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updateSM

Preparing for the upcoming October 1, 2015, ICD-10 compliance date page 3

Introducing Keystone 65 Focus Rx HMO, our new defined-network Medicare Advantage plan page 14

Changes coming in mid-September to NaviNet® page 6

September 2015

Models are used for illustrative purposes only. Some illustrations in this publication copyright 2015 www.dreamstime.com. 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 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Partners in Health UpdateSM is a publication of Independence Blue Cross and its affiliates (Independence), created to provide valuable information to the Independence-participating provider community. 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 CommunicationsIndependence Blue Cross1901 Market Street 27th FloorPhiladelphia, PA 19103

[email protected]

Inside this edition

► Articles designated with a blue arrow include notice of changes or clarifications to administrative policies and procedures.

For articles specific to your area of interest, look for the appropriate icon:

Professional Facility AncillaryKeystone Health Plan East, Personal Choice®, Keystone 65 HMO, and Personal Choice 65SM PPO have an accreditation status of Commendable from NCQA.

ICD-10 ► Preparing for the upcoming October 1, 2015, ICD-10

compliance date ► Join us for the next What’s Up Wednesday call on

September 16, 2015

Billing ► Professional Injectable and Vaccine Fee Schedule updates

effective October 1, 2015 ► Medical Nutrition Therapy coverage for Medicare Advantage

members

NaviNet®

► Changes coming in mid-September to NaviNet®

Medical ► Chiropractic services policy update ► View up-to-date policy activity on our Medical Policy Portal ► Annual Synagis® (palivizumab) distribution program approaches

● Reminder: Coverage for injectable drugs that reduce the risk of preterm birth

Pharmacy ► Select Drug Program® Formulary updates ► Prescription drug updates

Products ► Introducing Keystone 65 Focus Rx HMO, our new

defined-network Medicare Advantage plan

Health and Wellness ● Suicide: A concern for all health care providers:

Part 3 – After screening/assessing: How to assure safety of the person who is at risk for suicide

● Let’s Go See initiative raises awareness of vision problems in children

ICD-10

September 2015 | Partners in Health UpdateSM 3 www.ibx.com/providers

Preparing for the upcoming October 1, 2015, ICD-10 compliance dateOn October 1, 2015, the United States will transition from ICD-9 to ICD-10 as the medical code set for medical diagnoses and inpatient hospital procedures. The transition to ICD-10 is not just an update but rather a complete overhaul. Our entire industry – payers, providers, and vendors – is affected by the transition to the expanded ICD-10 code set. These coding changes will affect medical coding operations, software systems, reporting, administration, registration, and more. Any delay could result in your office or organization experiencing backlogs, denials, and impacts on revenue.

As we rapidly approach the October 1, 2015, compliance deadline, we encourage you to plan ahead and be fully aware of all of the changes that will occur with the implementation of ICD-10. If you do not use valid ICD-10 codes for dates of service or dates of discharge on or after October 1, 2015, you will not be able to successfully bill for your services. Also note that our claims processing system will not accept both ICD-9 and ICD-10 codes on a single claim.

Now is the time to make sure your office is ICD-10 ready. The transition will go much more smoothly for organizations that have planned ahead. A successful transition to ICD-10 will be vital to transforming our nation’s health care system and ensuring uninterrupted operations.

Please also be aware that Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes will continue to be used for outpatient, ambulatory, and office-based procedure coding.

Claims for services that span the compliance dateClaims submitted for a date of service or date of discharge (for facility inpatient claims) on or after October 1, 2015, are required to be submitted with valid ICD-10 codes.

If your office submits an ICD-9 code on or after the October 1, 2015, compliance date, your claim will be denied and sent back to you for compliant coding. Providers should work with their trading partners, clearinghouses, and billing vendors/billing software companies to ensure ICD-10 compliance and avoid claims rejections, processing delays, and revenue impacts.

Additionally, all authorization and referral requests submitted prior to and including September 30, 2015, are required to use ICD-9 codes. All authorization and referral requests submitted on or after October 1, 2015, are required to use ICD-10 codes.

Provider resourcesTo help you prepare, we encourage you to take advantage of the resources available through Independence and the Centers for Medicare & Medicaid Services (CMS).

