PA, QL: 372 capsules/31 days) Xalkori 200mg and 250mg capsules (PA, QL: 62 capsules/31 days) Xarelto 10mg tablet (QL: 35 tablets/365 days) Zelboraf TM 240mg tablet (PA; QL: 248 tablets/31 days) Zenpep DR 3,000 and 25,000 units capsules Zometa 4mg/100mL solution (PA) PA = Prior Authorization QL = Quantity Limit (continued on next page) 7

8 (continued from previous page) The Utilization Management criteria have changed for the following medications as noted below for the WellCare Medicare Formulary: drug name Lexapro 5mg, 10mg and 20mg tablets Lexapro 5mg/5mL solution Lidoderm 5% patch Vimpat 10mg/mL oral solution Vimpat 50mg, 100mg, 150mg and 200mg tablets Vimpat 200mg/20mL vial change ST removed (QL: 31 tablets/31 days) ST removed PA removed (QL: 93 patches/31 days) PA removed PA removed PA removed PA = Prior Authorization QL = Quantity Limit ST = Step Therapy Please refer to your provider manual available at to view more information regarding WellCare s pharmacy utilization management policy/procedures and medication co payments and coinsurance requirements that may apply. The most up to date complete formulary can be found at PLANNED MARKET DRUG WITHDRAWALS COMPANY NAME DRUG NAME DATE OF REMOVAL Lundbeck Inc. Mebaral (mephobarbital) 32mg tablets, 50mg tablets and 100mg tablets 1/6/2012 Additional Information Lundbeck is no longer able to manufacture Mebaral CIV (brand of mephobarbital tablets, USP), and the company s remaining inventory expired in March Due to product expiration, no product shipments were made after February 29, Once this current stock of Mebaral is depleted, the product will no longer be available. Lundbeck is aware of the difficult situation that some patients may face with regard to the upcoming Mebaral discontinuation. The company thoroughly evaluated all avenues for keeping Mebaral available to patients, but ultimately concluded that no matter what steps we took, patients would be forced to transition to a new therapy. Due to the limited remaining Mebaral supply, we encourage patients to work with their physician to transition to alternative therapies rather than starting a new course of therapy with Mebaral. For more information or with questions, Lundbeck s medical information team can be reached at

9 ACETAMINOPHEN A FEW POINTS TO CONSIDER A growing number of serious liver injury cases are caused by unintentional acetaminophen (APAP) overdoses each year. Recently, the Food and Drug Administration (FDA) has been enhancing awareness that the maximum recommended daily dose of APAP should not exceed four grams in healthy adults. Unfortunately, many people are overusing the drug. Here are some factors that may contribute to APAP over-utilization: The availability of APAP in many prescription combination medications, and in single-agent and combination over-the-counter (OTC) products The lack of patient knowledge and/or awareness Patients seeing multiple prescribers who are unaware of what is in the medications the other practitioners have prescribed for the patient The possibility of prescriber or pharmacist oversight The use of multiple pharmacies Beginning in the 1990s, APAP over-utilization emerged as a leading factor in cases of unintentional acute liver failure in the United States. One chief cause can be attributed to the fact that the majority of consumers are unaware they are exceeding the maximum recommended dosages. As mentioned above, APAP is available in numerous combination products with varying indications. As a result, much of this problem is flying under the radar. While some patient populations are already at a higher risk for liver damage, including those who consume greater than or equal to three alcoholic beverages daily, or already have some degree of liver dysfunction, this amount of liver failure is certainly cause for concern. The following tables detail select analgesics, both with and without acetaminophen, that are indicated for moderate to severe pain. For your reference, there is also a table indicating the maximum acetaminophen use for common strengths of analgesics that contain acetaminophen. Analgesics Without ACETAMINOPhen Tramadol Oxycodone (Immediate Release) Methadone/ Methadose Hydromorphone Morphine (Immediate Release or Extended Release) Analgesics With ACETAMINOPhen Codeine/Acetaminophen Oxycodone/Acetaminophen Hydrocodone/Acetaminophen Maximum ACETAMINOPhen usage Acetaminophen Strength (mg) Maximum Tablets/Day Maximum Tablets/Month Acetaminophen-induced liver toxicity is an easily avoidable injury that has gained escalating attention in the health care industry. Increased awareness in both health care professionals and patients will facilitate prevention of this undesirable outcome. Reference: 9

