1. health and fitness

Vol. 2 Winter 2007/2008
In this issue of STAT, the Anthem Blue Cross and Blue Shield (Anthem)
State Sponsored Business Provider e-News, you will find important policy
updates and new programs or services to help you care for our Hoosier
Healthwise program members.
Table of Contents
To view a specific article, click the article title.
Policy and Benefits
Features
How to Get
Authorization Quickly
To help you succeed in getting approval
for your requests for authorization, use our
online Prior Authorization Toolkit forms for
preservice review. Full story
4 Extension Period Aids NPI Compliance
5 Program Helps Reduce Inappropriate Emergency Room Use
6 Timely Clinical Information Needed for Concurrent Review
6 Best Practices Guidelines
6 What’s Required for Postservice Review
6 Reasons for Denials
6 New Cultural and Linguistics Tools Available
Operations
7 Profile on Anthony Nguyen, MD, MBA
7 After-Hours Access to Care
8 Confidentiality Statement
9 Member Rights and Responsibilities Statement
11 When Is It Fraud and Abuse?
11 Initial Health Assessments
12 Four Pointers for Better Patient Safety
Guided Asthma
Note Available
We have a new tool you can
download to help you take care
of your patients with asthma,
the Asthma Progress Chart
Note. It prompts you to address
elements of asthma patient
visits. Full story
Health Improvement
Four New Community
Resource Centers Staffed
to Serve You
Whether you have a question about
coding or want to connect with a local
community-based organization, our
Community Resource Centers’ staff
members can help. Full story
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Prestigious EPA Award Winner
Check Out Our New Program: Healthy Habits Count with Asthma
Asthma Guidelines Updated
Your Role in Helping Members Quit Smoking
MedCall® Means Peace of Mind
No-Cost Health Education Classes
Rx Updates
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Medicaid Formulary Is Available Through Epocrates®
Prior Authorization List
Formulary Update
Generic Medications
Drug Therapy Quantity and Dosage
Physician & Provider e-News, Vol. 2 Winter 2007/2008
Features
How to Get Authorization Quickly
What We Are Doing to Improve
We want to help you get the timely authorization you
need to serve our members. To help you succeed in getting
approval for your requests for authorization:
Building business in a new state can be challenging. We have
implemented the following internal business practices to
streamline our efforts:
• Use the online Prior Authorization Toolkit for
preservice review. Please be aware that certain requests
for services require specific clinical information for
authorization. The toolkit has a variety of forms that will
help you identify and provide the specific information
we need before we can authorize a service.
1. We have significantly reduced wait times by hiring
additional staff for medical intake. We strive to answer
each medical intake call in 30 seconds or less.
2. We respond to urgent prior authorization requests
within 24 hours.
• Always include the appropriate form or other clinical
information with the Request for Preservice Review
form to help expedite the prior authorization process.
Print, complete and fax the necessary forms to us
at 1-866-406-2803.
3. We respond to nonurgent prior authorization requests
within 72 hours, when you submit complete clinical
information with the request. You may incur a delay
in getting authorization when we do not receive the
requested clinical information.
If you need any service-specific prior authorization forms
sent to you, please call our Utilization Management
department at 1-866-408-7187.
Confirmation by Phone or Fax
For prior authorization and concurrent review, we will
provide you with an authorization confirmation number
either by phone or fax. We do not mail authorization letters.
If you have any questions, please call us at 1-866-408-7187.
Guided Asthma Note Available Online
SSB announces a new tool to help you take care of
patients with asthma, the Asthma Progress Chart Note.
Created with input by the Plan/Practice Improvement
Project (PPIP) team and nearly 30 additional physicians
from several states, it was designed to promote evidencebased asthma care and support decision making and
data management for patients with asthma. Along
with prompting you to address numerous elements of
asthma patient visits, the chart note also reminds you
to consider environmental factors that may affect your
patient’s asthma. Take advantage of this free tool! You can
download the Asthma Progress Chart Note for free.
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Physician & Provider e-News, Vol. 2 Winter 2007/2008
Features
Four New Community Resource Centers
Staffed to Serve You
The team members at these unique community-based offices
serve as a valuable resource to help:
Do you know we have local staff members who can help
resolve problems you experience? Staff members at each
recently opened Community Resource Center, or CRC,
serve as provider advocates. The CRCs also provide access to
outreach services, health education referrals, translation and
other specialized services for Hoosier Healthwise members
and their families. You’ll find these offices in Merrillville,
Indianapolis, Columbus and Evansville.
• Answer questions about billing or contracting.
• Resolve coding, billing or claims issues.
• Connect you with local community-based organizations
or different health departments.
• Help navigate the system.
Here are the Anthem Blue Cross and Blue Shield
Community Resource Centers in your area. Just call or stop
by any time.
