A monthly publication for participating HMSA health care providers, facilities, and their staff. Annual Preventive Health Evaluation

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1 HealthPro News A monthly publication for participating HMSA health care providers, facilities, and their staff. January 2017 ADMINISTRATION & NEWS What s Inside Coding & Claims 2 Pharmacy 4 Policy News 16 Calendar 17 Annual Preventive Health Evaluation Starting January 1, 2017, a new benefit, the Annual Preventive Health Evaluation (APHE), will be available for members 22 years of age or older who have certain non-grandfathered commercial preferred provider organization (PPO) or CompMED plans without a physical exam benefit. The APHE is an annual benefit and includes a health assessment and review of prior screening results, assessment of additional preventive screenings a member may need, and offers certain preventive screenings that are in the U.S. Preventive Services Task Force guidelines. A licensed practitioner other than a medical doctor, such as a physician s assistant or advanced practice registered nurse, may perform the APHE either online or by telephone. The APHE isn t a physical exam or follow-up visit. There s no copayment for CompMED and PPO plan members when a participating provider renders the services. If a nonparticipating provider performs the APHE, payment will be made according to the plan s outpatient physician visit benefit. The APHE is billed using one of the following HCPCS procedure codes: G0438 (Annual wellness visit; initial) or G0439 (Annual wellness visit; subsequent). HMSA Akamai Advantage members already have this benefit and their service will be unchanged. For more information on this new benefit and coding guidelines, please refer to the Annual Preventive Health Evaluation document in the Provider Resource Center at hmsa.com/portal/provider/zav_pel.ph.pre.600.htm. MAC Changes The following maximum allowable charges (MACs) increased effective December 1, 2016: Procedure Description New MAC Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB), 3-dose schedule, for intramuscular use Pneumococcal conjugate vaccine, 13-valent (PCV13), for intramuscular use Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use Hawai i Medical Service Association 818 Keeaumoku St. (808) An Independent Licensee of the Blue Cross and Blue Shield Association P.O. Box 860 Honolulu, HI hmsa.com hhin.hmsa.com Provider Resource Center hmsa.com/portal/provider

2 2 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 ADMINISTRATION & NEWS (CONTINUED) Medical Drug Fees for 2017 Fees for new HCPCS procedure codes will be effective January 1, Fee updates for existing HCPCS codes will be effective March 1, 2017, and may include both increases and decreases in MACs. Quarterly reviews will be made thereafter. Full fee schedules will be posted to the Hawaii Healthcare Information Network (HHIN). Correction: Gender Identity Services The article titled Gender Identity Services in the October 2016 issue of HealthPro News should have included that the policy also applies to HMSA Akamai Advantage plans. The Gender Identity Services policy will apply to Fed 87, PPO, HMO, HMSA Akamai Advantage, and QUEST plans upon renewal following January 1, All plans that the Gender Reassignment policy currently applies to will follow the Gender Identity Services policy on the next renewal date. The Gender Identity Services policy may be found in the Provider Resource Center at hmsa.com/portal/provider/ MM _Gender_Identity_Services_90_Day_Notice_ pdf. CODING & CLAIMS Sound Practices and Accurate Billing Accurate claims filing is important because it benefits you, your patients, HMSA, and the health care system. Please strive to accurately document the services you provide. When you submit a claim for your services, you re certifying that you earned the payment you re requesting and that you ve complied with the billing requirements. If you knew or should have known the claim was false, the claim may be illegal and/or in violation of your participating provider agreement. Please emphasize to your staff and/or billing service the importance of filing accurate claims and ensure that they re aware of claim submission guidelines and regulations. In particular, office managers in group practices may want to remind staff members that claims are always filed on behalf of the rendering provider even if payment for all group members goes to the same entity. The Health Insurance Portability and Accountability Act (HIPAA) prohibits submitting fraudulent claims to a health plan. Practices that are fraudulent or improper include: Billing for services that you didn t render. Providing and/or billing for services that aren t medically necessary. Billing for services performed by an improperly supervised or unqualified employee. Billing for services performed by an employee excluded from participation in federal health care programs. Billing for services of such low quality or so deficient that they re equivalent to no service being rendered at all. Unbundling or split billing for services that can be accurately described by a single CPT code.

