may 2013 network news - premera blue cross · an independent licensee of the blue cross blue shield...

News from Premera Blue Cross Blue Shield of Alaska

An Independent Licensee of the Blue Cross Blue Shield Association

May 2013

newsNetwork

CompaNy UpdatesChoosing Wisely

collaborates with

the national

medical specialty

associations to

identify services that

may be unnecessary

or cause harm.

More Specialty Lists Added to Choosing Wisely® Campaign

Choosing Wisely is a national campaign sponsored by physicians and their medical societies that promotes patients getting the right care at the right time. Designed to encourage conversations between physicians and patients about getting the most appropriate care,

Choosing Wisely collaborates with the national medical specialty associations to identify services that may be unnecessary or cause harm.

The campaign recently released 17 new specialty lists with the following highlights: ◗ American Academy of Family Practice (AAFP) released an additional five lists ◗ American College of Obstetrics & Gynecology (ACOG) and AAFP both address pre-term

inductions of labor ◗ Several societies made references to inappropriate imaging studies (including some societies

in which imaging is their mainstay)We encourage you to visit choosingwisely.org to review more than 25 lists

of recommendations. Patients can check out the Consumer Reports resource at consumerhealthchoices.org/campaigns/choosing-wisely/.

Premera Partners with Alere™ Women’s & Children’s Health for Maternity and Newborn Programs

Premera is partnering with Alere Women’s & Children’s Health, to bring Maternity and Newborn Programs to eligible members.

The Maternity Program will provide education and support services to all eligible pregnant members and case management services for those eligible members identified as high-risk, effective Sept. 1, 2013.

The Newborn Program will provide on-site or telephonic case management, and will assist facility staff in providing discharge planning, support, and resources for parents effective, July 1, 2013. It will also include concurrent review for neonatal intensive care unit (NICU) services effective Aug. 1, 2013. Watch for more details coming soon.

Alere is a trademark of the Alere group of companies.

ContentsCompany Updates page 1-2

Online Services Updates page 3-5

Claims & Payment Policy Updates page 6-7

Reminders & Tips page 8

Administrative Resources page 9-10

Pharmacy Updates page 11

Medical Policy Updates page 12-14

Prior Authorization/POS Edit page 15-16 Program Expansion

Biotech/Point Of Sale (POS) page 17-19 Edit Expansion

May 2013 Alaska Network News 1

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Company Updates

Wellness Package Promotes Biometric ScreeningBiometric screenings covered under the member’s preventive health benefit

In July 2012, Premera introduced a new wellness package for our employer groups that combines

health assessments and biometric screenings. As part of this program, members can go to their provider’s office for biometric testing.

Providers should be aware that biometric screenings such as cholesterol, blood pressure, blood sugar, heart rate, and body mass index (BMI) are covered under preventive benefits.*

Biometric screening and health assessments are part of Premera Blue Cross Blue Shield of Alaska’s wellness program to raise member awareness and educate members about lifestyle changes that can improve their health and quality of life.

The combination of screening tests were selected to give members information about the most common health risk areas and what decisions

they need to make about maintaining or enhancing health and quality of life.

Here are some important details regarding biometric screening: ◗ An exception can be made if a

provider believes it is unreasonably difficult for a member to complete a biometric screening due to a medical condition.

◗ Providers should inform the member when additional tests are being conducted, as these may be subject to deductible, copay, and coinsurance.

◗ If a member has participated in a screening within the past 12 months, those results can be provided to Vivacity (Premera’s wellness provider) as long as they were not used to submit for a prior year’s reward program.

◗ Using an out-of-network provider may result in charges for the screening.

◗ When billing preventive services for Premera members, providers should always verify member benefits by using the online Eligibility & Benefits Tool on premera.com/ak/provider, or by calling the Customer Service number on the back of the member’s ID card.

◗ Either the member or the provider may fax the Member Biometric Screening form to Vivacity at 425-918-5075 or 877-657-4183.

The Member Biometric Screening form can be found on premera.com/ak/member (Member Services > Manage My Account > Forms > Miscellaneous).

*Regardless of a member’s plan status, age and/or frequency, limits may still apply for some preventive benefits (such as one service per calendar year). Once the frequency limitation(s) are exceeded, Premera will deny any further claims for those procedures if they are coded as preventive.

online ServiCeS Updates

Improvements to Premera’s Eligibility & Benefits Tool

In late March, Premera Blue Cross Blue Shield of Alaska launched new features and improvements to the Eligibility & Benefits Tool on our provider website. The new features

are to help providers save time by checking patients’ eligibility and benefits online, reducing the need to call for benefit-related information.

Providers can use the tool to search eligibility and benefits for Premera, out-of-area BlueCard, FEP, and NASCO members. BlueCard member information is available through BlueExchange, a program across all Blue Cross Blue Shield (BCBS) plans that allows providers access to patient information electronically, regardless of which BCBS plan houses the membership information.

The new tool includes an improved member search page and an improved summary page with benefit information available by service type.

