1. health and fitness
2. disease
3. cancer

Volume 16 • Issue 12 • December 2014
2014 Provider Satisfaction Survey
Reminder:
Renew Your License!
Please remember to renew your
license with the State Board before
it expires. You may not practice in
Pennsylvania with an expired license.
Blue Cross of Northeastern Pennsylvania (BCNEPA) is
Reminder
conducting the annual First Priority Health® (FPH) and
!
First Priority Life Insurance Company® (FPLIC) Provider
Satisfaction Survey. Surveys were mailed in early November
to all PCPs, specialists and facilities in our FPH and FPLIC networks.
We use this survey to evaluate our Plan and determine what changes and
enhancements should take place. Please complete the survey and respond
by December 5, 2014.
Check out future issues of Provider Bulletin for feedback about the changes
that will take place in response to your concerns and comments.
(Policy Update 1612002)
The following practitioners have
licenses expiring this year:
Practitioner
New HEDIS Measures Available Online
Expiration
Date
Doctors of
Medicine
12/31/14
Doctors of
Podiatric
Medicine
12/31/14
Physical
Therapists
12/31/14
The following HEDIS measures will be added to the HEDIS Homepage
in November:
CAHPS Health Plan Survey 5.0H, Adult Version (CPA)
Measure Description
This measure provides information on the experiences of commercial members with
the organization and gives a general indication of how well the organization meets
members’ expectations. Results summarize members’ experiences through ratings,
composites and question summary rates.
Also on the HEDIS Homepage in December is the Annual HEDIS report for
2014, which includes scores for FPH and FPLIC for all HEDIS measures, and the
CAHPS survey.
Visit the HEDIS Homepage at bcnepa.com for these and other measures with
documentation tips, best practices and information about the importance of these
measures to your practice. Click on the Providers tab and select Quality Management.
Then click on the link to the HEDIS Homepage.
(Policy Update 1612003)
(Policy Update 1612001)
Table of Contents
3 Prepare for ICD-10 with
”What’s Up Wednesday“
4Changes to 2015
Primary Care Physician
Quality Incentive Program
6Radiation Safety
Awareness Initiative
8Medical Policy Updates
9BCNEPA’s Prescription
Drug Formulary Changes
updates
continued on page 3
Utilization Management Updates
New Prior Approval Requirements
We are transitioning certain services that historically required retrospective review to
requiring prior approval (prior authorization/precertification). Once transitioned, you will
know if these services will be considered medically necessary before they are rendered.
This helps to ensure that our members receive high quality and appropriate care.
Beginning January 1, 2015, the following services will require prior approval:
Reminder:
Lung Cancer CT
Screening Benefit
Services
Codes
As a reminder, beginning
Transcranial Magnetic Stimulation
(TMS)
Home Sleep Test (HST)
Fixed Wing Air Ambulance
90867, 90868, 90869
January 1, 2015, annual lung
G0398, G0399, G0400, 95800, 95801, 95806
A0430, A0435
Beginning February 1, 2015, the following services will require prior approval:
Services
Codes
Myoelectric Prostheses for Upper Limb,
Microprocessor-Controlled Prostheses
for the Lower Limb
L5828, L5845, L5856, L5857, L5858, L5859,
L5920, L5930, L5969, L6025, L6715, L6882,
L6925, L6935, L6945, L6955, L6965, L6975,
L7007, L7008, L7009, L7045
Genetic Testing for Long QT Syndrome
81280, 81281, 81282
Pneumatic Compression Devices
E0650, E0651, E0652, E0655, E0656, E0657,
E0660, E0665, E0666, E0667, E0668, E0669,
E0670, E0671, E0672, E0673, E0675, E0676
cancer screenings using low-dose
computed tomography (CT) will be
covered as a preventative service
for high-risk members.
Individuals are defined as
“high-risk” if all of the
following apply:
• An adult between
Prior approval requirements apply to all FPH and FPLIC products. Please continue to check
future issues of Provider Bulletin for more services which will require prior approval.
55 and 80 years of age
• At least a 30-pack-year history
of cigarette smoking
• If a former smoker, had quit
smoking within the previous
15 years
Reminder:
Note: For members whose health
Home Sleep Tests
plans have a Radiology Benefit
As noted above, beginning January 1, 2015, home sleep tests will be
eligible for coverage under certain benefit plans. All home sleep tests
will require prior approval. As always, please check a patient’s benefits
and eligibility prior to rendering any services.
Criteria that will be used for review of these services will be available
this month. If you would like a copy, please call Jenna Sladicka,
administrative assistant, Medical Management, at 570.200.4792.
After January 1, 2015, this criteria will be available on our Medical
Management website, under Medical Policies and Clinical Guidelines.
2
Management program, this CT
screening (code S8032) now
requires prior approval by
National Imaging Associates (NIA).
updates
continued from page 2
Utilization Management Updates
PerformCare Availability
Update:
For any UM issues or questions about behavioral health/
substance abuse, please call PerformCare at one of the
following numbers, weekdays, between 8 a.m. and 4:30 p.m.:
• BlueCare® HMO/CHIP: 1.800.599.2428
• BlueCare PPO, myBlue® Plans, BlueCare EPO,
AffordaBlueSM, BlueCare Traditional,
FEP and BC/BS: 1.800.577.3742
• For TTY services, please call: 1.855.375.8891
Medical Management Site Added
To give you better service, we have recently enhanced
our Provider website. You will now be able to find
medical policies, clinical guidelines and services needing
prior approval under the Medical Management link on
bcnepa.com/providers.
(Policy Update 1612004)
Prepare for ICD-10 with
“What’s Up Wednesday”
Administrative
Practice Guideline
An ICD-10 preparedness teleconference series
from Pennsylvania’s Blues Plans (Blue Cross of
Northeastern Pennsylvania, Capital Blue Cross,
Highmark Blue Shield and Independence Blue Cross)
will resume in January 2015.
The following Administrative Practice Guideline
has been updated as of October 21, 2014, and
approved by the Credentialing Committee:
MRD Non-physician Specialist
Administrative Practice Guidelines can be found
on our website at bcnepa.com. Just click on the
Provider Homepage tab and select the Quality
Management link. Then click on Practice Guidelines
on the right.