3 3 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 CODING & CLAIMS (CONTINUED) Tuberculin Testing and Treatment As a reminder, skin testing is a once-a-year benefit (January through December) for adults and as needed for children. This policy has been in effect since January 1, Certain claims submitted after that date were processed and paid in error. We ll honor all payments made to previously processed claims and won t recoup any claims that were paid in error. Use the appropriate CPT-4 code that describes the service provided. The fee for the test includes reading the test results. A separate visit to read the results isn t payable. When testing children as part of an EPSDT screening exam, the testing is included as part of the global fee reimbursement for EPSDT and shouldn t be billed separately. If this is a second test for an adult because the initial test was positive or inconclusive, include a notation in field #19 to explain the reason for the test. Updated Billing Codes Starting January 1, 2017, the following drugs will have specific billing codes: Adynovate. Bendeka. Cinqair. Coagadex. Darzalex. Empliciti. Hymovis. Idelvion. Imlygic. Kanuma. Nucala. Nuwiq. Onivyde. Portrazza. Vonvendi. Yondelis. These drugs previously didn t have a specific HCPC code assigned and were billed using a miscellaneous code. All providers other than specialty pharmacies, ambulatory infusion suite (AIS) providers, and home IV providers should use the most specific billing code available at the date of service. This list may not include all new or updated billing codes. Please refer to your billing code resource for new or updated billing codes. CMS-updated HCPC codes can be found at cms.gov/medicare/coding/medhcpcsgeninfo/ index.html?redirect=/medhcpcsgeninfo.

4 4 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 PHARMACY Billing for Durable Medical Equipment We d like to remind pharmacies that blood glucose meters, nebulizers, wheelchairs, walkers, and other durable medical equipment (DME) should be billed under a patient s medical plan and not their drug rider. To determine the patient s share for DME, see the following sections in HHIN (hhin.hmsa.com): PPO: Special Services/Appliances and Durable Medical Equipment. HMO: Additional Benefits/Appliance and Equipment. HMSA Akamai Advantage: Special Services/Durable Medical Equipment and Supplies. QUEST : No copayment for covered DME. Mail PPO, HMO, and HMSA Akamai Advantage paper claims to: HMSA - CMS 1500 Claims (Professional) P.O. Box Honolulu, HI Mail QUEST claims to: HMSA QUEST P.O. Box 3520 Honolulu, HI If you d like to start filing medical claims electronically, please call on Oahu or 1 (800) toll-free on the Neighbor Islands. To use the HMSA Provider Manual-Interactive claim form, go to hmsa.com/portal/provider/ cms1500_interactive_02_12.pdf. Additionally, view an HMSA training video for detailed filing instructions at youtube.com/watch?v=jr3jujajpx0&feat ure=youtu.be. Presentation slides used for training are at hmsa.com/portal/provider/basic_claims_filing_for_hmsa_ CMS_1500.pdf. If you have questions about filing CMS-1500 claims, call Customer Relations at on Oahu or 1 (800) toll-free on the Neighbor Islands. Medication Therapy Management Program Beginning this month, SinfoniaRx will replace Mirixa as HMSA s Medication Therapy Management (MTM) provider. SinfoniaRx will conduct medication reviews with eligible HMSA Akamai Advantage members. MTM services support the management of your more-vulnerable patients with a comprehensive medication review (CMR) of prescription and over-the-counter medications, herbal therapies, dietary supplements, and more. CMRs identify and address issues such as duplications in therapy, drug interactions, and poor adherence to optimize patient outcomes. This service will be offered at no cost to HMSA Akamai Advantage members who meet all of the following criteria: Have three or more chronic diseases such as asthma, a cardiovascular disorder, chronic obstructive pulmonary disorder (COPD), congestive heart failure (CHF), depression, diabetes, or osteoporosis. Are taking eight or more Medicare-D-covered maintenance medications. Reach $ spending (by the member and plan) per quarter (CY2017) for prescription drugs.

