Inside your Health A newsletter for commercial health plan members / FALL 2018 From Prominence Health Plan Behavioral health support any time, any place Use your telemedicine benefit for a $0 copay* Page 2 Pulmonary medicine comes to Northern Nevada Medical Group Get to know our new chief medical officer Medicare open enrollment is happening now! *See page 2 for details
Behavioral health now available via TELEMEDICINE for $0 copay* If the challenges of everyday life are affecting your well-being, talking to a therapist can help you regain your sense of health and happiness. Through the Prominence partnership with Teladoc, licensed therapists are available seven days a week.** Choose a provider from the Teladoc network that s right for you, pick a convenient time and then have a private conversation from your home or anywhere you feel comfortable. Controlled substance prescriptions cannot be prescribed. Teladoc therapists can help treat: Anxiety Depression Stress/post-traumatic stress disorder (PTSD) Panic disorder Family and marriage issues This care is offered in addition to the general health-related care that Teladoc provides for medical conditions such as allergies, respiratory infections, cold and flu, ear infections and more. Prominence Health Plan members have access to U.S. boardcertified doctors, pediatricians and therapists by phone or video 24-hours a day, every day of the year. Telemedicine services provided by Teladoc will be covered at no cost through a $0 copay.* Register for an account today! It s quick and easy to set up an account online or over the phone. Visit the Teladoc registration page at teladoc.com and provide the required information. You can also call Teladoc at 1-800-TELADOC (835-2362). *Health plan members enrolled in an HSA plan will still be subject to deductible per HSA plan eligibility IRS requirements. Once plan calendar year deductible has been met, the charge paid at time of service will be reimbursed by Teladoc. Texas members are responsible for a telemedicine copay equivalent to the PCP copay. Additionally, for commercial Texas members, Prominence will cover telemedicine services offered by any contracted provider who uses this technology. **Behavioral health benefits via Teladoc are only offered to those members age 18 and older. 2 Inside your Health / Fall 2018
Introducing our new CMO, Bernard Farzin, MD Prominence Health Plan warmly welcomes Dr. Bernard Farzin to our community as Chief Medical Officer. Pulmonary medicine introduced at Northern Nevada Medical Group Northern Nevada Medical Group recently opened a new pulmonary medicine specialty clinic led by boardcertified internal medicine and pulmonary care providers Aleem Surani, MD (top), and Aaron Viray, MD (left). The clinic focuses on advanced diagnosis and treatment options for patients managing lung and respiratory disorders, and is a contracted innetwork facility for Prominence Health Plan members. We are pleased to expand our scope of services, and provide local care to patients, said Alan Olive, CEO of Northern Nevada Medical Center. Pulmonary disease is a top health indicator in Washoe County, and with our new clinic, we anticipate meeting the community s need for such services. Care is provided for a range of lung and respiratory conditions, from asthma, sleep apnea, interstitial lung disease and pneumonia to COPD and lung nodules/lung cancer. Additionally, pulmonary function tests (PFTs), which measure how well the lungs are working, may be provided. Drs. Surani and Viray are accepting new patients at the clinic located at 2385 E. Prater Way, Suite 302. To learn more, visit NNMG.com. In his role Dr. Farzin will focus on strategies to improve the patient experience, strengthen communication with providers, and enhance efficiency and outcomes. Prior to joining Prominence, he worked to support the health initiatives for several Medicare Advantage plans in Nevada. Dr. Farzin has also served as the director of primary care for Providence Medical Group in Anchorage, Alaska, and had a family practice in