<Date> <Group> <Address1> <Address2> <City> <State> <zip> RE: 2015 Blue Physician Recognition (BPR) Program. Dear <Group>:

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1 Three Penn Plaza East Newark, NJ HriznBlue.cm <Date> <Grup> <Address1> <Address2> <City> <State> <zip> RE: 2015 Blue Physician Recgnitin (BPR) Prgram Dear <Grup>: Hrizn Blue Crss Blue Shield f New Jersey values yur participatin in ur netwrks and the excellent care yu prvide t yur patients, ur members. As part f ur cntinuing effrt t align ur netwrk initiatives with the current insurance marketplace, we will revise the criteria fr the Blue Physician Recgnitin Prgram, effective January 1, The revised criteria will impact dates f service n and after January 1, Eligible practices fr the BPR prgram will be recgnized in 2016 based n 2015 claims and administrative data. Our revised BPR prgram will include, but is nt limited t, the fllwing changes: There are new measures such as chlesterl management fr patients with diabetes and all-cause readmissins. Enclsed is a list f all the measures fr each specialty. There is a revised list f specialties participating in the prgram. General surgery and urlgy are n lnger in the prgram at this time. We are currently reviewing quality measures t determine the mst apprpriate and meaningful criteria fr these specialties. Physicians in the fllwing 10 specialties wh are in the tp 25 percent (scre f 75 percent r better) f the quality and pharmacy measures will be recgnized with the BPR lg in ur nline Prvider Directry at HriznBlue.cm/Directry and the Blue Crss and Blue Shield Assciatin s Natinal Dctr & Hspital Finder at prvider.bcbs.cm. Cardilgy. Nephrlgy. Endcrinlgy. Obstetrics/Gyneclgy. Family Practice. Orthpedic Surgery. Gastrenterlgy. Otlarynglgy. Internal Medicine. Pediatrics. Physicians in the fllwing six specialties wh are in the tp 15 percent (scre f 85 percent r better) f the quality and pharmacy measures will receive financial recgnitin (enhanced reimbursement) and will be recgnized with the BPR lg in ur nline Prvider Directry at HriznBlue.cm/Directry and the Blue Crss and Blue Shield Assciatin s Natinal Dctr & Hspital Finder at (Over, please) 2430 (W1112) CMC (0914) An Independent Licensee f the Blue Crss and Blue Shield Assciatin.

2 Cardilgy Internal Medicine Endcrinlgy Obstetrics/Gyneclgy Family Practice Pediatrics Physician practices that participate in ther Hrizn BCBSNJ nnstandard reimbursement arrangements and Hrizn BCBSNJ value-based prgrams are nt eligible fr enhanced reimbursement. This includes practices that participate in Hrizn BCBSNJ s patient-centered prgrams, such as Patient-Centered Medical Hmes, Accuntable Care Organizatins and Episde f Care prgrams. Enhanced reimbursement des nt apply t: Services including but nt limited t, HCPCS cdes, immunizatins, lab tests, durable medical equipment and radilgy cdes Medicare primary r incme-based (service benefits) member plicies We lk frward t wrking with yu n this prgram and welcme yur feedback. If yu have any questins r cmments, please CntactUS@HriznBlue.cm, Attentin: Charlene Rberts. Thank yu fr yur cmmitment t prviding quality health care t ur members. Sincerely, Nathan Negin, MD Executive Medical Directr Quality Imprvement Enclsure 2430 (W1112) CMC (0914) An Independent Licensee f the Blue Crss and Blue Shield Assciatin.

3 HriznBlue.cm Metrics by Specialty Cardilgy Chlesterl Management fr Patient with Cardivascular Cnditins. (S) Persistence f Beta-Blcker Treatment After a Heart Attack. (H) Endcrinlgy Diabetic Chlesterl Management. (S) Diabetic Cntrl. (H,S) Diabetic Testing. (H,S) Family Practice All-Cause Readmissins (infrmatinal nly). (H,S) Antidepressant Medicatin Management. (H) Apprpriate Imaging fr Back Pain. (H) Apprpriate Treatment fr Children with Upper Respiratry Infectin. (H) Apprpriate Use f First Line Antibitics fr Sre Thrat. (H) Avidance f Antibitic Treatment in Adults with Acute Brnchitis. (H) Breast Cancer Screening (infrmatinal nly). (H,S) Cervical Cancer Screening. (H) Childhd Immunizatins. (H) Chlamydia Screening. (H) Chlesterl Management fr Patient with Cardivascular Cnditins. (S) Clrectal Cancer Screening. (H,S) Diabetic Chlesterl Management. (S) Diabetic Cntrl. (H,S) Diabetic Testing. (H,S) Medicatin Adherence fr Chlesterl (Statins). (S) Medicatin Adherence fr Hypertensin (RAS antagnists). (S) Medicatin Adherence fr Oral Diabetes Medicatins. (S) Osteprsis Management in Wmen Wh Had a Fracture. (H,S) Persistence f Beta-Blcker Treatment After a Heart Attack. (H) Pharmacy Management fr COPD. (H) Prstate Cancer Screening (infrmatinal nly). (A) Rheumatid Arthritis Management. (H,S) Use f Apprpriate Medicatins fr Children with Asthma. (H) Gastrenterlgy Clrectal Cancer Screening. (H,S) Internal Medicine All-Cause Readmissins (infrmatinal nly). (H,S) Antidepressant Medicatin Management. (H) Apprpriate Imaging fr Back Pain. (H) Apprpriate Treatment fr Children with Upper Respiratry Infectin. (H) Apprpriate Use f First Line Antibitics fr Sre Thrat. (H) Avidance f Antibitic Treatment in Adults with Acute Brnchitis. (H) Breast Cancer Screening (infrmatinal nly). (H,S) Cervical Cancer Screening. (H)