Northwest CRC
Central CRC
51 W. 78th Place, Merrillville, IN 46410
1-866-724-6533
2425 N. Meridian St., Suite A, Indianapolis, IN 46208
1-866-795-5440
Southwest CRC
Southeast CRC
1318 N. Green River Road, Evansville, IN 47715
1-866-461-3586
505 Washington St., Suite B, Columbus, IN 47201
1-877-225-0595
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Physician & Provider e-News, Vol. 2 Winter 2007/2008
Policy and Benefits
Extension Period Aids NPI Compliance
How the Latest News About NPI Affects You
We are working to ensure a smooth transition to the National
Provider Identifier (NPI) as required by the Health Insurance
Portability and Accountability Act also known as HIPAA.
On May 23, 2007, health care professionals began using
the unique 10-position identifiers when performing
electronic transactions.
Our front-end systems will ensure valid NPIs are included
on paper and electronic claims. NPI validity is confirmed by
applying the Luhn formula logic, an industry standard using
an algorithm or mathematical computation to generate and/
or validate and verify the accuracy of identification numbers
such as used for credit card numbers.
Many physician practices and institutions have had several
critical tasks to complete before the federally mandated
NPI implementation. Even the best-prepared provider offices
and institutions encountered problems with the transition
to NPI.
Before this extension period ends, we will send you a 60-day
reminder notice. Please remember that May 23, 2008, is
the last day we will accept your Anthem Medicaid provider
number (legacy identifier). After that date, your NPI will
be required and will become the standard provider number
accepted on electronic transactions.
Extra Time
In early April, The Centers for Medicare and Medicaid
Services (CMS) relaxed its approach to enforcement. Health
plans and covered entities showing “good faith efforts” now
have until May 23, 2008, one additional year, to complete
testing and other activities toward NPI compliance in order
to mitigate potential payment disruption.
Being proactive before the end of the contingency period
may help you avoid unnecessary payment delays. We urge
you to address any outstanding NPI issues as soon as possible
to ensure smooth business operations as we complete the
transition to NPI.
Registering your NPI(s) with us helps ensure a seamless
conversion to NPI, and minimizes any potential payment
disruptions. Register your NPI(s) on our NPI registration
website now! For provider offices with many NPIs, a bulk
submission process is available. You can find instructions on
our NPI registration website.
We are committed to making this extension period as easy as
possible for our providers.
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Physician & Provider e-News, Vol. 2 Winter 2007/2008
Policy and Benefits
Program Helps Reduce Inappropriate
Emergency Room (ER) Use
As more and more emergency rooms close around the
country and those remaining are filled past capacity, we are
faced with scarce emergency resources. This, coupled with
high utilization of resources for nonemergencies, led us to
create the Self-Care Initiative – ED Diversion Program.
The program addresses both of these issues to redirect
nonurgent care into the primary care environment.
The initiative targets members with one or more ER visits
within a 12-month period through ER claims data. (This
threshold will change as more data comes in.)
Keeping You Informed
For the program to be successful, we need your help. Each
month, we will notify primary medical providers through
faxes with targeted members names, ER visit dates and
diagnoses. We ask you, the physicians in the network, to file
each patient-specific fax in the patient’s medical record to
serve as a reminder to discuss the patient’s ER use during his
or her next office visit.
The Healthwise Handbook: A Self-Care Guide for You is
the tool MedCall nurses use to help members who call in,
whenever self-care is indicated. Members can follow along
with the nurse during the phone call.
Members who are identified in this initiative may receive
a free copy of the Healthwise Handbook if they call the
Customer Care Center number on their ID card. These
targeted members also may receive outreach phone calls or
case management services.
Giving Members Tools
To educate members about when to go to the ER or when
to see the doctor, we offer members a number of resources
including MedCall® and the Healthwise Handbook : A SelfCare Guide for You. MedCall, the toll-free nurse help line,
is available to our members 24 hours a day, 7 days a week
to call in for answers to health questions and to help them
decide what steps to take next for a health concern.
Many ER visits are necessary. Rest assured the program is
not designed to eliminate necessary visits, but to help reduce
inappropriate use of the ER, while educating our members
about options to help them make informed decisions
about their care.
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Physician & Provider e-News, Vol. 2 Winter 2007/2008
Policy and Benefits
Timely Clinical Information Needed for
Concurrent Review
Be ready to provide:
When prior authorization does not exist, medical facilities
are required to provide clinical information within 24 hours
or the next business day of the admission notification.
Having the clinical information within the required
time frame:
• Medical record number and Anthem member ID
number.
• Clinical information such as:
• Facilitates concurrent review.
- Diagnosis, presenting symptoms, physical findings and treatment plan.
• Certifies approved inpatient days.
- Level of care or service.
• Expedites discharge planning and authorizations and
ensures proper claims payment.