5 5 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 Your HMSA Akamai Advantage patients who are eligible for this Medicare benefit will receive a call from a SinfoniaRx pharmacist. Please encourage your patients who receive this offer to take advantage of this valuable service. Please be aware that the pharmacist may contact you to alert you to a patient s potential medication-related problems and issues. If you have questions about our MTM program, call HMSA Medicare Pharmacist Wendell Oumaye, Pharm.D., at on Oahu, or Wendy Iwasaki, Pharm.D., B.C.A.C.P., B.C.G.P., at on Oahu. SinfoniaRx is an independent company providing medication therapy management services on behalf of HMSA. Control Formulary Changes The Pharmacy and Therapeutics Committee made the following formulary changes effective April 1, The Control Formulary is available in the HMSA Provider Resource Center at hmsa.com/portal/provider/hmsa_control_formulary.pdf. albuterol sulfate aerosol ProAir Respiclick Respiratory 2 amphetamine extended release suspension Dyanavel XR Central Nervous System 3 azelastine fluticasone propionate nasal spray Dymista Respiratory 2 butalbital/acetaminophen/ caffeine capsules butalbital/acetaminophen/ caffeine capsules Generic Fioricet Analgesics 1 Fioricet Analgesics 3 Alternatives: naratriptan, rizatriptan, sumatriptan, zolmitriptan, Relpax, Zomig nasal spray Alternatives: naratriptan, rizatriptan, sumatriptan, zolmitriptan, Relpax, Zomig nasal spray calcipotriene foam Sorilux Topical 2 3 Alternative: calcipotriene dabigatran etexilate mesylate capsule darifenacin hydrobromide SR tablet Pradaxa Hematologic 2 Enablex Genitourinary 3 desvenlafaxine SR tablet Khedezla Central Nervous System 2 3 dexamethasone tablet therapy pack doxazosin mesylate SR tablet Dexpak Endocrine and Metabolic 3 Cardura XL Genitourinary 3 2 Alternatives: warfarin, Eliquis, Xarelto Alternatives: oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium extrel, Myrbetriq, Toviaz, Vesicare Alternatives: duloxetine, venlafaxine, venlafaxine ext-rel capsule, Pristiq Alternatives: dexamethasone, methylprednisolone, prednisone

6 6 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 esomeprazole magnesium DR capsule esomeprazole magnesium DR suspension packet fentanyl citrate sublingual tablet fesoterodine fumarate SR tablet folic acid-cholecalciferol capsule glycopyrrolate-formoterol fumarate aerosol Hydrocortisone ace-pramoxine-aloepolysaccharides gel ibuprofen-famotidine tablet insulin glargine cartridge insulin glargine pen-injector insulin glargine pen-injector insulin glargine vial insulin pen needle insulin regular (human) pen injector iodoquinol-aloe polysaccharides gel iodoquinol-hydrocortisone-aloe-polysaccharide gel Nexium Gastrointestinal 3 Nexium granules Gastrointestinal 3 Abstral Analgesics 2 Toviaz Genitourinary 2 Zolate Nutritional/ supplements 3 Bevespi Respiratory 2 Alternatives: esomeprazole, pantoprazole, lansoprazole, omeprazole, Dexilant Alternatives: esomeprazole, pantoprazole, lansoprazole, omeprazole, Dexilant Alternatives: fentanyl transmucosal lozenge, Fentora, Subsys Novacort Topical 3 Alternative: hydrocortisone Duexis Analgesics 3 Lantus CRT Lantus Solostar Toujeo Solostar Lantus vial Pen Needles Mis Humulin R U-500 Kwikpen Endocrine and Metabolic Endocrine and Metabolic Endocrine and Metabolic Endocrine and Metabolic Endocrine and Metabolic Endocrine and Metabolic Alternatives: Basaglar, Levemir, Toujeo Alternatives: Basaglar, Levemir, Toujeo Alternatives: Basaglar, Levemir, Toujeo Alternatives: Basaglar, Levemir, Toujeo Aloquin Topical 3 Alternative: hydrocortisone Alcortin A Topical 3 Alternative: hydrocortisone levocarnitine oral solution Carnitor SF Endocrine and Metabolic 3 Alternative: levocarnitine levocarnitine tablet Carnitor Endocrine and Metabolic 3 Alternative: levocarnitine lubiprostone capsule Amitiza Gastrointestinal 2 methylphenidate HCl ER capsule metoprolol and hydrochlorothiazide SR tablet mometasone furoate nasal suspension Aptensio XR Central Nervous System 2 Dutoprol Cardiovascular 3 Nasonex Respiratory 2 3 Alternatives: metoprolol succinate ext-rel AND hydrochlorothiazide Alternatives: flunisolide, fluticasone, mometasone, triamcinolone, Dymista

7 7 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 naloxone HCl auto-injector Evzio Central Nervous System 2 naproxen-esomeprazolemagnesium tablet Vimovo Analgesics 3 nilutamide tablet Nilandron Antineoplastic Agents 3 penciclovir cream Denavir Topical 2 3 prednisolone sodium phosphate oral solution Millipred Solution Endocrine and Metabolic 3 prednisolone tablet Millipred Tablet Endocrine and Metabolic 3 prednisolone tablet therapy pack rosuvastatin calcium tablet venlafaxine ER tablet (37.5 mg, 75 mg, 150 mg) Millipred DP Pak Endocrine and Metabolic 3 Alternatives: naloxone injectable, Narcan nasal spray Alternatives: bicalutamide, Zytiga Alternatives: acyclovir, valacyclovir Alternatives: dexamethasone, methylprednisolone, prednisone Alternatives: dexamethasone, methylprednisolone, prednisone Alternatives: dexamethasone, methylprednisolone, prednisone Crestor Cardiovascular 2 Alternative: rosuvastatin Central Nervous System 3 Alternatives: duloxetine, venlafaxine, venlafaxine ext-rel capsule, Pristiq

