Spring 2015 - Cloudfront.net

S P R I N G 2015
Look inside!
■■
New for 2015:
employer Health Care
Reform fact sheets
page 4
■■
Specialty prescription
drugs and health care costs
page 10
How to reach us
The answers to most of your questions can be found on our website at
bcnepa.com. If you have a question about your coverage, just call or email
our Group Benefits Administrator (GBA) Team. We’re here to help you,
weekdays, between 8 a.m. and 5 p.m.
About Benefits Bulletin
Editor
Ann Poepperling
Benefits Bulletin is published
semiannually for Blue Cross
of Northeastern Pennsylvania
employers.
This material is not intended
as medical advice. Please talk to
your doctor about this and any
health information.
BlueCare® HMO Plans: This
managed care plan may not
cover all your health care
expenses. Read your contract
carefully to determine which
health care services are covered.
1.800.822.8753
Please note that self-funded group
benefits may be different from the
benefits and services described
here. Check your Summary Plan
Description for complete details
of your program.
Blue Cross of Northeastern
Pennsylvania administers health
insurance plans offered by Blue
Cross of Northeastern Pennsylvania,
Highmark Blue Shield, First
Priority Health® and First Priority
Life Insurance Company®.
Page 2 n bcnepa.com
GBA team
Logon to our Self-Service site and select Message Center.
Or call 1.866.GBA.TEAM (1.866.422.8326), 570.200.6868 (Fax)
BlueCare Traditional
1.800.829.8599
1.866.280.0486 (TTY)
BlueCare HMO, BlueCare HMO Plus
1.800.822.8753
1.800.413.1112 (TTY)
BlueCare PPO, BlueCare QHD PPO
1.888.338.2211
1.866.280.0486 (TTY)
BlueCare Custom PPO, BlueCare
QHD Custom PPO, BlueCare EPO
and AffordaBlueSM
1.888.345.2346
1.866.280.0486 (TTY)
In-network providers
View a list of in-network providers
on our website. To learn more about
your plan’s network, select your health
insurance plan on My Insurance Plan
and click on Your Network Map.
Blue Health SolutionsSM
Visit our Health & Wellness website.
Prescription drug benefit
Express Scripts Customer
Service Call Center
1.877.603.8399, anytime. Or, visit our
website or Express-Scripts.com to
find an in-network pharmacy.
Vision coverage
1.800.406.1324, weekdays, between
8 a.m. and 5 p.m. Or, visit our
website or davisvision.com to find
an in-network provider.
Dental coverage
1.800.332.0366, weekdays, between
8 a.m. and 8 p.m. Or, visit our
website or UCCI.com to find an
in-network provider.
Wellness & Lifestyle, Health
Management programs and
Life-Balance Resources
1.866.262.4764, weekdays, 8 a.m.
to 8 p.m. 1.877.720.7771 (TTY)
Case Management programs
1.800.346.6149, weekdays, 8 a.m.
to 8 p.m. 1.877.720.7771 (TTY)
24/7 Nurse Now
1.866.442.2583, anytime
Discount program
Visit the Blue365 website for a full
list of discount programs, or call
Customer Service.
BlueCare FSA, HRA and HSA health care funding accounts
1.877.825.2065, anytime. Or logon to healthequity.com and click
on the Employers tab.
Table of
contents
Health Care Reform
4
New for 2015: employer Health Care
Reform fact sheets
News
5
Guthrie Robert Packer Hospital
recognized for excellence
6
Preventive health reminders
for women
6
Employer Manual: updated for 2015
7
ICD-10: change to new coding
system an ongoing process
Care delivery
Join the conversation
10 At-home sleep studies need
prior approval
Like Blue Cross of Northeastern
Pennsylvania’s Facebook page and
stay up to date on topics about
your health, our community
and life in northeastern and
north central Pennsylvania.
For more information, visit
facebook.com/BCNEPA.
8
Wide cost variations for knee and
hip replacement
10 Specialty prescription drugs and
health care costs
Benefits
11 Home delivery: convenient,
safe and cost effective
12 Summary of Contract/Policy changes
12 Medical policy updates
available online
13 Blue Cross of Northeastern
Pennsylvania’s multi-tier
formulary changes
Services
17 New and improved group
reporting tool
17 Online resources can help manage
your plan
18 Authorization forms help protect
your privacy
Small business?
Big savings!
If your business has fewer than 25 full-time
and full-time equivalent employees, you
may be eligible for the small business
health care tax credit, saving you up to
50% of your premium contributions!
If you qualify, we can help you enroll in a
Blue health insurance plan through the
SHOP (Small Business Health Options
Program) Marketplace. Learn more on
our Employer Education Center.
Small Bu
siness Hea
lth Care Ta
x Credit ov
erview
If you hav
e fewer tha
n 25 full-tim
for a tax
credit wo
e and full
rth up to
50% of you -time equivalent
employee
r premiu
Am I eligib
s, you ma
m costs!
y
le
for the
Health Ca
re Tax Cre Small Business
dit?
To qualify
for the tax
credit, you
• Have less
must:
than 25 full-t
ime and full-t
• Have aver
ime equivale
age salaries
nt employe
of $50,000
es
• Pay at leas
per year or
t 50% of
less
premium
costs for
• Offer cove
full-time
rage to fullemploye
time emp
es
Business
loyees thro
Health Opt
ugh the Sma
ions Prog
ll
ram (SHO
P) Marketp
lace
How mu
ch
is the tax
credit wo
rth?
The tax cred
it is worth
up to 50%
contribution
of an emp
(up to 35%
loyer’s prem
for tax-exem
ium
pt employe
rs).
How do I
claim the
tax
credit?
In order to
claim the
tax credit,
in coverage
you must
through the
first enroll
SHOP Mar
Marketplace
ketplace.
allows you
The SHOP
to:
• Compare
plan opti
ons, apply
employe
for coverage
e participa
, manage
tion and
Your emp
pay your
loyees enro
premium
ll online too!
s online.
qualify
• Use your
current agen
t or broker
new agen
to help you
t or broker
in your area
enroll, find
Northeas
a
, work with
tern Pennsyl
a Blue Cros
vania sale
enrollme
s of
s professio
nt yourself
nal or han
dle your
Once enro
lled in cove
rage thro
for the tax
ugh the SHO
credit whe
P,
n filing taxe
you can app
s for the year
ly
.
How can
PennsylvaBlue Cross of No
rtheaste
nia help?
rn
• Blue Cros
s of Northeas
tern Pennsyl
Blue plan
that’s righ
vania can
t for you.
help find
insurance
We offer
a
plans for
several heal
small busi
Marketplace
th
nesses on
. Click on
the SHOP
any of thes
options we
e plans to
offer: Blue
see what
Care® PPO
BlueCare
, BlueCare
Custom PPO
QHD PPO
and AffordaB
,
• Call us
lue SM
now, so a
sales prof
How to Enro
essional can
ll in the SHO
walk you
through
P Marketp
Sour
lace
ce: Healt
hcare.gov
Blue Cros
s of Nort
heastern
Pennsylva
Blue Cross
nia is a Qual
of Northeaste
Pennsylva
ified Heal
rn Pennsylva
nia, High
th Plan issue
nia admi
mark Blue
r in the Fede
nisters healt
Shield, First
h insurance
rally Facil
Priority Healt
itated Mark
plans offere
h® and First
etplace.
d by Blue
Priority Life
Cross of North
Insurance
eastern
Company®.