“What’s Up Wednesday” is a monthly teleconference for
Pennsylvania’s health care professionals about the transition
to ICD-10. “What’s Up Wednesday” will feature special guests
and ICD-10 experts who will lead discussions to help you get
ready for the October 1, 2015, compliance date.
For questions, or to request a copy of the Guidelines,
please contact Gina Klepadlo, nurse analyst, at
570.200.4388, weekdays, between 8 a.m. and 5 p.m.
When is the next call?
This is tentatively scheduled for January 21, 2015.
Going forward, calls will take place on the 3rd Wednesday
of each month.
Who should participate?
All providers, clearinghouses, trade associations and
information networks are encouraged to participate.
How do I participate?
Before the call, visit BCNEPA’s ICD-10 page at bcnepa.com.
On the Provider Homepage select the Resources and Tools
tab, and then choose the Privacy link. Click on ICD-10 to
access the presentation.
Questions can be emailed before or during the
teleconference to [email protected].
(Policy Update 1612005)
(Policy Update 1612006)
3
quality corner
continued on page 5
Changes to 2015 Primary Care Physician
Quality Incentive Program
Our Primary Care Physician (PCP) Quality Incentive
Program (QIP) rewards PCPs for delivering high-quality,
cost-effective care to BCNEPA members via our FPH
and FPLIC networks.
For review of program results for incentive periods prior
to January 1, 2015, BCNEPA will use the benchmarks
for each CQM from the then current NCQA Quality
Compass® (All Lines of Business) metric benchmark, as
of the last day of the month following the close of the
QIP review period.
BCNEPA is modifying the QIP HEDIS-like clinical
quality measures (CQM) to more closely align with
the HEDIS score definitions for calendar year 2014.
The breast cancer screening and cervical cancer
screening measures have notable changes. BCNEPA
is also removing 2 LDL-C screening measures (for
diabetes and coronary artery disease) that are no
longer measured for HEDIS and is adding one new
measure for medication management for asthmatics.
These changes are being made for an effective date of
January 1, 2015.
In the event the NCQA metric benchmark logic is
significantly different than the BCNEPA measurement
due to timing issues, or there is not an NCQA metric
benchmark available, the prior period NCQA metric
benchmark result will be used.
BCNEPA will use the same measurement logic going
forward to ensure that the results for each incentive
period are measured against comparable benchmarks.
As HEDIS score definitions change in the future, BCNEPA
will continue this practice of modifying the QIP CQMs to
be aligned with those definitions.
2015 Clinical Quality Measures will be as follows:
CQM #
Clinical Quality Measure Description
(1)
MMR Vaccination—The percentage of children 2 years of age during the measurement year
who received an MMR (measles, mumps, rubella) vaccination by their 2nd birthday, or who
have a history of having the disease.
(2)
Varicella Vaccination—The percentage of children who turned 2 years of age during the
measurement year and received a varicella vaccination by their 2nd birthday, or with a history
of having the disease.
(3)
Breast Cancer Screening—The percentage of women 52 through 74 years of age who had
a mammogram to screen for breast cancer in the measurement year, or the 12-month period
prior to the measurement year.
4
quality corner
CQM #
continued from page 4
Clinical Quality Measure Description
(4)
Colorectal Cancer Screening—
The percentage of members 51 through 75 years of age, who had the appropriate screening for
colorectal cancer. Colorectal cancer screening tests include the following: a fecal occult blood
test during the measurement year, a flexible sigmoidoscopy during the measurement year or
preceding 4 years, or a colonoscopy during the measurement year or the preceding 9 years.
(5)
Cervical Cancer Screening—
The percentage of women 24 through 64 years of age, who were screened for cervical cancer
using either of the following criteria: Step 1—women ages 24–64 who received one or more
Pap tests to screen for cervical cancer during the measurement year or the 24-month period
preceding the measurement year; Step 2—for women who did not meet above criteria,
identify women ages 30–64 who received a Pap test and an HPV test (with services dates 4 or
less days apart) during the measurement year, or the 4 years prior to the measurement year.
(6)
Chlamydia Screening in Women—
The percentage of women 16 through 24 years of age, who were identified as sexually active
(i.e., who have been prescribed an oral contraceptive), and who had at least one test for
chlamydia during the measurement year.
(7)
Appropriate Testing for Children with Pharyngitis—
The percentage of members 2 through 18 years of age, who were diagnosed with pharyngitis
during the measurement year, dispensed an antibiotic within 3 days of the pharyngitis visit and
received a group A strep test for the episode 3 days before or after such visit.
(8)
Appropriate Treatment for Children with Upper Respiratory Infection (URI)—
The percentage of members 3 months through 18 years of age, who were given a diagnosis of
URI during the measurement year and who were not dispensed an antibiotic prescription on
or within 3 days of the URI visit.
(9)
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis—
The percentage of members 18 through 64 years of age, with a diagnosis of acute bronchitis
during the measurement year who were not dispensed an antibiotic prescription on or within
3 days following the acute bronchitis visit.
(10)
Medication Management for Members with Asthma—
The percentage of members 5 to 64 years of age, who were identified as having persistent
asthma during the measurement year, and who were dispensed appropriate medications that
they remained on for at least 75% of their treatment period.
(11)
Diabetes HbA1c Test—The percentage of members 18 through 75 years of age, with diabetes
(type 1 and type 2) who had an HbA1C test during the measurement year.
(12)
Diabetes Eye Exam—The percentage of members 18 through 75 years of age, with diabetes
(type 1 and type 2) who had an eye exam (retinal) performed during the measurement year.
(13)
Diabetes Microalbumin Test — The percentage of members 18 through 75 years of age,
with diabetes (type 1 and type 2) who had medical attention for nephropathy during the
measurement year.
(Policy Update 1612007)
5
Radiation Safety Awareness Initiative
We are pleased to inform you that
BCNEPA will begin a Radiation Safety
Awareness Initiative in conjunction
with National Imaging Associates
(NIA)*, our nationally-recognized
radiology benefits manager. We are
taking this proactive approach in
order to improve patient safety and
raise awareness regarding radiation
exposure. This program is slated to
begin in the first quarter of 2015.
As you know, radiation exposure from
medical imaging is a rapidly growing
patient safety issue. Patients are now
exposed to nearly 7 times more
radiation from medical diagnostic tests
than they were in 1980. The largest
contributors to the increase in medical
radiation exposure are CT scans and
nuclear medicine.