The Eligibility & Benefits Search page [see Figure 1] has fewer required fields and includes a drop-down list of benefit types for both Premera and BlueCard members (previously only available for BlueExchange inquiries).

On the new Eligibility & Benefits summary page [see Figure 2], the Premera member, subscriber, and group details now appear at the top, like the existing BlueExchange summary. For Premera member searches, the new summary combines several separate pages of information into one with expandable sections: Plan Eligibility, Plan Messages, Deductibles and Maximums, Benefits, and Other Payer.

Also for Premera member searches, the Benefit Summary page now includes both Eligibility and Claims tabs. Selecting the Claims tab will automatically submit a claims inquiry for that member.

During this initial phase, the vision hardware and dental benefits sections will temporarily indicate only either Active Coverage or Non-covered. In the coming months, however, functionality will be restored first for vision hardware and then dental benefits—with even more detail than previously available. In the meantime, please call the number on the back of the member ID card for benefit information.

Additional enhancements will be made in the coming months. Please check our website regularly for updates.

For more information

Additional information regarding the Eligibility & Benefits Tool will be posted at premera.com/ak/provider. If you have questions about the Eligibility & Benefits Tool, call Physician and Provider Relations at 800-722-4714, option 4.

Figure 1: Member search page with BlueExchange option checked

Figure 2: Eligibility & Benefits summary page


online ServiCeS Updates online ServiCeS Updates

How to Use the Change Clinic/Facility tool

If your OneHealthPort login is affiliated with more than one organization, you can use the “Change Clinic/Facility” tool to change affiliations at any time. When using our secure website tools, remember that the organization under which you’re

currently logged in gives you access only to that particular organization.In the example below, the active affiliation is displayed in the upper right corner.

To switch to another organization you’re affiliated with, simply click on the Change Clinic/Facility tool and make your selection. It’s that easy! If you have questions about this tool, please contact Physician and Provider Relations at 800-722-4714, option 4.

Premera Mobile App for Windows 8 and Kindle Fire Now Available

Now Premera members have two more ways to connect to their health plan information while on the go. The newest Windows 8 app is now available in the Windows Phone Marketplace, designed for Windows 8 Surface and PC users. The app has also recently been optimized for the Kindle Fire and is available for download on Amazon.

The Premera Mobile app allows users to quickly search for in-network providers with our Find a Doctor tool, locate nearby hospitals or urgent care facilities, connect to Customer Service or 24-Hour NurseLine with one touch, and use their mobile phone as a convenient backup for their Premera ID card to show proof of healthcare coverage. The app is available at premera.com/ak/visitor/mobile/.

New! Access to Cost and Quality Information via Find a Doctor Tool

Providers can now access cost and quality information using our Find a Doctor tool. Simply log in to our secure provider website where you can: ◗ See the providers who participate in a member’s network ◗ View the cost for a particular procedure, service or treatment ◗ Find a provider in convenient location for your patient.

This information can help you make recommendations to your patients based on quality, cost, member coverage and provider location. We encourage you to check it out today.

New Appeal Authorization Form Now Available

If you need to submit an appeal on behalf of one of our members, please use the Appeal Authorization Form, now available at premera.com/ak/provider (Library > Forms >

Claims and Billing). This form must be signed by the member authorizing release of healthcare information and records.

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ClaimS & Payment Policy Updates

Helpful Tips for Corrected Claims and RebillingCorrected Claims

A corrected claim is any claim that has changes or corrections to one of the following: ◗ Diagnosis code ◗ Date of service/date span ◗ Total charges or units billed ◗ Member/patient information ◗ Provider information ◗ Originally submitted procedure/CPT

code ◗ Modifier on a previously processed

claimNote: If a claim is missing critical

information and we are unable to process it, we will return it with instructions. These are not considered ‘corrected claims’ and should be resubmitted as new claims. Submitting these as new claims will expedite handling. See “Rebilling and Other Items” below for more information.

Electronic Claims

If you have the capability, please submit a corrected claim electronically using the HIPAA 837 standard claims transaction, as follows: ◗ Frequency code 5: Use for late charges

only. ◗ Frequency code 7: Use to submit

a corrected replacement claim, indicating what needs to be changed or corrected. o Note: When billing a Frequency 7, bill all services from the original claim, including the corrected services. Do not bill only the line you are changing, as this will be the only line paid on the claim.

◗ Include the payer’s initial claim number if known.

◗ Use Loop 2300, NTE02 segment to submit a claim level note remark electronically.

Verify filing guidelines in your provider contract. Contact EDI with questions: 800-435-2715 or [email protected].

Paper Claims

For paper claims, always attach the corrected claim to the completed Corrected Claim Standard Cover Sheet located at premera.com/documents/013063.doc

Complete each section, including the reason and any specific information regarding the line item or claim information that was corrected. The cover sheet is available online at premera.com/ak/provider (Library > Forms > Claims and Billing). ◗ Bill all services from the original

claim, including the corrected services. Do not bill only the line you are changing, as this will be the only line paid on the claim.