© Blue Cross
of Northe
astern PennsyEBG118 2/15
lvania. 2015
bcnepa.com n Page 3
•
health care reform
New for 2015:
employer Health Care Reform fact sheets
Health
Care Reform is here
and with so much changing, it’s
important to understand what you need
to do as a result of the Affordable Care
Act (ACA). Blue Cross of Northeastern
Pennsylvania is dedicated to keeping
you informed, so you can make the
best choices for your business, your
employees and your bottom line.
Download our worksheet to help figure
out if you will be considered a large or
small employer in 2015. And, to make
sure you’re compliant with the ACA—
download the ACA Checklist for Large
Employers. For more details on some
of the key provisions for 2015, check out
our fact sheets on the following topics:
Large employers
• Shared Responsibility Penalty
For large employers, the biggest
changes from the ACA start in 2015.
This includes the Employer Shared
Responsibility Requirement, a provision
that requires large employers to offer
affordable health insurance coverage
that meets minimum value, or potentially
pay tax penalties. The definition of
large employer under this provision
is complex, and the provision will
be phased in from 2015 to 2016.
• Information Reporting
Worksheet
Page 4 n bcnepa.com
• Coverage Requirements
Small employers
Many small employers with a Blue
Cross of Northeastern Pennsylvania
health insurance plan chose to stay
with their pre-ACA coverage, which
hasn’t changed much.
But for those considering a move to an
ACA health insurance plan, you should
know that the ACA changes the way
Checklists
health insurance is offered and what is
offered to your employees. For example,
small group rates for new ACA plans can
vary based on only a limited number
of factors, including age, tobacco use
and level of coverage—and cannot
be based on health status. If you are
a small employer looking to offer
new group coverage, your plan must
include the Essential Health Benefits.
Make sure you are compliant with the
ACA—download the ACA Checklist
for Small Employers.
Blue Cross of Northeastern Pennsylvania
is dedicated to keeping you informed
on Health Care Reform so you can make
the best choices for your company, your
employees and your bottom line. Check
out our Employer Education Center
for ACA information, tools, news and
resources designed just for you. n
Fact sheets
news
Guthrie Robert Packer Hospital
recognized for excellence
Making
informed decisions about
health care is important to you and your
employees. And we know it’s not just about
finding a doctor or health care facility—it’s
about finding the best care for a specific
condition or need. That’s why the Blue Cross Blue
Shield Association’s national Blue Distinction®
program can help everyone make smarter
choices when they need specialty care.
Recently, Guthrie Robert Packer Hospital in
Sayre, Bradford County, earned a Blue Distinction Center+ designation for its gastric stapling
program, and a Blue Distinction Center designation for its gastric banding program.
The program has 2 levels of recognition—Blue
Distinction Centers and Blue Distinction Centers+:
You can find more information about the Blue
Distinction Center program—as well as a link
to the nationwide listing of Blue Distinction
Centers—on our website at bcnp.co/bdc.
• Blue Distinction Centers have met nationally
established quality care and outcomes
criteria developed with input from the
medical community
• Blue Distinction Centers+ have satisfied the
Blue Distinction criteria and have additionally
met cost measures that address consumers’
needs for affordable health care
Each program will be identified in the Blues’
National Doctor and Hospital Finder, and
special signs will be placed at the facility to
recognize this accomplishment.
Please remember, your costs for care at a Blue
Distinction Center depend on your health
insurance plan and if the hospital is part of our
local network or if it’s part of the national
BlueCard® network. Be sure to check your health
insurance plan documents for more information. n
Blue Distinction® Centers (BDC) met overall quality measures for patient safety and outcomes, developed with input from the medical community. Blue Distinction®
Centers+ (BDC+) also met cost measures that address consumers’ need for affordable healthcare. Individual outcomes may vary. National criteria is displayed on
www.bcbs.com. A Local Blue Plan may require additional criteria for facilities located in its own service area. For details on Local Blue Plan Criteria, a provider’s
in-network status, or your own policy’s coverage, contact your Local Blue Plan. Each hospital’s Cost Index is calculated with data from its Local Blue Plan.
Hospitals in CA, ID, NY, PA, and WA may lie in two Local Blue Plans’ areas, resulting in two Cost Index figures; and their own Local Blue Plans decide whether
one or both Cost Index figures must meet BDC+ national criteria. Neither Blue Cross and Blue Shield Association nor any Blue Plans are responsible for damages
or non-covered charges resulting from Blue Distinction or other provider finder information or care received from Blue Distinction or other providers.
bcnepa.com n Page 5
news
Preventive health reminders for women
Give this gu
ide
Research
to yo
A girl’s gu ur preteen or young girl
ide to preventive
healt
h
A parent’s
You don’t nee
d a mirro to
up. Soon, you
see you’re gro
’ll be a teerna
wing
ger.
You
guide to preventiv
e healt
for pre
teens and
young girls
h
’ve probab
ly been goi
since you
ng to you
were a bab
r doctor for
y. Now the
vaccination
vaccination
re are 3 mo
s
s that you
re importa
need to get
nt
before you
r 13th birt
Get “the
hday.
combo”
(also called
While it may
Tdap)
not be as
exciting as
drink or sna
a burger
pping a selfi
and fries
e on your
a one-sho
and
new sma
t vaccine
rtphone,
that will kee
diseases.
there is
p you safe
It’s called
from 3 sep
Tdap, but
is that “the
arat
all you real
combo” will
ly need to Someeti
protect you
whooping
kno
mes it’s diffi
cough and
from getting anw
cult to see
diphtheria
yth
want to get
lockjaw
, ing but a chi
—all con
!
ditions youone
ld. She ma your little girl as
don
’tday soon she
The Tdap
’ll be a teenay be young, but
vaccine is
one
It’s
ears pierced
simple inje
ger.
important
ction. If you
, relax. The
that both
’ve had
shot is less
you
fem
and your
aler depend
you
painful.
daughter
ent) are
P
Get the MC
forrewvenotivemheeanlth
V4 vaccinWhat you
e
need to
(or
aware of
need bef
the vaccina
ore they turn
tions girls
13. There
are 3 vac
It may sou
nd like a new
w about
cinations
ortant to
we
mu
that protect
and oth
sicllne
that
prevent cer
app,ss
scrMCeen
er serious
but
s you from
vical cancer
V4 ing
s and
is a vac
meningoc
meningiti
cinevaccinati illnesses.
occal dise
s—an infe
ons
ases, like Th
ction
can cause
e 3-in-1 co
hearing loss of the brain and spin
mbo
al cord tha
, seizures
and strokes
If yout’re trac
The MCV4
.
shot is alm
kin
g
you
ost painless
r child’s imm
at age 11 or
already kno
. You need
unizations
12 and the
w about the
to get thepro
n get the
, you mig
3-in-1 sho
vacvid
MCV4 boo
ht
cinees protec
t (called Tda
ster when
tion against
p) that
you
per’retus
diphtheria
16.sis. If you
knoare critically imp
, tetanus
r child is not
and
diseases can
vaccinated
cause seri
, each of the
ous health
tetanus (or
se
issues. For
lockjaw) can
example,
be contac
the skin, and
ted through
it can cau
a break in
se painfu
the jaw. Per
l spasms—li
tussis (or
ke locking
whooping
can lead to
of
cough), if
pneumoni
not treated
a or seizure
chance, act
,
s. So don
now!
’t take a
The good
news is tha
t girls nee
vaccination
d the 3-in
only once
-1 combo
in their life.
this shot
before the
It’s importa
ir 13th birt
nt they get
hday.
has shown
that the health needs of women differ
throughout the stages of their lives.