How is your patient identified?
At-risk patients are identified through
radiology claims, which are provided
twice a year to NIA by BCNEPA.
The National Research Council
estimates that Americans receive
an average of 0.5 mSv per year from
medical imaging. Based on that
estimate, you would expect the
average 75-year-old individual to
have had approximately 37.5 mSv 1.
To account for all age groups, we
have set the “at-risk” threshold for
cumulative radiation exposure equal
to, or exceeding, 50 milliSieverts
(mSv)—a level intended to identify
individuals who are above the norm.
More information on milliSieverts is
available on the following page.
How am I notified if one of my
patients is identified at risk?
You will be notified when you
request a preauthorization by
phone, through NIA’s provider
website, RadMD.com or via
NaviNet. At that time, you will be
offered an NIA peer discussion,
should you want to discuss the case
with another physician. In addition,
a provider alert letter will be sent via
fax or mail with the authorization or
denial letter.
Note: The patient’s level of
radiation exposure does not
affect the preauthorization or
decision-making process for
requested imaging studies.
You will be notified
when you request a
preauthorization
by phone, through
NIA’s provider
website, RadMD.com
or via NaviNet.
continued on page 7
6
Radiation Safety Awareness Initiative continued from page 6
How can I use this information when
ordering diagnostic testing?
• Consider the risk versus the benefit
of the radiology study
• Consider how the results of
this study will help in managing
this patient
• Consider if this ionizing
radiation study is the best one
to perform
How radiation exposure is measured
Radiation exposure estimates are
measured in milliSieverts (mSv).
Radiation effective dose is the
amount of radiation received by the
patient and depends on many factors
including distance from the source,
time of exposure, overall body and
organ size, location and nature of
tissue exposed. Given these variables,
there is some variation in the amount
• Consider if there are other tests,
such as ultrasound, lab or
endoscopy testing which would
be a more appropriate initial
investigative study
• Carefully consider the necessity
of repeating a CT scan, especially
in young girls and young women,
due to the radiation dose to
breasts and ovaries
• Be aware of a patient’s prior
history of imaging studies.
Discuss this with the radiologist
• Consider discussing this
information with patients as
this may enable them to take
a more active role in their
health care
You can also find out more
information on radiation exposure
on NIA’s website at RadMD.com.
of radiation received from similar
medical procedures. However, studies
suggest a significant health risk at
radiation effective dose levels of 50
mSv. Reaching this effective dose is
not uncommon in patients having
multiple CT and/or nuclear imaging
studies. For comparable reference,
note that federal health standards
limit workers’ exposure to whole-body
ionizing radiation to 50 mSv per year.
The following table illustrates the estimated
effective radiation dose of common medical procedures.
—Radiation Dose Comparison—
Typical
Effective Dose
(mSv)2
Diagnostic
Procedure
Number of Chest X-rays
(PA film) for Equivalent
Effective Dose
Chest X-ray
(posterior/anterior film)
0.02
1
Mammography
0.04
2
Lumbar
spine X-ray
1.50
75
CT brain
2.00
100
United States
background
radiation level
3.00
150
Upper G.I. series
3.00
150
CT of pelvis
6.00
300
CT abdomen
8.00
400
15.60
780
Myocardial
perfusion imaging
1
Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation, National Research Council. Health Risk from Exposure to Low Levels of
Ionizing Radiation: BEIR VII phase 2. Washington DC: The National Academies Press; 2006; 155-188.
2
Fazel R, Krumholz H, Wang Y, et al. Exposure to Low-Dose Ionizing Radiation from Medical Imaging Procedures. NEJM 2009; 361:849-857.
* National Imaging Associates, Inc. is an affiliate of Magellan Health Services.
(Policy Update 1612008)
7
Medical Policy
Updates
Experimental/Investigative Services
Pathology/Laboratory (MPO-490-0134)
Identification of Microorganisms Using Nucleic Acid Probes
Effective 01/01/15
The policy table has been updated with the following
new information:
Transcranial Magnetic Stimulation (TMS)
(MPO-179-0000)
Status of Nucleic Acid Probes
The following new language has been added:
BCNEPA will provide coverage for repetitive transcranial magnetic
stimulation (rTMS) of the brain when medically necessary.
Repetitive transcranial magnetic stimulation (rTMS) of the brain
may be considered medically necessary as a treatment of major
depressive disorder when all of the following conditions have
been met:
Microorganism
Amplified Probe
Gastrointestinal
Pathogen Panel
87505-87507 (inv)
Capsule Endoscopy (MPO-490-0158)
Wireless Capsule Endoscopy as a Diagnostic Technique in
Disorders of the Small Bowel, Esophagus and Colon
• Confirmed diagnosis of severe major depressive disorder
(single or recurrent) documented by standardized rating
scales that reliably measure depressive symptoms AND
The policy language has been updated as follows:
BCNEPA will provide coverage for wireless capsule endoscopy
when medically necessary.