◗ Complete all required fields. ◗ Provide the original claim number. ◗ Attach the corrected CMS 1500 or

UB04. ◗ Give specific correction instructions.

Note: Do not use highlighter or red ink, as our imaging system blacks out most highlighting and colors. Also, make sure that all sticky notes are removed.

Rebilling and Other Items

If a claim is missing critical information and we are unable to process it, we will return it with instructions on what information is needed. These are not considered corrected claims and should be resubmitted as new claims to ensure proper processing.

Critical claims data elements include: ◗ Name of subscriber ◗ Name of enrollee who incurred the

expense ◗ Member ID number ◗ Provider name ◗ Provider address ◗ Provider tax ID number ◗ Date of service ◗ Diagnosis code (ICD-9) ◗ Procedure code (CPT-4, HCPCS,

ADA, NDC, or Revenue Code) and descriptive English nomenclature for each service

◗ Itemized billed charges for each service rendered.

The following items also should not be sent as corrected claims: ◗ Accident investigation forms ◗ Massage therapy prescription forms ◗ Submission of additional information

(i.e., medical records, Explanation of Medicare Benefits). Please refer to the specific instructions included in the corresponding letter or form. Be sure to include the claim number only and not the claim form.

ClaimS & Payment Policy Updates

Payment Policy Notification for Qualitative Drug Screening

Premera is implementing a new payment policy for qualitative drug screening following the Centers for Medicare and Medicaid Services’ (CMS) guidelines. CPT codes 80100,

80101 and 80104 will no longer be reimbursed for qualitative drug screening. Providers will need to bill the appropriate HCPCS codes when billing for this service.

As stated in Medicare guidelines: if you represent an independent lab or office that performs high complexity testing methods, use code G0431. If you perform lab tests other than chromatographic tests, use G0434.

The new policy is effective for any claims with dates of service on or after Aug. 1, 2013. Claims processed with dates of service Aug. 1, 2013 and after with the incorrect code will be denied at the line item level and need to be resubmitted with the correct HCPCS code.

For more information please refer to “Medicare B News Issue 269 April 13 2011- Drug Screen Testing” at noridianmedicare.com, or contact Physician and Provider Relations at 800-722-4714, option 4.

You can view the Qualitative Drug payment policy online at premera.com/ak/provider: (To post Aug. 1, 2013).

CPT Code Range for Molecular Pathology Procedures

On Jan. 1, 2013, CPT code range 81200-81479 was introduced by the American Medical Association (AMA) to provide more current descriptions of the technology required for molecular pathology procedures and to more accurately identify and describe such services.

Molecular pathology procedures are medical laboratory procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g. constitutional disorders) or somatic (e.g. neoplasia) conditions, or to test for histocompatibility antigens (e.g. HLA).

Claims with dates of service after Dec. 31, 2012 that contain CPT codes in the 81200-81479 range will be accepted by Premera. At the same time, Premera will not be accepting claims that contain molecular pathology CPT codes in the 83890-83913 range for any services after Dec. 31, 2012. This code range (commonly referred to as “stacking” codes) was deleted by the AMA on Jan. 1, 2013 following the introduction of the 81200-81479 CPT code range.

For a complete list of medical policies that reference these newly introduced codes, please refer to the Medical Policies section at premera.com/ak/provider/reference/medical-policies/.


. . . . .

. REM

INDERS . .&TIPS

Reminder: ICD-10 Deadline Is Oct. 1, 2014

In August 2012, the Centers for Medicare and Medicaid Services (CMS) announced theICD-10 compliance deadline was

delayed from Oct. 1, 2013 to Oct. 1, 2014. For more information, view ICD-10 Implementation Timelines at CMS.gov.

How Premera Is Preparing for

ICD-10

While ICD-10 implementation impacts processes across our entire family of companies, we are well prepared. Our implementation planning is underway and we are confident we’ll meet the new federal compliance date of Oct. 1, 2014.

We understand this is a significant transition for providers. Our plan includes testing with select providers and clearinghouses in advance. We will monitor claims closely post-implementation to ensure any impacts are identified and resolved early in the process.

Premera works collaboratively with healthcare providers to assist in their compliance efforts regarding the ICD-10 mandate.

Find more ICD-10 information under Quick Links at premera.com/ak/provider.

New FAQ Available on onehealthport.com

Another great resource for providers is an ICD-10 FAQ recently posted at onehealthport.com. The FAQ was produced by the ICD-10 Work Group, a collaboration of health plans and providers in Washington, facilitated by OneHealthPort. The FAQ will be updated on a quarterly basis.

Here are a few sample questions from the FAQ:

Does the ICD-10 mandate apply to paper claims?

ICD-9 codes will no longer be accepted on claims (including electronic and paper) with dates of service (on professional and supplier claims) or dates of discharge/through dates (on institutional claims) on or after October 1, 2014.