- X-rays, EKGs, CTs, MRIs, labs, vital signs, and other
pertinent diagnostic studies.
- Anticipated discharge planning needs.
Best Practices Guidelines
We follow Milliman, Inc. Guidelines as our evidence-based
“best practice” guidelines to assure that when admitted, our
members meet the appropriate level of care at point of care.
We use these guidelines in combination with our training
and experience to authorize admission and length of stay.
New Cultural and Linguistics
Tools Available
Culture and language can affect the way that patients view
illness and disease, as well as their attitudes toward health
care providers. You can now find a comprehensive set of
Cultural and Linguistic Resources for understanding
and addressing racial and cultural health disparities in
their communities—online and right at your fingertips.
The new resource offers:
What’s Required for Postservice Review
Postservice review determines the medical necessity and/
or level of care for services that may have been rendered
without obtaining concurrent review. For inpatient
admissions where no notification was received, facilities are
required to submit a copy of the medical record with the
claim. Please help with retrospective review by providing:
• The latest research on health care disparities.
• Tools for communicating with diverse populations.
• Medical record number and Anthem member
ID number.
• Links to training courses and information on federal
guidelines for providing culturally- and linguisticallyappropriate services.
• History and physical information.
• Progress notes.
• Health education and disease-specific materials in
both Spanish and Chinese.
• Discharge summary.
• Resources and tips for the provision of language
translation during an office visit.
Reasons for Denials
• Links to assessment tools that will help physicians
better understand the demographics and
psychographics of the populations you serve.
Our medical directors may issue denials when:
• There is a lack of clinical information from a provider.
• A service does not meet our medical necessity guidelines.
Try this free resource!
• A service is not a covered benefit.
• A service is considered investigational or cosmetic.
For full details, please refer to your Provider Operations
Manual (POM).
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Physician & Provider e-News, Vol. 2 Winter 2007/2008
Operations
Health Care Quality and Innovation, which embodies two
core values. His philosophy is that state sponsored plans may
not be big in market share relative to commercial business
but we definitely have “mindshare.” Dr. Nguyen says,
“Innovative ideas that make a difference for some of our
most challenging members are the passion that drives our
medical management.”
Profile on Anthony Nguyen, MD, MBA
Dr. Nguyen comes to us from another division of our
company where he held a medical director position. Prior
to that, Dr. Nguyen served as assistant clinical professor
of medicine for the University of California at Irvine and
as vice president of Kaiser Permanente Orange County
Professional Staff. He also was a hospital-based physician for
the Southern California Permanente Medical Group.
We would like to introduce you to our newest team leader,
Anthony Nguyen, vice president and medical director of
Health Care Quality and Innovations. Heading our team of
medical directors, Dr. Nguyen has a history of innovative
ideas and an understanding of a variety of managed health
care models including hands-on experience leading a 350physician medical group. His department’s official name is
Board-certified in internal medicine, Dr. Nguyen holds an
MD from Tufts University School of Medicine and an MBA
from the University of California at Irvine. He has received
numerous awards including Internal Medicine Physician of
the Year at Kaiser Permanente and has served as alternate
delegate for the California Medical Association to represent
the interests of physicians in forming health policy.
After-Hours Access to Care
Emergency Calls
We are committed to providing our plan members with
access to quality health care services 24 hours a day, 7 days a
week. Members have the right to call their primary medical
provider (PMP) with a request for assistance after normal
office hours. If you are a PMP, you must have an after-hours
system in place to ensure that members can reach you, or an
on-call physician, with medical concerns or questions.
If you use an answering machine, automated telephone
response system or after-hours answering service, you must
have it set up to direct the caller to 911 or the nearest
emergency room in an emergency.
After-Hours Messages for Non-English
Non-English speaking members who call their provider
after hours expect to receive language-appropriate messages
with appropriate care instructions. So we recommend
that answering machines also provide instructions in a
language other than English. These instructions direct the
member to dial 911 or to proceed directly to the nearest
hospital emergency room in the event of an emergency, or
provide instructions on how to call the on-call provider in a
nonemergency. If not possible, telephone-based interpreters
are available 24/7.
On-Call Services
We prefer that as the PMP, you use a plan-contracted,
in-network physician for on-call services. When it’s not
possible, you must ensure that the non-contracted, on-call
physician who is covering abides by the terms of the
provider contract.
If you have an answering machine, telephone response
system or service, it must be able to direct the caller to
another number to reach you (the PMP) or the on-call
physician. Otherwise, you must have a system in place to
make sure that a caller is contacted back within 30 minutes
of the call.
We regularly monitor PMP compliance with after-hours
access standards. Failure to comply with the standards can
result in corrective action.
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Physician & Provider e-News, Vol. 2 Winter 2007/2008
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Confidentiality Statement
Privacy
WellPoint State Sponsored Business was in compliance with
the provisions of the HIPAA Privacy Rule by the required
date of April 14, 2003. Compliance efforts included, but
were not limited to, the appointment of a Privacy and
Security Officer, establishment of a Privacy and Security
Office, and creation of an infrastructure designed to support
ongoing compliance requirements throughout the company,
including the adoption of policies, standards and procedures,
and the training of all associates.
We are committed to delivering excellent service. Part of
that commitment includes compliance with, and support
of, the HIPAA Privacy mandate. Most importantly, we are
committed to protecting member and patient privacy and
safeguarding related health information.
Security
We achieved compliance with the provisions of the
HIPAA Security Rule by the required date of April 20,
2005. Compliance efforts included, but were not limited
to, the appointment of a Privacy and Security Officer,
establishment of a Privacy and Security Office, and creation
of an infrastructure designed to support ongoing compliance
requirements throughout the company including the
adoption and communication of policies, standards and
procedures, and the training of all associates.
We have adopted policies and procedures that meet
compliance with the HIPAA Privacy regulation including the
granting of the following individual rights:
• The right to have access to designated records that
contain Protected Health Information (PHI).
• The right to request an amendment to PHI contained in
designated records.
We are compliant with the HIPAA Security regulation
through a corporate Information Assurance program
designed to:
• The right to place restrictions on the use and
disclosure of PHI for treatment, payment and health
care operations.
• Maintain an information assurance risk
management program.
• The right to receive confidential communications at an
alternate address or location.
• Protect the confidentiality, integrity and availability of
electronic PHI.
• The right to request a disclosure accounting.
• Utilize administrative, physical and technical safeguards
to address reasonably anticipated threats and hazards to
electronic PHI.
• The right to voice a complaint pertaining to our privacy
policies and procedures.
Privacy notices describing the company’s use and disclosure
of PHI are provided to all existing and new members. These
notices are available upon request, printed in all new member
handbooks and found on the website.
• Continually evaluate the effectiveness and adequacy of
the program.
Our company and its affiliates are committed to delivering
excellent service. Part of that commitment includes
compliance with and support of the HIPAA Security
mandate. Most importantly, we are committed to protecting
member and patient privacy and safeguarding related
health information.
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Physician & Provider e-News, Vol. 2 Winter 2007/2008
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Member Rights and
Responsibilities Statement
What We Share With Members
Anthem frequently distributes the Members Rights and
Responsibilities statement and includes it in our member
kit. Please take this opportunity to review these guidelines as
part of your continuing assessment of your office procedures.
We are proud to work with you to help ensure access to
quality health care for our members. We thank you for your
continued efforts in pursuit of this goal.
• Have access to their medical records as allowed by
federal and state laws.
Member Rights
Our members have the right to:
• Find out how we decide if new treatment should be part
of a benefit.
• Talk honestly with their doctors about the right
treatment for their condition regardless of the cost or
their benefit coverage.
• Be told about other treatment choices or plans for care in
a way that fits their condition.
• Know their rights and responsibilities.
• Always be treated with respect.
• Get the help they need to understand their evidence of
coverage (member handbook.)
• Have their medical records and information about them
and their health insurance kept private by us, their
doctors, and all of their other health care providers.
• Get news about our services, doctors or other health care
providers with whom we have contracts.
• Have problems taken care of fast. (This includes things
you think are wrong, as well as issues that have to do
with getting an OK from us, their coverage, or payment
of services.)
• Know that the date they joined Anthem is used as the
date when their benefits begin. (Anthem will not cover
services received before this date.)
• Be treated the same as others.
• Get care that should be done for medical reasons.
• Have access to medical advice from their doctor, either
in person or by phone, 24 hours a day, seven days a
week (this includes emergency or urgent care).
• Be free from any form of restraint or seclusion used as a
means of coercion, discipline, convenience or retaliation.
• Choose a PMP who is part of our network.
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Physician & Provider e-News, Vol. 2 Winter 2007/2008
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• Change their PMP without cause or reason.
– National origin
• Be told which hospitals they are to use and have access
to them.
– Language needs
• Get interpreter services at no charge if they speak a
language other than English or if they have hearing,
vision or speech loss.
• Know that we can make changes to their health plan
benefits as long as we tell them about those changes in
writing before they take effect.
– Degree of illness or health condition
• Get information in other formats (if they ask for it)
such as:
Member Responsibilities
Our members have the responsibility to tell us, their doctor
and their other health care providers what they need to
know in order to treat them. They have the responsibility to:
– Braille
– Large-size print
– Audio
• Understand their health problems.
• File a grievance with us.
• Help their doctor set treatment goals.
• File an appeal if a service that was OK’d before is
denied, reduced or ended. (They and their doctor will
get a letter telling them why this action took place.)