Independence resources ● ICD-10 web page: www.ibx.com/icd10 ● ICD-10 frequently asked questions: www.ibx.com/pdfs/ providers/claims_and_billing/icd_10/icd_10_faq.pdf

● Provider News Center: www.ibx.com/pnc ● NaviNet® Plan Central: www.navinet.net

CMS resources ● ICD-10 web page: www.cms.gov/ICD10 ● Road to 10: The Small Physician Practice’s Route to ICD-10: www.roadto10.org

● Provider Resources: www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

ATTENTION: After the October 1, 2015, compliance date, we encourage you to closely monitor your Health Care Claim Acknowledgement (277CA) transactions, Provider Explanation of Benefits (Provider EOB), and/or Provider Remittance to quickly identify and address coding issues related to ICD-10. If the incorrect code set is submitted after the compliance date, your claim will be denied and sent back to you for proper coding.

www.ibx.com/pdfs/providers/claims_and_billing/icd_10/icd_10_faq.pdf

www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

ICD-10


Join us for the next What’s Up Wednesday call on September 16, 2015 The October 1, 2015, compliance deadline for ICD-10 is fast-approaching. Join us on this month’s What’s Up Wednesday call to learn up-to-date details about ICD-10 and how we are working with you to help make the transition as smooth as possible.

What’s Up Wednesday is a monthly teleconference hosted by Pennsylvania’s Blue Plans to help prepare health care professionals for the ICD-10 transition on October 1, 2015. What’s Up Wednesday features special guest speakers and ICD-10 experts who will lead discussions to help you get ready for the compliance date. All providers, clearinghouses, information trading partners, and information networks are encouraged to participate.

How to participateNo registration is required. Prior to the call, visit the What’s Up Wednesday web page at www.ibx.com/providers/claims_and_billing/icd_10/whatsupweds.html to access and download the presentation materials.

On the day of the call, dial 1-800-882-3610 and enter pass code 5411307 when prompted. Please dial in five minutes prior to the start of the call.

QuestionsIf you have specific ICD-10-related questions during the call, please email them to [email protected].

Call details

Date: Wednesday, September 16, 2015Time: 2 – 3 p.m. ETPhone number: 1-800-882-3610Pass code: 5411307

BILLING

Professional Injectable and Vaccine Fee Schedule updates effective October 1, 2015 Effective October 1, 2015, 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.

Allowance Inquiry transactionTo 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 www.ibx.com/pnc/navinet.

Note: The Allowance Inquiry transaction returns current rates for professional providers only. The reimbursement rates that go into effect October 1, 2015, 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 the updates, please contact your Network Coordinator.

www.ibx.com/providers/claims_and_billing/icd_10/whatsupweds.html

www.ibx.com/providers/claims_and_billing/icd_10/whatsupweds.html

BILLING


Medical Nutrition Therapy coverage for Medicare Advantage membersThe Medical Nutrition Therapy benefits for your Keystone 65 Basic HMO, Keystone 65 Select HMO, Keystone 65 Preferred HMO, and Personal Choice 65SM PPO Medicare Advantage patients changed on January 1, 2015. Please review the information below regarding eligibility and coverage limitations to avoid claim processing delays and/or denials.

Who is eligible?Keystone 65 Basic HMO, Keystone 65 Select HMO, Keystone 65 Preferred HMO, and Personal Choice 65 PPO members with a Medicare medical benefit Part B who meet at least one of the following conditions are eligible to receive coverage for Medical Nutrition Therapy Services:

● diabetes ● renal (kidney) disease (but not on dialysis) ● have had a kidney transplant in the last 36 months (when therapy is ordered by a doctor)

Medical Nutrition Therapy services require a referral (HMO members only) and must be performed by a registered dietician or nutrition professional who meets certain requirements. Services may include nutritional assessment, one-on-one counseling, and therapy services.

Limitations of coverageEligible Medicare Advantage HMO and PPO members are limited to the following benefits for Medical Nutrition Therapy per calendar year:

● three hours of one-on-one counseling during the first year of Medical Nutrition Therapy under their Medicare Advantage coverage;

● two hours of one-on-one counseling each year after the first year.

There is no copayment, coinsurance, or deductible for eligible patients receiving Medical Nutrition Therapy within the limitations listed.

Providers may prescribe additional hours of treatment if the patient’s condition changes; however, a claim may be denied if a provider recommends services for patients who do not meet the eligibility requirements, recommends services that Medicare does not cover, or requests services more often than Medicare covers.