1. Wireless capsule endoscopy may be considered medically
necessary for the following indications:
a) Initial diagnosis in patients with suspected Crohn’s
disease, without evidence of disease on conventional
diagnostic tests such as small bowel follow through (SBFT)
and upper and lower endoscopy
b) In patients with an established diagnosis of Crohn’s
disease, when there are unexpected change(s) in
the course of disease or response to treatment,
suggesting the initial diagnosis may be incorrect and
that re-examination may be indicated
c) Obscure gastrointestinal (GI) bleeding suspected of being
of small bowel origin, as evidenced by prior inconclusive
upper and lower gastrointestinal endoscopic studies
performed during the current episode of illness
d) For surveillance of the small bowel in patients with
hereditary GI polyposis syndromes, including familial
adenomatous polyposis and Peutz-Jeghers syndrome
Any one of the following:
– Failure of 4 trials of psychopharmacologic agents, including
2 different agent classes and 2 augmentation trials OR
– Inability to tolerate a therapeutic dose of medications as
evidenced by 4 trials of psychopharmacologic agents, with
distinct side effects OR
– History of response to rTMS in a previous depressive episode
(at least 3 months since the prior episode) OR
– The patient is a candidate for electroconvulsive therapy
(ECT) and ECT would not be clinically superior to rTMS
(e.g., in cases with psychosis, acute suicidal risk, catatonia
or life-threatening inanition. Therefore, rTMS should NOT
be utilized)
AND
– Failure of a trial of a psychotherapy known to be effective in
the treatment of major depressive disorder of an adequate
frequency and duration, without significant improvement
in depressive symptoms, as documented by standardized
rating scales that reliably measure depressive symptoms
BCNEPA will not provide coverage of wireless capsule
endoscopy for the following indications, as they are considered
investigational; and, therefore, not covered because the safety
and effectiveness of these services cannot be established by
review of the available published peer-reviewed literature:
1. Evaluation of the extent of involvement of known Crohn’s
disease or ulcerative colitis
2. Evaluation of the esophagus in patients with gastroesophageal
reflux disease (GERD) or other esophageal pathologies
3. Evaluation of other gastrointestinal diseases and conditions
not presenting with GI bleeding including, but not limited
to, celiac sprue, irritable bowel syndrome, Lynch syndrome,
portal hypertensive enteropathy, small bowel neoplasm and
unexplained chronic abdominal pain
4. Evaluation of the colon including, but not limited to,
detection of colonic polyps or colon cancer
5. Initial evaluation of patients with acute upper GI bleeding
6. All other indications not identified above as medically necessary
rTMS for major depressive disorder that does not meet the
criteria listed above is considered investigational.
Continued treatment with rTMS of the brain as maintenance
therapy is considered investigational.
Transcranial magnetic stimulation of the brain is considered
investigational as a treatment of all other psychiatric/neurologic
disorders, including but not limited to, bipolar disorder,
schizophrenia, obsessive-compulsive disorder or
migraine headaches.
Genetic Testing (MPO-490-0083)
Whole Exome and Whole Genome Sequencing for
Diagnosis of Patients With Suspected Genetic Disorders
The policy language has been updated as follows:
BCNEPA will not provide coverage for whole exome sequencing
and whole genome sequencing, as they are considered
investigational for all indications.
(Policy Update 1612009)
8
Blue Cross of Northeastern Pennsylvania’s
Prescription Drug Formulary Changes continued on page 10
Multi-tier Formulary Changes
Tier 1
Tier 2
Effective 01/01/15
Tier 3
Autonomic and CNS Drugs, Neurology and Psychiatry
Combination
Narcotic/Analgesics
Xartemis XR2
(oxycodone/acetaminophen)
NSAIDs/COX II Inhibitors
Vimovo2,3,8
(esomeprazole/naproxen)
Tecfidera2,3,4,7
(dimethyl fumarate)
Miscellaneous
Neurological Treatments
Gilenya2,3,4,7
(fingolimod)
Cardiovascular, Hypertension and Lipids
Anticoagulants
Eliquis (apixaban)
Vasodilators
Orenitram ER2,3,4,8
(treprostinil)
Lipid/Cholesterol
Lowering Agents
Vytorin8
(ezetimibe/simvastatin)
Dermatologicals/Topical Treatment
Topical Antifungals
Luzu (luliconazole)
Immunology, Vaccines and Biotechnology
Nutropin2,3,4,8 (somatropin)
Growth Hormones
Musculoskeletal and Rheumatology
Miscellaneous
Rheumatological Agents
Otezla2,3,8
(apremilast)
Ophthalmology
Lumigan2 (bimatoprost)
Travatan Z2 (travoprost)
Other Glaucoma Drugs
Respiratory, Allergy, Cough and Cold Miscellaneous
Pulmonary Agents
Anoro Ellipta2
(umeclidinium/vilanterol)
Key: 1Step Therapy, 2Quantity Limit, 3Prior Authorization, 4Specialty Pharmacy, 5Tier Zero, 6Tier One, 7Tier 2, 8Tier 3.
These descriptions indicate the change in status and/or special requirements for coverage.
Please refer to the complete Utilization Management policies for full prior authorization criteria, step therapy and quantity
limits, as well as additional information and restrictions. Visit our website at bcnepa.com and click on the Providers tab.
Then choose the Pharmacy Benefits link on the right, and select the link for Utilization Management Criteria on the right.
9
Blue Cross of Northeastern Pennsylvania’s
Prescription Drug Formulary Changes continued on page 11
Multi-tier Formulary Changes
Effective 10/01/14
(These are all positive changes that result in lower copays for members.)
Tier 1
Tier 2
Tier 3
Endocrine/Diabetes
Oral hypoglycemic agents
Invokana1,2,7 (canagliflozin)
Invokamet1,2,7
(canagliflozin/metformin)
Androgens
Axiron2,7
(topical testosterone)
Gastrointestinal
Lialda7 (mesalamine)
Miscellaneous
gastrointestinal agents
Pentasa7 (mesalamine)
Respiratory, Allergy,
Cough and Cold
Adrenergics
Auvi-Q2,7 (epinephrine)
Miscellaneous
pulmonary agents
Tudorza Pressair2,7
(aclidinium bromide)
Urologicals
Anticholinergics and
Antispasmodics
Myrbetrig2,7
(mirabegron)
Key: 1Step Therapy, 2Quantity Limit, 3Prior Authorization, 4Specialty Pharmacy, 5Tier Zero, 6Tier One, 7Tier 2, 8Tier 3.
These descriptions indicate the change in status and/or special requirements for coverage.
New Medications Covered Under the Medical Benefit
Beleodaq (belinostat)
Beleodaq is a histone deacetylase inhibitor indicated for the treatment of patients with relapsed
or refractory peripheral T-cell lymphoma (PTCL). This medication is covered under the medical
benefit; it cannot be self-administered. Medical records documenting the patient’s diagnosis as
well as other specified criteria, including information on previous medications used for treatment,
should accompany the authorization request. Please see the policy for complete criteria as well as
additional information.
Keytruda (pembrolizumab)
Keytruda is a human programmed death receptor-1 (PD-1) blocking antibody indicated for
the treatment of patients with unresectable or metastatic melanoma and disease progression
following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor. Medical records
documenting the patient’s diagnosis, as well as other specified criteria, including previous
medications and BRAF mutation results, should accompany the authorization request. This
medication is covered under the medical benefit; it cannot be self-administered. Please see
the policy for complete criteria as well as additional information.