• Follow the treatment plans that they, their doctors, and their other health care providers agree to.
• File an appeal with the State Medicaid Office for
Hearings and Appeals if they are not pleased with the
final decision after using our grievance procedure.
• Treat their doctor and other health care providers
with respect.
• Refuse care from their PMP or other health
care providers.
• Keep all scheduled appointments.
• Do the things that keep them from getting sick.
• Make appointments with their doctor when needed.
• Make a living will (also called an “advance directive”).
• Be on time for appointments.
• Tell us what they would like to change about our
health plan.
• Call their doctor if they cannot keep their appointment.
• Always call their PMP first for all of their medical care
(unless they have a true emergency).
• Question a decision we make about coverage for care
they got from their doctor. (They will not be treated
differently if they file a complaint.)
• Show their ID cards each time they get
medical care.
• Tell us what they do not like about our rights and
responsibilities policy.
• Use the emergency room only for true emergencies.
• Pay for services that are not covered by us, including
copays.
• Ask about our Quality Program and tell us if they would
like to see changes made.
• Know that Anthem does not take the place of workers’
compensation insurance.
• Ask us how we do Utilization Review and give us ideas
for changing it.
• Tell us and their social worker if:
• Know that we only cover health care services that are
part of their plan.
– They move.
• Know that Anthem, their doctors, or their other health
care providers cannot treat them differently because of
their:
– They have any changes to their insurance.
– They change their phone number.
– Age
– The number of people in their
household changes.
– Sex
– They become pregnant.
– Race
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When Is It Fraud and Abuse?
What to Do When…
Fraud is any type of intentional deception or
misrepresentation made with the knowledge that the
deception may result in some unauthorized benefit. The
attempt itself is fraud, whether or not it is successful. Abuse
is any practice that is inconsistent with sound fiscal, business
or medical practices, and results in an unnecessary cost to
the program.
• A member needs to be reported for medication abuse?
You should contact our Customer Care Center
(CCC) to reach our Care Management department
at 1-866-408-6132.
• A member has altered a prescription, stolen a
prescription or prescription pad, called in his or her own
prescription, or threatened the physician or office staff?
Here are a few examples of fraud and abuse:
• Frequent emergency room visits with
nonemergent diagnoses.
You should contact our CCC at 1-866-408-6132 to
reach the Fraud and Abuse department.
• Obtaining controlled substances from
multiple providers.
• You aren’t sure whom to call about a potential case of
fraud or abuse?
• Violation of a pain management contract.
Call our Customer Care Center at 1-866-408-6132.
• Using more than one physician to obtain
similar treatments and/or medications.
Although you may remain anonymous when you report
an incident, we encourage you to provide as much detailed
information as possible. The more information you provide,
the sooner the case can be resolved successfully. You can find
contact information and procedures for handling fraud and
abuse in the Anthem Indiana POM.
• Disruptive or threatening behavior.
• Forging or selling prescriptions.
• Loaning an insurance ID card to friends or family.
Initial Health Assessments
Attention primary medical providers: Be
sure to perform a complete history, physical
examination and assessment of health
behaviors for all new members. Called an
“initial health assessment,” or IHA, this is a
recommended procedure.
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Four Pointers for Better Patient Safety
2. Communicate clearly with patients and caregivers.
Patient safety is an ongoing national health care priority.
The health care industry and patient safety groups hold
health plans, providers and patients accountable. Anthem’s
resulting standards target reducing errors in surgery, hospital
care, prescriptions and treatment plans. These tips can help
you and your staff improve patient safety and help reduce
preventable medical errors.
It’s important to put treatment plans in writing. Outline
in writing how and when you will let patients know about
test results, instructions to take medications properly, any
other steps they need, and any steps or actions required by
the patient. When a patient is in the hospital, confirm the
treatment and discuss your patient’s needs with the health
care professionals taking care of him or her. Remember that
literacy often is a problem for our members. Ask patients
if they have questions or find it hard to understand or read
your instructions. Refer patients to our Customer Care
Center for interpreter services, if necessary.
When you work with a caregiver, take extra steps to
communicate as clearly as possible. You should ask any
patient, legal surrogate or caregiver to recount what he or
she was told about treatment instructions, test results or
medication orders.
3. Organize your office.
A few simple organizational steps can help ensure you use
the correct tools and supplies for any tests or samples you
need. Standardizing your office procedures and methods
for labeling, packaging and storing medications will
help prevent confusion. Try to keep workspaces where
medications are prepared or samples collected clean, neat
and free of clutter or distraction.
4. Write clear prescriptions.
1. Understand member rights and responsibilities.
By taking your time and writing legibly, you can help your
patients avoid misinterpreting drug dosages and medication
usage instructions. Use standardized abbreviations and dose
designations. Another rule of thumb is to give patients
verbal and written information on how to use the drug and
include possible side effects and interaction warnings.