To help women better understand
their bodies and the changes they
can expect during their lives, a series
of preventive health wellness cards
will be mailed to your employees and
their families who are covered by a Blue
Cross of Northeastern Pennsylvania
health insurance plan throughout 2015.
Each mailing targets a specific age group
and the related preventive health actions
that are recommended for females
during those years. These actions support
the related HEDIS measures for 2015.
Preventive health topics include:
• Tdap, meningococcal (MCV4) and
HPV vaccinations
• Testing for chlamydia and
cervical cancers
• Prenatal and postnatal care visits
for pregnant women
• Screenings for breast cancer,
colorectal cancer and osteoporosis
Wellness cards for the Tdap and MCV4
immunizations and the HPV vaccine
will be sent to parents of girls, 11 and 12
years of age, along with a separate card
that parents can give to their daughter/
dependent, at their discretion. All other
mailings will be sent directly to the
identified member.
For more information about these
preventive health mailings, please
call Jane Yeomans, senior coordinator,
Quality Management/Improvement,
at 570.200.4389. n
Employer Manual: updated for 2015
Your Employer Manual has recently
been updated and is now available on
our Employer website at bcnepa.com/
employers. New for 2015, the updated
Employer Manual covers the member
materials your employees receive, such as:
• Open enrollment kit, including network
map and plan overview sheets
• Member handbook kit,
including network book
Your Employer Manual is a valuable
resource to help you manage your
health insurance plan. Review the
Page 6 n bcnepa.com
process to enroll new hires, make status
changes and update address changes.
We recommend you carefully review
your Employer Manual. If you have any
questions about your group-specific
benefits, refer to your Policy/Contract.
However, if you have questions and
are unable to find the answers in your
Policy/Contract or manual, call your
account manager for help.
You can find your Employer Manual on
bcnepa.com/employers. Just click on
Manage my Group Coverage and then
select the Employer Manual. You will
have to sign in to Self-Service, but it’s
easy and takes only a few seconds.
If you prefer, please contact a group
benefits administrator (GBA) team rep
at 1.866.GBA.TEAM (1.866.422.8326)
or your account manager for a printed
copy of the Employer Manual. n
news
ICD-10: change to new coding
system an ongoing process
Health
insurance plans and health
care providers across the country are making
progress toward compliance with a new
medical coding system.
ICD, which is short for International
Classification of Diseases, is the global coding
system that serves as the standard to report
and categorize diseases, health-related
conditions, and external causes of disease and
injury. It’s also helpful in compiling useful
information about deaths, sickness and injuries.
Currently, insurance
companies and
providers use ICD-9
codes for all services
and procedure coding
for inpatient services.
The U.S. Department
of Health and Human
Services has mandated
that every entity
covered by the Health
Insurance Portability
and Accountability Act
(HIPAA) must transition from ICD-9 to ICD-10
by October 1, 2015.
Did you know?
Despite the challenges
of switching to this new
system, the benefits
outweigh the costs.
Why the change?
The change to ICD-10 is happening
because ICD-9 produces limited data about
patients’ medical conditions and hospital
inpatient procedures. ICD-9 is 30 years old,
has outdated terms and is inconsistent
with current medical practice. The structure
of ICD-9 also limits the number of new
codes that can be created and many ICD-9
categories are full.
What will change?
The number of diagnosis and procedure codes
will increase greatly with ICD-10. Diagnosis
codes will increase from about 14,300 to
roughly 69,000. Procedure codes will have an
even larger increase—from 3,800 to 72,000.
How will this affect me and
my employees?
One of the challenges involved in the shift to
the new coding system is that the mapping
from ICD-9 to ICD-10 is not a one-to-one
match. For example, a single code in ICD-9 may
map to many codes in ICD-10. This mapping
could lead to disruptions in certain areas.
Provider payments could end up being different
when using an ICD-10 code. Therefore, your
employees could see occasional delays in
claims payments during the transition period.
What are the benefits?
Despite the challenges of switching to this
new system, the benefits outweigh the costs
because ICD-10 will provide better data to:
• Measure the quality, safety and
effectiveness of care
• Support electronic health record systems
• Conduct research, studies and clinical trials
• Set health policy, operational and
strategic planning
• Design health care delivery systems
For more information on the transition to
ICD-10, visit the Centers for Medicare &
Medicaid Services (CMS) website. n
bcnepa.com n Page 7
care delivery
Wide cost
The
variations for
knee and hip
replacement
cost of knee and hip replacements can vary
widely from market to market across the country, as well as
within the same market, according to a new report jointly
produced by the Blue Cross Blue Shield Association (BCBSA)
and Blue Health Intelligence (BHI).
The report spotlights the wide cost difference for a common
medical procedure and highlights the importance of the work
that Blue companies are doing to use their claims data to provide
consumers and employers with health care quality and cost
information. It’s the first in a series of reports called “The Health
of America Report” that the 2 organizations are collaborating on
to look at key trends and insights into health care dynamics.
“A Study of Cost Variations for Knee and Hip Replacement
Surgeries in the U.S.” is based on an analysis of 3 years of Blue
companies’ medical claims data gathered from 64 markets in
the U.S. According to the study, the average cost of a total knee
replacement surgery—among the fastest-growing medical
procedures in the U.S.—was $31,124 based on a review of
markets during the 36 months ending July 2013. However, it
could cost as little as $11,317 in Montgomery, Alabama, and
as much as $69,654 in New York City.
Page 8 n bcnepa.com
care delivery
In addition to sharp variations in the cost of a knee replacement from market
to market, the cost of the procedure also varied widely within the same city. In
Dallas, Texas, for instance, a knee replacement could cost between $16,772 and
$61,585 depending on the facility at which the patient underwent the procedure.
Knee replacement surgery is rapidly growing in the U.S. According to a study
in the June 2014 issue of the Journal of Bone and Joint Surgery, the number
of typical knee replacements more than tripled between 1993 and 2009. Hip
replacement surgery also is increasing rapidly. During that same 16-year period,
typical hip replacements doubled, according to the journal study. In 2011 alone,
306,600 typical knee replacements and 645,062 typical hip replacements were
performed in the U.S., according to an American Academy of Orthopedic
Surgeons report.
“The Health of America Report” also looked at the cost of hip replacement
surgery, which varied greatly from market to market during the 3-year period
examined. The average cost of a hip replacement was $30,124 in the markets
studied, but the actual cost fluctuated from a low of $11,327 in Birmingham,
Alabama, to a high of $73,987 in Boston, Massachusetts, the market which
also had the largest same-market price variation for the procedure ($17,910
to $73,987, a 313% cost variation).*
What are the Blues doing to help?
To empower consumers, Blue companies are using their claims data to generate
tools that help them obtain cost estimates, access information on provider
quality and read and write patient reviews. These tools, which are available on
our website at bcnepa.com/finddoctorhospital or the National Doctor and
Hospital Finder, give consumers the information needed to comparison shop
for common medical procedures and treatments.
Total hip
replacement
Cost in Boston, MA
$73,987
$11,327
Cost in Birmingham, AL
$30,124
average cost in 64 markets
where data was reviewed
In addition, the Blue Distinction® Center+ designation recognizes hospitals that
demonstrate expertise in delivering safe and effective patient care and
also are 20% or more cost-efficient than non-designated hospitals. Hospitals
with the designation include 427 Blue Distinction Centers+ for Knee and Hip
Replacement, which are located in most of the 64 markets studied in the
report. Consumers can look up Blue Distinction Center+ hospitals on our
website at bcnp.co/bdc or on bcbs.com.