Please refer to the complete Utilization Management policies for full prior authorization criteria, step therapy and quantity
limits, as well as additional information and restrictions. Visit our website at bcnepa.com and click on the Providers tab.
Then choose the Pharmacy Benefits link on the right, and select the link for Utilization Management Criteria on the right.
10
Blue Cross of Northeastern Pennsylvania’s
Prescription Drug Formulary Changes continued on page 12
New Pharmacy Prior Authorization/Step Therapy Criteria
Effective 10/01/14
Adagen
(pegademase bovine)
Prior Authorization Criteria
Adagen is an enzyme replacement therapy used in the treatment of children with adenosine
deaminase (ADA) deficiency in patients with severe combined immunodeficiency disease
(SCID) who are not suitable candidates for, or who have failed, bone marrow transplantation. A
prior authorization must be submitted for coverage of this medication. The prior authorization
request must be accompanied by medical records documenting the member’s diagnosis as well
as specified criteria. When approved, Adagen must be obtained through a limited distribution
pharmacy at a tier 3 copay. Please see policy for complete criteria and additional information.
raloxifene/tamoxifen
Prior Authorization Criteria
Members may currently obtain the prescription drugs raloxifene and tamoxifen at a tier 1
copay. Starting September 24, 2014, as per Health Care Reform law, if one of these medications,
raloxifene or tamoxifen, is being used for primary prevention of breast cancer and the member
is considered at high risk for breast cancer, one may be able to obtain one of these medications
at no cost, i.e. zero copay. In order to be approved for the zero copay, the prescribing physician
must submit a prior authorization for either raloxifene or tamoxifen indicating that the
medications are being used for the primary prevention of breast cancer. If after review, all of the
specified criteria are met, the raloxifene or tamoxifen may be obtained at a retail pharmacy for
zero copay. Otherwise, the tier 1 copay applies. Please see policy for complete criteria as well as
additional information.
Sutent (sunitinib)
Prior Authorization Criteria
Sutent is an oral multi-kinase inhibitor indicated in the treatment of specified cases of advanced
renal cell carcinoma, gastrointestinal stromal tumor (GIST), and pancreatic neuroendocrine
tumors (pNET). A prior authorization from an oncologist must be submitted for coverage of
this medication. The prior authorization request must be accompanied by medical records
documenting the member’s diagnosis as well as specified criteria. When approved, Sutent must
be obtained through a specialty pharmacy at a tier 3 copay. Please see policy for complete criteria
and additional information.
Zydelig (idelalisib)
Prior Authorization Criteria
Zydelig is an oral kinase inhibitor indicated in the treatment of specified cases of relapsed chronic
lymphocytic leukemia (CLL), relapsed follicular B-cell non-Hodgkin lymphoma (FL) and relapsed
small lymphocytic leukemia (SLL). A prior authorization must be submitted from an oncologist for
coverage of this medication. The prior authorization request must be accompanied by medical
records documenting the member’s diagnosis as well as specified criteria including information
on previous medications used and response to therapy. When approved, Zydelig must be
obtained through a limited distribution pharmacy at a tier 3 copay. Please see policy for complete
criteria and additional information.
New Medical Prior Authorization/Step Therapy Criteria
Beleodaq (belinostat)
Prior Authorization Criteria
Beleodaq is an intravenous histone deacetylase inhibitor indicated in the treatment of relapsed
or refractory peripheral T-cell lymphoma (PTCL). A prior authorization must be submitted for
coverage of this medication. The prior authorization request must be accompanied by medical
records documenting the member’s diagnosis as well as specified criteria including information
on previous medications used and response to therapy. Since this medication cannot be selfadministered, when approved, Beleodaq is covered under the medical benefit. Please see policy
for complete criteria and additional information.
Keytruda (pembrolizumab)
Prior Authorization Criteria
Keytruda is a first in-class PD-1 (programmed death receptor-1) blocking antibody indicated for
the treatment of patients with unresectable or metastatic melanoma and disease progression
following ipilimumab, and if BRAF V600 mutation positive, a BRAF inhibitor. A prior authorization
from an oncologist must be submitted for coverage of this medication. The prior authorization
request must be accompanied by medical records documenting the member’s diagnosis as well
as specified criteria including information on previous medications used, response to therapy
and BRAF mutation results. Since this medication cannot be self-administered, when approved,
Beleodaq is covered under the medical benefit. Please see policy for complete criteria and
additional information.
Please refer to the complete Utilization Management policies for full prior authorization criteria, step therapy and quantity
limits, as well as additional information and restrictions. Visit our website at bcnepa.com and click on the Providers tab.
Then choose the Pharmacy Benefits link on the right, and select the link for Utilization Management Criteria on the right.
11
Blue Cross of Northeastern Pennsylvania’s
Prescription Drug Formulary Changes continued on page 13
Revised Pharmacy Prior Authorization/Step Therapy Criteria
Effective 10/01/14
(These are all positive changes that benefit members through the elimination of Utilization Management criteria.)
Inflammatory Bowel
Medications Step Therapy
(UMC 530-0039)
Lialda will no longer require step therapy. The 1st step products are now balsalazide,
sulfasalazine, Delzicol, Asacol HD, Pentasa and Lialda. The use of two 1st products is required for
coverage of the 2nd step products, Giazo, Dipentum and Apriso.
Testosterone (topical)
Supplements Step Therapy
(UMC 530-0087)
Axiron will no longer require step therapy. The 1st step products are now Androgel and Axiron.
The use of both of these 1st step products is required for coverage of the 2nd step products,
Testim, Fortesta, Vogelxo and Testosterone topical.
Overactive Bladder
Medications Step Therapy
(UMC 530-0085)
Myrbetriq will no longer require step therapy. The 1st step products are now oxybutynin, oxybutynin
ER, trospium, trospium ER, tolterodine, tolterodine ER, Vesicare and Myrbetriq. The use of 3 of our 1st
step medications is required for coverage of the 2nd step products Enablex and Toviaz.
“Triptan”
Step Therapy Criteria
The Triptan step therapy is no longer in existence. Naratriptan, sumatriptan, zolmitriptan, and
rizatriptan will continue to be available at a tier 1 copay. Relpax (tier 2), Frova and Axert (tier 3)
will be available without step therapy. All of the medications in this category continue to be
subject to quantity level limits; however, no step therapy criteria is in place now.