See cms.gov/MLNMattersArticles/Downloads/MM7492.pdf

When will the ICD-10 codes stop being accepted?

As long as the date of service/discharge is prior to October 1, 2014, ICD-9 codes will still be valid. Because of claims timely filing limits, appeals, retroactive coverage and other administrative processes can span the implementation date, the length of time that ICD-9 codes can be accepted will vary by payer.

See MLN Article MM7492cms.gov/MLNMattersArticles/downloads/MM7492.pdfcms.gov/MLNMattersArticles/downloads/SE0832.pdfcms.gov/ContractorLearningResources/downloads/JA0832.pdf

Should we expect updates to the Impairment Group Codes (for

Rehab, SNF, etc)? If so, when?

According to the CMS ICD-10 Impact Analysis, Impairment Group Codes will be translated to ICD-10 which will impact current CMS business processes. No specific dates are indicated for these updates to the Impairment Group Codes. The complete CMS ICD-10 Impact Analysis can be found at:cms.gov/Medicare/Coding/ICD10/CMSImplementationPlanning.html

Click the embedded link “ICD-10 Impact Analysis” in the last paragraph under the section “CMS ICD-10 Impact Analysis.”

Are there any providers exempt from having to use ICD-10

codes?

All providers designated as a HIPAA covered entity must use ICD-10. See cms.gov/ICD10/Downloads/ICD-10MythsandFacts.pdf

Realigning Colonoscopy Benefits to Market Standards

In compliance with the Affordable Care Act (ACA), we are updating our payment process for preventive colonoscopy services. For dates of service Aug. 1 , 2013 or after, CPT codes 45381 and 45382 will be reimbursed under the member’s medical

benefit, not preventive.This change is a result of a recent internal claims review which showed that some

colonoscopies have been paid as a preventive benefit (reimbursed at 100%), when in fact they were done for medical indications.

Premera adjudicates colonoscopy claims to meet ACA standards, in accordance with U.S. Preventive Services Task Force guidelines. These guidelines recommend screening colonoscopies every 10 years, from age 50 through 75. For individuals younger than 50, a colonoscopy may be considered preventive when the member has a personal or family history that increases their risk of developing colon cancer.

Send Provider Updates and Changes 30 days in Advance

Please notify Premera of any updates or changes to your practice information 30 days prior to the change. This allows us to update our payment systems and provider directory so your patients have accurate contact information and your payments are sent to the correct address.

Providers can notify Premera of any new information or changes by email, using the Contracted Provider Information Change/Update Form. The form is located at premera.com/ak/provider (Library > Forms > Miscellaneous).

Providers can also send updates by fax at 425-918-4937, email at [email protected] mail to:Premera Blue Cross Blue Shield of AlaskaP.O. Box 327, MS-453Seattle WA 98111-0327

For more information, call Physician and Provider Relations at 800-722-4714, option 4.

National Committee for Quality Assurance (NCQA) AccreditationYou May Have Received or Will Receive a Credentialing Application

Premera Blue Cross Blue Shield of Alaska is in the process of becoming accredited with the National Committee for Quality Assurance (NCQA). It is a requirement of the new Health Care Reform law that insurance carriers must be accredited to sell their products in the Exchange.

One of the NCQA requirements is to assure that practitioners and providers whose name is listed in a directory must be credentialed. If you receive a credentialing application, it means you are listed in a directory and must be credentialed. If you have any questions, please call Physician and Provider Relations at 800-722-4714, option 4.

reminderS & Tips adminiStrative Resources

8 May 2013 Alaska Network News

Practitioner Credentialing NotificationsPractitioner’s Right to Review

Credentialing File

A practitioner has the right to review their credentialing file by notifying the Credentialing Department and request an appointment to review their file. Allow up to seven days to coordinate schedules.

Practitioner’s Right to Correct

Erroneous Information

A practitioner has the right to correct erroneous information. The Plan will notify the practitioner in writing in the event that credentialing information obtained from other sources varies from that supplied by the practitioner’s. The practitioner must explain the discrepancy, may correct any erroneous information, and may provide any proof available.

Practitioner’s Right to be

Informed of Application Status

Practitioner’s have the right upon request to be informed of the status of their credentialing application. Please note that after the initial credentialing process, practitioner’s who are in the recredentialing cycle are considered approved unless otherwise notified.

For more information about these notifications, contact Physician and Provider Relations at 877-342-5258, option 4.


adminiStrative Resources

Notification Regarding Provider Credentialing

Following the initial credentialing process, providers who are in the recredentialing cycle are considered approved unless the provider is otherwise notified. If you have specific credentialing

questions, please call Physician and Provider Relations at 800-722-4714, option 4.

How is Network News working for you?We want to make sure Network News provides you and your staff

with the most useful information to help your practice run efficiently. We appreciate any suggestions you may have, such as if you prefer receiving the newsletter in the mail or online, or any new features we could offer. Please send your comments about Network News in an email to [email protected]. We hope to hear from you!