This is the best way to understand what is expected of you
in taking care of members and the steps patients must take
as well. Patients have the right to clear instructions, legible
prescriptions and concise explanations. They need to be
completely honest with you about their symptoms, medical
background and drug history. See page 10 for a copy of our
Member Rights and Responsibilities.
These tips may take a little extra time to implement, but
they can make a big difference in patient safety.
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Physician & Provider e-News, Vol. 2 Winter 2007/2008
Health Improvement
Prestigious EPA Award Winner
Addressing Asthma Management in a
Medicaid Population
State Sponsored Business (SSB) received the 2006 National
Environmental Leadership Award in Asthma Management
from the United States Environmental Protection Agency
(EPA). This important award acknowledged the Medicaid
plan and physicians/providers in the affiliated plan in
California for offering comprehensive resources to help
people with asthma lead healthy, active lives. Elements of
this program are being implemented in your state as well.
See below.
It also allows you to utilize critical information to make
optimal use of their visits, and help reduce the need for
reactive intervention after a patient is already in crisis.
Titled “Asthma, Air Quality, and Community Health: A
Health Plan’s Contribution,” it emphasized the exceptional
importance and value of community partnerships in
addressing the significant health challenges asthma poses
for members and communities. The award honored
our unique accomplishments in addressing both indoor
and outdoor environmental asthma triggers through the
Asthma Management Program statewide, the Plan/Practice
Improvement Project Asthma Collaborative in San Francisco
and the Valley Air Quality Project in Fresno.
Working with the EPA
The EPA award jump-started our collaboration with the
EPA. The coordinator for the EPA’s Pacific Southwest
Region Indoor Air Program, Barbara Spark, served as a
guest speaker at our Family Reunion, an annual event for
our field staff to share best practices. Spark’s presentation,
in turn, prompted our health promotion consultants
at Community Resource Centers to organize a focused
project on environmental asthma management this year in
collaboration with local schools. This effort will augment
ongoing asthma interventions, and should help identify
additional best practices in community collaboration for
improved asthma outcomes.
Asthma Management Program
Our Asthma Management Program provides a wide range
of educational resources, tools and information to members,
physicians and pharmacists to help improve member
asthma outcomes. Asthma education emphasizes minimizing
contact with asthma triggers and improving patient
self-management skills.
Check Out our New Program:
Healthy Habits Count with Asthma
Plan/Practice Improvement Project
Asthma Collaborative
Facilitated by the Center for Health Care Strategies, the
National Initiative for Children’s Health Care Quality, and
the California Health Care Foundation, this collaborative
is a pilot project in which we engaged five practices in
San Francisco to join the PPIP and then worked with
them closely to enhance participation. The collaborative
encourages physicians to apply the Chronic Care Model
to asthma care, and streamline daily clinical activities, so
that evidence-based interactions between informed patients
and prepared practice teams become the norm. By creating
planned disease-management visits, maximizing patient
self-management, and teaching patients to reduce exposure
to environmental asthma triggers, patients and physicians are
better prepared to focus on chronic illness management.
If you have Medicaid members with asthma, our Healthy
Habits Count with Asthma Program can help enhance
their care plan. Participation is easy:
• We have automatic enrollment in the program through
quarterly claims and/or pharmacy data sweeps.
• Members can enroll by self-referral.
• As a provider, you can refer your member patients.
We provide enrolled members with educational mailings,
outreach phone calls, referrals to local asthma or educational
services and care management for high-risk asthmatics,
as needed.
To learn more about our asthma program, contact Health
Services at 1-800-319-0662.
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Physician & Provider e-News, Vol. 2 Winter 2007/2008
Health Improvement
Asthma Guidelines Updated
The Asthma Clinical Practice
Guidelines have been updated. The
new National Heart, Lung and Blood
Institute guidelines can be easily
viewed and downloaded.
Your Role in Helping Members Quit Smoking
In June, Jeffrey M. Wells, MD, MBA, the director of
Medicaid for the Indiana Family and Social Services, sent all
Medicaid providers a letter announcing a 44 percent increase
in the cigarette tax, raising the total state cigarette tax to 99.5
cents, in hopes of motivating patients to quit using tobacco.
• Tell members they can take a stop-smoking class. Health
Services offers smoking cessation classes at no cost to
members. Call 1-800-319-0662.
• Prescribe Nicotine Replacement Therapy or gum—
free to our members. However, they need to fill the
prescription at the pharmacy.