8 8 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 Specialty iloprost inhalation solution Ventavis Cardiovascular 4 5 imatinib mesylate tablet Gleevec Antineoplastic Agents 5 nintedanib esylate capsule Ofev Respiratory 4 nitisone suspension Orfadin suspension Endocrine and Metabolic 5 pirfenidone capsule Esbriet Respiratory 4 sofosbuvir tablet Sovaldi Anti-infectives 4 5 sofosbuvir-velpatasvir tablet tobramycin inhalation capsule tobramycin nebulizer solution tobramycin nebulizer solution treprostinil diolamine CR tablet treprostinil inhalation solution Epclusa Anti-infectives 4 Tobi Podhaler Respiratory 5 Bethkis Respiratory 5 4 Tobi Respiratory 5 Orenitram Cardiovascular 5 4 Tyvaso Cardiovascular 4 5 Alternatives: Letairis, Orenitram, Tracleer Alternatives: imatinib mesylate, Bosulif, Sprycel Alternatives: Epclusa, Harvoni Effective January 1, 2017 Alternatives: tobramycin inhalation solution, Bethkis Alternatives: tobramycin inhalation solution, Bethkis Alternatives: Letairis, Orenitram, Tracleer

9 9 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 Essential Prescription Formulary Changes The Pharmacy and Therapeutics Committee made the following formulary changes effective April 1, The Essential Prescription Formulary is available in the HMSA Provider Resource Center at hmsa.com/portal/provider/ HMSA_Essential_Prescription_Formulary.pdf. albuterol ProAir Respiclick Short Acting Beta Agonist 2 canagliflozin-metformin SR 24 hours Invokamet XR Antidiabetic 3 Step therapy: Must try metformin or metformin combo clindamycin/tretinoin Ziana Antiacne 3 Alternative: Use generic dofetilide Tikosyn Anti-arrhythmic 3 Alternative: Use generic enalapril maleate oral solutoin Epaned Cardiovascular Agent 3 3 Age limit: 1 month to 12 years of age frovatriptan Frova Anti-migraine 3 Alternative: Use generic linagliptin Tradjenta DPP-4 2 linagliptin/metformin Jentadueto DPP-4 2 linagliptin/metformin XR Jentadueto XR DPP-4 2 lisinopril oral solution Qbrelis Cardiovascular Agent 3 Age limit: 6 to 12 years of age saxagliptin Onglyza DPP-4 2 Alternatives: Januvia, Tradjenta saxagliptin/metformin Kombiglyze XR DPP-4 2 Alternatives: Janumet XR, Jentadueto XR mesalamine delayed release Asacol HD Anti-inflammatory 3 Alternative: Use generic repaglinide/metformin Prandimet Antidiabetic 2 Alternative: Use generic Specialty ombitasvir/ paritaprevir/ ritonavir/dasabuvir Viekira Hepatitis C 5 sofosbuvir Sovaldi Hepatitis C 4 sofosbuvir/valpatasvir Epclusa Hepatitis C 4 Alternative: Harvoni Alternatives: Epclusa, Harvoni Effective January 1, 2017

10 10 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 Metallic Formulary Changes The Pharmacy and Therapeutics Committee made the following formulary changes effective April 1, albuterol ProAir Respiclick Short Acting Beta Agonist 3 2 canagliflozin-metformin SR 24 hours Invokamet XR Antidiabetic 3 Step therapy: Must try metformin or metformin combo clindamycin/tretinoin Ziana Antiacne 3 Alternative: Use generic dofetilide Tikosyn Anti-arrhythmic 3 Alternative: Use generic enalapril maleate oral solution Epaned Cardiovascular Agent 3 3 Age limit: 1 month to 12 years of age frovatriptan Frova Anti-migraine 3 Alternative: Use generic linagliptin Tradjenta DPP linagliptin/metformin Jentadueto DPP linagliptin/metformin XR Jentadueto XR DPP lisinopril oral solution Qbrelis Cardiovascular Agent 3 Age limit: 6 to 12 years of age mesalamine delayed release Asacol HD Anti-inflammatory 2 Alternative: Use generic repaglinide/metformin Prandimet Antidiabetic 2 Alternative: Use generic saxagliptin Onglyza DPP Alternatives: Januvia, Tradjenta saxagliptin/metformin Kombiglyze XR DPP Alternatives: Janumet XR, Jentadueto XR Specialty ombitasvir/ paritaprevir/ ritonavir/ dasabuvir Viekira Hepatitis C 5 sofosbuvir Sovaldi Hepatitis C 4 Sofosbuvir /valpatasvir Epclusa Hepatitis C 4 Alternative: Harvoni Alternatives: Epclusa, Harvoni Effective January 1, 2017

