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Table of contents

Chief Medical Officer Comments and New Guideline Application .....................1

Chief Medical Officer Comments and Pharmacy Corner .......................................2

Allergic Rhinitis ............................................3

Improving Continuity of Care for Children with ADHD ..................................4

Promoting Good Outcomes for Depression Management .......................5

Utilization Management ..........................5

Who to call? ..................................................6

AETNA BETTER HEALTH® OF TEXASProvider Relations newsletterSummer 2017

TX‑17‑05‑09

www.aetnabetterhealth.com/texas

Chief Medical Officer Comments and New Guideline ApplicationJim Small, MD, MPH, MMM, FACPM

I would like to thank all of our physicians and providers for your concern and conscientious delivery of quality care to your patients and our members of Aetna Better Health ‑ Texas. We know it is not easy to provide care, manage or participate in necessary business activities, and successfully negotiate all of the external administrative demands from payers and government agencies.

We at Aetna want to work with you in providing quality care. We exist not only to reimburse you for appropriate services you deliver, but to work with you and the State to promote better health for the Star and CHIP populations. To that end we incentivize providers for quality (as measured by certain HEDIS metrics) and we work to ensure benefits are provided at an appropriate level of care and place of service. One of the processes we use to help ensure that the appropriate level of care and place of service is occurring is utilization review where requests are reviewed against established guidelines. At times, we realize this can cause some friction between the requesting provider and us.

Approximately two years ago we delegated OB ultrasound reviews to eviCore, formerly known as Med Solutions. With some members receiving a high number of OB ultrasounds per gestation, upwards 50 OB ultrasounds per gestation, we thought it prudent to have eviCore apply established and periodically evaluated guidelines to OB ultrasound requests. Basically the first four OB ultrasounds are auto approved with notification to eviCore. Subsequent ultrasounds require a prior authorization by eviCore. More specifically, for a woman presenting during the 1st trimester CPT codes 76801, 76805, 76813, and 76816 are auto approved with notification. For a woman presenting in the 2nd or 3rd trimester CPT codes 76805 and 76816 will be auto approved with notification. Batch requests may receive

Continued on page 2

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Chief Medical Officer Comments and New Guideline Application Continued from page 1

a prior authorization for high risk pregnancies.

Effective September 5, 2017 we will also be delegating the review of approximately 56 outpatient cardiac imaging requests for Star (not STAR Kids) and CHIP to eviCore. Requests will be taken as of August 22 for outpatient cardiac procedures to be scheduled on or after

September 5. Additionally, there will some training sessions offered in August to explain the process of requesting a review and authorization for cardiac imaging. Details on the outpatient cardiac imaging process will be forthcoming in a letter that should be received by early June for those providers that would request these procedures.

Pharmacy CornerAetna Better Health of Texas in order to meet NCQA standards must notify providers of all Vendor Drug Program formulary additions, deletions and changes. The following changes have been made to the VDP Preferred list and Non Preferred Drug list.

Preferred Drug List

Brunavil (buprenonorphine/naloxone) Cosentyx (secukinumab)

Dyanavel (amphetamine) Epclusa (Velpatasvir/sofosbuvir)

erythromycin base glyburide/metformin

Granix (tbo‑ gilgrastim) halobetasol

metformin XR Neupogen (filgrastim) vial

Quillachew ER (methylphenidate) tindazole (gastrointestinal antibiotic)

Valcyte Tablets (antivirals) Viekera XR

Non Preferred Drug List

Adzenyz ODT (amphetamine) alogliptin

alogliptin/metformin alogilptin/pioglitazone

Bydureon Erythrocin

Flurandrenolide Fortamat

glipizide/metformin Glucophage

Glucophage XR Glumetza

Humalin 500 units/ml pen Jentadueto XR

Luekine (sargrasmastim) metformin ER (Fortamet and Glumetza)

Nanmenda XR (Alzheimer agent) neomycin/polymixin/gramicidin ophthalmic suspension

Ocaliva (obeticholic acid) Bile Salts olopatadine

oxiconazole Ozentra Xsail (sumatriptan)

paliperidone pimozide

Prednisone Dose pak repaglinide

Riomet sulfacetamide ointment and suspension Sernivo (betamethasone propionate)

sulfacetamide ointment and suspension Tinadamax (tindazole) gastrointestinal antibiotic

