AETNA BETTER HEALTH OF TEXAS Provider Relations newsletter Summer 2017 Table of contents Chief Medical Officer Comments and New Guideline Application...1 Chief Medical Officer Comments and Pharmacy Corner...2 Allergic Rhinitis...3 Improving Continuity of Care for Children with ADHD...4 Promoting Good Outcomes for Depression Management...5 Utilization Management...5 Who to call?...6 www.aetnabetterhealth.com/texas TX 17 05 09 Chief Medical Officer Comments and New Guideline Application Jim Small, MD, MPH, MMM, FACPM I would like to thank all of our physicians and providers for your concern and conscientious delivery of quality care to your patients and our members of Aetna Better Health Texas. We know it is not easy to provide care, manage or participate in necessary business activities, and successfully negotiate all of the external administrative demands from payers and government agencies. We at Aetna want to work with you in providing quality care. We exist not only to reimburse you for appropriate services you deliver, but to work with you and the State to promote better health for the Star and CHIP populations. To that end we incentivize providers for quality (as measured by certain HEDIS metrics) and we work to ensure benefits are provided at an appropriate level of care and place of service. One of the processes we use to help ensure that the appropriate level of care and place of service is occurring is utilization review where requests are reviewed against established guidelines. At times, we realize this can cause some friction between the requesting provider and us. Approximately two years ago we delegated OB ultrasound reviews to evicore, formerly known as Med Solutions. With some members receiving a high number of OB ultrasounds per gestation, upwards 50 OB ultrasounds per gestation, we thought it prudent to have evicore apply established and periodically evaluated guidelines to OB ultrasound requests. Basically the first four OB ultrasounds are auto approved with notification to evicore. Subsequent ultrasounds require a prior authorization by evicore. More specifically, for a woman presenting during the 1st trimester CPT codes 76801, 76805, 76813, and 76816 are auto approved with notification. For a woman presenting in the 2nd or 3rd trimester CPT codes 76805 and 76816 will be auto approved with notification. Batch requests may receive Continued on page 2 1
Chief Medical Officer Comments and New Guideline Application Continued from page 1 a prior authorization for high risk pregnancies. Effective September 5, 2017 we will also be delegating the review of approximately 56 outpatient cardiac imaging requests for Star (not STAR Kids) and CHIP to evicore. Requests will be taken as of August 22 for outpatient cardiac procedures to be scheduled on or after September 5. Additionally, there will some training sessions offered in August to explain the process of requesting a review and authorization for cardiac imaging. Details on the outpatient cardiac imaging process will be forthcoming in a letter that should be received by early June for those providers that would request these procedures. Pharmacy Corner Aetna Better Health of Texas in order to meet NCQA standards must notify providers of all Vendor Drug Program formulary additions, deletions and changes. The following changes have been made to the VDP Preferred list and Non Preferred Drug list. Preferred Drug List Brunavil (buprenonorphine/naloxone) Cosentyx (secukinumab) Dyanavel (amphetamine) Epclusa (Velpatasvir/sofosbuvir) erythromycin base glyburide/metformin Granix (tbo gilgrastim) halobetasol metformin XR Neupogen (filgrastim) vial Quillachew ER (methylphenidate) tindazole (gastrointestinal antibiotic) Valcyte Tablets (antivirals) Viekera XR Non Preferred Drug List Adzenyz ODT (amphetamine) alogliptin alogliptin/metformin alogilptin/pioglitazone Bydureon Erythrocin Flurandrenolide Fortamat glipizide/metformin Glucophage Glucophage XR Glumetza Humalin 500 units/ml pen Jentadueto XR Luekine (sargrasmastim) metformin ER (Fortamet and Glumetza) Nanmenda XR (Alzheimer agent) neomycin/polymixin/gramicidin ophthalmic suspension Ocaliva (obeticholic acid) Bile Salts olopatadine oxiconazole Ozentra Xsail (sumatriptan) paliperidone pimozide Prednisone Dose pak repaglinide Riomet sulfacetamide ointment and suspension Sernivo (betamethasone propionate) sulfacetamide ointment and suspension Tinadamax (tindazole) gastrointestinal antibiotic Tobradex Suspension ophthalm tolnafate Triamincinolone aerosol and lotion Trintellix (vartioxetine) antidepressant Valcyte Solution valganciclovir tablets XTampza XR (analgesic non narcotic) Xrylix (diclofenac) Vraylar (cariparizine) antipsychotics Zario (filgrastim Sndz) Zembrace Symtouch (sumatriptin) Zepitier 2
Allergic Rhinitis Second generation antihistamines may be prescribed first line for allergic rhinitis. Along with prescribing appropriate medication, it important to counsel members and caregivers on environmental controls (Children s Hospital of Philadelphia: http://www.chop.edu/conditions-diseases/allergic-rhinitis). Intranasal steroids are useful for the management of allergic rhinitis when a second generation oral antihistamine alone is not sufficient. 1 Currently, no studies prove superiority of one intranasal corticosteroid product over another. See below the available preferred agents on the Texas Medicaid Formulary, preferred product categories are highlighted in yellow. This summary provides the available products and their Texas Medicaid Preferred Drug List status. TEXAS VENDOR DRUG PROGRAM FORMULARY 2 * ALLERGIC RHINITIS NASAL AGENTS Highlights represent preferred status in 2016 PREFERRED AGENTS NON PREFERRED AGENTS Corticosteroids Nasal NASONEX (mometasone) fluticasone (generic Flonase) BECONASE AQ (beclomethasone) FLONASE (fluticasone) FLONASE OTC (fluticasone) NASACORT OTC (triamcinolone) NASACORT AQ (triamcinolone) OMNARIS (ciclesonide) QNASL (beclomethasone dipropionate) RHINOCORT AQUA (budesonide) triamcinolone VERAMYST (fluticasone furoate)isolide) ZETONNA (ciclesonide) budesonide lunisolide Antihistamines Nasal PATANASE (olopatadine) PAZEO (olopatadine) ASTELIN (azelastine) ASTEPRO (azelastine) ATROVENT (ipratropium) nasal spray azelastine ipratropium nasal spray ipratropium nasal spray Combinations DYMISTA (azelastine/fluticasone) TEXAS VENDOR DRUG PROGRAM FORMULARY 2 * ALLERGIC RHINITIS ORAL SECOND GENERATION ANTIHISTAMINES (NON SEDATING OR MINIMALLY SEDATING) cetirizine solution, tablets loratadine ODT, solution, tablets ALLEGRA (fexofenadine) CLARINEX (desloratadine) CLARITIN (loratadine) XYZAL (levocetirizine) ZYRTEC (cetirizine) cetirizine chewable desloratadine fexofenadine levocetirizine References: 1 Wallace DV, Dykewicz MS, Bernstein DI, Blessing Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122:S1 S84. 2 TX VDP Formulary (Last Update July 2013) 3
Improving Continuity of Care for Children with ADHD Attention deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders of childhood and often continues into adulthood. Children with ADHD have trouble paying attention and controlling impulsive behavior such that it often interferes with their daily lives at home, at school, at work, and in social settings. ADHD can have serious consequences on a child s development, including difficulty making friends or being accepted by his/her peers. Aetna Better Health Texas supports the recommendation and guidelines of the American Academy of Pediatrics: ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention Deficit/Hyperactivity Disorder in Children and Adolescents. These ADHD guidelines are intended for use by a primary care provider working in a primary care setting to assess, diagnose, treat, and refer a patient, if needed, to a behavioral health specialist. According to the guidelines the PCP should initiate the evaluation and if the patient is thought to have ADHD he/she should prescribe medication and encourage parent and/or teacher administered behavior therapy. Both behavior therapy and medications have been demonstrated to reduce behaviors associated with ADHD and improve function. Follow up recommendations for children include 3 follow up visits over a 10 month period. The 1st appointment should occur within 30 days after the child begins medication. The next follow up appointments should occur over the next 9 months. Tips for Providers: Schedule the initial follow up appointment for 2 3 weeks and complete this task before the patient leaves the office. Educate the parent/guardian about ADHD. Encourage the parent/guardian to ask questions about ADHD. Encourage the parent/guardian to call the office if they have any concerns about the medication before the next appointment. Educate the parent/ guardian about the importance of follow up care. Encourage the parent/ guardian to consider therapy and learn how to manage ADHD behaviors in the home. No refills unless the child has the initial follow up visit. After the initial follow up visit, schedule at least 2 more visits over the next 9 months to check the child s progress. 4
Promoting Good Outcomes for Depression Management Prescription of antidepressant medications has been shown to be a critical part of the effective care of patients with depression. The consequences of untreated or inadequately treated depression are significant, and taking antidepressant medication correctly is a very important part of appropriate treatment. When medications are used together with appropriate forms of psychological therapy, most patients experience good outcomes. Patients need to be monitored very carefully during the first three to six months of treatment so that the clinician can adjust the dosage or type of medication, if necessary. Taking the correct medication as it is prescribed and for the prescribed amount of time is vitally important to the long term health and well being of the patient. Aetna Better Health Texas supports the recommendation and guidelines of the American Psychiatric Association s Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition. When pharmacotherapy is part of the treatment plan, it must be integrated with the psychiatric management and any other treatments that are being provided. Patients who have started taking an antidepressant medication should be carefully monitored to assess their response to pharmacotherapy as well as the emergence of side effects, clinical condition and safety. Tips for Providers: Schedule follow up appointments before the patient leaves the office. Educate the patient about their diagnosis and treatment plan. Encourage the patient to ask questions about depression and ongoing care. Inform the patient that the medication may take several weeks to become effective. Inform the patient about potential side effects/ reactions and encourage them to call the office with their concerns. Inform the patient that they should not stop medication abruptly and call the office for assistance. Stress the importance of medication compliance. Encourage therapy to address life stressors and build healthy coping skills. Outreach patients that cancel appointments and have not rescheduled. Utilization Management The purpose of the utilization management department is to coordinate delivery of the best possible care to members and manage the use of health care resources to ensure an effective and efficient physical and behavioral health care delivery system. The UM department adheres to the below timelines for making coverage determinations. Within 3 business days after receipt of the request for routine authorization of services Within 1 business day after receipt of the request for urgent authorization of services Within 1 business day for concurrent hospitalization decisions Requests for urgent care services that do not qualify as urgent will be handled within the routine authorization of services timeline. Routine care or elective surgeries are examples of care that typically would not qualify as urgent. To avoid rescheduling of appointments, please keep in mind the timelines above for making coverage determination prior to the appointment being made. The following are the fax numbers to submit your requests. Please submit the Texas Standard Prior Authorization of Services form and include all pertinent information, ICD 10 code(s), dates of service and signature. STAR Kids Long Term Services and Supports (LTSS) Fax: 1 866 275 5728 Acute Services Prior Authorization Fax: 1 866 835 9589 Concurrent Review: 1 866 706 0529 To prevent delays in processing requests, please submit requests on the correct form and fax to the designated fax number. 5
AETNA BETTER HEALTH OF TEXAS Provider Relations P.O. Box 569150 Dallas, TX 75356 9150 Who to call? Provider Relations and Member Services lines: Medicaid Bexar 1 800 248 7767 Medicaid Tarrant 1 800 306 8612 CHIP Bexar 1 866 818 0959 CHIP Tarrant 1 800 245 5380 Superior Vision 1 800 879 6901 LogistiCare Medical Transportation (For Medicaid members only) 1 877 633 8747 (Aetna Bexar County) 1 855 687 3255 (Aetna Tarrant County) Nurse Line 1 800 556 1555 Behavioral Health Provider Credentialing 1 800 999 5698 Report Fraud, Waste or Abuse 1 800 436 6184 Fax Numbers Aetna Prior Authorization fax# 1 866 835 9589 Aetna Inpatient Authorization fax# 1 866 706 0529 Behavioral Health Prior Authorization fax # 1 855 857 9932 1 855 841 8355 (Concurrent Review) Dental MCNA Dental 1 855 494 6262 Denta Quest 1 800 516 0165 (Medicaid) 1 800 508 6775 (CHIP) Vital Savings (adults only) 1 888 238 4825 CVS Caremark (Pharmacy) CVS Caremark Help Desk 1 877 874 3317 BIN# 610591 PCN: ADV GROUP# RX8801 Prior Auth Call In 1 855 656 0363 Prior Auth fax 1 866 255 7534 6