11 11 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 Select Formulary Changes The Pharmacy and Therapeutics Committee made the following formulary changes effective April 1, The Select Formulary is available in the HMSA Provider Resource Center at hmsa.com/portal/provider/index.htm. albuterol ProAir Respiclick Short Acting Beta Agonist 3 2 canagliflozin-metformin Step therapy: Must try metformin or metformin combo Invokamet XR Antidiabetic 3 3 SR 24 hours enalapril maleate oral Age limit: 1 month to 12 years Epaned Cardiovascular Agent 3 3 solution of age lifitegrast Xiidra Ophthalmic/Dry Eye Quantity limit: Two vials 3 3 Disease per day linagliptin Tradjenta DPP linagliptin/metformin Jentadueto DPP linagliptin/metformin XR Jentadueto XR DPP lisinopril oral solution Qbrelis Cardiovascular Agent 3 3 Age limit: 6 to 12 years of age mesalamine delayed release Asacol HD Anti-inflammatory 2 3 Alternative: Use generic oxycodone hcl and naltrexone hcl Troxyca ER Central Nervous System Agent 3 3 Quantity limit: Three tablets per day repaglinide/metformin Prandimet Antidiabetic 2 3 Alternative: Use generic saxagliptin Onglyza DPP Alternatives: Januvia, Tradjenta saxagliptin/metformin Kombiglyze XR DPP Alternatives: Janumet XR, Jentadueto XR Specialty sofosbuvir Sovaldi Hepatitis C 4* 4 sofosbuvir/valpatasvir Epclusa Hepatitis C 4 4* *Preferred product Preferred products: Epclusa, Harvoni Effective January 1, 2017 QUEST Formulary Changes The Pharmacy and Therapeutics Committee made the following changes to the HMSA QUEST formulary effective April 1, We encourage you to talk with your patients to determine if an alternative medication is appropriate for them. Patients who are currently taking a medication that will be removed from the formulary must switch to a formulary alternative that s a benefit of their plan. If you believe your patient should continue taking their current medication, you can request a non-formulary exception. Please use the form at hmsa.com/portal/provider/cvs_formulary_exception_(br)_prior_auth_ pdf. The HMSA QUEST formulary is available in the HMSA Provider Resource Center at hmsa.com/portal/provider/index.htm.

12 12 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 Medication Strength Drug class Change/Criteria Advair Diskus 100/50 250/50 500/50 Advair HFA 45/21 115/21 230/21 Amicar solution 0.25 gm/ml Amicar tablet Aristada injection Arnuity Ellipta Auryxia tablet BD Insulin Syringe Ultrafine U ml BD Insulin Syringe Ultrafine U ml BD Insulin Syringe Ultrafine U ml BD Insulin Syringe Ultrafine Half-Unit U ml BD Insulin Syringe Ultrafine Short U ml BD Insulin Syringe Ultrafine Short U ml Respiratory Agent Respiratory Agent Blood Modifier Agent 500 mg 1000 mg Blood Modifier Agent 441 mg/1.6 ml 662 mg/2.4 ml Antipsychotics 882 mg/3.2 ml 100 mcg 200 mcg Steroid Inhalants QL 210 mg 30G x 1/2 31G x 15/64 31G x 5/16 30G x 1/2 31G x 5/16 31G x 15/64 30G x 1/2 31G x 5/16 31G x 5/16 31G x 5/16 BD Pen Needle 29G x 1/2 31G x 5/16 31G x 3/16 32G x 5/32 Canasa suppositories 1,000 mg Copaxone injectable 20 mg/ml Cortifoam Rectal Foam 10% Dulera aerosol Emend suspension mcg/act mcg/act Phosphate Binder Agents Antidiabetic supplies Antidiabetic supplies Antidiabetic supplies Antidiabetic supplies Antidiabetic supplies Antidiabetic supplies Antidiabetic supplies Inflammatory Bowel Disease Multiple Sclerosis Agents Inflammatory Bowel Disease Steroid/Beta Agonist Combinations 125 mg/5 ml Antiemetic PA, QL QL QL ST Step therapy removed Quantity limit: One inhaler per month Step therapy removed Quantity limit: One inhaler per month as of December 2016 as of December 2016 Quantity limit: One inhaler per month Step therapy: must try generic PhosLo (calcium acetate) Alternatives: hydrocortisone enema, mesalamine rectal suppositories Alternatives: glatiramer 20 mg/ ml, Copaxone 40 mg/ml Alternatives: hydrocortisone enema, mesalamine rectal suppositories Step therapy removed Quantity limit: 12 kits per 21 days (single dose kits)