Tobradex Suspension ophthalm tolnafate

Triamincinolone aerosol and lotion Trintellix (vartioxetine) antidepressant

Valcyte Solution valganciclovir tablets

XTampza XR (analgesic non narcotic) Xrylix (diclofenac)

Vraylar (cariparizine) antipsychotics Zario (filgrastim‑Sndz)

Zembrace Symtouch (sumatriptin) Zepitier

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Allergic RhinitisSecond‑generation antihistamines may be prescribed first line for allergic rhinitis. Along with prescribing appropriate medication, it important to counsel members and caregivers on environmental controls (Children’s Hospital of Philadelphia: http://www.chop.edu/conditions-diseases/allergic-rhinitis). Intranasal steroids are useful for the management of allergic rhinitis when a second‑generation oral antihistamine alone is not sufficient.1 Currently, no studies prove superiority of one intranasal corticosteroid product over another. See below the available preferred agents on the Texas Medicaid Formulary, preferred product categories are highlighted in yellow.

This summary provides the available products and their Texas Medicaid Preferred Drug List status.

TEXAS VENDOR DRUG PROGRAM FORMULARY2*ALLERGIC RHINITIS – NASAL AGENTS

Highlights represent preferred status in 2016

PREFERRED AGENTS NON‑PREFERRED AGENTS

Corticosteroids‑Nasal

Brand Generic Brand Generic

NASONEX (mometasone)

fluticasone (generic Flonase) BECONASE AQ (beclomethasone)FLONASE (fluticasone)FLONASE OTC (fluticasone)NASACORT OTC (triamcinolone)NASACORT AQ (triamcinolone)OMNARIS (ciclesonide)QNASL (beclomethasonedipropionate)RHINOCORT AQUA (budesonide)triamcinoloneVERAMYST (fluticasonefuroate)isolide)ZETONNA (ciclesonide)

budesonidelunisolide

Antihistamines‑ Nasal

Brand Generic Brand Generic

PATANASE (olopatadine)PAZEO (olopatadine)

ASTELIN (azelastine)ASTEPRO (azelastine)ATROVENT (ipratropium) nasal spray

azelastine ipratropium nasal sprayipratropium nasal spray

Combinations

Brand Generic Brand Generic

DYMISTA (azelastine/fluticasone)

TEXAS VENDOR DRUG PROGRAM FORMULARY2*ALLERGIC RHINITIS – ORAL SECOND GENERATION ANTIHISTAMINES

(NON SEDATING OR MINIMALLY SEDATING)

Brand Generic Brand Generic

cetirizine solution, tabletsloratadine ODT, solution, tablets

ALLEGRA (fexofenadine) CLARINEX (desloratadine) CLARITIN (loratadine) XYZAL (levocetirizine) ZYRTEC (cetirizine)

cetirizine chewable desloratadinefexofenadine levocetirizine

References:1

Wallace DV, Dykewicz MS, Bernstein DI, Blessing‑Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122:S1–S84.2 TX‑VDP Formulary (Last Update July 2013)

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Improving Continuity of Care for Children with ADHDAttention‑deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders of childhood and often continues into adulthood. Children with ADHD have trouble paying attention and controlling impulsive behavior such that it often interferes with their daily lives at home, at school, at work, and in social settings. ADHD can have serious consequences on a child’s development, including difficulty making friends or being accepted by his/her peers.

Aetna Better Health Texas supports the recommendation and guidelines of the American Academy of Pediatrics: ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention‑Deficit/Hyperactivity Disorder in Children and Adolescents. These ADHD guidelines are intended for use by a primary care provider working in a primary care setting to assess, diagnose, treat, and refer a patient, if needed, to a behavioral health specialist. According to the guidelines the PCP should initiate the evaluation and if the patient is thought to have ADHD he/she should prescribe medication and encourage parent and/or teacher administered behavior therapy. Both behavior therapy and medications have been demonstrated to reduce behaviors associated with ADHD and improve function.

Follow up recommendations for children include 3 follow up visits over a 10 month period. The 1st appointment should occur within 30 days after the child begins medication. The next follow‑up appointments should occur over the next 9 months.

Tips for Providers:• Schedule the initial follow‑up appointment for 2‑3 weeks

and complete this task before the patient leaves the office.

• Educate the parent/guardian about ADHD. • Encourage the parent/guardian to ask questions about

ADHD.• Encourage the parent/guardian to call the office if they

have any concerns about the medication before the next appointment.