2013 Holiday Business Closure DatesPremera will be closed on the following dates:Friday, May 24, Closure DayMonday, May 27, Memorial Day

Thursday, July 4, Independence DayMonday, Sept. 2, Labor Day

Thursday, Nov. 28, Thanksgiving DayFriday, Nov. 29, Day after ThanksgivingTuesday, Dec. 24, Christmas EveWednesday, Dec. 25, Christmas Day

Growth Hormone Therapy Form Gets a Makeover and Moves to a New Location

We’re updating the Growth Hormone Therapy Benefit Advisory Form and moving it to the Pharmacy page on the provider website. If you prescribe Growth Hormone therapy medications you’ll want to take note of the new

form name and location.As of May 31, 2013, you’ll find the new “Pharmacy Services Growth Hormone Fax

Back Form” at premera.com/ak/provider under Library > Pharmacy > Drugs Requiring Approval (under Understanding Your Benefits) > Benefit Advisory Drug List.

In addition to the new name, the form will be updated to improve the process for requesting Growth Hormone therapy review.

For questions or assistance with a Benefit Advisory between now and May 31, 2013 please contact Care Management at 800-722-4714, option 3. After June 1, 2013, you can contact our Pharmacy Services department at 888-261-1756, option 1 for assistance.

Effective May 31, 2013 you will find the Pharmacy Services Growth Hormone Fax-back Form under Pharmacy:

pharmaCy Updates

May 2013 Alaska Network News 11


Premera Medical Policies

Premera medical policies are guidelines used to evaluate the medical necessity of a particular service or treatment. We adopt policies after careful review of published, peer-reviewed scientific literature, national guidelines, and local standards of practice. Since medical technology is constantly changing, we reserve the right to review and update our policies as appropriate.

When there are differences between the member’s contract and medical policy, the member’s contract prevails. The existence of a medical policy regarding a specific service or treatment does not guarantee that the member’s contract covers that service.

You’ll find our medical policies in the Library, Reference Info at premera.com/ak/provider or you can send us an email request for medical policy information at [email protected].

Note: All policy numbers are listed here in numeric order.

1.01.507 Electrical Stimulation Devices Transcutaneous electrical modulation pain reprocessing (scrambler therapy) is considered investigational.

1.01.514 Stretching Devices Mechanical (dynamic) stretching devices may be considered medically necessary only when used in a structured physical therapy program to treat a recent injury or surgery; if after four months of use, there has not been measurable improvement, continued use may be considered not medically necessary.

5.01.512 Botulinum Toxin The use of botulinum toxin may be considered medically necessary in the treatment of patients with overactive bladder (now an FDA-approved indication).

5.01.521 Pharmacologic Treatment of Neuropathy, Fibromyalgia and Seizure Disorders Duloxetine (Cymbalta®) may be considered medically necessary for the following conditions: diabetic peripheral neuropathy; management of chronic musculoskeletal pain from chronic osteoarthritis pain and chronic low back pain; and fibromyalgia.

7.01.132 Transcatheter Aortic-Valve Implantation for Aortic Stenosis Transcatheter aortic valve replacement, performed via the transfemoral approach, is considered medically necessary with additional criterion of >20% left ventricular ejection fraction. Transcatheter aortic valve replacement, performed via the transapical approach, may be considered medically necessary when criteria are met. (See policy for details.) Investigational statement added for treatment of degenerated bio-prosthetic valve for failed TAVR.

12.04.36 Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer Use of a subset of genes from the 21-gene RT-PCR assay for predicting recurrence risk in patients with noninvasive ductal carcinoma in situ (i.e., Oncotype DX™ DCIS) to inform treatment planning following excisional surgery is considered investigational.

The following policy changes are effective for dates of service of Feb. 11, 2013 and later:

The following policy changes are effective for dates of service of March 11, 2013 and later:

1.01.525 Outpatient Use of Limb Compression Devices for Venous Thromboembolism (VTE) Prophylaxis New policy. Outpatient use of limb pneumatic compression devices for venous thromboembolism (VTE) prophylaxis may be considered medically necessary after either major orthopedic surgery or major non-orthopedic surgery only in specific patient populations when criteria are met. (See policy for details.)

2.01.64 Biofeedback for the Treatment of Constipation and Fecal Incontinence Biofeedback for constipation in adults may be considered medically necessary for patients with dyssynergia-type constipation when criteria are met.

2.01.87 Confocal Laser Endomicroscopy New policy. Use of confocal laser endomicroscopy is considered investigational.

4.01.21 Sequencing-based Tests to Determine Trisomy 21 from Maternal Plasma DNA New policy. Nucleic acid sequencing-based testing of maternal plasma for trisomy 21 may be considered medically necessary in women with high-risk singleton pregnancies undergoing screening for trisomy 21(or other trisomy disorders).