In a news release announcing the report, Maureen Sullivan, BCBSA’s senior vice
president of Strategic Services and chief strategy officer, stressed the importance
of providing consumers with the information they need to make thoughtful
choices for their health care.
“To effectively address health care costs and ensure access to care, consumers,
employers and industry leaders must have information on these price variations
and be provided with the tools to become informed shoppers,” Sullivan said. n
*Data was analyzed based on Metropolitan
Service Areas (MSAs) in accordance with
Census data, which can include large
population areas that may cross state lines.
The Boston MSA, for example, includes
areas within New Hampshire and Rhode
Island. For more information, visit:
www2.census.gov/geo/maps/metroarea/
stcbsa_pg/Feb2013/cbsa2013_MA.pdf.
Page
bcnepa.com
9 n bcnepa.com
n Page 9
care delivery
At-home sleep studies
need prior approval
We
recognize it’s important for you to have the most
up-to-date benefit information in order to best manage your
employees’ health insurance plans. Starting in 2015, upon your
group health insurance plan’s yearly renewal, your benefits cover
at-home sleep studies, with prior approval.
Sleep studies record what happens to your body while you are asleep.
They are usually performed to test for sleep apnea, a condition that
can cause you to regularly stop breathing during sleep. While many
sleep studies are performed in hospitals or labs, your doctor may
recommend having the test performed at your home, a home sleep study.
Please remind your employees that if their doctors recommend
a sleep study, it’s important to check their Policy/Contract or call
Customer Service at the number on the back of their ID card to make
sure the service is eligible for coverage. Then, the doctor must submit
a request for approval before they receive care. This process helps
ensure your employees receive the right care, in the right setting,
at the most appropriate time.
For a complete list of services that need prior
approval, you and your employees can check our
website at bcnepa.com/products.aspx. Just
choose your health insurance plan. The link for
Services That Need Approval is on the left side
of the page. n
Specialty prescription drugs and health care costs
Managing the growing cost of specialty
drugs is a challenge that most employers
face. It’s helpful to understand why
specialty drugs are necessary and why
they cost so much, so we can work
together to contain the rising costs.
At Blue Cross of Northeastern
Pennsylvania, we use a team of clinical
professionals—including pharmacists,
doctors and nurses—to conduct
ongoing reviews of specialty drug use.
This ensures that your employees and
their families have coverage for the
most appropriate medications to treat
their complex conditions. This review
also helps ensure that specialty drug
Page 10 n bcnepa.com
bcnepa.com
n Page 10
treatment is working effectively and is
helping them get better.
Recently, a guest column attributed
to Dr. Nina Taggart, vice president of
Clinical Operations and chief medical
officer at Blue Cross of Northeastern
Pennsylvania, was published by the
Northeast Pennsylvania Business
Journal to explain the rising cost
of specialty drugs and how we can
contain costs.
We encourage you to read the article
and learn more. Then give your Blue
Cross of Northeastern Pennsylvania
sales professional a call. Together we
can better understand how specialty
drugs drive health care costs and find
ways to manage these rising costs. n
Specialty
Drugs &
Specialty
February
2015
Pharmac
y
Listing-
CuraScript
Pharmacy
www.cura
– Division
scrip
of Express
Medication t.com
Scripts- 1-86
s listed mu
6-848-98
st be obt
70
ained thro
ifiers
Aranesp®
ugh CuraSc
, Epogen®,
ript.
Procrit®,
Neumega®,
Neu
Blood Mod
Leukine®
, Promacta pogen®, Neulasta®,
®
Growth Hor
mone Diso
Cancer Che
Norditrop
in®, Nutropin
Humatro
®, Nutropin
pe®, Gen
AQ®, Omn
otro
Zorbtive®
, Tev-Trop pin®, Increlex®, Saize itrope®,
in®, Som
n®, Serostim
avert®
®,
Hepatitis
mot
herapy
Afinitor®,
Bosu
Iclusig®, Inlyt lif®, Erivedge®, Glee
a®, Jakafi®,
vec®, Gilo
injection,
trif®, Hyca
Mekinist®,
Oforta®,
mtin ®cap
capecitab
Pomalyst
Sylatron®,
s,
ine, Nexa
®, Revlimid
Tafinlar®
var®, octr
®, Sprycel®
Tarceva®
Tykerb®,
eotide
, Stiva
, Tasigna®,
Valchlor®,
temozolomid rga®, Sutent®,
Vida
Zolinza®,
Zytiga®, Zyka za®, Votrient®,
e, Thalomid
Xalkori®,
dia, Purixan®
®,
Xtandi®,
Susp
Zelboraf®,
Hemoph
rders
ilia,
Disorders von Willebrand Dise
ase and
Advate®,
Related Blee
AlphaNin
ding
e SD®, Alpr
desmopre
olix®, Bebu
ssin injec
tion, Feib
lin VH®, Bene
M®, Hum
a NF®
ate
fix®, Corifact®
P®, Novosev P®,Koate DVI®, Koge , Feiba VH®, Helix
ate FS®, Hem ,
en RT®, Prof
nate FS®,
Xyntha®,
ofil
Mononin
ilinine SD®,
Wilate®
e®, Monocla
Recombin
te
ate®, Rixu
bis, Tretten ®
Metabolic
,
Disorders
Aldurazyme®
Elaprase®, , Carbaglu®, Cerd
elga®,Cerezy
Fabrazym
e®,
Naglazym
me®, Cyst
e®, Orfadin® Kuvan®, Kynamro
adane®,
®,
Zavesca®
,Vimizim® , Procysbi®, Signifor® Lumizyme®, Myo
zyme®,
, Ravicti®,
Vpriv®,
Rhe
C
Intron A®,
Peg-Intro
n®, Pega
Ribavirin®,
sys®, Infer
Incivek®,
gen®, Riba
Victrelis®
sphere®,
, Olysio®,
Sovaldi ® ,
Viekara pak®
Multiple
Scle
rosis
Ampyra®
, Aubagio
®, Avonex®,
Extavia®,
Beta
Gilenya®,
Rebif®, Tecf seron®, Copaxone
®,
idera®
umatoid
Arthritis
Actemra
(subcutaneou
Simponi®
s inj), Cimz
, (sub
ia®, Enbrel®,
Adcirca®,
Hypertensio
(subcutaneou cutaneous injec
Adempas®
Humira®,
n Medicat
tion, not
s injection
Kineret®
, epoprost
Opsumit®
Simponi Aria
ions
, not infu
enol
, Orenitram
®), Orencia® ,
sion), Otez
Tyvaso®,
®, Remodul sodium, Flolan®,
la®, Xelja
Pulmona
Vele
Letairis®,
in®, silde
nz®
ry Medicat
nafil oral,
Miscellaneo tri®, Ventavis®
Aralast NP®
ions
Tracleer®
us
,
,
Acthar H.P.