Maryland focusing on patients 65 and older. We are very fortunate to have secured the talents of Dr. Farzin given his professional background, said Kamal Jemmoua, Chief Operating Officer for Prominence. His wealth of experience will help us with the continued healthcare transformation at Prominence. Dr. Farzin received his medical degree from St. George s University School of Medicine. He is board certified in Family Medicine. I look forward to playing my part in connecting the Reno healthcare community to Prominence Health Plan and the many collaborative opportunities that await us all. Bernard Farzin, MD prominencehealthplan.com 3
Prescription drug FORMULARY UPDATES Changes to the health plan formulary are common and take place throughout the year. Changes can include: Addition of drugs to the formulary; New drug restrictions, such as prior authorization, quantity limits and/or step therapy; Transition of a drug to a lower cost sharing tier; and Addition of generics which are equivalent to the brand name drugs and result in brand name drug cost-sharing tier changes to promote generic use and reduce member share of cost. Additionally, if the Food and Drug Administration deems a drug to be unsafe or the drug s manufacturer removes the drug from the market, Prominence Health Plan (PHP) will immediately remove the drug from the formulary. The updates listed below are the result of decisions made by the PHP Pharmacy & Therapeutics Committee during the quarterly review. These high-level changes impact the Commercial (Employer Group) formulary and prior authorization (PA) criteria. Additional authorization criteria may apply for each drug. These changes are not applicable to PHP s Medicare Advantage formulary. The pharmacy formulary is updated monthly. To view the most current information online, visit prominencehealthplan.com and click on the Pharmacy Services tab. If you have questions regarding the prescription drug plan, please call the pharmacy Help Desk at 844-282-5339. Member services representatives are available to assist members and providers 24/7. DRUG NAME TIER STATUS AND DRUG EDIT Prevymis (letermovir) Added under Tier 5 (Specialty Tier) with PA criteria Frivanq (vancomycin oral solution) PA criteria revised Symbeko (tezacaftor/ ivacaftor) Added under Tier 5 (Specialty Tier) with PA criteria Lonhala Magnair (glycopyrrolate) Non-formulary (not covered) with PA criteria Sublocade (buprenorphine ER injection) Non-formulary (not covered) with PA criteria Durolane (hyaluronate) Non-formulary (not covered) with PA criteria Hemlibra (emicizumab-kxwh) Added under Tier 5 (Specialty Tier) with PA criteria Fulphila (pegfilgrastim-jmbd) Added under Tier 5 (Specialty Tier) with PA criteria Retacrit (epoetin alfa-epdx) Added PA criteria and Step Therapy requirement Erleada (apalutamide) Added under Tier 5 (Specialty Tier) with PA criteria 4 Inside your Health / Fall 2018 RX BY MAIL Don t miss out on a simple way to save on out-of-pocket expenses. Prominence Health Plan members may obtain a 90-day supply of ongoing medication(s) by mail with our pharmacy partner, MedImpact Direct. With mail order, you can save money and time by having prescriptions for maintenance medication(s) delivered right to your home. Important Note: You will need a 90-day supply prescription for your first custom delivery order and will need to register with MedImpact Direct at medimpactdirect.com. Prescriptions can be sent to MedImpact Direct in 1 of 3 ways: OPTION 1 Call MedImpact Direct 855-873-8739 Monday through Friday 7 a.m. 7 p.m. (CST) Saturdays: 8 a.m. 4 p.m. (CST) With a simple call, MedImpact Direct will contact your provider or transfer in your prescriptions. OPTION 2 Mail Us Your Prescription Download and complete the MedImpact Direct Medication Order form available on the Forms and Resources page of prominencehealthplan.com. You must mail your paper prescription and payment with the form. OPTION 3 From Your Prescriber Ask your doctor to send your prescription e lectronically to MedImpact Direct or fax it to 888-783-1773.