13 13 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 Entresto tablet Farxiga tablet Medication Strength Drug class Change/Criteria mg mg mg 5 mg 10 mg Neprilysin Inhibitor removed Alternative: Invokana Flovent HFA 44 mcg 110 mcg Respiratory Agent AL Age limit: less than 12 years 220 mcg of age Gardasil vaccine Age limit: years of age Immunological Agent AL, QL Quantity limit: Three doses per lifetime Effective January 1, 2017 insulin pen needle all brands except Alternative: BD insulin pen for BD needles insulin syringes all brands except for BD Alternative: BD insulin syringes Invokamet tablet mg mg Step therapy: Must have ST 50-1,000 mg tried metformin, sulfonylurea, or 150-1,000 mg thiazolidinedione Invokana tablet 100 mg Step therapy: Must have ST 300 mg tried metformin, sulfonylurea, or thiazolidinedione Janumet tablet mg Step therapy: Must have ST 50-1,000 mg tried metformin, sulfonylurea, or thiazolidinedione Janumet XR tablet mg Step therapy: Must have 50-1,000 mg ST tried metformin, sulfonylurea, or 100-1,000 mg thiazolidinedione Januvia tablet 25 mg Step therapy: Must have 50 mg ST tried metformin, sulfonylurea, or 100 mg thiazolidinedione Jardiance tablet 10 mg 25 mg Alternative: Invokana Jentadueto tablet mg mg 2.5-1,000 mg Alternatives: Janumet, Janumet XR levocarnitine solution 1g/10 ml Nutritive Agents levocarnitine tablet 330 mg Nutritive Agents Linzess capsule 145 mcg Irritable Bowel Syndrome 290 mcg modafinil tablet 100 mg Narcolepsy PA 200 mg Moxeza solution 0.5% Ophthalmic, Antiinfectives oxycodone with acetaminophen solution mg/5 ml Opioid Analgesics QL Alternatives: ciprofloxacin, levofloxacin, ofloxacin Quantity limit: 4,000 mg of APAP per day

14 14 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 Ranexa tablet Medication Strength Drug class Change/Criteria 500 mg 1,000 mg Antianginal Relenza Diskhaler 5 mg/blister Influenza Agents Simbrinza suspension 1-0.2% sulfacetamide sodium with sulfur cleansing cloth sulfacetamide sodium with sulfur cleansing pad sulfacetamide sodium with sulfur cream sulfacetamide sodium with sulfur emulsion sulfacetamide sodium with sulfur lotion Symbicort Aerosol Tanzeum injectable Tivicay tablet Ophthalmic, Anti-glaucoma Agents 10-5% Acne 10-4% Acne 10-2% 10-5% 10-1% 10-5% Acne Acne 10-5% Acne mcg/act mcg/act 30 mg 50 mg 10 mg 25 mg Steroid/Beta Agonist Combinations Antiretrovirals Tradjenta tablet 5 mg ST Step therapy: Must try a nitrate plus a beta blocker or a calcium channel blocker Alternative: Tamiflu Alternatives: dorzolamide WITH brimonidine 0.15% or brimonidine 0.2%, OR dorzolamide/ timolol Alternatives: benzoyl peroxide (except foam); clindamycin gel, lotion, solution; erythromycin gel 2%; erythromycin solution; erythromycin/benzoyl peroxide; sulfacetamide lotion 10%; metronidazole cream, gel, lotion Alternatives: benzoyl peroxide (except foam); clindamycin gel, lotion, solution; erythromycin gel 2%; erythromycin solution; erythromycin/benzoyl peroxide; sulfacetamide lotion 10%; metronidazole cream, gel, lotion Alternatives: benzoyl peroxide (except foam); clindamycin gel, lotion, solution; erythromycin gel 2%; erythromycin solution; erythromycin/benzoyl peroxide; sulfacetamide lotion 10%; metronidazole cream, gel, lotion Alternatives: benzoyl peroxide (except foam); clindamycin gel, lotion, solution; erythromycin gel 2%; erythromycin solution; erythromycin/benzoyl peroxide; sulfacetamide lotion 10%; metronidazole cream, gel, lotion Alternatives: benzoyl peroxide (except foam); clindamycin gel, lotion, solution; erythromycin gel 2%; erythromycin solution; erythromycin/benzoyl peroxide; sulfacetamide lotion 10%; metronidazole cream, gel, lotion Alternatives: Dulera, Advair Alternatives: Trulicity, Victoza Alternative: Januvia