Pulmozym Arcalyst®, Bethkis®,
Gel®, Actim
e®, Tobi®,
Esbriet ®,
Ilaris®, Impl
mune®, Apo
Tobi Podh
Glassia®,
anon®, Ipriv
kyn®, Beri
Kalydeco
aler®, Zem
Sensipar®
ask ®, Kyna
nert®,Bic
®,
aira®, Esbr
, Sucraid®
illin
mro
iet®
CR®,
®, Makena®
, , Xenazine
, MuGard® Bicillin LA®, Cinryze®
®,Xyrem®,
, Myalept®
,
Ruconest
Limited Dist
, Nexplano Egrifta®, Exjade®,
®
ribution
Firaz
n®, Orafate®
Biologics,
Qsymia®,P yr®, Forteo®, Gatt
Inc. -(800)85 Products¹
ex®,
rothelial®,
(800)823
Sabril®, Sam Hizentra®,
-4506 Lynp 0-4306 Caprelsa®
,
arza®
sca®,
Caremark
Other Spe
- (800)237
cialty Net
-2767 Cyst
Centric Hea
Freedom
work Pha
agon ®, Mire ®
lth
Fertility Phar
rmacies
na
Elelyso ®(855 Resources - Chen
www.free
mac
odal ®
) 353-5976
domfertility.c y- Division of Expr
Korlym®
, Ferripro ® (866) 785-7068,
Ganirelix®,
(866) 758ess Scripts
om (800)660
7138, Prol x ®and Juxtapid ® (855
Follistim
Vecamyl®
-4283
AQ®, Gon
astin (800
Ovidrel®,
(855
) 898-2743
al
)305-788
Novarel®
CF Services, ) 832-2695
,
1,
, Repronex F®, Cetrotide®, Brav
injection,
Inc - (877
®,
elle®, Prof
Menopur
Diplomat
)722-978
®, Progeste Synarel®, Pregnyl®
asi®,
6 Cayston ®
Specialty
, HCG, leup
rone in oil®
Phar
Cometriq ®,
rolide
Walgreens’
(877) 977- macy -(877) 8303797 Cuvp ®
Specialty
9118 Imbr
Matulane®,
Pharmacy
osa
uvica ®, (877
(888) 347Kalydeco
) 977-9118 and
3416 Adag
®
(800)420
Zydelig®
¹ The manu
-3228 Ofev
en®, Cyst
facturers
aran®,
®
of the follow
These “Limit
ed Distrib
ing
ution” medic medications have
BioCARE
determined
ations must
(800) 304that they
be obtain
Blue Cross
be
ed throug
3064 Obiz
of Northeaster
h the design made available throug
the Blue
ur®
n Pennsylvani
ated pharm
h specif
Cross
®
Pulmona
ry Arterial
and Blue
Shield Associ a provides prescr
iption drug
ation.
acy.
coverage
with admin
istrative
ied Pharm
assistance
from
acies.
Express Scripts
, Inc., an
independent
pharmacy
benefit mana
gement compa
ny
not affilia
ted with
benefits
Home delivery:
convenient, safe and cost effective
Home
delivery, also called
mail order, can help you and your
employees save money on most
maintenance prescription drugs.
And, they’re conveniently delivered
right to your home. Maintenance
medications are those that you take
long term, usually for a condition like
high blood pressure or high cholesterol.
How does home delivery work?
• First, check your Policy/Contract or
Self-Service for your specific home
delivery copay amount
• Then call your doctor to get a
prescription for up to a 90-day
supply of medicine. It’s your
responsibility to ask your doctor
to specify a 90-day supply on your
prescription, so you get the greatest
benefit from this program. You must
pay your home delivery copay no
matter what amount is ordered
• Check the formulary or ask your
doctor if you need prior approval for
the drug before you order it
• Next, fill out the home delivery
pharmacy registration form and
send it with your prescription and
payment to the address on the form
• You can also ask your doctor’s
office to fax the registration form
to Express Scripts for the quickest
possible service. The Rx ID number on
your ID card is needed to fill your order
• Once you’ve sent your prescriptions
to Express Scripts, allow up to 14 days
for your medications to arrive. You’ll
get a phone call telling you when your
order has shipped and when you can
expect delivery. You can also track your
order online at express-scripts.com
The law calls for pharmacies to have
the original prescription on file. This
means you will need to get a new written
prescription from your doctor to use
the Express Scripts Home Delivery
program. Prescriptions you may have
on file with any other home delivery
service will not transfer to Express Scripts.
Is it safe?
Millions of prescriptions are sent safely
through the mail every year. Plus,
registered pharmacists carefully screen
each prescription throughout the
dispensing process, so you can feel
secure that you’ll get the attentive
service you deserve.
Is it cost-effective?
Express Scripts Home Delivery Pharmacy
helps you save money by providing
the generic version of a drug when
possible, unless you or your doctor
specifically asks for the brand-name
version. To ask for a brand-name drug
when the generic is available, attach a
note requesting the brand name or call
Express Scripts with your request.
If you or your doctor selects brand-name
drugs when generics are available, you
will have to pay the extra cost between
the brand name and the generic, plus
your deductible, copay and coinsurance,
if applicable. This can cost quite a bit
more than the generic drug.
How can I order refills?
A reorder envelope and refill notice will
be sent with all prescriptions. It will tell
you the number of refills left on your
prescription, if any. To order your refill,
simply send your refill order no later than
the date marked on the notice, or call
1.877.603.8399. For the quickest possible
service, you can order your refills online.
Just logon to Express Scripts Self-Service
at bcnepa.com/pharmacy.aspx and
follow the on-screen directions. n
Blue Cross of Northeastern Pennsylvania provides prescription drug coverage with administrative assistance from Express Scripts, Inc., an independent
pharmacy benefit management company not affiliated with the Blue Cross and Blue Shield Association.
bcnepa.com n Page 11
benefits
Summary of Contract/Policy changes
Policy/Contract changes are usually made twice a year in
January and July. The changes are endorsements to the
Contracts/Policies of the specific plans noted below. We
encourage you to review this information and share it with
your employees.
These changes are effective July 1, 2015, and will be
added into your Policy/Contract at your group’s next
yearly renewal:
Definitions:
The definitions of these terms will be clarified: inpatient
non-hospital residential care, inpatient non-hospital
residential facility and partial hospitalization psychiatric
care services.
BlueCare Contracts/Policies affected: HMO, HMO Plus, QHD
PPO, PPO, Custom PPO, QHD Custom PPO, Traditional, EPO
and AffordaBlue.
A definition of intensive outpatient alcohol and/or drug
abuse program will be added.
BlueCare Contracts/Policies affected: HMO, HMO Plus, QHD
PPO, PPO, Custom PPO, QHD Custom PPO, Traditional, EPO
and AffordaBlue.
Description of Benefits:
The Mental Health Care Services and Treatment for Alcohol
and/or Drug Abuse and Dependency sections of the
Description of Benefits will be modified to clarify the benefits.
BlueCare Contracts/Policies affected: HMO, HMO Plus, QHD
PPO, PPO, Custom PPO, QHD Custom PPO, Traditional, EPO
and AffordaBlue.
Exclusions:
The exclusion for dental procedures and oral surgery will
include an exception for orthognathic surgery for the
treatment of obstructive sleep apnea. This means, even
though dental services are generally not covered under your
plan, if you are being treated for sleep apnea, you may be
covered for this type of dental surgery.
BlueCare Contracts/Policies affected: HMO, HMO Plus, QHD
PPO, PPO, Custom PPO, QHD Custom PPO, Traditional, EPO
and AffordaBlue.
General Provisions:
Section GP (General Provisions) will be updated to add a
subsection on Payment of Claims.
BlueCare Contracts affected: HMO, HMO Plus. n
Medical policy updates available online
Blue Cross of Northeastern Pennsylvania establishes and
administers medical policy, which guides how your health
insurance plan’s covered benefits are applied. Because we
continually review and evaluate our medical policies, they
are generally updated on a monthly basis.
