NETWORK MATTERS January 2016

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1 HPHCURRENT EVENTS Medicare Advantage Stride Provider Service Center Phone Number As a reminder, if you have any questions related to our two Medicare Advantage plans Harvard Pilgrim Stride SM Value Rx (HMO) and Stride Value Rx Plus (HMO) please contact our dedicated Medicare Advantage Provider Service Center at In the past, a second Medicare specific phone number was also operational, but as of January 30, this phone number ( ) will no longer be in use. You can find helpful information in the Medicare Advantage section of our provider website, as well as in our Medicare Advantage Stride (HMO) Quick Reference Guide both of which have been recently updated. The website includes resources such as forms (the referral form, claims appeal form, and prior authorization request forms), a link to the Medicare Advantage Provider Portal, the Medicare Advantage Provider Manual, and a product summary. The quick reference guide details how to request authorizations, submit claims, conduct e transactions, request claims adjustments or appeal claims, and more. Hospital and Ancillary Facilities: Tell Us How We re Doing At Harvard Pilgrim, we strive to provide exceptional service to our members and provider network, and your feedback gives us insight into what s working well and what areas offer an opportunity for improvement. In late 2015, we gathered feedback from primary care physicians and specialists in our network. Now, we are asking participating hospital and ancillary facilities to provide feedback. Because we know your time is valuable, we ve developed a streamlined, web based survey. We suggest anyone who has frequent interactions with Harvard Pilgrim on matters such as claims processing, credentialing/enrollment, or resolving service issues complete the survey by clicking on the following link: Take the survey now! Harvard Pilgrim Health Care 1 Network Matters January 2016

2 The survey will be available online from January 15 February 15. We would like to hear from you and as many of your staff who interact with Harvard Pilgrim as possible. As you complete the survey, we encourage you to use the comment boxes to provide further details about your experiences with Harvard Pilgrim. Your participation and insight into working with Harvard Pilgrim can aid us in improving our operations and providing better service to our Hospital and Ancillary providers. We appreciate and value your input. New Cost Estimator Tool Coming to Maine A new online health care cost estimator will soon be available to Maine members enrolled in national plans offered jointly by Harvard Pilgrim Health Care and UnitedHealthcare. With a targeted go live timeframe of late March, myhealthcare Cost Estimator will replace the Treatment Cost Estimator tool in Maine. In Massachusetts and New Hampshire, myhealthcare Cost Estimator is currently available. By using a secure login, members enrolled in products offered through Passport Connect and Compass (Choice Plus and Options PPO) may access myhealthcare Cost Estimator. This new tool features an improved design and more detailed information about estimated costs of care, services provided, and the nature of those services. This information can help members better plan for treatment and out of pocket costs. Among the improvements: Instead of offering only cost ranges, specific total cost estimates will now be displayed for the services in the treatment care path (episode). The care path includes the initial office visit, specific procedures involved, and associated follow up care. Costs will be measured at the care path level to ensure that estimates are complete and members are aware of the services they should expect to receive. Cost estimates for facility and professional services will be presented separately, rather than as a combined total. Members will be offered descriptions of the relevant medical procedures and treatments. Estimates will be based on provider specific costs for hospitals, physicians, and facilities. Harvard Pilgrim Health Care 2 Network Matters January 2016

3 The fees and rates used to calculate cost estimates will be based on the current applicable fee schedule or rate for the specific service and facility or physician. However, when a set fee schedule value is inapplicable or unavailable, estimates will be based on claims data. Providers can access the tool through UnitedHealthcare s online provider portal. For more information, please contact the Provider Service Center at CLINICIAN CORNER Smoking Cessation Treatment and Resources As we transition into 2016, many of your patients are likely attempting to adhere to their New Year s resolutions. Smoking cessation is a common resolution that is as difficult to uphold as it is beneficial to one s overall health, but there is an abundance of resources available for physicians to share with their patients to guide them in their goal to quit smoking. Early action in the primary care setting The primary care physician is often fundamental in the development of a personalized smoking cessation plan, which can vastly improve a patient s health and both quality and length of life. The treatment plan is different for each smoker, beginning with probing questions related to tobacco consumption and an assessment of the patient s willingness to quit. Early and persistent encouragement by health professionals and follow up during subsequent visits can be the difference between an abandoned resolution and a lifelong improvement of a patient s health through permanent smoking cessation. Depending on the patient, an effective treatment plan may include prescribing appropriate nicotine replacement therapy (e.g., nicotine patch, nicotine inhaler, nicotine lozenge), referral to behavioral health practitioners, and more. Smoking cessation resources There are many resources available for you to share with your patients who smoke and have expressed an interest in quitting. Harvard Pilgrim recommends referring such patients to smokefree.gov, a multifaceted smoking cessation resource operated by the Harvard Pilgrim Health Care 3 Network Matters January 2016

4 U.S. Department of Health and Human Services. For free telephone or online counseling services, quit tips, and more, your patients can call 800 QUIT NOW ( ). Another excellent website for Massachusetts providers is QuitWorks.com. QuitWorks is a free, evidence based stop smoking service developed by the Massachusetts Department of Public Health in collaboration with health plans in the state, including Harvard Pilgrim. The program is designed to conveniently aid providers in their efforts to help their patients stop smoking. You can use the QuitWorks website to refer your patients for appropriate care by FAX, secure , or e referral. Through the QuitWorks program, you will also receive information regarding your patient s quit status. You can also find several useful links to various government sponsored programs and other organizations in the Smoking Cessation section on page 19 of this resource guide. How Optum/UBH can help your patients For complex clinical situations, Optum/UBH is available to provide consultative assistance. Practitioners can call the Optum/UBH Physicians Consultation Service at To refer a patient for behavioral health services and to facilitate the coordination of care, call Optum at Members Rights and Responsibilities Harvard Pilgrim members receive a copy of the Members' Rights and Responsibilities upon enrollment, and all clinicians receive a copy at the time of contracting and credentialing and annually thereafter. Periodically, Harvard Pilgrim includes this information in Network Matters. Please take a moment to review. Because this information may vary among states, please be sure to read the full Rights and Responsibilities page of the Provider Manual. Members have a right to: Receive information about Harvard Pilgrim, its services, its practitioners, and providers, and members' rights and responsibilities Be treated with respect and recognition of their dignity and right to privacy Participate with practitioners in decision making regarding their health care Harvard Pilgrim Health Care 4 Network Matters January 2016

5 Engage in a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage Voice complaints or appeals about Harvard Pilgrim or the care provided Make recommendations regarding the organization s members' rights and responsibilities policy Members have a responsibility to: Provide, to the extent possible, information that Harvard Pilgrim and its practitioners and providers need in order to care for them Follow the plans and instructions for care that they have agreed on with their practitioners Understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible. P&T Committee Updates At the December 14, 2015 meeting, the Harvard Pilgrim Pharmacy & Therapeutics Committee reviewed three medications and decided the following. Corlanor (ivabradine) P&T Committee Review and Decisions Drug Description and Indication Decision Corlanor is a hyperpolarizationactivated cyclic nucleotide gated channel blocker indicated to reduce the risk of hospitalization for worsening heart failure in patients with stable, symptomatic chronic heart failure with left ventricular ejection fraction 35%, who are in sinus rhythm with resting heart rate 70 beats per minute and either are on maximally tolerated doses of beta blockers or have a contraindication to beta blocker use. Added as a Non Preferred Brand to the Value and Medicare Advantage formularies with prior authorization and a quantity limit of 60 tablets per 30 days Continued coverage as Non Preferred Brand on the Premium formularies with prior authorization and a quantity limit of 60 tablets per 30 days Harvard Pilgrim Health Care 5 Network Matters January 2016