Be sure to renew services yearly for patients if treatment continues into the next calendar year.

Claims processingTo avoid delays in processing claims and/or denials, it is imperative that your office staff do the following at every visit:

● Verify eligibility and benefits using the NaviNet® web portal prior to prescribing or rendering Medical Nutrition Therapy services.

● Obtain a copy of the member’s current ID card to ensure that you submit the most up-to-date information to Independence.

If you have any questions about coverage for Medical Nutrition Therapy services for Medicare Advantage HMO and PPO members, please contact your Network Coordinator.

NAVINET®


Changes coming in mid-September to NaviNet® The following new transactions and enhancements will be introduced on the NaviNet web portal in mid-September:

● Eligibility and Benefits Inquiry. A new Eligibility and Benefits Inquiry transaction will be introduced in a phased approach. In mid-September, the member search criteria will be modified, and the presentation of the Eligibility and Benefits Detail screen will change. The Details screen will continue to include links to the member’s capitated site information (where applicable), the member’s ID card, and product-wide provisions associated with the member’s benefits plan; however, other benefit links will not be available.

● Provider File Management. This new transaction replaces the previously retired Provider Change Form transaction. Provider File Management will allow professional providers to: - modify practice information - add hospital affiliations - add participating providers

● ICD-10. To support the October 1, 2015, compliance deadline for ICD-10, portal transactions that reference or leverage diagnosis codes will be updated. When submitting referrals, encounters, and authorization requests or when searching for a diagnosis on NaviNet for dates of service or dates of discharge (for facility inpatient claims) on or after October 1, 2015, providers must use ICD-10 codes.

● COB Questionnaire. A new transaction will be introduced with a new Coordination of Benefits (COB) Questionnaire. This electronic form will allow providers to report and submit Other Party Liability coverage for members. Reporting COB information at the time of service will help claims process correctly.

More information about these new and updated transactions will be communicated in the coming weeks and through future editions of Partners in Health Update. In addition, we will also publish new user guides in the NaviNet Resources section of our Provider News Center at www.ibx.com/pnc/navinet to help you better navigate the listed transactions. Announcements will be made on Independence NaviNet Plan Central and on our Provider News Center once the new guides are available.

If you have any questions, please call the eBusiness Hotline at 215-640-7410.

MEDICAL


View up-to-date policy activity on our Medical Policy Portal Changes to our medical and claim payment policies for our commercial and Medicare Advantage Benefits Programs occur frequently 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 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.

To access the Site Activity section, go to our Medical Policy Portal at www.ibx.com/medpolicy 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. You can also get to our Medical Policy Portal through the NaviNet® web portal by selecting the Reference Tools transaction, then Medical Policy.

Chiropractic services policy update On October 1, 2014, policy notifications for Independence Medicare Advantage HMO and PPO members were made available on the Independence Medical Policy Portal. The Medicare Advantage policies were developed in accordance with Centers for Medicare & Medicaid Services (CMS) coverage requirements and became effective on January 1, 2015. Chiropractic Services (#MA10.004) was one of the policies included in the Medicare Advantage book of policies.

Clarification to chiropractic services policyProvider feedback indicated that more clarity was required regarding the criteria in the chiropractic services policy. As a result, both the Policy and Coding and Billing Requirements sections of this policy have been updated to reflect that chiropractic services are covered when both the established coverage criteria and the medical necessity criteria are met in accordance with CMS guidelines.

To review Medical Policy #MA10.004a: Chiropractic Services, visit the Medical Policy Portal at www.ibx.com/medpolicy. Select Accept and Go to Medical Policy Online, select the Medicare Advantage tab from the top of the page, and then type the policy name or number in the Search field.

MEDICAL


Annual Synagis® (palivizumab) distribution program approaches The northeastern part of the United States is approaching the annual respiratory syncytial virus (RSV) season, which is November 2015 through March 2016. RSV is the most common cause of bronchiolitis and pneumonia among children younger than one year. During RSV season, Independence will approve the monthly administration of Synagis® (palivizumab) for children in accordance with the most recent recommendations from the American Academy of Pediatrics (AAP).

It is mandatory for all participating providers to obtain Synagis® (palivizumab) through ACRO Pharmaceutical Services, an independent company.