Stay on top of these monthly policy changes by checking
our website at bcnepa.com/employer/news. Click on
the Employer Homepage, select Employer News and
then select the link Medical Policy Updates on the
right side of the page for the latest information. n
Page 12 n bcnepa.com
benefits
Blue Cross of Northeastern Pennsylvania’s
multi-tier formulary changes
These are the most recent changes, now in effect:
Prescription drug
Tier change
Alternatives that cost you less
Anoro Ellipta (umeclidinium/vilanterol)
Tier 2, has quantity limits
Luzu (luliconazole)
Tier 3
econazole, ketoconazole
Orenitram ER (treprostinil)
Tier 3, needs prior approval and has quantity limits
Other formulary pulmonary arterial hypertension
(PAH) medications
Otezla (apremilast)
Tier 3, needs prior approval and has quantity limits;
must be obtained through a specialty pharmacy
Humira, Enbrel
Xartemis XR (oxycodone/acetaminophen)
Tier 3, has quantity limits
oxycodone/acetaminophen immediate release
Tecfidera (dimethyl fumarate)
Tier 2, needs prior approval, step therapy and has quantity
limits; must be obtained through a specialty pharmacy
Gilenya (fingolimid)
Tier 2, needs prior approval, step therapy and has quantity
limits; must be obtained through a specialty pharmacy
Vytorin (ezetimibe/simvastatin)
Tier 3, has quantity limits
Generic antihyperlipidemic agents
Nutropin (somatropin)
Tier 3, needs prior approval; must be obtained through
a specialty pharmacy
Norditropin
Eliquis (apixaban)
Tier 2
Vimovo (esomeprazole/naproxen)
Tier 3, needs prior approval and has quantity limits
Generic NSAIDs + generic PPIs
Lumigan (bimatoprost) Ophthalmic Solution
Tier 3, has quantity limits
latanoprost
Travatan Z (travoprost) Ophthalmic Solution
Tier 3, has quantity limits
latanoprost
These prescription drugs now have a lower copay.
Prescription drug
Change
Invokana (canagliflozin) and
Invokamet (canagliflozin w/metformin)
Tier 2, step therapy and quantity limits apply
Pentasa (mesalamine)
Tier 2
Lialda (mesalamine)
Tier 2
Auvi-Q (epinephrine)
Tier 2, has quantity limits
Axiron (topical testosterone)
Tier 2, has quantity limits
Myrbetriq (mirabegron)
Tier 2, has quantity limits
Tudorza Pressair (aclidinium bromide)
Tier 2, has quantity limits
New medications covered under the medical benefit
Beleodaq (belinostat)
Beleodaq is a new intravenous medication used in the treatment of adults with peripheral T-cell lymphoma after other medications have
been used. Beleodaq needs prior approval.
Keytruda
(pembrolizumab)
Keytruda is a new intravenous medication used in the treatment of adults with metastatic melanoma in specified circumstances following
previous use of certain medications. Keytruda needs prior approval.
Please refer to the complete utilization management (UM) policies for full prior approval criteria, step therapy criteria, quantity limits and additional information and
restrictions. Visit bcnepa.com, click on Rx Drug Benefits and select the Utilization Management Criteria link.
bcnepa.com n Page 13
benefits
New pharmacy and medical prior approval/step therapy criteria
Adagen
(pegademase bovine)
prior approval criteria
Adagen is a medication used in children who have a specified enzyme deficiency and also have severe combined immunodeficiency disease. In
addition, the child is not a suitable candidate for, or has failed a bone marrow transplant. Your doctor must request prior approval of coverage.
Medical records accompanying the prior approval request must document your diagnosis as well as specified criteria for this medication to
be covered. When approved, this medication is available through a limited distribution pharmacy at a tier 3 copay. Please see UM policy for
complete criteria and additional information.
Beleodaq (belinostat)
prior approval criteria
Beleodaq is an intravenous medication used in the treatment of peripheral T-cell lymphoma in adults after other medications have been used
to treat this condition. Your doctor must request prior approval of coverage. Medical records accompanying the prior approval request must
document your diagnosis as well as specified criteria for this medication to be covered. This medication cannot be self-administered. If approved,
it is covered under the medical benefit. Please see UM policy for complete criteria as well as additional information.
Keytruda
(pembrolizumab)
prior approval criteria
Keytruda is an intravenous medication used in the treatment of specified cases of metastatic melanoma. It is used after other specific
chemotherapy agents have been used. Your doctor must request prior approval of coverage. Medical records accompanying the prior
approval request must document your diagnosis as well as specified criteria for this medication to be covered. This medication cannot be
self-administered. If approved, it is covered under the medical benefit. Please see UM policy for complete criteria as well as additional information.
raloxifene/tamoxifen
prior approval criteria
Members may currently obtain the prescription drugs raloxifene and tamoxifen at a tier 1 copay. As of September 24, 2014, as per Health Care
Reform law, if raloxifene or tamoxifen is being used for primary prevention of breast cancer and the member is considered at high risk for breast
cancer, one may be able to obtain one of these medications at no cost; i.e., a $0 copay. In order to be approved for the $0 copay, the prescribing
doctor must request prior approval for either raloxifene or tamoxifen indicating that the medications are being used for the primary prevention
of breast cancer. If after review, all of the specified criteria are met, you may get the medication at a retail pharmacy for $0 copay. Otherwise,
the tier 1 copay applies. Please see UM policy for complete criteria as well as additional information.
Sutent (sunitib)
prior approval criteria
Sutent is an oral medication used in specified cases of gastrointestinal stromal tumor, advanced renal cell carcinoma and pancreatic
neuroendocrine tumors. Your doctor must request prior approval of coverage. Medical records accompanying the prior approval request must
document your diagnosis as well as specified criteria for this medication to be covered. If approved, Sutent must be obtained through a specialty
pharmacy at a tier 3 copay. Please see UM policy for complete criteria as well as additional information.
Zydelig (idelalisib)
prior approval criteria
Zydelig is an oral medication used in the treatment of specified types of leukemia and lymphoma after other medications have been used.
Your doctor must request prior approval of coverage. Medical records accompanying the prior approval request must document your diagnosis
as well as specified criteria for this medication to be covered. If approved, it must be obtained through a specialty pharmacy at a tier 3 copay.
Please see UM policy for complete criteria as well as additional information.
Please refer to the complete UM policies for full prior approval criteria, step therapy criteria, quantity limits and additional information and restrictions. Visit bcnepa.com,
click on Rx Drug Benefits and select the Utilization Management Criteria link.
Revised pharmacy and medical prior approval/step therapy criteria
Multiple Sclerosis
Disease Modifying
Self-Administered
Injectables step
therapy criteria
Plegridy is a new, multiple sclerosis (MS) disease modifying self-injectable. It has been added to this Step Therapy policy. Both of our preferred
medications, Betaseron and Rebif, must be given a trial before Plegridy is covered. Plegridy is self-administered and is covered under the
pharmacy benefit. When step therapy is met, Plegridy may be obtained through our specialty pharmacy at a tier 3 copay. Quantity limits apply.
Please see UM policy for complete criteria and additional information.
Multiple Sclerosis Oral
(by mouth) Disease
Modifying Medications
step therapy criteria
The Multiple Sclerosis Oral Disease Modifying Medications Step Therapy Criteria has been revised. The first step medication as per our policy is
one of the MS modifying self-administered injectables. When step therapy is met, either Tecfidera or Gilenya is available through our specialty
pharmacy at a tier 2 copay. Aubagio is step 3 in our policy; one must have had a trial of an MS self-injectable disease modifying medication as well
as one oral MS disease modifying medication (Tecfidera, Gilenya). When step therapy is met, Aubagio may be obtained at a tier 3 copay through
our specialty pharmacy. Quantity limits apply for all of these medications. Please see UM policy for complete criteria and additional information.