Uloric
Step Therapy Criteria
Itraconazole
Prior Authorization Criteria
COX II (Celebrex)
Prior Authorization Criteria
The Uloric step therapy is no longer in existence. Uloric will be available at the tier 3 copay;
quantity limits are still in place.
Itraconazole capsules will no longer require a prior authorization. Itraconazole will be available at
retail pharmacies at a tier 1 copay without a prior authorization. Onmel, a branded itraconazole,
will continue to require a prior authorization.
Celebrex will no longer require a prior authorization. Celebrex will be available at retail
pharmacies at a tier 3 copay. It is still subject to quantity limits.
Revised Pharmacy Prior Authorization/Step Therapy Criteria
Effective 01/01/15
Multiple Sclerosis
Disease Modifying
Self-Administered Injectables
Step Therapy Criteria
Plegridy (peginterferon beta 1a) has been added to the non-preferred, step 2 medications in
this step policy. Both preferred, 1st step medications, Betaseron and Rebif, must be given a
trial before any of the non-preferred, 2nd step medications, Extavia, Avonex, and Plegridy, are
covered. All of these medications must be obtained through a specialty pharmacy. Please see
policy for complete criteria and additional information.
Multiple Sclerosis
Oral Disease
Modifying Medications
Step Therapy Criteria
This policy has been extensively revised to allow specified oral disease modifying agents after a
trial of one injectable agent. A first step medication, any of the self-injectable disease modifying
agents (Betaseron, Rebif, Extavia, Avonex, Plegridy, Copaxone) must be given a trial before a
preferred, 2nd step medication, Tecfidera or Gilenya, is covered. Use of Aubagio, a non-preferred,
3rd step medication, requires the use of a 1st step and 2nd step medication. Tecfidera and Gilenya
are available at the tier 2 copay; Aubagio is available at the tier 3 copay. All of these medications
must be obtained through our specialty pharmacy. Please see policy for complete criteria and
additional information.
Growth Hormone
Prior Authorization Criteria
All of the criteria in the Growth Hormone Prior Authorization policy remain as previously
established. However, Nutropin is no longer a preferred growth hormone product. Norditropin is
now the only preferred, growth hormone product. Nutropin will now only be covered if medical
necessity has been established, i.e. a trial of Norditropin has been given and treatment failure/
intolerance has been documented. All affected members and prescribers have been notified of
this change. Norditropin will continue to require a prior authorization. When approved it may be
obtained through a specialty pharmacy at a tier 2 copay. Quantity limits will be established at
the time of authorization. If a prior authorization for Nutropin is submitted, medical necessity is
established and authorization is given, Nutropin will be available through our specialty pharmacy
with a tier 3 copay. Again, quantity limits will be established at the time of authorization. Please
see policy for complete criteria and additional information.
Please refer to the complete Utilization Management policies for full prior authorization criteria, step therapy and quantity
limits, as well as additional information and restrictions. Visit our website at bcnepa.com and click on the Providers tab.
Then choose the Pharmacy Benefits link on the right, and select the link for Utilization Management Criteria on the right.
12
Blue Cross of Northeastern Pennsylvania’s
Prescription Drug Formulary Changes continued on page 14
Revised Pharmacy Prior Authorization/Step Therapy Criteria
Effective 01/01/15
Vimovo
Step Therapy Criteria
Vimovo will now require step therapy for new starts as well as for those members who are
currently using it. Affected members have been made aware of this upcoming change. Vimovo
is a proprietary product composed of the NSAID, naproxen and the PPI, esomeprazole. The step
therapy requires that 2 generic PPIs as well as 2 generic NSAIDs must appear on the member’s
prescription claims history in the past 180 days for Vimovo to be covered. When criteria are met,
Vimovo is available at retail pharmacies with a tier 3 copay. Quantity limits do apply. Please see
policy for complete criteria and additional information.
Ophthalmic
Prostaglandin Agonists
Step Therapy Criteria
Lumigan (bimatoprost) and Travatan Z (travoprost) will no longer require step therapy, but
they will move to a tier 3 copay level. They are now step 1 in this policy. Latanoprost, a tier
1 medication, is also available as a step 1 medication. Zioptan (tafluprost) remains a step 2
medication. A trial of 3 step 1 medications (latanoprost, travoprost, Lumigan, Travatan Z) must
be shown before Zioptan is covered. Quantity limits remain in place for Lumigan, Travatan Z and
Zioptan. Please see policy for complete criteria and additional information.
Pegasys
(peginterferon alfa 2a)
Prior Authorization Criteria
Due to extensive changes in the various medications used in the treatment of hepatitis C, as
well as extensive changes in the recommendations from the American Association for the
Study of Liver Diseases (AASLD), this policy has been extensively revised. As per the new AASLD
recommendations and our prior authorization criteria, use of Pegasys in the treatment of
hepatitis C can be approved when used with either the NS3/4A protease inhibitor, Olysio, or the
nucleotide analog NS5B polymerase inhibitor, Sovaldi. In addition, specified criteria must be met
for approval of coverage. Both Olysio and Sovaldi also require prior authorization. Please refer
to the UM criteria for these medications as well. When coverage of Pegasys is given, it must be
obtained through our specialty pharmacy at a tier 2 copay. Quantity limits and length of therapy
covered will be established at the time of authorization. Please see policy for complete criteria
and additional information.
Injectable/Oral Medications
in the Treatment of
Gaucher’s Disease
A new, oral medication in the treatment of Gaucher’s disease, Cerdelga (eliglustat), has been
added to the current policy. Cerdelga is indicated in the long-term treatment of adults with
Gaucher’s disease type 1 (GD1) who are CYP2D6 extensive metabolizers (EMs), intermediate
metabolizers (IMs) or poor metabolizers (PMs), as detected by an FDA-cleared test. Patients
who are CYP2D6 ultra-rapid metabolizers (URMs) may not achieve adequate concentrations of
Cerdelga to achieve a therapeutic effect. In addition to other specified criteria in place for other
Gaucher’s medications, the results of the FDA-approved test, indicating the type of metabolizer
a patient is, must be submitted along with a prior authorization for review. If criteria are met and
the medication is approved, Cerdelga may be obtained through a specialty pharmacy at a tier 3
copay. Please see policy for complete criteria and additional information.