15 15 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 Medication Strength Drug class Change/Criteria Trulicity injectable 0.75 mg/0.5 ml 1.5 mg/0.5 ml Velphoro chewable 500 mg Phosphate Binder Agents zolpidem ER tablet 6.25 mg 12.5 mg Central Nervous System Agent ST QL Step therapy: Must have tried metformin, sulfonylurea, or thiazolidinedione Alternatives: calcium acetate, Auryxia Quantity limit: 1 tablet per day Specialty Avonex kit Medication Strength Drug class Change/Criteria 30 mcg (33 mcg (6.6MU)/vial) Multiple Sclerosis Agents Avonex Pen kit 30 mcg/0.5 ml Multiple Sclerosis Agents PA Avonex Prefilled kit 30 mcg/0.5 ml Multiple Sclerosis Agents PA Bethkis Nebulizer solution 300 mg/4 ml Cystic Fibrosis PA Bosulif tablet Epclusa tablet Iclusig tablet Ofev capsule 100 mg 500 mg mg 15 mg 45 mg 100 mg 150 mg Kinase Inhibitors Antivirals, Hepatitis Agents Kinase Inhibitors Pulmonary Fibrosis Agents Sovaldi tablet 400 mg Hepatitis C Agents Sprycel tablet Tasigna capsule 20 mg 50 mg 70 mg 80 mg 100 mg 140 mg 150 mg 200 mg Kinase Inhibitors Kinase Inhibitors Tecfidera Starter Pack 120 mg & 240 mg Multiple Sclerosis Agents PA Tecfidera capsule Uptravi tablet 120 mg 240 mg 200 mcg 400 mcg 600 mcg 800 mcg 1,000 mcg 1,200 mcg 1,400 mcg 1,600 mcg Multiple Sclerosis Agents Pulmonary Arterial Hypertension PA PA PA PA PA Alternative: imatinib on January 1, 2017 Alternative: imatinib Alternatives: Epclusa, Harvoni, Zepatier Alternative: imatinib Alternative: imatinib

16 16 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 Specialty Medication Strength Drug class Change/Criteria Uptravi Therapy Pack Xtandi capsule Zytiga tablet 200 mcg (140) & 800 mcg (60) 40 mg 250 mg Pulmonary Arterial Hypertension Hormonal, Antineoplastic Agents Hormonal, Antineoplastic Agents PA PA Alternative: Zytiga POLICY NEWS Medical policies are in the Provider E-Library at hmsa.com/prc0004. For copies, call Provider Services at on Oahu or 1 (800) toll-free on the Neighbor Islands. Medical Specialty Drug Policy Correction In the December 2016 issue of HealthPro News, Lupron was inadvertently omitted from the Medical Specialty Drug Policy changes section. The effective date is January 1, Annual Review of Medical Policies The following policies have been reviewed and updated in the Provider E-Library at hmsa.com/prc0006; printed copies are available on request. Digital Breast Tomosynthesis. Erectile Dysfunction. Esophageal ph Monitoring. Home Health Care. Home Infusion Pain Management Therapy. Multigene Expression Assay for Predicting Recurrence in Colon Cancer. Significant Changes for Policies Requiring 90-day Notice The following policies have undergone significant changes and go into effect April 1, 2017: Continuous Glucose Monitoring System. Insulin Pumps. Low-Molecular-Weight Heparin. Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy. New Medical Policies The following policy goes into effect April 1, 2017: Breast Pumps. Please refer to the current medical policies for information, such as precertification requirements, at hmsa.com/prc0006.