If you have questions about the Synagis® (palivizumab) distribution program, please contact Customer Service at 1-800-ASK-BLUE. The October 2015 edition of Partners in Health Update will include detailed information about how to order Synagis® (palivizumab), as well as the complete list of recommendations for Synagis® (palivizumab) from the AAP.

Learn moreReview Medical Policy #08.00.22l: Immune Prophylaxis for Respiratory Syncytial Virus (RSV) to learn more. Visit our Medical Policy Portal at www.ibx.com/medpolicy, select Accept and Go to Medical Policy Online, select the Commercial tab, and then type the policy name or number in the Search field.

Note: MedImmune, LLC, the maker of Synagis® (palivizumab), has a voluntary program called RSV ConnectionTM; however, Independence does not participate in this program.

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 use the NaviNet® web portal to view the member’s applicable benefits information. Members should be instructed to call the Customer Service telephone number listed on their ID card.

Reminder: Coverage for injectable drugs that reduce the risk of preterm birth For pregnant women who have a history of preterm birth, Independence covers two injectable drugs to reduce the risk of preterm birth:

● 17-alpha-hydroxyprogesterone caproate (17P), a preservative-free compound ● Makena® (hydroxyprogesterone caproate), which is approved by the U.S. Food and Drug Administration

Both drugs use the same active pharmaceutical ingredients and are available through the Independence Direct Ship Drug Program, but Makena contains preservatives as a result of the manufacturing process. Providers are encouraged to select the drug that is appropriate for each individual patient, given her unique circumstances.

For more information about 17P and Makena, review Medical Policy #08.01.00c: Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies. To do so, go to www.ibx.com/medpolicy, select Accept and Go to Medical Policy Online, select the Commercial tab, and then type the policy name or number in the Search field.

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 additionsThese 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

adapalene lotion Differin® Lotion 5. Skin Medications April 6, 2015

cefixime susp 100 mg/5 ml and 200 mg/5 ml

Suprax® Susp 100 mg/5 ml and 200 mg/5 ml

1. Antibiotics & Other Drugs Used for Infection April 27, 2015

dexmethylphenidate hcl er 10 mg Focalin® XR 10 mg 3. Pain, Nervous System, & Psych February 9, 2015

doxycycline ir-dr Oracea® 1. Antibiotics & Other Drugs Used for Infection April 6, 2015

esomeprazole magnesium* Nexium® 8. Stomach, Ulcer, & Bowel Meds February 23, 2015

lamotrigine odt Lamictal® ODT 3. Pain, Nervous System, & Psych February 2, 2015

metaxalone 400 mg N/A 9. Bone, Joint, & Muscle April 6, 2015

methylphenidate hcl chewable tabs Methylin® Chewable Tabs 3. Pain, Nervous System, & Psych March 16, 2015

metoclopramide hcl Metozolv® ODT 8. Stomach, Ulcer, & Bowel Meds April 13, 2015

naproxen cr Naprelan® CR 9. Bone, Joint, & Muscle March 16, 2015

noreth-ethinyl estradiol/iron Generess® FE 10. Female, Hormone Replacement, & Birth Control April 6, 2015

pramipexole er 0.375 mg Mirapex® ER 0.375 mg 3. Pain, Nervous System, & Psych April 27, 2015

pramipexole er 0.75 mg and 1.5 mg

Mirapex® ER 0.75 mg and 1.5 mg 3. Pain, Nervous System, & Psych February 16, 2015

trandolapril-verapamil er Tarka® 4. Heart, Blood Pressure, & Cholesterol March 2, 2015

triamcinolone acetonide spray Kenalog® Spray 5. Skin Medications April 27, 2015

*Generic requires prior authorization.

continued on the next page

PHARMACY


Brand deletionsEffective October 1, 2015, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Generic drug Formulary chapter

Generess® FE noreth-ethinyl estradiol/iron 10. Female, Hormone Replacement, & Birth Control

Mirapex® ER pramipexole er 3. Pain, Nervous System, & Psych

Oracea® doxycycline ir-dr 1. Antibiotics & Other Drugs Used for Infection

The generic drugs for the above brand drugs are on our formulary and available at the generic formulary level of cost-sharing.