5.01.513 Omalizumab (Xolair®) Omalizumab (Xolair®) may be considered medically necessary to treat antihistamine-refractory chronic idiopathic urticaria.

mediCal poliCy UpdatesmediCal poliCy Updates

The following policy changes are effective for dates of service of April 1, 2013 and later:

5.01.542 Medical Necessity Criteria for Medication Safety: Controlled Substances Utilization Service Program One-provider restriction may be considered medically necessary when evidence exists of excessive use, misuse, non-medical use, or diversion of one or more controlled substances by a member, and when other attempts to contact and work with the member have failed. (See policy for details.) This policy supports a controlled substance utilization case management program.

5.01.518 Bcr-Abl Kinase Inhibitors 1. Bosutinib (Bosulif™) may be considered medically necessary for adults with resistance or intolerance to prior therapy with imatinib for chronic, accelerated, or blast phase Philadelphia chromosome positive chronic myeloid leukemia. 2. Ponatinib (Iclusig™) and Omacetaxine (Synribo™) may be considered medically necessary in similar populations when criteria are met. (See policy for details.)

5.01.541 Medical Necessity Exception Criteria for Closed Formulary Benefits and for Dispense as Written (DAW) Exception Reviews Policy outlines the process used to review for medical necessity when the formulary requires use of a generic equivalent (DAW), with a financial penalty. The provider may need to file a report with the FDA. (See policy for details.)

5.01.601 Pharmacologic Treatment of Rheumatoid Arthritis, Other Arthropathies and Miscellaneous Autoimmune Diseases Tofacitinib (Xeljanz®) may be considered medically necessary as a second line agent for the treatment of moderate to severe active RA (new FDA-approved indication) in patients who have had an inadequate response or intolerance to methotrexate.

5.01.605 Medical Necessity Criteria for Pharmacy Edits 1. Aripiprazole (Abilify®) may be considered medically necessary for specific psychotic disorders without a trial/failure of a generic SGA. (See policy for details.) 2. Aripiprazole (Abilify®) may be considered medically necessary for augmentation of medications for depressive disorders, generalized anxiety disorder, and obsessive compulsive disorder, without a trial/failure of a generic SGA, when trials of other medications, as specified, have failed. (See policy for details.)

7.01.521 Mastectomy for Gynecomastia Mastectomy surgery for gynecomastia may be considered medically necessary for non-malignant indications in adults and adolescents only when specific criteria are met, including functional impairment. (See policy for details.)


Premera Formulary and Pharmacy Prior Authorization Criteria

Premera updates these items routinely throughout the year. The Pharmacy and Therapeutics Committee approves all formularies annually in May. To see the most current information, visit our Pharmacy pages at premera.com/ak/provider/pharmacy/

New Edits Included in the Prior Authorization/Point of Sale Program

Prior Authorization/POS Edit Program Expansion

Premera has added new review criteria based on clinical best practice and approval by an independent Pharmacy & Therapeutics Committee. The program is designed to promote appropriate drug selection, length of therapy, and utilization of specific drugs while improving the overall quality of care.

Newly added Prior Authorization/POS Program drugs are listed to the right. Drugs may be added or deleted from this list without prior notification. If you have questions concerning the POS Edit Program, please call the Pharmacy Services Center at 888-261-1756 or fax us at 888-260-9836, Monday through Friday, 8:00 a.m. – 5:00 p.m. Pacific Time.

Effective June 1, 2013

premera.com/medicalpolicies/CMI_037976.htm

AndrogensAxiron® (testosterone topical solution)Fortesta® (testosterone gel)Testim® (testosterone gel)

Coverage CriteriaAxiron, Fortesta or Testim may be considered medically necessary when there has been a trial and failure with AndroGel® (testosterone gel).

Please note:•There will be NO 1x override allowed when criteria is not met for this medication.•There will be NO grandfathering of current members.•Express Scripts will be sending out a targeted member mailing on May 1, 2013 to members who may be affected

by the change in criteria. The letter will include a fax back form with instructions to follow up with their provider for prior authorization.

Effective June 1, 2013

Advair Diskus® (fluticasone propionate/salmeterol)Advair HFA® (fluticasone propionate/salmeterol)premera.com/medicalpolicies/CMI_037976.htm

Coverage CriteriaAdvair Diskus or Advair HFA may be considered medically necessary when there has been a trial and failure of Dulera® (mometasone furoate/formoterol fumarate dehydrate) or Symbicort® (budesonide/formoterol fumarate dehydrate).

Advair Diskus may be considered medically necessary for:

•Patients under 12 years of age•Patients with documented arthritis or coordination issues

prior authorization/poS edit Program ExpansionmediCal poliCy Updates

New Hysterectomy Surgery Policy Takes Effect on May 19

Premera’s new hysterectomy surgery policy takes effect on May 19, 2013. The policy, Hysterectomy

Surgery 7.01.548, was adopted and first communicated to providers in February 2013. It is being implemented to ensure that hysterectomies are available as a treatment option when medically necessary and to help safeguard against complications that can occur from unnecessary hysterectomies.

Policy overview

While Milliman Care Guidelines® serve as the foundation for Premera’s medical policy for hysterectomy, the policy includes more specific criteria in addition to the Milliman Care Guidelines. These additions are based on interviews with several community gynecology groups and literature reviews. Briefly, the policy states:

◗ Hysterectomy surgery, with or without salpingo-oophorectomy, may be considered medically necessary for diagnosed cancer of the uterus, cervix, ovaries, fallopian tubes or endometrium, and malignant gestational trophoblastic disease (when specific criteria are met).

◗ Hysterectomy surgery, with or without salpingo-oophorectomy, may be considered medically necessary for non-cancer diagnoses when Milliman Care Guidelines, and in some instances additional criteria, are met for the following conditions: o Abnormal uterine bleeding o Endometrial hyperplasia o Endometriosis o Gynecologic cancer prevention o Pelvic organ prolapse o Pelvic pain o Tubo-ovarian abscess o Uterine leiomyoma (fibroid)

◗ Hysterectomy surgery is considered not medically necessary for asymptomatic women or for women without a documented clinical indication that meets medical necessity criteria.

Pre-service review

For services performed on May 19, 2013, and later, hysterectomy procedures will be reviewed for medical necessity. The plan recommends a pre-service review (benefit advisory or pre-authorization) to assess whether the hysterectomy procedure is covered. Services that are not medically necessary will not be covered.

View the policy

To view the policy, visit premera.com/medicalpolicies/CMI_146560.htm.


prior authorization/poS edit Program Expansion

Please note:•There will be NO 1x override allowed when criteria is not met for this medication.•There will be NO grandfathering of current members.•Express Scripts will be sending out a targeted member mailing on May 1, 2013 to members who may be affected

by the change in criteria. The letter will include a fax-back form with instructions to follow up with their provider for prior authorization.

Effective April 1, 2013

Proton Pump Inhibitors (PPI)Aciphex® (rabeprazole)Dexilant™ (dexlansoprazole)First®-Lansoprazole (lansoprazole)First®-Omeprazole (omeprazole)Nexium® (esomeprazole)*Prevacid® (lansoprazole)*Prilosec® (omeprazole)*Prilosec packets® (omeprazole magnesium)Protonix® (pantoprazole)*Zegerid® (omeprazole/sodium bicarbonate)

premera.com/medicalpolicies/CMI_037976.htm

*Preferred proton pump inhibitors

Coverage CriteriaProton Pump Inhibitors other than omeprazole (in its generic form), pantoprazole (in its generic form), lansoprazole (in its generic form) and esomeprazole (Nexium®) may be considered medically necessary for acid peptic diseases such as GERD, esophagitis or ulcer in cases when the patient has failed trials of two of the following medications; omeprazole, pantoprazole, lansoprazole or esomeprazole (Nexium).

Please note:•This is an UPDATE to an existing edit.•Previous coverage criteria only required a trial of one preferred agent.•Additional preferred trial will apply to NEW requests only. Members with current authorizations for non-preferred

medications will not be required to have additional preferred trial.•This updated criteria only applies to groups that have a step therapy requirement.

Premera has added new review criteria based on clinical best practice and approval by an independent Pharmacy and Therapeutics Committee. The program is designed to promote appropriate drug selection, length of therapy, and utilization of specific drugs while improving the overall quality of care. Newly added Biotech and POS Edit and POS Program drugs may

be added or deleted from this list without prior notification. If you have questions, please call the Pharmacy Services Center at 888-261-1756 or fax us at 888-260-9836, Monday through Friday, 8 a.m. – 5 p.m. Pacific Time.

New Edits in the Biotech Edit Program

Effective May 1, 2013

Xtandi® (enzalutamide)premera.com/medicalpolicies/CMI_148306.htm

Coverage CriteriaEnzalutamide (Xtandi®) may be considered medically necessary for:Treatment of castration-resistant prostate cancer (mCRPC) in patients that have demonstrated resistance or intolerance to prior therapy with:•Docetaxel-based regimen AND•abiraterone (Zytiga®)

All other uses of enzalutamide are considered investigational.

Please note:•The criteria will apply to new therapy requests only. Current members will automatically be grandfathered if on therapy

prior to May 1, 2013.

Xtandi is a specialty pharmacy drug covered under the pharmacy benefit.