• Educate the parent/ guardian about the importance of follow‑up care.

• Encourage the parent/ guardian to consider therapy and learn how to manage ADHD behaviors in the home.

• No refills unless the child has the initial follow‑up visit.• After the initial follow‑up visit, schedule at least 2 more

visits over the next 9 months to check the child’s progress.

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Promoting Good Outcomes for Depression ManagementPrescription of antidepressant medications has been shown to be a critical part of the effective care of patients with depression. The consequences of untreated or inadequately treated depression are significant, and taking antidepressant medication correctly is a very important part of appropriate treatment. When medications are used together with appropriate forms of psychological therapy, most patients experience good outcomes. Patients need to be monitored very carefully during the first three to six months of treatment so that the clinician can adjust the dosage or type of medication, if necessary. Taking the correct medication as it is prescribed and for the prescribed amount of time is vitally important to the long‑term health and well‑being of the patient.

Aetna Better Health Texas supports the recommendation and guidelines of the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition. When pharmacotherapy is part of the treatment plan, it must be integrated with the psychiatric management and any other treatments that are being provided. Patients who have started taking an

antidepressant medication should be carefully monitored to assess their response to pharmacotherapy as well as the emergence of side effects, clinical condition and safety.

Tips for Providers:• Schedule follow‑up appointments before the patient

leaves the office.• Educate the patient about their diagnosis and treatment

plan.• Encourage the patient to ask questions about depression

and ongoing care.• Inform the patient that the medication may take several

weeks to become effective.• Inform the patient about potential side effects/ reactions

and encourage them to call the office with their concerns.• Inform the patient that they should not stop medication

abruptly and call the office for assistance.• Stress the importance of medication compliance.• Encourage therapy to address life stressors and build

healthy coping skills.• Outreach patients that cancel appointments and have

not rescheduled.

Utilization ManagementThe purpose of the utilization management department is to coordinate delivery of the best possible care to members and manage the use of health‑care resources to ensure an effective and efficient physical and behavioral health care delivery system.

The UM department adheres to the below timelines for making coverage determinations.• Within 3 business days after receipt of the request for

routine authorization of services• Within 1 business day after receipt of the request for

urgent authorization of services• Within 1 business day for concurrent hospitalization

decisions

Requests for urgent care services that do not qualify as urgent will be handled within the routine authorization of services timeline. Routine care or elective surgeries are examples of care that typically would not qualify as urgent.

To avoid rescheduling of appointments, please keep in mind the timelines above for making coverage determination prior to the appointment being made.

The following are the fax numbers to submit your requests. Please submit the Texas Standard Prior Authorization of Services form and include all pertinent information, ICD 10 code(s), dates of service and signature.

• STAR Kids Long Term Services and Supports (LTSS) Fax: 1-866-275-5728

• Acute Services Prior Authorization Fax: 1-866-835-9589• Concurrent Review: 1-866-706-0529

To prevent delays in processing requests, please submit requests on the correct form and fax to the designated fax number.

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Who to call?Provider Relations and Member Services lines:Medicaid ‑ Bexar 1-800-248-7767Medicaid ‑ Tarrant 1-800-306-8612CHIP ‑ Bexar 1-866-818-0959CHIP ‑ Tarrant 1-800-245-5380

Superior Vision1-800-879-6901

LogistiCare‑Medical Transportation (For Medicaid members only)1-877-633-8747 (Aetna Bexar County)1-855-687-3255 (Aetna Tarrant County)

Nurse Line1-800-556-1555

Behavioral Health Provider Credentialing1-800-999-5698

Report Fraud, Waste or Abuse1-800-436-6184

Fax Numbers

Aetna Prior Authorization fax#1-866-835-9589

Aetna Inpatient Authorization fax#1-866-706-0529

Behavioral Health Prior Authorization fax #1-855-857-99321-855-841-8355 (Concurrent Review)

Dental

MCNA Dental1-855-494-6262

Denta Quest1-800-516-0165 (Medicaid)1-800-508-6775 (CHIP)

Vital Savings (adults only)1-888-238-4825

CVS Caremark (Pharmacy)

CVS Caremark Help Desk1-877-874-3317BIN# 610591 PCN: ADVGROUP# RX8801

Prior Auth Call In1-855-656-0363

Prior Auth fax1-866-255-7534

AETNA BETTER HEALTH® OF TEXASProvider RelationsP.O. Box 569150Dallas, TX 75356‑9150