Effective October 1, 2015, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Formulary therapeutic alternative Formulary chapter

Alkeran® cyclophosphamide 2. Cancer & Organ Transplant Drugs

Epivir® HBV Sol adefovir, entecavir, lamivudine 1. Antibiotics & Other Drugs Used for Infection

Fareston® exemestane, letrozole, tamoxifen 2. Cancer & Organ Transplant Drugs

Hexalen® etoposide, letrozole, tamoxifen 2. Cancer & Organ Transplant Drugs

Kristalose® lactulose solution 8. Stomach, Ulcer, & Bowel Meds

Myleran® cyclophosphamide, Gleevec® 2. Cancer & Organ Transplant Drugs

Novoseven® RT Advate®, Feiba® NF, Hexilate® FS, Recombinate® 4. Heart, Blood Pressure, & Cholesterol

Rixubis® AlphaNine® SD, BeneFix®, Humate-P® 4. Heart, Blood Pressure, & Cholesterol

Viramune® XR 100 mg Atripla®, Complera®, nevirapine 200 mg, Sustiva® 1. Antibiotics & Other Drugs Used for Infection

Wilate® AlphaNine® SD, BeneFix®, Humate-P® 4. Heart, Blood Pressure, & Cholesterol

There are no generic equivalents for the above brand drugs; however, there are formulary therapeutic alternative drugs. These therapeutic alternative drugs are available at the appropriate formulary level of cost-sharing. We encourage you to discuss formulary alternatives with your patients.

continued from the previous page

PHARMACY


Prescription drug updatesFor 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 authorizationThe 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

Cholbam® Not available 8. Stomach, Ulcer, & Bowel Meds April 6, 2015

Corlanor® Not available 4. Heart, Blood Pressure, & Cholesterol April 27, 2015

CosentyxTM Not available 5. Skin Medications February 9, 2015

Cresemba® Not available 1. Antibiotics & Other Drugs Used for Infection March 30, 2015

EntrestoTM Not available 4. Heart, Blood Pressure, & Cholesterol July 13, 2015

EvekeoTM Not available 3. Pain, Nervous System, & Psych February 2, 2015

Farydak® Not available 2. Cancer & Organ Transplant Drugs March 9, 2015

Glyxambi® Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones February 9, 2015

Ibrance® Not available 2. Cancer & Organ Transplant Drugs February 9, 2015

JadenuTM Not available 15. Diagnostics & Miscellaneous Agents April 13, 2015

Lenvima™ Not available 2. Cancer & Organ Transplant Drugs February 23, 2015

N/A fentanyl 37.5 mcg, 62.5 mcg, 87.5 mcg/hr patch 3. Pain, Nervous System, & Psych March 2, 2015

NatestoTM Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones March 16, 2015

Natpara® Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones April 6, 2015

Novoeight® Not available 4. Heart, Blood Pressure, & Cholesterol March 16, 2015

Saxenda® Not available 3. Pain, Nervous System, & Psych April 13, 2015

Zubsolv® 8.6-2.1 mg Not available 3. Pain, Nervous System, & Psych February 9, 2015


PHARMACY


Effective October 1, 2015, the following non-formulary drugs will be added to the list of drugs requiring prior authorization:


Inderal® LA propranolol er 4. Heart, Blood Pressure, & Cholesterol

Oracea® doxycycline ir-dr 1. Antibiotics & Other Drugs Used for Infection

Pennsaid® 2% drops Not available 9. Bone, Joint, & Muscle

Tenoretic® atenolol/chlorthalidone 4. Heart, Blood Pressure, & Cholesterol

Tenormin® atenolol 4. Heart, Blood Pressure, & Cholesterol

Viibryd® Not available 3. Pain, Nervous System, & Psych

Wellbutrin® XL bupropion hcl xl 3. Pain, Nervous System, & Psych

Zorvolex® Not available 9. Bone, Joint, & Muscle

Effective October 1, 2015, the following drug category has been added to the list of drugs requiring prior authorization, and these requirements apply to all members:

Category

Compound products with total ingredient cost equal to or greater than $75 per prescription*

*All compounds will be covered at the appropriate non-formulary brand level of cost-sharing.