We heard you! Changes to prior authorization requirements In an effort to make getting the care you need easier and enhance our partnership with providers, as of November 1, 2018, Prominence Health Plan no longer requires prior authorization for the following services: Physical therapy Occupational therapy Speech therapy Chiropractic care Like all health insurance carriers, Prominence requires prior authorization for certain services, procedures and medications to ensure medical necessity. We continuously evaluate our prior authorization process for safety purposes, as well as to help prevent fraud, waste and abuse. For a list of specialty provider services and procedures that require prior authorization, visit the Forms and Resources page found on prominencehealthplan.com. IMPROVE the care you receive You can play an important role in your healthcare. If you receive treatment from a specialist or someone other than your primary care provider (PCP), it s important that your PCP be informed, so that he or she can oversee and coordinate the care you receive. A FEW SIMPLE STEPS CAN HELP ENSURE YOU RECEIVE THE QUALITY OF CARE YOU ARE ENTITLED TO: Always present your Prominence Health Plan membership card when receiving services and/or treatment. If you see a specialist, request that a copy of the diagnosis and treatment plan be forwarded to your PCP. Whether you are in the hospital or having tests outside the hospital, request that a copy of all test results be sent to your PCP, regardless of who ordered the test. Keep a current list of all the medications you are taking. Include the name of the medication, the dose and how many times a day you are taking it (this information can be copied right off the label on the bottle). Update the list including allergies when medications are changed, added or discontinued. Carry the medication list with you and show it to all doctors involved in your care each time you have an appointment. If you are seen at an urgent care facility or in an emergency room, notify your PCP s office. Your doctor may want to see you to follow up on the problem that prompted you to seek urgent or emergent care. Schedule an annual well-visit appointment with your PCP to review your health and treatment plan and ensure ageappropriate preventive and maintenance care. Information regarding your healthcare should be noted in your primary medical record at your PCP s office. By following these simple steps, you can help your doctor facilitate your access to high-quality care. prominencehealthplan.com 5
Flu season is here! Get the vaccine! Helpful tips for flu prevention: Immunize your children As a parent, you want to ensure your children are as healthy as possible. One of the easiest and most important steps is to make sure they receive the right immunizations, at the right time. Immunizations protect children from possible life-threatening effects of vaccine-preventable diseases. No child should ever have to suffer from these diseases simply because he or she was not vaccinated on time. For a newborn, a number of standard vaccinations are recommended to prevent diseases like measles, polio and others. Take your child to see his or her physician when he or she is 2 months old, 4 months old, 6 months old, and 12 to 18 months old for immunizations and wellbaby checks. Recommended childhood vaccinations should be completed by your child s second birthday. For children 6 to 12 years of age, be sure they have had all recommended and required vaccinations for school. Recommended adolescent vaccinations should be completed by the start of seventh grade. Preventive guidelines recommend that children in this age group see their physician at least once a year for a well-child visit to keep them healthy. Each visit to the doctor is an opportunity to talk about immunizations. For more information about immunizations, visit our website at prominencehealthplan.com and click on the Members tab, then go to Wellness Services and click on Wellness Resources. Get the shot. The best way to prevent getting the flu is to get vaccinated. Flu vaccines are updated each year against various strains that will be circulating in order to improve immunity. Limit the spread of germs. Take everyday preventive measures to stay safe, like washing your hands, covering your nose and mouth when you sneeze or cough and avoiding close contact with people who are sick. Listen to your body. If you develop flu symptoms, contact your physician right away for treatment to minimize the risk of flu-related complications. Flu vaccines are offered to all Prominence Health Plan members at no cost from an in-network provider. The importance of well-child annual checkups To ensure a healthy future for your child as he or she reaches important milestones, a well-child visit each year is recommended. Well-child visits with your child s primary care provider (PCP) are an important tool used to screen for medical and developmental issues. During these checkups, your healthcare provider will assess your child s physical and emotional development, offer age-specific guidance on topics such as safety, nutrition, physical activity and adolescent decision-making, as well as offer advice about needed immunizations or other tests. The once-a-year visit is recommended for children ages 3 to adolescence; however, discuss the visit frequency with your child s PCP to establish a schedule that meets your child s developmental needs. 6 Inside your Health / Fall 2018