4 Chlamydia Screening. (H) Chlesterl Management fr Patient with Cardivascular Cnditins. (S) Clrectal Cancer Screening. (H,S) Diabetic Chlesterl Management. (S) Diabetic Cntrl. (H,S) Diabetic Testing. (H,S) Medicatin Adherence fr Chlesterl (statins). (S) Medicatin Adherence fr Hypertensin (RAS antagnists). (S) Medicatin Adherence fr Oral Diabetes Medicatins. (S) Osteprsis Management in Wmen Wh Had a Fracture. (H,S) Persistence f Beta-Blcker Treatment After a Heart Attack. (H) Pharmacy Management fr COPD. (H) Prstate Cancer Screening (infrmatinal nly). (A) Rheumatid Arthritis Management. (H,S) Nephrlgy Chrnic Kidney Disease Mnitring f Prteinuria. (A) Chrnic Kidney Disease Mnitring f Renal Functin. (A) Ob/Gyn Breast Cancer Screening (infrmatinal nly). (H,S) Cervical Cancer Screening. (H) Chlamydia Screening. (H) Osteprsis Management in Wmen Wh Had a Fracture. (H,S) Pstpartum Care. (H) Orthpedic Surgery Orthpedic Surgery Trial f Cnservative Treatment Prir t Surgery. (A) Osteprsis Management in Wmen Wh Had a Fracture. (H,S) Otlarynglgy Otlarynglgy Acute sinusitis. (A) Otlarynglgy Otitis Media. (A) Otlarynglgy Tnsillectmy. (A) Pediatrics Apprpriate Treatment fr Children with Upper Respiratry Infectin. (H) Apprpriate Use f First Line Antibitics fr Sre Thrat. (H) Childhd Immunizatins. (H) Use f Apprpriate Medicatins fr Children with Asthma. (H) All Specialties Pharmacy Dispensing Behavir Ntes: H= Healthcare Effectiveness Data and Infrmatin Set (HEDIS) quality measure, Natinal Cmmittee fr Quality Assurance (NCQA), Website: NCQA.rg/HEDISQualityMeasurement.aspx S= Centers fr Medicare and Medicaid Services (CMS) Medicare Star quality measure, Website:

5 CMS.gv/Medicare/Prescriptin-Drug Cverage/PrescriptinDrugCvGenIn/PerfrmanceData.html A= U.S. Department f Health & Human Services, Agency fr Healthcare Research and Quality, Natinal Guideline Clearinghuse quality measure, Website: Guideline.gv/brwse/by-tpic.aspx Metrics Definitins All-Cause Readmissins (infrmatinal nly): Percentage f patients wh are readmitted (all cause) within 30 days f discharge (lwer is better). Antidepressant Medicatin Management: Percentage f patients 18 years f age and lder wh were newly treated with antidepressant medicatin and wh remained n an antidepressant medicatin treatment. Apprpriate Imaging fr Back Pain: Percentage f patients wh did nt have an imaging study (plain X-ray, MRI, CT scan) within 28 days f lw back pain diagnsis. Apprpriate Treatment fr Children with Upper Respiratry Infectin: Percentage f patients 3 mnths t 18 years f age nt dispensed an antibitic prescriptin n r three days after the episde start date. Apprpriate Use f First Line Antibitics fr Sre Thrat: Percentage f patients 1 t 17 years f age wh were treated with an antibitic during the measurement year where the apprpriate first line antibitic (penicillin, amxicillin, a first generatin cephalsprin r erythrmycin) was prescribed. Avidance f Antibitic Treatment in Adults with Acute Brnchitis: Percentage f patients 18 t 64 years f age nt dispensed an antibitic prescriptin n r seven days after the episde start date. Breast Cancer Screening (infrmatinal nly): Percentage f female patients 40 t 69 years f age wh received a mammgram screening. Cervical Cancer Screening: Percentage f female patients 21 t 64 years f age wh received a pap smear. Childhd Immunizatins: Percentage f patients wh received immunizatins prir t their secnd birthday. Chlamydia Screening: Percentage f female patients ages 16 t 24 wh received an annual chlamydia test. Chlesterl Management fr Patient with Cardivascular Cnditins: Percentage f patients 65 years and lder with a statin (r ther where apprpriate) class drug where at least tw prescriptins filled. Chlesterl Management fr Patient with Diabetes: Percentage f patients age 65 years and lder with a statin (r ther where apprpriate) class drug where at least tw prescriptins were filled. Chrnic Kidney Disease Mnitring f Prteinuria: Percentage f patients 18 t 75 years f age wh received annual testing f Urine micralbumin r prtein test. Chrnic Kidney Disease Mnitring f Renal Functin: Percentage f patients 18 t 75 years f age wh received egfr r serum creatinine test in last 12 reprted mnths. Clrectal Cancer Screening: Percentage f patients 50 t 75 years f age wh received the apprpriate screening fr cln cancer: fecal ccult bld test (FOBT) during the measurement year regardless f FOBT type, guaiac (gfobt) r immunchemical (ifobt); flexible sigmidscpy during the measurement year r the fur years prir t the measurement year, r clnscpy during the measurement year r the nine years prir t the measurement year. Diabetic Cntrl: Percentage f patient 18 t 75 years f age wh received annual test results fr HbA1c (<8%). Diabetic Testing: Percentage f patients 18 t 75 years f age wh received annual HbA1c testing, LDL-C screening, Retinal eye exam, and Nephrpathy mnitring. Medicatin Adherence fr Chlesterl (Statins): Percentage f patients 18 years and lder wh adhere t their prescribed statin drug therapy.

6 Medicatin Adherence fr Hypertensin (RAS antagnists): Percentage f patients 18 years and lder wh adhere t their prescribed drug therapy fr RAS antagnists. Medicatin Adherence fr Oral Diabetes Medicatins: Percentage f patients 18 years and lder wh adhere t their prescribed drug therapy acrss fur classes f ral diabetes medicatins: biguanides, sulfnylureas, thiazlidinedines, and dipeptidyl peptidase (DPP)-IV Inhibitrs Orthpedic Surgery - Trial f Cnservative Treatment Prir t Surgery: Percentage f patients wh received trial f cnservative treatment prir t surgery when apprpriate. Cnservative treatment may include any ne f the fllwing: physical, ccupatinal, chirpractic therapy and/r lcal crticsterid, if applicable. Osteprsis Management in Wmen Wh Had a Fracture: Percentage f female patients 67 years f age and wh received a bne mineral density (BMD) test r 180-day curse f treatment with a drug t treat r prevent steprsis in the six mnths after the fracture. Otlarynglgy - Acute sinusitis: Percentage f patients with acute sinusitis episde where a first line antibitic was dispensed (amxicillin, amxicillin clavulanate, sulfamethxazle/trimethprim) date f ffice visit r within five days f ffice visit. Otlarynglgy - Otitis Media: Percentage f patients 2 mnths t 13 years f age n antibitic therapy with acute titis media that received either a first line r secnd line antibitic within 3 days f diagnsis f titis media. Otlarynglgy Tnsillectmy: Percentage f patients less than 21 years f age wh had a tnsillectmy and met clinical criteria fr this prcedure. Persistence f Beta-Blcker Treatment After a Heart Attack: Percentage f patients 18 years f age and lder wh received a 180-day curse f treatment with beta-blckers. Pharmacy Management fr Crnary Obstructive Pulmnary Disease (COPD): Percentage f patients 40 years f age and lder wh received apprpriate medicatins fr COPD. Pharmacy Dispensing Behavir: Percentage f grup practice's generic versus brand prescriptins cmpared t peers during the measurement year. The medicatins that d nt have a generic alternative r have a narrw therapeutic index are excluded. Pstpartum Care: Percentage f patients wh received a pstpartum visit n r between 21 and 56 days after delivery. Prstate Cancer Screening: (infrmatinal nly): Percentage f patients 50 years and lder that had a prstate specific antigen test in last 12 reprted mnths. Rheumatid Arthritis Management: Percentage f patients 18 years ld and lder wh received ne r mre prescriptin(s) fr an anti-rheumatic drug in measurement year. Use f Apprpriate Medicatins fr Peple with Asthma: Percentage f patients 5 t 64 years f wh received the apprpriate medicatins fr asthma. Infrmatinal nly measures will nt be included in the physician practice s final scre in BPR 2015: 1. All-Cause Readmissins. 2. Breast Cancer Screening and Prstate Cancer Screening: At the time f this printing, the US Preventive Services Task Frce (USPSTF) is reviewing the guidelines fr these screenings.