Provider Toolkit PFFS/PPO

Transcription

1 Provider Toolkit Y0067_PR_PhysTlkt_0514_IA 05/14/2014 PFFS/PPO

2 TABLE OF CONTENTS Sample Letter from Physician to Patient...4 HEDIS Quick Reference Guide...5 High Risk Medication Formulary Alternative List...11 Preventive Checklist

3 Provider Toolkit Dear Healthcare Provider: We truly appreciate the care and support you provide to your patients who are Today s Options PFFS/PPO members. We know you are busy, which is why we have packaged some helpful forms and materials into this convenient Provider Toolkit. This kit contains updated versions of: The Sample Letter from Physician to Patient For your convenience, we have included a pre-written sample letter that you can customize and send to your Today s Options PFFS/PPO patients who may be in need of medical services. To use this letter, save the file to your computer, type your updates into the editable fields, and print on your letterhead. It s that easy.* * Note: to remain compliant with Federal guidelines, the wording in the Sample Letter from Physician to Patient must remain as written. When printing, please be sure to include the tracking number located on the bottom left corner of the page. The HEDIS Quick Reference Guide Use this guide as a reference to code specific medical services. By coding properly, such as by using the appropriate ICD-9 codes for a patient s BMI index, you will help to reduce gaps through the claims system and reduce the potential for medical record requests. The Chart of High Risk Medications (HRM) and Alternatives The Centers for Medicare & Medicaid Services (CMS) has determined that there are medications that may create a high risk for the elderly. For your convenience, we have included this list along with alternative medications based on the CMS guidance. The Preventive Checklist Form for Physician Offices This Checklist can be handed to your Today s Options PFFS/PPO patients. It will remind them to ask you about their needed medical services. We hope you find this Provider Toolkit to be helpful. If you have any questions about how to use the items contained within this package, please contact Provider Relations at Sincerely, Erin Page President, Medicare Advantage Y0067_PR_TK_Lett_0514_IA 06/27/2014 3

4 I am writing to let you know that, according to our records, you are due for the following important medical services checked below: Annual physical exam Diabetes Screenings (may include the following): Eye Exam Blood Sugar Check (HbA1c) Screening for Kidney Disease (Nephropathy) Cholesterol Check (LDL) Blood Pressure Check Medication Review Body Mass Index (BMI) Bone Mineral Density Test (Test for Osteoporosis) Mammogram Colorectal Screening Your health is very important to us, which is why we ask that you contact our office at to schedule an appointment at your earliest convenience. If you have had any of these services at another location, please let us know when and where they were completed. We wish you good health. Y0067_MBR_PQPP_MBRLetter_0514_IA 05/09/2014

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10 HEDIS Measure Goal Measure Requirements Time Frame Age Range *Recommended Service Codes Exclusions 10

11 INFORMATION FOR YOUR CONSIDERATION High Risk Medications ( 65 years old) Formulary Alternative List Plan Year 2014 Please consider prescribing alternative therapy or discontinuing High Risk Medications for your patient(s) 65 years or older. The High Risk Medication (HRM) list is based upon the new American Geriatrics Society (AGS) recommendations and was first developed by the National Committee for Quality Assurance (NCQA) through its Healthcare Effectiveness Data and Information Set (HEDIS) and then adapted and endorsed by the Pharmacy Quality Alliance and by the National Quality Forum (NQF). Information contained in this document is for reference use only. We recognize that you, the prescriber, are best qualified to balance quality and cost-of-care considerations versus potential risk when selecting appropriate therapy for your patients. Our recommendations are provided as supplementary information for you to consider. Information provided or made available through a Today s Options PFFS or Today s Options PPO Representative is not intended to replace the professional judgment of a licensed medical prescriber. HIGH RISK MEDICATION - FORMULARY ALTERNATIVE LIST PLAN YEAR 2014 Drug Class High-Risk Medications (Tier) Antiarrhythmic Drug Digoxin (>0.125mg/day) (2) Antidepressants, Tricyclic Antihistamines, First Generation Amitriptyline (2), Clomipramine (3), Doxepin (2), Imipramine (2), Trimipramine (4) Brompheniramine (OTC), Chlorpheniramine (OTC), Clemastine (OTC), Dexbrompheniramine (OTC), Dexchlorpheniramine (OTC), Diphenhydramine (OTC), Doxylamine (OTC), Triprolidine (OTC), Carbinoxamine (NF), Hydroxyzine (NF) Promethazine Tabs (NF) *Promethazine Tabs (NF), Phenadoz, Promethgan suppositories (1) Y0067_Rx_2014HRMAlterRefChartGenSTD_1013 IA 10/18/ Formulary Alternatives (Tier) Generic Standard Higher doses associated with no additional benefit and may increase risk of toxicity Citalopram (1,3), Fluoxetine (2,3), Mirtazapine (2,3), Nortriptyline (2,4), Paroxetine (2,4), Sertraline (1,3), Trazodone (1), Budeprion (3), Bupropion (3), Venlafaxine (3), Pristiq (3), Viibryd (4) Astepro (nasal spray) (3), Azelastine (nasal spray) (3), Patanase (nasal spray) (3), Cetirizine Syrup (3), Levocetirizine (2) Ondansetron (3,4), alt for Promethazine for indication of nausea/vomiting *Ondansetron (2) alt for Promethazine for indication of nausea/vomiting*