Indiana currently has the fifth highest smoking rate among
all states, according to findings from the 2006 Indiana
Behavior Risk Factor Surveillance Survey. In his letter,
Dr. Wells asked that you, as physicians, providers and
health care professionals, help the state reduce smoking and
tobacco use. “You are one of the most important sources of
information for your patients and their families on health
issues and health risks,” he wrote. “Smokers need help to
quit, but only half (49 percent) of smokers advised by their
physician to quit smoking were given specific advice on how
to do so.” Please make sure you share the following tools and
resources with our members who smoke and want to quit:
• Have members call the state’s toll-free line, 1-800-QUIT
NOW, or visit www.indianatobaccoquitline.net.
• Access additional resources. Most counties in Indiana
have a funded Indiana Tobacco Prevention and
Cessation Coalition that can help provide resources.
You can access the coalition in your community at
www.in.gov/itpc.
• Remind members that they can order a free The Last
Cigarette Quit Kit. You can give members the kit. Just
call our Customer Care Center at 1-866-408-6132 to
order kits for free.
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Physician & Provider e-News, Vol. 2 Winter 2007/2008
Health Improvement
MedCall Means Peace of Mind
When you schedule appointments with Medicaid members,
remind them about the free nurse help line. To access
MedCall, members simply call toll-free, 1-866-800-8789,
or MedCall’s TTY line, 1-800-368-4424. When members
call MedCall, they also have access to
audiotopics on 200 health conditions
such as:
Recommend the Free 24-Hour Nurse Help Line
It’s 10 p.m. and one of your patients is running a fever. Nothing
seems to help and he’s miserable. His wife doesn’t know what
to do. She knows your office is closed right now and she doesn’t
know if it’s serious enough to call you or go to urgent care or the
emergency room. Instead, she calls MedCall, our 24-hour nurse
help line. The nurse serves as a resource to help her make an
informed decision and get relief for her spouse. She’s planning to
call you first thing tomorrow to figure out her next steps.
• High blood pressure
• Diabetes
Overutilization of emergency rooms for nonemergencies is
a big problem across the country. However, health concerns
don’t just happen 9 to 5 Monday through Friday during
office hours. We want our members to take care of health
concerns as soon as possible, but we want them to know
they have a resource to call 24 hours a day, 7 days a week to
provide information that helps them make informed choices
about what their options are, based on symptoms.
• HIV/AIDs
• Alcohol and drug problems
• Pregnancy
• Sexually transmitted diseases
MedCall is just one more health
education tool available to our members to help them make
smart health care decisions and take a little pressure off
providers. Please be sure to remind members about MedCall.
No-Cost Health Education Classes
Here is a list of core classes currently offered:
Our Health Services department wants to help you improve
the health and well-being of your patients by offering nocost health education and health management programs that
promote and encourage self-care.
• Asthma
• Smoking Cessation/Tobacco Prevention
• Diabetes Management
• Childbirth/Lamaze
• Prenatal Education
• Parenting/Well Child
• Substance Abuse
• Sexually Transmitted Diseases
• Nutrition/Weight Management
• Injury Prevention
When one of our members completes a class, you, the
provider, will receive an attendance confirmation letter that
includes the patient’s name, ID number and class title. If a
patient fails to attend a class, both you and the patient will
receive a “no show” letter in the mail. Please be sure to file
these letters in the patient’s chart and follow up as needed.
Among the many educational tools available are no-cost
classes that patients may access either by self-referral, or a
Classes can take place at either a hospital or communitybased organization and vary from county to county. To
schedule a class, or find out what is available for patients in
your area, call Health Services at 1-800-319-0662.
referral by a contracted provider like you. These classes are
designed to meet specific health care needs, promote healthy
living, and improve the health status of those living with
chronic diseases.
We have free health education topic brochures you can order
for your office. To place an order or for a complete list of
topics, send an e-mail to [email protected]
and request a health education materials order form or
call Health Services.
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Physician & Provider e-News, Vol. 2 Winter 2007/2008
Rx Updates
Medicaid Formulary Is Available Through Epocrates®
Epocrates is a drug reference software application that
allows you to check formulary status, prior authorization
requirements, formulary alternatives, general substitutes and
quantity limits. It also features drug reference information
including indication, dosing, contraindications, drug
interactions, adverse reactions and cost information.
You can download
the software from the
Epocrates website at
www.epocrates.com.
Premium versions that
include alternative
medicines, clinical tables,
and disease and lab
references are available for an annual fee.
Epocrates Rx® software is available free of charge
for handheld devices that synchronize with
Windows computers.
Prior Authorization List
written prior authorization is required. Prior authorization
from Anthem Blue Cross and Blue Shield must be received
prior to dispensing. If you have questions regarding the Prior
Authorization program, please contact WellPoint NextRx
Prior Authorization at 1-877-652-1223.