Growth Hormone
prior approval criteria
Nutropin will no longer be covered without a trial of our preferred growth hormone agent, Norditropin. You and your doctor will receive a letter
telling you about this trial requirement. Nutropin will only be approved if a prior approval documenting the medical necessity for the use of
only Nutropin has been submitted, reviewed and approved. When Nutropin is approved, it must be obtained through our specialty pharmacy
and is available at a tier 3 copay. Our preferred growth hormone product, Norditropin, is also available through our specialty pharmacy but has
a tier 2 copay. Quantity limits for all growth hormones are determined at the time of authorization. Please see UM policy for complete criteria
and additional information.
Page 14 n bcnepa.com
benefits
Revised pharmacy and medical prior approval/step therapy criteria continued
Vimovo (esomeprazole/
naproxen) step
therapy criteria
As of January 1, 2015, Vimovo will require step therapy for new starts as well as for those members who are currently using it. Vimovo is a
combination of naproxen, an NSAID (non-steroidal anti-inflammatory drugs), and esomeprazole, a PPI (proton pump inhibitor). The step
therapy criteria require that you must use at least 2 different, prescription, generic NSAIDs, as well as at least 2 different, prescription, generic
PPIs (proton pump inhibitors) before Vimovo will be covered. These NSAIDs and PPIs must appear on your prescription claims history. When
approved, Vimovo may be obtained at a retail pharmacy at a tier 3 copay. Please see UM policy for complete criteria and additional information.
Ophthalmic
Prostaglandin Agonists
step therapy criteria
Lumigan (bimatoprost) and Travatan Z (travoprost) will no longer need step therapy. They are now step 1 in our formulary. They are available
from your pharmacy at a tier 3 copay. Latanoprost, a tier 1 medication, is also available as a step 1 medication. Zioptan (tafluprost) remains
a step 2 medication; a trial of 3 step 1 medications (latanoprost, travoprost, Lumigan, Travatan Z) must be shown before Zioptan is covered.
Quantity limits remain in place for Lumigan, Travatan Z and Zioptan. Please see UM policy for complete criteria and additional information.
Synagis (palivizumab)
prior approval criteria
Synagis is an immunization used to prevent serious lower respiratory tract disease caused by the RSV virus in specified pediatric patients at high
risk. The prior approval criteria have been extensively revised to reflect the new recommendations of the American Academy of Pediatrics (AAP).
The new AAP recommendations limit the use of Synagis to only those infants most likely to benefit from Synagis prophylaxis. The prescribing
doctor must request prior approval for coverage of Synagis. Synagis is not self-administered; when approved, it is covered under the medical
benefit. Please see UM policy for complete criteria and additional information.
Pegasys
(peginterferon alfa 2a)
prior approval criteria
Our policy has been completely revised to follow the current recommendations from the American Association for the Study of Liver Diseases
(AASLD) in the treatment of Hepatitis C. Your doctor must request prior approval for coverage. When approved, Pegasys is available through our
specialty pharmacy at a tier 2 copay. Quantity and length of therapy will be determined at the time of authorization. Please see UM policy for
complete criteria as well as additional information.
Injectable/Oral
Medications in the
Treatment of
Gaucher’s Disease
A new oral medication, Cerdelga, has been added to the current policy. Cerdelga is used for the treatment of adult patients with Gaucher
disease, type 1, when specified criteria are met. When approved, Cerdelga has quantity limits and is available at a tier 3 copay through our
specialty pharmacy. Please see UM policy for complete criteria and additional information.
Humira
prior approval criteria
Humira is an immunologic agent used in the treatment of various inflammatory diseases. Due to changes in FDA approved indications, the
criteria have been updated. When specified criteria are met, Humira may be used in the treatment of children 2 years of age and older with
polyarticular juvenile idiopathic arthritis, and children 6 years of age and older with moderately to severely active Crohn’s Disease. When
approved, Humira has quantity limits and is available at a tier 2 copay through our specialty pharmacy. Please see UM policy for complete
criteria and additional information.
Hereditary Angioedema
Medications prior
approval criteria
A new agent, Ruconest, has been added to the current policy. Ruconest is an injectable medication used to treat acute angioedema attacks in
adolescents and adults with hereditary angioedema (HAE). It is not indicated for the treatment of laryngeal attacks. Ruconest can be given by
a health care professional or you can be trained to administer it yourself. When given by a health care professional in an emergency situation,
claims are reviewed afterwards to make sure that specified criteria were met. When you administer the medication yourself, a prior approval
must first be sent in and approved. Specified criteria must be met. When approved, Ruconest has quantity limits and is available at a tier 3
copay through our specialty pharmacy. Please see UM policy for complete criteria and additional information.
Immunomodulators
in the Treatment of
Inflammatory Disease
prior approval criteria
The prior approval criteria for Otezla have been updated to allow consideration for a new FDA approved indication, plaque psoriasis.
Your prescribing doctor, a dermatologist, must request prior approval for coverage of Otezla. As per the criteria, Otezla in the treatment
of plaque psoriasis requires documented prior treatment with Enbrel and Humira as well as other specified requirements. When approved,
Otezla may be obtained through a specialty pharmacy at a tier 3 copay. Quantity limits apply. Please see UM policy for complete criteria
and additional information.
Immune Globulin,
Subcutaneous prior
approval criteria
The subcutaneous Immune Globulin Prior approval criteria policy has been updated to include a new medication, Hyqvia. The criteria have
also been updated to specify what documentation must be submitted for initial as well as continued approval of these medications. The use of
subcutaneous immune globulin is considered self-administrable; when approved, these medications must be obtained through our specialty
pharmacy at a tier 3 copay. Please see UM policy for complete criteria and additional information.
Lumizyme, Myozyme
prior approval criteria
As per action by the FDA, the use of Lumizyme has been expanded to permit use in all Pompe patients; there is no limitation as to age and
phenotype. In addition, the Risk Mitigation Evaluation Strategy (REMS) program has been removed. However, Lumizyme still has a boxed
warning regarding serious adverse reactions. The prior approval criteria have been updated to reflect these changes. Lumizyme will continue
to require prior approval sent in by your doctor; specified criteria must be met for approval of coverage of Lumizyme. If approved, Lumizyme is
available at a tier 3 copay through our specialty pharmacy. Please see UM policy for complete criteria and additional information.
Hyaluronic Acid
Derivatives prior
approval criteria
A new hyaluronic acid derivative (HA) product, Monovisc, has been added to the prior approval policy as a non-preferred product. Our preferred,
covered HA products continue to be Euflexxa and Synvisc/Synvisc-1. Prior approval will continue to be required for coverage of these products.
The HA derivatives must be administered by a health care professional; when approved, they are covered under the medical benefit. Please see
UM policy for complete criteria as well as additional information.
bcnepa.com n Page 15
benefits
Revised pharmacy and medical prior approval/step therapy criteria continued
Zytiga/Xtandi
prior approval criteria
Our policy has been revised to follow a change in FDA labeled uses for Xtandi. Previously, use of the chemotherapeutic agent docetaxel
was required for consideration of the use of Xtandi. This requirement has been eliminated from the criteria. The use of Xtandi still requires
that prior approval be submitted by your prescriber, an oncologist. All remaining criteria must be met for consideration of approval of this
medication. When approved, Xtandi is available at a tier 3 copay through our specialty pharmacy. Please see UM policy for complete criteria
and additional information.