Drugs with quantity limitsQuantity 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

Aciphex® tabs rabeprazole tabs 60 tabs per 30 days October 1, 2015

Cresemba® Not available 68 caps per 30 days March 30, 2015

Dexilant® Not available 60 caps per 30 days October 1, 2015

Dilaudid® 1 mg/ml liquid hydromorphone 1 mg/ml liquid 360 ml per 30 days October 1, 2015

Entresto™ Not available 60 tabs per 30 days July 13, 2015

Evekeo™ 5 mg Not available 90 tabs per 30 days February 2, 2015

Evekeo™ 10 mg Not available 180 tabs per 30 days February 2, 2015

N/A fentanyl 37.5 mcg, 62.5 mcg, 87.5 mcg/hr patch 15 patches per 30 days March 2, 2015

Nexium® caps esomeprazole caps 60 caps per 30 days October 1, 2015

Prevacid® caps lansoprazole caps 60 caps per 30 days October 1, 2015



PHARMACY


Brand drug Generic drug Quantity limit Effective date

Prilosec® caps omeprazole caps 60 caps per 30 days October 1, 2015

Protonix® tabs pantoprazole tabs 60 tabs per 30 days October 1, 2015

Restasis® Not available 60 droperettes per 30 days October 1, 2015

Tussionex® ER susp hydrocodone/chlorpheniramine ER susp 120 ml per 30 days October 1, 2015

Zubsolv® 8.6-2.1 mg Not available 60 tabs per 30 days February 9, 2015

Drugs no longer requiring prior authorizationEffective July 1, 2015, the prior authorization requirement was removed for the following drugs:


Chantix® Not available 15. Diagnostics & Miscellaneous Agents

Toujeo Solostar® Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones

various nicotine gum, lozenges, patches, and sprays 15. Diagnostics & Miscellaneous Agents

Zyban® bupropion 15. Diagnostics & Miscellaneous Agents

For additional information on pharmacy policies and programs, please visit www.ibx.com/rx.


PRODUCTS


Introducing Keystone 65 Focus Rx HMO, our new defined-network Medicare Advantage plan Independence will introduce Keystone 65 Focus Rx HMO (Keystone 65 Focus), a new Medicare Advantage plan beginning January 1, 2016.

Keystone 65 Focus is a defined-network plan with more than 23,000 participating providers in southeastern Pennsylvania. Keystone 65 Focus members will enjoy the same benefits as broader-network plans while taking advantage of lower premiums and out-of-pocket costs due to their more defined network of quality providers.

In addition, members will have added benefits such as: ● routine chiropractic and podiatry visits; ● optional preventive dental, routine vision, and hearing benefits; ● lower maximum out-of-pocket limit; ● lower prescription drug copayments.

More information coming soonLater in September, we will mail providers in our HMO network their eligibility status for the Keystone 65 Focus network. Then in the October 2015 edition of Partners in Health Update, we will publish more detailed information about Keystone 65 Focus, including premiums, covered services, and cost-sharing amounts (i.e., coinsurance, deductibles, copayments).

Since this is a new plan for 2016, please refrain from discussing Keystone 65 Focus with your patients prior to October 1. In addition, please keep in mind that providers must remain neutral when assisting patients with enrollment decisions. Any discussions with patients should be an objective assessment of the patient’s needs and potential options.

After October 1, 2015, if you have Medicare patients who are interested in learning more about Keystone 65 Focus, please have them contact Customer Service toll-free at 1-800-645-3965 (TTY/TDD: 711), 8 a.m. to 8 p.m., seven days a week.

HEALTH AND WELLNESS


Suicide: A concern for all health care providers Part 3 – After screening/assessing: How to assure safety of the person who is at risk for suicideWhen it is determined that a patient is at risk for suicide, there could be many responses by the provider. One response that is becoming the standard for both behavioral health providers (BHP) and primary care physicians (PCP) is the Suicide Care Management Plan.1 The plan is developed in collaboration with the patient during an open discussion with the goal of preventing the patient from acting on his or her suicidal impulses. This response uses the healthy connectedness of the relationship between the provider and patient to promote coordination and collaboration that will assure safety for the patient. However, some patients are reluctant to tell providers that they may have suicidal ideas. For some, they are embarrassed, and for others, they may fear being hospitalized. In such cases, it is the responsibility of the provider to develop the trusting relationship that encourages all patients to talk openly about their concerns.2

For the PCP, an important aspect of the plan is to ensure that the patient is seen that same day by a BHP. If a BHP is not immediately available, contact Magellan Healthcare, Inc. by calling the phone number on the back of the member’s ID card and choosing the “Crisis” option to find providers. Another option is to refer the patient to a Crisis Center for a behavioral health evaluation. A list of local crisis centers will be available on www.ibx.com and the NaviNet® web portal in the next few months.