17 17 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 POLICY NEWS (CONTINUED) Annual Review of Medical Specialty Drug Policies The following policy has undergone review and is effective April 1, 2017: Arcalyst. Drafts of medical specialty drug policies will be posted online for your review. Please visit info.caremark.com/ hmsapolicies in the CVS HMSA Medical Policies for drafts of policies that may affect your practice. Physicians may contact CVS Caremark with questions or comments by to HMSAPAReview@caremark.com or by fax to 1 (866) toll-free. Please comment by the due date indicated online. CVS Caremark is an independent company providing pharmacy benefit management services on behalf of HMSA. CALENDAR Well-Being Workshops The following workshops are available to HMSA members at no cost. These informative sessions can help your patients improve their health and well-being. For more information, refer your patients to hmsa.com/well-being/workshops or have them call 1 (855) toll-free to register at least three days before the workshop date. HAWAII ISLAND Exercise: The Magic Bullet Get fitness motivation and tips. 1/12, a.m. HMSA Hilo Wellness 101 Take the first step toward improved well-being. 1/10, a.m. HMSA Hilo KAUAI Germ Busters Find out treatment and prevention recommendations for common respiratory illnesses. 1/30, 5 6 p.m. Kuhio Medical Center MAUI Wellness 101 Take the first step toward improved well-being. 1/20, a.m. HMSA Maui Office OAHU Exercise: The Magic Bullet Get fitness motivation and tips. 1/19, a.m. HMSA Pearl City 1/21, 9:30 10:30 a.m. Kaimuki Plaza, Kaimana Room 1/24, 9:30 10:30 a.m. HMSA Honolulu 1/28, a.m. HMSA Pearl City Wellness 101 Take the first step toward improved well-being. 1/13, a.m. HMSA Honolulu 1/14, a.m. Kaimuki Plaza, Kaimana Room 1/21, a.m. HMSA Pearl City

18 18 HealthPro News - Health Care Providers, Facilities, and Staff January 2017 CALENDAR (CONTINUED) Community Activities Adult Fitness at Queen s: Learn body shaping, tai chi, kickboxing, yoga, and more. Times and instructors vary. The Queen s Medical Center, Women s Health Center Classroom. Six classes for $ for details and to register. Health & Education at Queen s: The Queen s Medical Center, Women s Health Center Classroom. Genetics Class: Learn about prenatal genetic screening and tests to check the health of your baby Free. Lamaze Class: Sundays, 1 4 p.m. Get birthing techniques from a Lamaze-certified instructor in this birthpartner-focused class. $150 per couple for five sessions. Instructor: Nicia Platt. Lymphedema/Breast Cancer Clinic: First and third Thursdays, 1:30 2:30 p.m. Learn exercises to prevent lymphedema (swelling of the arms). Free. Mammogram and Cervical Cancer Screening: Every other Friday, 8 a.m. noon. Free for women ages 50 64, uninsured or underinsured, or low income Aloha Kidney Classes: Learn how to manage conditions related to chronic kidney disease (CKD). Free six-week series. To enroll or for more information, go to alohakidney.com or call Big Island Ostomy Group: January 21, 11:30 a.m. Hilo Medical Center. Open to ostomates, pre-ostomy patients, caregivers, medical professionals, and the general public COPD Support Group: January 10, 10 a.m. noon. Pali Momi Women s Center at Pearlridge. Get support and information on medication, breathing techniques, exercise, and more. To register, call Valerie Chang at , valerie@hawaiicopd.org, or visit hawaiicopd.org. Diabetes Adult Support Group: January 5, 1 2:30 p.m. American Diabetes Association Office, Honolulu. This month, Diabetes Wellness and Goal Setting with Fitness and Wellness Coach Terri Levins Dietz. Free. Parking validation available Eat Well for Life: January 26, 6 7:15 p.m. Castle Wellness Center Travel the world of plant-based cuisine as we learn about ingredients and sample vegan dishes of different regions and countries. This month, enjoy comforting chowder and other regional favorites of the U.S. East Coast. $10 per person Farmers Market at HMSA: Every Friday, 11 a.m. 2 p.m. HMSA Honolulu. Fresh island-grown produce and ready-to-eat local food. For information on vendors, call HMSA at Hawaii Prostate Cancer Support Group: This free support group provides men and their families with information, materials, and support to help them make informed decisions about prostate cancer treatment. For locations and meeting times, go to hawaiiprostatecancer.org or call How to Feel Good: January 12, 6 7:30 p.m. Castle Wellness Center. Learn how to focus on your emotional and spiritual domains as a part of a multi-dimensional wellness program. Free Kardiac Kids Support Group: January 13, 6:30 9 p.m. Kapiolani Medical Center Cafeteria. Education, encouragement, and support for families with children who have congenital heart defects. Jullie Passos, Mommy & Me Hui: Every Friday, 11:15 a.m. 12:30 p.m. Castle Medical Center. Learn about breastfeeding and connect with new mothers Stroke Support Group: January 10, 4 5 p.m. Hilo Medical Center. A forum for stroke survivors, caregivers, family members, and friends. Amy Shipley, or ashipley@hhsc.org. Walk with a Doc on Hawaii Island: Every Sunday, 8 a.m. Liliuokalani Gardens, Hilo. Walk includes a brief warm-up/stretch and an informative talk from a community physician or medical student. Meets rain or shine. wwadbigisland.org.