Stivarga® (regorafenib)premera.com/medicalpolicies/CMI_125837.htm

Coverage CriteriaRegorafenib (Stivarga®) may be considered medically necessary for:

Treatment of metastatic colorectal cancer (mCRC) in patients that have demonstrated resistance or intolerance to prior therapy with:•Fluoropyrimidine-, oxaliplatin-, AND irinotecan based chemotherapy AND•Previous therapy with anti-VEGF therapy such as bevacizumab (Avastin®) or ziv-alfibercet (Zaltrap®)•Previous therapy with anti-EGFR therapy such as cetuximab (Erbitux®) or panitumumab (Vectibix®) for patients who express non-

mutated (wild-type) KRAS gene

Treatment of metastatic or unresectable gastrointestinal stromal tumor (GIST) in patients that have demonstrated resistance or intolerance to prior therapy with:•imatinib (Gleevec®) AND•sunitinib (Sutent®)

All other uses of regorafenib are considered investigational



BioteCh/point of Sale (poS) Edit Expansion




Sprycel® (dasatinib) and Tasigna® (nilotinib) premera.com/medicalpolicies/CMI_057871.htm

Coverage CriteriaDasatinib (Sprycel®) and Nilotinib (Tasigna®) may be considered medically necessary in patients with resistance or intolerance to prior therapy with imatinib for:

• Treatmentofadultswithchronic,accelerated,orblastphasePhiladelphiachromosomepositivechronicmyeloidleukemia(Ph+CML);• TreatmentofadultswithPhiladelphiachromosomepositiveacutelymphoblasticleukemia(Ph+ALL);and• Treatmentofpatientswithgastrointestinalstromaltumor(GIST).

All other uses of dasatinib and nilotinib are considered investigational.

Patients that have not demonstrated objective response to imatinib therapy after three months are considered imatinib-resistant for purposes of prescribing an alternative therapy.


prior to May 1, 2013.•This is an UPDATE to an existing edit. Prior to May 1, 2013 coverage for Sprycel and Tasigna did not require prior therapy

with imatinib.

Sprycel and Tasigna are specialty pharmacy drugs covered under the pharmacy benefit.


Xeljanz™ (tofacitinib citrate) premera.com/medicalpolicies/CMI_031644.htm

Coverage CriteriaTofacitinib citrate (Xeljanz™) may be considered medically necessary for:

Treatment of Rheumatoid Arthritis (RA) in patients that have demonstrated resistance or intolerance to prior therapy with:•entanercept (Enbrel®) AND•adalimumab (Humira®)•doses limited to 5mg twice daily

All other uses of tofacitinib citrate are considered investigational.



Xeljanz is a specialty pharmacy drug covered under the pharmacy benefit.


Synribo™ (omacetaxine) premera.com/medicalpolicies/CMI_057871.htm

Coverage CriteriaOmacetaxine (Synribo™) may be considered medically necessary for:•TreatmentofadultswithchronicoracceleratedphasePhiladelphiachromosomepositivechronicmyeloidleukemia(Ph+CML).

Treatment with omacetaxine may be considered medically necessary ONLY in patients that have demonstrated resistance or intolerance to prior therapy with:•Imatinib AND•One other tyrosine kinase inhibitor (dasatinib, nilotinib or bosutinib).

All other uses of omacetaxine are considered investigational.

Patients that have not demonstrated objective response to imatinib therapy after three months are considered imatinib-resistant for purposes of prescribing an alternative therapy.

Patients that have not demonstrated objective response to dasatinib, nilotinib or bosutinib therapy after three months are considered resistant for purposes of prescribing ponatinib therapy.




Bosulif™ (bosutinib) premera.com/medicalpolicies/CMI_057871.htm

Coverage CriteriaBosutinib (Bosulif™) may be considered medically necessary in patients with resistance or intolerance to prior therapy with imatinib for:•Treatment of adults with chronic, accelerated, or blast phase Philadelphia chromosome positive chronic myeloid leukemia

(Ph+CML);

All other uses of bosutinib are considered investigational.

Patients that have not demonstrated objective response to imatinib therapy after three months are considered imatinib-resistant for purposes of prescribing an alternative therapy



Bosulif is a specialty pharmacy drug covered under the pharmacy benefit.


Iclusig™ (ponatinib) premera.com/medicalpolicies/CMI_057871.htm

Coverage CriteriaPonatinib (Iclusig™) may be considered medically necessary for:•treatment of adults with chronic, accelerated, or myeloid or lymphoid blast phase Philadelphia chromosome positive chronic

myeloidleukemia(Ph+CML);or•treatmentofadultswithPhiladelphiachromosomepositiveacutelymphoblasticleukemia(Ph+ALL).

Treatment with ponatinib may be considered medically necessary ONLY in patients that have demonstrated resistance or intolerance to prior therapy with:•imatinib AND•one other tyrosine kinase inhibitor (dasatinib, nilotinib or bosutinib).

All other uses of ponatinib are considered investigational. Patients that have not demonstrated objective response to imatinib therapy after three months are considered imatinib-resistant for purposes of prescribing an alternative therapy.

Patients that have not demonstrated objective response to dasatinib, nilotinib or bosutinib therapy after three months are considered resistant for purposes of prescribing ponatinib therapy.



Iclusig is a specialty pharmacy drug covered under the pharmacy benefit.


20 November 2012 Alaska Network News20 May 2013 Alaska Network News

Premera Blue Cross Blue Shield of Alaska

P.O. Box 327

Seattle, WA 98111

PRESORTED STANDARD

U.S. POSTAGE PAIDSEATTLE, WA

PERMIT NO. 2944

012335 (05-2013)DR 4893

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