Humira (adalimumab)
Prior Authorization Criteria
Humira is a tumor necrosis factor (TNF) blocker used in the treatment of various inflammatory
diseases. Due to changes in FDA-approved indications, the criteria have been updated. When
specified criteria are met, Humira may be used in the treatment of children, 2 years of age and
older, with polyarticular juvenile idiopathic arthritis, and in children 6 years of age and older with
moderately to severely active Crohn’s disease. The dose for children is based on the child’s weight.
After initial dosing, maintenance doses are administered every 2 weeks. A prior authorization
must be submitted for coverage of Humira for any indication. When approved, Humira is subject
to quantity limits and is available at a tier 2 copay through our specialty pharmacy. Please see
policy for complete criteria and additional information.
Hereditary Angioedema
Medications
Prior Authorization Criteria
Ruconest, a new C1 esterase inhibitor (recombinant), has been added to the medications
included in this policy. Ruconest is indicated for the treatment of acute attacks in adult and
adolescent patients with hereditary angioedema (HAE). The effectiveness of Ruconest was not
established in HAE patients with laryngeal attacks.
Ruconest can be given by a health care professional or members can be trained to administer
it to themselves. When given by a health care professional in an emergency situation, claims
are retrospectively reviewed to ascertain that specified criteria are met. When the medication
is administered by the member, the physician must first submit a prior authorization. When
approved, Ruconest is subject to quantity limits and is available at a tier 3 copay through our
specialty pharmacy. Please see policy for complete criteria and additional information.
Please refer to the complete Utilization Management policies for full prior authorization criteria, step therapy and quantity
limits, as well as additional information and restrictions. Visit our website at bcnepa.com and click on the Providers tab.
Then choose the Pharmacy Benefits link on the right, and select the link for Utilization Management Criteria on the right.
13
Blue Cross of Northeastern Pennsylvania’s
Prescription Drug Formulary Changes continued on page 15
Revised Pharmacy Prior Authorization/Step Therapy Criteria
Effective 01/01/15
Immunomodulators
in the Treatment of
Inflammatory Disease
Prior Authorization Criteria
The phosphodiesterase 4 inhibitor, Otezla (apremilast), has now been granted another approved
indication by the FDA. Otezla previously was approved for the treatment of psoriatic arthritis. It is
now approved for the treatment of plaque psoriasis as well. The prior authorization criteria have been
updated to allow consideration of coverage for this new indication. A prior authorization submitted
by a dermatologist requires documented prior treatment with Enbrel and Humira as well as other
specified requirements. When approved, Otezla may be obtained through a retail pharmacy at a tier 3
copay. Quantity limits apply. Please see policy for complete criteria and additional information.
Immune Globulin,
Subcutaneous,
Prior Authorization Criteria
The Immune Globulin, Subcutaneous, Prior Authorization Criteria policy has been updated
to include a new product, Hyqvia. Hyqvia is an immune globulin with a recombinant human
hyaluronidase. The hyaluronidase increases dispersion and absorption of the immune globulin.
This allows the use of only one injection site per infusion to deliver the full dose. The criteria
have also been updated to specify what documentation must be submitted for initial as well as
continued approval of these medications. The use of subcutaneous immune globulin is considered
self-administrable; when approved, these medications must be obtained through our specialty
pharmacy at a tier 3 copay. Please see policy for complete criteria and additional information.
Lumizyme, Myozyme
Prior Authorization Criteria
Lumizyme and Myozyme are proprietary names for alglucosidase alfa, a recombinant form of
the enzyme acid alpha-glucosidase, which is required for glycogen cleavage. These enzyme
preparations are indicated for use in patients with Pompe disease. As per action by the FDA, the use
of Lumizyme has been expanded to permit use in all Pompe patients. There is no limitation as to age
and phenotype as per previous prescribing restrictions. In addition, the Risk Mitigation Evaluation
Strategy (REMS) program has been removed. Lumizyme still has a boxed warning regarding serious
adverse reactions. The prior authorization criteria have been updated to reflect these changes.
Lumizyme will continue to require a prior authorization. Specified criteria must be met for approval
of coverage of Lumizyme. When approved, Lumizyme is available at a tier 3 copay through our
specialty pharmacy. Please see policy for complete criteria and additional information.
Zytiga/Xtandi
Prior Authorization Criteria
Xtandi (enzalutamide) is an androgen receptor inhibitor. Both Xtandi and Zytiga are indicated
for the treatment of metastatic castration-resistant prostate cancer. This policy has been revised
to follow a change in FDA labeled uses for Xtandi. Previously, use of the chemotherapeutic
agent docetaxel was required for consideration of the use of Xtandi. This requirement has
been eliminated from the criteria. The use of Xtandi still requires that a prior authorization be
submitted by an oncologist. All remaining criteria must be met for consideration of approval
of this medication. When approved, Xtandi is available at a tier 3 copay through our specialty
pharmacy. Please see policy for complete criteria and additional information.
Protease Inhibitors in the
Treatment of Hepatitis C
Prior Authorization Criteria
Due to extensive changes in the various medications used in the treatment of hepatitis C, as well as
extensive changes in the recommendations from the American Association for the Study of Liver
Diseases (AASLD), the NS3/4A protease inhibitor, Incivek (telaprevir), has been discontinued. As per
the latest AASLD recommendations, the use of Victrelis (boceprevir) is no longer recommended.
The recommendations for the use of the remaining NS3/4A protease inhibitor, Olysio, have been
revised to reflect the AASLD recommendations. A prior authorization must be submitted for
consideration of approval of Olysio. Specified criteria, including information on HCV genotype and
previous treatment, must be met, documented and submitted via medical records and lab results.
When the coverage of Olysio has been approved, this medication is available through our specialty
pharmacy at a tier 2 copay. Quantity limits and length of therapy will be determined at the time of
authorization. Please refer to the UM criteria for these medications as well.
Please refer to the complete Utilization Management policies for full prior authorization criteria, step therapy and quantity
limits, as well as additional information and restrictions. Visit our website at bcnepa.com and click on the Providers tab.
Then choose the Pharmacy Benefits link on the right, and select the link for Utilization Management Criteria on the right.