For both the PCP and BHP, the Suicide Care Management Plan should also include the self-management techniques the patient will use to maintain his or her safety, which includes preventing access to means for suicide and how the patient will involve his or her support systems to enhance efforts to stay safe. Another important aspect of the plan includes follow-up with the patient to evaluate his or her status and make modifications, if necessary.3

Most importantly, all health care providers should do the following for a patient who is at risk for suicide: ● Discuss their concerns and Suicide Care Management Plan directly with the patient. ● Make sure the plan is brief and clear and that the patient has a copy. ● Encourage involvement of support systems. ● Always act for the safety of the patient.3

1www.zerosuicide.com2Jobes, D, et al. Ethical and competent care of suicidal patients: Contemporary challenges, new developments, and considerations for clinical practice (2008). Professional Psychology: Research and Practice, Vol 39(4), Aug 2008, 405-413.3Stanley, B., & Brown, G. (2012). Safety Planning Intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. See more at http://zerosuicide.sprc.org/resources/safety-planning-intervention-brief-intervention-mitigate-suicide-risk#sthash.I6pNi6k5.dpuf.

Magellan Healthcare, Inc., an independent company, manages mental health and substance abuse benefits for most Independence members.

We are pleased to introduce the third in a short series of articles in Partners in Health Update, “Suicide: A concern for all health care providers,” that is designed to provide you with information on suicide and the importance of your role in assessing your patients who may be at risk.

http://zerosuicide.sprc.org/resources/safety-planning-intervention-brief-intervention-mitigate-suicide-isk%20-%20sthash.I6pNi6k5.dpuf

http://zerosuicide.sprc.org/resources/safety-planning-intervention-brief-intervention-mitigate-suicide-isk%20-%20sthash.I6pNi6k5.dpuf

www.zerosuicide.com

HEALTH AND WELLNESS


Let’s Go See initiative raises awareness of vision problems in childrenThis back-to-school season, Visionworks® and Davis Vision, independent companies, have teamed up to raise awareness of the importance of annual eye exams for children. This initiative, aptly named Let’s Go See, will not only serve as a public awareness campaign, but it will also help 10,000 children in need receive free eye exams and eyeglasses. Independence encourages physicians, especially pediatric physicians, to promote the Let’s Go See initiative.

Did you know that one in four children has a vision problem? According to Prevent Blindness America, 60 percent of children labeled as problem learners have an undetected vision problem. Many U.S. parents simply don’t know their children have a vision problem or don’t have the means to afford routine vision care. Let’s Go See commits to raising awareness of vision problems in children throughout the U.S. and the importance of an annual eye exam.

Please visit the Let’s Go See website at www.letsgosee.net for more information and to nominate a child, school, or organization in need of free comprehensive eye exams and eyeglasses.

Administered by Davis Vision, an independent company. An affiliate of Independence Blue Cross has a financial interest in Visionworks.

Visit our Provider News Center: www.ibx.com/pnc

*Outside 215 area code

Important Resources

Anti-Fraud and Corporate Compliance

Hotline 1-866-282-2707 or www.ibx.com/antifraud

Care Management and Coordination

Baby BluePrints® 215-241-2198 / 1-800-598-BABY (2229)*

Case Management 1-800-313-8628

Condition Management Program 1-800-313-8628

Credentialing

Credentialing Violation Hotline 215-988-1413 or www.ibx.com/credentials

Customer Service

Provider Services 1-800-ASK-BLUE (1-800-275-2583)

Provider Services user guide www.ibx.com/providerautomatedsystem

Electronic Data Interchange (EDI)

Highmark EDI Operations 1-800-992-0246

FutureScripts® (commercial pharmacy benefits)

Prescription drug prior authorization 1-888-678-7012

Pharmacy website (formulary updates, prior authorization) www.ibx.com/rx

FutureScripts® Secure (Medicare Part D pharmacy benefits)

FutureScripts Secure Customer Service 1-888-678-7015

Formulary updates www.ibxmedicare.com

NaviNet® web portal

Independence eBusiness Hotline 215-640-7410

Registration www.navinet.net

Other frequently used phone numbers and websites

Independence Direct Ship Drug Program (medical benefits) www.ibx.com/directship

Medical Policy www.ibx.com/medpolicy

Provider Supply Line 1-800-858-4728 or www.ibx.com/providersupplyline

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