10 Behavioral Health Clinical Practice Guidelines As a participating provider with the WellCare Group of Companies, you have access to a wealth of information regarding behavioral health and substance abuse care. You can obtain the information by visiting Magellan Health Services website: You can go directly to the clinical practice guidelines site by entering this URL in your Web browser: You can find clinical practice guidelines on topics such as attention deficit hyperactivity disorder, autism, bipolar disorder, depression, eating disorders and substance use disorders. For Connecticut Medicare Providers: You can obtain the information by visiting CompCare s website You can find clinical practice guidelines on topics such as attention deficit hyperactivity disorder, bipolar disorder, depression, substance use disorders and Stress & PTSD by entering this URL in your Web browser: Then access Provider Resources => Clinical Reference Info => Clinical Practice Guidelines 10

11 QUALITY IMPROVEMENT HIGHLIGHTS FROM 2011 The Medicare Quality Improvement (QI) program is an ongoing, comprehensive and integrated system that exists to actively initiate, monitor and evaluate standards of health care practice and infrastructures essential to the delivery of quality clinical care and service to members. SOME HIGHLIGHTS FROM THE 2011 QI PROGRAM INCLUDE: Conducted regular audits of UM, Case Management, Appeals, HR records, Contracting, Complaint & Grievance files to assess ongoing compliance and provide targeted feedback Maintained a standard evidence library containing exemplary reports and templates that reflect evolving NCQA health plan standards Localized quality strategy that includes a membercentric approach to increase health outcomes and member engagement in care Continuously inventoried all initiatives related to HEDIS improvement action plans and focused on removing barriers to member compliance. The three areas of focus were: member engagement, provider engagement and data capture and analysis Focused on Consumer Assessment of Health Plan Systems (CAHPS) survey measures with specific action plans related to metrics Educated Medical Groups and Physicians on the Quality Initiatives and HEDIS measures HEDIS Care Gap CS Inbound Program was initiated in collaboration between Customer Service and Quality Improvement. HIGHLIGHTS OF OUR GOALS FOR 2012 INCLUDE: Identify providers with significant decreases in availability and accessibility and continue faceto-face assessments to identify solutions for improvement Continue to educate providers on the importance of maintaining member demographic information Continue to monitor health plan compliance to current and new standards Investigate, analyze, and follow up on QI action planning for key composite areas found to be highly correlated with overall health plan satisfaction Offer Internet access for health information and advice Develop Discharge Planning Model to include UM, Pharmacy, and Case Management connectivity, as well as identify both medical and socio-economic barriers Redirection Initiative for appropriate level of setting of surgical services Utilize reduction of emergency room visits, inpatient admissions and readmission rates Increase partnerships with acute care facilities to increase access to clinical information Investigate opportunities to educate providers and members to enhance effective communication Prepare for a successful National Committee for Quality Assurance (NCQA) Health Plan Accreditation Develop specific interventions to improve HEDIS outcomes Increase key member and provider satisfaction levels CONNECTICUT YALE MEDICAL GROUP JOINS WELLCARE NETWORK Effective February 1, 2012, Yale Medical Group officially joined the WellCare network. Yale Medical Group consists of nearly 1,000 multi-specialty providers throughout New Haven and Fairfield counties, specializing in a broad range of services like Allergy Immunology, Cardiology, Dermatology, Endocrinology, Gastroenterology, Geriatric Medicine, Infectious Disease, Nephrology, Neurology, Pulmonology, Radiology, Oncology, Rheumatology, Urology and Cardiothoracic Surgery. Please welcome them to the WellCare family! 11

12 WellCare Health Plans 8765 Henderson Road Ren 1 Tampa, FL NA019640_PRO_NEW_ENG WellCare 2012 NA_07_12 Special Needs Training Requirements If you are a provider who is caring for a WellCare special needs member, you are required to complete a Model of Care training that outlines the requirements around special needs. We have free online training available through our WellCare provider portal ( We can also mail you a copy of the training with request for written attestation. If you would like more information, you may contact your WellCare Provider Relations representative or call the Customer Service number listed on your state s Quick Reference Guide for assistance. To contact WellCare, please call the following: WellCare of Connecticut: WellCare of Louisiana: WellCare of Missouri: WellCare of New Jersey: WellCare of Texas: Or visit