The following list of preferred medications requires
written prior authorization for Indiana Hoosier Healthwise
program members. This list is a guide for your use and is
subject to change with the release of the U.S. Food and
Drug Administration’s newly approved drug lists. For all
nonpreferred medications not included on the following list,
Brand Name
Brand Name
Brand Name
Brand Name
Alora
Fentanyl lollipop
Nutropin AQ
Singulair †
Amnesteem
Fexofenadine HCL
Nutropin Depot
Singulair granules †
Aristocort A
Finasteride***
Peg-Intron
Sotret
Avita**
Genotropin
Peg-Intron Redipen
Sutent
Butorphanol NS
Gleevec
Pegasys
Tarceva
Byetta
Humatrope
Prevacid
Targretin
Ciprodex
Hyzaar
Prevacid Solutabs
Thalomid
Claravis
Infergen
Procrit
Tretinoin**
Climara
Intron A
Promethazine products ††
Vivelle
Cozaar
Intron A Pen
Protopic
Vivelle Dot
Derma-Smoothe/FS
Itraconazole
Rebetol solution
Xeloda
Differin**
Lamisil
Rebetron 1000
Zavesca
Elidel
Leuprolide Acetate
Rebetron 1200
Zetia
Enbrel
Naglazyme
Rebetron 600
Estraderm
Neumega
Revlimid
Exjade
Nexavar
Ribavirin
Nutropin
Roferon-A
Peg-Intron
All nonpreferred agents
** Prior Authorization (PA) required if member is younger than 12 years of age or older than 35 years of age.
*** PA required if male member is less than 45 years of age.
† PA required if member is 18 years of age or older.
†† PA required if member is under 2 years of age.
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Physician & Provider e-News, Vol. 2 Winter 2007/2008
Rx Updates
Formulary Update
The following grid lists the outcomes of the 2nd quarter 2007 WellPoint NextRx Pharmacy and Therapeutics Committee
meetings held in June 2007.
Product
DETROL®, DETROL LA®
OXYTROL®
ALUPENT® Inhaler
LIPITOR®
DIOVAN®, DIOVAN HCT®
ALTACE®
Methadone Oral Solution
OXYCONTIN®
VENTOLIN® HFA
Generic Name
Formulary Status
Tolterodine
Oxybutynin
Metaproterenol
Atorvastatin
Valsartan
Ramipril
Methodone
Oxycodone
Albuterol
Nonformulary
Nonformulary
Nonformulary
Nonformulary
Nonformulary
Nonformulary
Nonformulary
Nonformulary
Nonformulary
Generic Medications
A Cost-Effective Alternative
Educating patients on the use of generic medication is
a great way to reduce health care costs. Patients who
understand the equality of generic medicine to brand-name
counterparts most likely will convert to buying the former,
and at a much lower price.
rigorous testing as their rivals, and are no different
when it comes to strength, dosage form, route of
administration or intended usage. Summed up, generic
products produce the same clinical effects and safety profiles
as brand-name medicines.
Overall, patients should be aware that generic drugs are
FDA-approved, and a safe, equally-effective alternative,
when clinically appropriate. Generic drugs require the same
You can get a copy of our formulary at the Pharmacy
section of our website or by calling WellPoint NextRx at
1-800-227-3032.
Drug Therapy Quantity and Dosage
Dose Optimization Program
The Dose Optimization Program helps increase patient
adherence to drug therapies. This program works with the
member, the member’s physician, or health care provider
and the pharmacist to replace multiple doses of lowerstrength medications with a single dose of a higher-strength
medication, where clinically appropriate. This may be done
only with the prescribing physician’s approval. For questions,
please contact WellPoint NextRx at 1-800-227-3032.
30-Day Quantity Supply Limits
Defined by quantity limits based on the FDA’s dosing
recommendations, the pharmacy benefit program allows up
to a 30-day supply of most medications. Select maintenance
medications on the 90-day supply list are the exception. If a
medical condition warrants a greater supply than what has
been recommended, then PAB is required in order to ensure
access to a medically-appropriate quantity. Medications in
this program require our internal review prior to dispensing.
If you want to reach us by phone:
STAT Physician & Provider e-News is published by Anthem Blue Cross and Blue Shield to
serve our State Sponsored Business providers.
Customer Care Center: 1-866-408-6132
In Indiana: Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance
Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association.
® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are
registered marks of the Blue Cross and Blue Shield Association. ® MedCall is a registered mark
of WellPoint, Inc.
Community Resource Centers:
Columbus
Evansville
Indianapolis Merrillville 1-877-225-0595
1-866-461-3586
1-866-795-5440
1-866-724-6533
Epocrates® and Epocrates Rx® are registered trademarks of Epocrates, Inc.
All rights reserved.
WellPoint Next Rx is a service mark of WellPoint, Inc. Services are provided by a WellPoint
PBM (either Professional Claims Services, Inc. doing business as WellPoint Pharmacy
Management, or Anthem Prescription Management, LLC, as appropriate). WellPoint Next Rx
is a division of WellPoint, Inc.
© 2007 WellPoint, Inc.
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