6 Entresto (sacubitril/valsartan) Entresto is a combination of sacubitril, a neprilysin inhibitor, and valsartan (Diovan), an angiotensin II receptor blocker, indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure (NYHA Class II IV) and reduced ejection fraction. Added as a Non Preferred Brand to the Value and Medicare Advantage formularies with prior authorization and a quantity limit of 60 tablets per 30 days Continued coverage as Non Preferred Brand on the Premium formularies with prior authorization and a quantity limit of 60 tablets per 30 days Specialty Pharmacy Program Updates Harvard Pilgrim s Specialty Pharmacy Program has added the following medications for both the Premium and Value formularies. Name Description and Indication Coverage Available From Lonsurf (trifluridine and tipiracil) Lonsurf is a combination of trifluridine, a nucleoside metabolic inhibitor, and tipiracil, a thymidine phosphorylase inhibitor, indicated for the treatment of patients with metastatic colorectal cancer who have been previously treated with fluoropyrimidine, oxaliplatin and irinotecan based chemotherapy, an anti VEGF biological therapy, and if RAS wild type, an anti EGFR therapy. Pharmacy Accredo Harvard Pilgrim Health Care 6 Network Matters January 2016

7 Repatha (evolocumab) Repatha is a PCSK9 (proprotein convertase subtilisin kexin type 9) inhibitor antibody indicated as an adjunct to diet and: Maximally tolerated statin therapy for treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (CVD), who require additional lowering of LDL C Other LDL lowering therapies (e.g., statins, ezetimibe, LDL apheresis) in patients with homozygous familial hypercholesterolemia (HoFH) who require additional lowering of LDL C Pharmacy Walgreens Specialty Pharmacy Harvard Pilgrim s Specialty Pharmacy Program has added the following medications to the Premium formularies only. Name Indication Coverage Available From ProThelial (polymerized sucralfate malate) ProThelial is paste that forms a protective layer over the oral mucosa by adhering to the mucosal surface and is used in the Pharmacy Accredo Ravicti (glycerol phenylbutyrate) Zarxio (filgrastim-sndz) management of mouth lesions. Ravicti is indicated for use as a nitrogen binding agent for chronic management of adult and pediatric patients 2 years of age with urea cycle disorders (UCDs) who cannot be managed by dietary protein restriction and/or amino acid supplementation alone. Zarxio, a leukocyte growth factor, is the first biosimilar agent approved Pharmacy Pharmacy Accredo Accredo Harvard Pilgrim Health Care 7 Network Matters January 2016

8 by the FDA. It shares 5 of the 6 indications for which the originator product, Neupogen, is approved. The indications shared are: patients with cancer receiving myelosuppressive chemotherapy; patients with acute myeloid leukemia receiving induction or consolidation chemotherapy; patients with cancer undergoing bone marrow transplantation; patients undergoing autologous peripheral blood progenitor cell collection and therapy; patients with severe chronic neutropenia. Harvard Pilgrim Health Care 8 Network Matters January 2016

9 2016 Fee Schedule Updates OFFICE ASSISTANT On April 1, 2016, Harvard Pilgrim will update its: Standard professional fee schedule, incorporating recently released Medicare relative value units (RVUs) and laboratory rates for 2016 Durable medical equipment (DME) fees, which may also include changes resulting from Harvard Pilgrim s annual review of purchase (NU), maintenance (MS), and rental (RR) terms Individual consideration pricing for unclassified drug codes to better align with Harvard Pilgrim s standard fee schedule pricing for injectable drugs Beginning in mid February, providers may request 2016 sample fee schedules by calling the Provider Service Center at Network Matters is a monthly newsletter for the Harvard Pilgrim provider network Eric H. Schultz, President and Chief Executive Officer Robert Farias, Vice President, Network Services Annmarie Dadoly, Editor Joseph O Riordan, Writer Kristin Edmonston, Production Coordinator Read Network Matters online at For questions or comments about Network Matters, contact Annmarie Dadoly at annmarie_dadoly@harvardpilgrim.org or (617) Harvard Pilgrim Health Care 9 Network Matters January 2016