14
Blue Cross of Northeastern Pennsylvania’s
Prescription Drug Formulary Changes continued from page 14
Revised Pharmacy Prior Authorization/Step Therapy Criteria
Effective 01/01/15
Revlimid
Prior Authorization Criteria
Revlimid (lenalidomide) is a thalidomide analog; it is an immunomodulatory agent with
anti-angiogenic properties. The existing criteria included coverage for specified patients with
diagnoses of multiple myeloma and myelodysplastic syndromes (MDS). This policy has been
revised to allow consideration of approval of Revlimid in the FDA labeled use for mantle cell
lymphoma after the use of other specified therapies. The use of Revlimid requires that a prior
authorization be submitted by an oncologist. In addition, a number of specified criteria must be
met for consideration of approval of this medication. When approved, Revlimid is available at a
tier 3 copay through our specialty pharmacy. Quantity limits apply. Please see policy for complete
criteria and additional information.
Imbruvica
Prior Authorization Criteria
Imbruvica (ibrutinib) is an irreversible Bruton tyrosine kinase (BTK) inhibitor. Due to changes
in FDA approved indications, the criteria have been updated to include a diagnosis of chronic
lymphocytic leukemia with a specific gene (17P) deletion. This indication is in addition to
its previously approved indications for chronic lymphocytic leukemia (CLL) and mantle cell
lymphoma, both after at least one prior treatment. A prior authorization must be submitted by
an oncologist with accompanying medical records documenting that the diagnosis as well as
specified criteria have been met. When approved, Imbruvica is subject to quantity limits and is
available at a tier 3 copay through our specialty pharmacy. Please see policy for complete criteria
and additional information.
Revised Medical Prior Authorization/Step Therapy Criteria
Effective 10/01/14
Synagis (palivizumab)
Prior Authorization Criteria
The American Academy of Pediatrics (AAP) has extensively revised their recommendations for
the use of Synagis. Evidence of declining rates of RSV hospitalizations, regardless of whether
infants receive Synagis prophylaxis, has been seen. Also, new data is available about which
children are at highest risk of RSV hospitalization. These 2 factors have led to a complete revision
of AAP recommendations, and hence BCNEPA prior authorization criteria. A prior authorization
is required for consideration of coverage of Synagis immunizations. It is not self-administered.
Therefore, when approved, it is covered under the medical benefit. Please see policy for complete
criteria and additional information.
Hyaluronic Acid Derivatives
Prior Authorization Criteria
A new hyaluronic acid (HA) derivative product, Monovisc, has been added to the prior
authorization policy as a non-preferred product. Our preferred, covered HA products continue to
be Euflexxa and Synvisc/Synvisc-1. A prior authorization will continue to be required for coverage
of these products. The HA derivatives must be administered by a health care professional. When
approved, they are covered under the medical benefit. Please see policy for complete criteria as
well as additional information.
Revised Quantity Limits granisetron 1 mg tablets
Androgel 1.62% gel pump
Axiron pump solution
Increased to allow 10 tablets/30 days
Increased to allow 2x75 gm pump bottles per 30 days
Increased to allow 2x90 ml pump bottles per 30 days
Please refer to the complete Utilization Management policies for full prior authorization criteria, step therapy and quantity
limits, as well as additional information and restrictions. Visit our website at bcnepa.com and click on the Providers tab.
Then choose the Pharmacy Benefits link on the right, and select the link for Utilization Management Criteria on the right.
(Policy Update 1612010)
15
presorted
standard
u.s. postage
paid
wilkes-barre, pa
permit no. 84
19 North Main Street
Wilkes-Barre, PA 18711-0302
bcnepa.com
Address Service Requested
Editor:
Lily A. Stahley
Blue Cross of Northeastern Pennsylvania administers health insurance
plans for Blue Cross of Northeastern Pennsylvania, Highmark Blue
Shield, First Priority Health® and First Priority Life Insurance Company®.
Blue Cross of Northeastern Pennsylvania is a Qualified Health Plan
issuer in the Federally Facilitated Marketplace.
Independent Licensee of the Blue Cross and Blue Shield Association.
®Registered Mark of the Blue Cross and Blue Shield Association.
Provider Relations department:
1.800.451.4447
How You Can Reach Us
For questions about benefits,
eligibility or claims, please call,
weekdays, between 8 a.m. and 5 p.m.:
• BlueCare® HMO/HMO Plus—1.800.822.8752
• BlueCare PPO/myBlue® Plans—1.866.262.5635
Important fax numbers:
BC Claims....................................... 570.200.6790
(For claims adjustments, BlueCare Senior, FEP)
BC Precertification........................ 570.200.6788
• BlueCare Traditional—1.888.827.7117
BlueCard® ITS Claims.................. 570.200.6790
• BlueCare EPO/Custom PPO—1.888.345.2353
FPH Claims..................................... 570.200.6790
(For Maternity Precertification forms, adjustments, Claims Research Request forms, etc.)
Valuable health resources:
Refer your BCNEPA patients to the following Blue
Health Solutions health and wellness resources:
Provider Relations........................ 570.200.6880
SM
• Personalized health management and
wellness programs, care management
resources and much more—1.866.262.4764
• 24/7 Nurse Now—Call 1.866.442.2583 anytime
or chat online at bcnepa.com. Logon to
Self-Service; click on the Health & Wellness
tab and then select 24/7 Nurse Now
Report fraud:
Call our Fraud Hotline at 1.800.352.9100, or email our
Special Investigations Unit at [email protected].
Provider Customer Service......... 570.200.6868
FPH Complaint/Grievance.......... 570.200.6770
FPH Non-par Referral Requests.... 570.200.6840
FPH Pharmacy................................ 570.200.6870
FPH Precertification...................... 570.200.6799
Other Party Liability (OPL)......... 570.200.6790
BCNEPA Provider
Relations Consultants
Odette Ashby • 570.200.4658
[email protected]
Cheryl Hashagen • 570.200.4670
[email protected]
Jill Jenkins • 570.200.4669
[email protected]
Louise LoPresto • 570.200.4674
[email protected]
Tracie Wyandt • 570.200.4647
[email protected]
Senior Manager,
Provider Relations
Dave Levenoskie • 570.200.4673
[email protected]
Senior Manager,
Provider Services
Kevin Quaglia • 570.200.4676
[email protected]
Questions?
Call Provider Relations at
1.800.451.4447
© Blue Cross of Northeastern Pennsylvania. 2014.