Protease Inhibitors
in the Treatment
of Hepatitis C
prior approval criteria
Our policy has been completely revised to follow the current recommendations from the American Association for the Study of Liver Diseases
(AASLD) in the treatment of Hepatitis C. Incivek (telaprevir) and Victrelis (boceprevir) are no longer commercially available and recommendations
for usage have been eliminated from the policy. Recommendations for the use of Incivek (telaprevir) and Victrelis (boceprevir) have also been
eliminated from our policy. Prior approval for the one remaining HCV NS3/4A protease inhibitor, Olysio (simeprevir), has been revised to reflect
the current recommendations of the AASLD. When approved, Olysio must be obtained through our specialty pharmacy at a tier 2 copay. Quantity
and length of therapy will be determined at the time of authorization. Please see UM policy for complete criteria as well as additional information.
Revlimid
prior approval criteria
Our policy has been revised to allow consideration of approval of Revlimid in the FDA labeled use for mantle cell lymphoma after the use of
other specified therapies. The use of Revlimid requires that prior approval be requested by your prescriber, an oncologist. All specified criteria
must be met for consideration of approval of this medication. When approved, Revlimid is available at a tier 3 copay through our specialty
pharmacy. Quantity limits apply. Please see UM policy for complete criteria and additional information.
Imbruvica
prior approval criteria
Imbruvica is an oral medication used in the treatment of specified leukemia/lymphoma. Due to changes in FDA approved indications, the
criteria have been updated to include a diagnosis of chronic lymphocytic leukemia with a specific gene (17P) deletion. When approved,
Imbruvica is has quantity limits and is available at a tier 3 copay through our specialty pharmacy. Please see UM policy for complete criteria
and additional information.
The following prescription drugs no longer need step therapy or prior approval.
Revised pharmacy and medical prior approval/step therapy criteria
Inflammatory
Bowel Medications
step therapy criteria
Lialda no longer needs step therapy. It is available from your pharmacy with a tier 2 copay.
Testosterone (topical)
step therapy criteria
Axiron no longer needs step therapy. It is available from your pharmacy with a tier 2 copay; quantity limits apply.
Overactive Bladder
Medications step
therapy criteria
Myrbetriq no longer needs step therapy. It is available from your pharmacy with a tier 2 copay; quantity limits apply.
Triptan
step therapy criteria
Axert, Frova and Relpax no longer need step therapy. They are available from your pharmacy with a tier 3 copay; quantity limits apply.
Uloric
step therapy criteria
Uloric (febuxostat) will no longer need prior approval. Uloric is available from your pharmacy at a tier 3 copay; quantity limits apply.
Itraconazole
prior approval criteria
Itraconazole capsules no longer need prior approval. Itraconazole is available from your pharmacy at a tier 1 copay. Onmel (a branded
itraconazole) still requires prior approval.
COX II (Celebrex)
prior approval criteria
Celebrex is now available as a generic medication, celecoxib. Celecoxib does not need prior approval. Celecoxib is available from your pharmacy
at a tier 1 copay; quantity limits apply.
Page 16 n bcnepa.com
services
New and improved
group reporting tool
Online resources
can help manage
your plan
We can help you manage your plan
Blue Cross of Northeastern Pennsylvania is excited to offer a new and
improved reporting system for our large (51+) employer accounts. Now,
managing your company’s health plan strategy can be easier than ever!
Enhanced reports with Employer Insights
We have transitioned from CoNexus to the Employer Insights™ account
reporting solution to bring you the most meaningful analytics to help you
proactively manage your company’s health care costs.
What does this mean to me?
The new Employer Insights reporting solution will give you a suite of reliable,
credible, employer health plan performance reports. Plus, you’ll notice the
following valuable features:
• A standard set of easy-to-read reports that cover utilization, clinical,
prescription drug and provider network analyses
• A report displaying participation in Blue Health Solutions programs
• Compelling, sophisticated graphics that show how your health care
dollars are being spent
• A dashboard summarizing key data for employers
Call your Blue Cross of Northeastern Pennsylvania account manager
today to learn more
and get started! n
At Blue Cross of Northeastern Pennsylvania,
we recognize how important it is for you
to have a primary source of information
for managing your employees’ health
insurance plan. We encourage you to visit
our website at bcnepa.com/employers
for important resources such as:
• Employee handbooks
• Annual Health Guide
• Employer and member newsletters
The Annual Health Guide and these other
resources contain information for you and
your employees about:
• Quality Improvement program
• Member Rights and Responsibilities
• Complaint and Grievance process
• Utilization Management process
• Prescription Drug benefits
• Covered benefits and services,
including exclusions
• Notice of Privacy Practices
Blue Cross of Northeastern Pennsylvania provides analytic reporting services with assistance
from Employer Insights, a group reporting solution offered by Truven Health Analytics, Inc.,
an independent company not affiliated with the Blue Cross and Blue Shield Association.
If you need a copy of these online materials,
call a group benefits administrator rep at
1.866.GBA.TEAM (422.8326). n
bcnepa.com
Page
17 n bcnepa.com
n Page 17
services
Authorization forms
help protect your privacy
The
privacy of your protected health
information is important to us. That’s why Blue Cross of
Northeastern Pennsylvania has a number of safeguards in
place to comply with the Health Insurance Portability and
Accountability Act (HIPAA) Privacy Rule. Members must
complete an Authorization form before allowing others
to receive their protected health information for purposes
other than payment, treatment or health care operations.
Why do I need an authorization form on file?
For example, you may find that your adult son or daughter
who’s away at college or on vacation is admitted to the
hospital for emergency care. Without an Authorization
form on file, the law requires all insurers, including Blue
Cross of Northeastern Pennsylvania, to decline requests
for information until a form is filed, or unless a verbal
agreement can be obtained. There are no exceptions.
“Having a HIPAA Authorization form on file for each adult
member listed on your health insurance contract ensures
that another person, such as you, a spouse, close family
member or friend, can receive information in the event
that they unexpectedly need medical care,” said Dawna
Gardner, privacy and security officer at Blue Cross of
Northeastern Pennsylvania.
You and your employees should consider completing an
Authorization form as a best practice in managing their
own health care and that of their family members. Our
Authorization forms are available on bcnepa.com by
clicking on the Privacy/HIPAA link at the bottom of the
page and then selecting HIPAA Forms. The Authorization
forms are valid for a maximum of 2 years. At the end of the
2-year period, we will send the member a new form to be
completed and returned to us.
What other form is useful?
Another fairly common HIPAA form is the Personal
Representative form. This form is used to appoint an
individual as your personal representative. A personal
representative can act on behalf of a member in making
decisions related to the member’s health care.
In order to appoint someone as your personal representative,
you must send in valid court documentation that names
another individual as having the authority to act on your
behalf. The types of documentation that we will accept
are Power of Attorney, Court Orders, Guardianship papers,
Short Certificate, Letters of Administration and Letters of
Testamentary. We cannot appoint a personal representative
unless we have the appropriate documentation on file
with us.
Where should I send my completed forms?
All completed BCNEPA Authorization forms should be sent to:
Privacy & Security Office
Blue Cross of Northeastern Pennsylvania
19 North Main Street
Wilkes-Barre, PA 18711
All forms are processed on the day that they are received
and are maintained in our HIPAA Privacy Database.
What if I have questions?
For more information, please contact our Privacy &
Security Office at 1.866.262.5867 or via email at
[email protected]. n
19 North Main Street, Wilkes-Barre, PA 18711-0302
bcnepa.com
Page 18 n bcnepa.com
EBG119 3/15
© Blue Cross of Northeastern Pennsylvania. 2015.