Tips for lowering your blood pressure Last year, the American Heart Association (AHA) and several other health organizations updated the blood pressure categories. Based on the new guidelines outlined in the included chart, the measurements that identify hypertension (high blood pressure) have been revised. New AHA blood pressure guidelines BLOOD PRESSURE CATEGORY Normal Elevated High Blood Pressure (Hypertension) Stage 1 High Blood Pressure (Hypertension) Stage 2 Hypertensive Crisis (Consult your doctor immediately) SYSTOLIC mm Hg (UPPER #) less than 120 120 129 130 139 140 or higher Higher than 180 IF YOU HAVE HYPERTENSION, THERE ARE LIFESTYLE CHANGES YOU CAN MAKE TO GET HEALTHIER. 1. Watch your weight. Losing extra pounds can be an effective way to improve your numbers and feel better as well. 2. Reduce your sodium and processed food intake. A diet high in sodium not only increases your blood pressure but also impacts your heart health. Evaluating your overall diet gives you the opportunity to incorporate more nutritious options, including eating more whole grains, fruits and vegetables and less canned foods. 3. Exercise regularly.* Being consistent with your exercise routine can increase your overall health and wellness and give you long-lasting benefits. 4. Decrease your stress. Chronic stress may contribute to hypertension. To help combat this, find activities you enjoy and take time to relax. 5. Limit your alcohol consumption. Too much alcohol can be problematic and may also have a negative effect on medications you may be taking. By making these lifestyle modifications, you can also decrease your chances of a possible heart attack and stroke. It s important to monitor your blood pressure and discuss any changes with your primary care provider. *Before starting a new exercise program, consult a doctor. and and or or and/or DIASTOLIC mm Hg (LOWER #) less than 80 less than 80 80 89 90 or higher Higher than 120 Live better. FEEL BETTER. BREAST CANCER EDUCATION Why is screening important? Screening can help diagnose cancer earlier. By the time symptoms appear, cancer may have begun to spread. Possible symptoms New lump in the breast or underarm (armpit) Thickening or swelling of part of the breast Dimpling of breast skin Redness or flaky skin in the breast area Pulling in or pain in the nipple area Nipple discharge other than breast milk, including blood Any change in size or shape of the breast BREAST CANCER SCREENING (U.S. Preventive Services Recommendation) AGES 40-49: Women with a parent, sibling or child with breast cancer are at higher risk. Talk to your provider to start screening with mammogram. AGES 50-74: Mammography screening every other year. AGE 75 OR OLDER: Talk to your provider, to assess the balance of benefits and harm of mammography screening. Screening should continue as long as the individual is in good health. Early detection is your best defense against breast cancer. Don t delay getting your doctor recommended mammogram. Bernard Farzin, MD, Chief Medical Officer, Prominence Health Plan prominencehealthplan.com 7
FPO 1510 Meadow Wood Lane Reno, Nevada 89502 FREE PATIENT ADVOCACY FOR out-of-network bills Medicare open enrollment is now through December 7, 2018 Zero is your lucky number with a Prominence Medicare Advantage plan. This is the time of year when people who are Medicare-eligible have the option to enroll in a new health plan. Prominence Health Plan has Medicare Advantage plans that offer all the benefits Original Medicare provides and more. Plans are available to residents of northern Nevada and northern and south Texas who want a Medicare Advantage HMO plan with innetwork access to local hospitals. This year, we re rolling out some of our best benefits yet, including zero-dollar premiums, doctor visits, telemedicine and a fitness benefit. If you or someone you know is eligible for Medicare, call us at 855-969-5882 (TTY: 711) 8 a.m. to 8 p.m., seven days a week, or visit ProminenceMedicare.com. I m a health insurance broker/agent and I chose Prominence for my health plan. Why Prominence? This year zero. $0 premium, $0 primary care office visits, $0 telemedicine, and even $0 lab copays. Mike Colson, Medicare Advantage Member since 2015 Prominence Health Plan is an HMO plan with a Medicare contract. Enrollment in Prominence Health Plan depends on contract renewal. Prominence Health Plan complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-969-5882 (TTY: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-969-5882 (TTY: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-969-5882 (TTY: 711). Y0109_FALLNEWSLTR19_M CMS Accepted To help members deal with unexpected charges that can result from out-ofnetwork care, Prominence Health Plan has partnered with The Karis Group to provide Prominence members who have more than $1,000 worth of outstanding medical bills access to the Karis Bill Negotiator services. The goal of Karis Bill Negotiator is to reduce members outstanding medical bill balances by working directly with their healthcare providers, provider offices and/or hospitals. To learn more: Call Prominence Health Plan Customer Service at the phone number on the back of your member ID card. Call The Karis Group directly at 855-397-0897. Visit thekarisgroup.com and select Member Access in the upper right corner of the home page, then select Karis360 to submit a bill negotiation service request. If you need assistance understanding this document or any other Prominence Health Plan coverage-related materials, including benefit information, in a language other than English, you may request translation assistance for free by calling Customer Service at the number on the back of your member ID card. TTY/TDD services are available by dialing 800.326.6868. For language assistance, disability accommodations and the non-discrimination notice, visit our website.