12 Drug Class Anti-Infectives Nitrofurantoin (3) High-Risk Medications (Tier) Antiparkinsonian Agents Benztropine (Oral) (2,4) Antithrombiotics Barbiturates Benzodiazepines: Long Acting Cardiovascular: Central Alpha Agonists Endocrine Agents Estrogen/Progestin (Single and/or Combination Products Oral/Patch) Non-Benzodiazepine Hypnotics Non-Cox-Selective NSAIDs Ticlopidine (NF), Dipyridamole, oral short acting (NF) Butalbital (containing prod) (NF) Phenobarbital (2) Amitriptyline-Chlordiazepoxide (NF), Chlordiazepoxide (NF), Chlordiazepoxide-Clidinium (NF), Diazepam (1,2), Flurazepam (NF) Methyldopa (NF), Guafacine (NF), Guanabenz (NF), Reserpine (>0.1mg/day) (NF) Armour Thyroid (dessicated)(nf) Megace ES (3), Megesterol (2,3) Premarin (NF), Estropipate (NF), Prempro, Premphase (NF), Estradiol (2), Vivelle Dot (NF) Lunesta (3), Zolpidem Tartrate (2), Zaleplon (3) Indomethacin (NF) Ketorolac (NF) Formulary Alternatives (Tier) Generic Standard Sulfamethoxazole-Trimethoprim (1,2), Ciprofloxacin (1,4), Levofloxacin (3), Carbidopa-Levodopa (3,4), Pramipexole Dihydrochloride (3), Ropinirole HCL (3), Selegiline HCL (3), Azilect (3) Clopidogrel (2), Aggrenox (4) Replace with Non-Butalbital containing analgesics Carbamazepine (2,3,4), Divalproex (3), Gabapentin (2), Lamotrigine (2,3,4), Levetiracetam (3), Oxcarbazepine (3,4), Phenytoin (2,3), Primidone (3), Valproic acid (2,3) Consult with physician Thiazide Diuretics, Ace Inhibitors, Angiotensin Recptor Blockers, Long-Acting Dihydropyridine CCB (various)* Levothyroxine Sodium (1), Levoxyl (2), Levothroid (1) Nutritional Supplementation Consult with physician Avoid use >90 days; Non-Pharmacological Alternatives (Behavioral and/or Environmental Modifications) Suggested for short-term use Ibuprofen (1,3), Meloxicam (1,4), Naproxen (1,2), Celebrex (3) Sulfonylureas, Long Acting Chlorpropamide (NF), Glyburide (3) Glipizide (1), Metformin (1) Skeletal Muscle Relaxants Carisoprodol (NF), Cyclobenzaprine (NF), Methocarbamol (NF), Metaxalone (NF), Chlorzoxazone (NF), Orphenadrine (NF) Baclofen (2), Tizanidine (2) *Alternatives consist of multiple therapeutic classes. See formulary for specific tier. If you have any questions about this list, please contact Provider Relations at Today s Options PFFS or Today s Options PPO , Monday-Friday, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 711). 12

13 Screenings/Test Treatment Recommended Frequency Date Completed Next Due Date Appointment Scheduled Doctor Contact Information Cardiovascular Screening Every 5 years Date: Time: Colorectal Cancer Screening: Fecal Occult Blood Test Annually Date: Time: Diabetes Screening Annually Date: Time: Breast Cancer Screening Annually for women Date: Time: Glaucoma Screening Annually Date: Time: Pap Test and Pelvic Exam Every 1-2 years or as directed by your doctor Date: Time: Prostate Cancer Screening Annually for men Date: Time: Flu Shot Annually Date: Time: Wellness Visit Annually Date: Time: Bone Mass Measurement Every 2 years Date: Time: Colorectal Cancer Screening: Barium Enema Every 2-4 years Date: Time: Colorectal Cancer Screening: Flexible Sigmoidoscopy Every 4-10 years Date: Time: Colorectal Cancer Screening: Colonoscopy Pneumococcal Shot Every 2-10 years Date: Time: You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information. Date: Time: