November 2023 Provider News
Date: 11/28/23
In this issue:
- General Updates - Coordinated Care Provider Portal, New EPSDT Provider Webpage Available
- Quality - Influenza Vaccine Recommendation, Well Child Visits, CPT II Coding, Comprehensive Diabetes and Care HEDIS Measures
- Tribal - Native American Heritage Month
- Clinical Policy - Monthly updates
- Wellcare - Epic Payer Platform
- Apple Health Core Connections - Health Care for Youth First Entering Foster Care: EPSDTs, Interim Vouchers, and CHET Reports
- Training/Education - Resiliency, Trauma 101, Building protective factors using the Social Development Strategy, Integrated Care Conference
- Pharmacy Updates - Makena Prior Authorization Change, 2023/2024 Synagis, January 1, 2024 Apple Health Preferred Drug List (AHPDL) Changes, January 1, 2024 Wellcare Formulary Changes, Pharmacy Claim Processing Change
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General Updates
Coordinated Care Provider Portal
Coordinated Cares Provider Portal is available for both Physical and Behavioral Health Providers to utilize. The Portal can be used to submit and check claims status, submit reconsiderations, and appeals, check member eligibility, and more. The provider portal is located on our website.
Please reach out to your Provider Engagement Administrator with any questions.
New EPSDT provider webpage available
The Health Care Authority (HCA) recently published a new Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) webpage for providers. The page is for billers, providers, or any professional working with you enrolled in Apple Health and includes EPSDT information.
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Quality
Medicaid Quality
Influenza Vaccine Recommendation
Strong professional recommendation plays a critical role in our members receiving their vaccination for influenza. Your help in reminding members to get vaccinated, following up to ensure its receipt, repeating the recommendation to those who are unvaccinated and answering any questions they may have will ensure that the most members receive this vital vaccine.
Well Child Visits
As providers, you know that well child checkups are essential for their children’s growth and development and vaccines help protect children’s health. We need your help educating parents on the importance of getting their children up to date on well child visits and routine vaccinations. Here are some resources provided by the CDC to aid in this education.
CPT II coding
Benefits of Providing CPT II Data
- Better tracking of gaps measures throughout the year.
- Better reporting for providers.
- Potential reduction of administrative burden of chart retrieval.
- Fewer errors by billing agencies.
- Increases number of administrative claims submitted that will help to improve members care outcomes-through more accurate clinical data.
Medicare Quality
Influenza Vaccine Recommendation
Strong professional recommendation plays a critical role in our members receiving their vaccination for influenza. Your help in reminding members to get vaccinated, following up to ensure its receipt, repeating the recommendation to those who are unvaccinated and answering any questions they may have will ensure that the most members receive this vital vaccine.
CPT II coding
Benefits of Providing CPT II Data
- Better tracking of gaps measures throughout the year.
- Better reporting for providers.
- Potential reduction of administrative burden of chart retrieval.
- Fewer errors by billing agencies.
- Increases number of administrative claims submitted that will help to improve members care outcomes-through more accurate clinical data.
Comprehensive Diabetes and Care HEDIS Measure
- *Assesses adults 18-75 years of age with diabetes (type 1 and type 2) who had each of the following:
- *Hemoglobin A1c (HbA1c) testing
- *HbA1c poor control (>9.0%)
- *HbA1c control (>8.0%)
- *Eye exam (retinal) performed.
- *Medical attention for nephropathy
- *BP control (>140/90 mmHg)
Please refer to this link for more information.
*This indicator is only reported for the Medicare product line
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Tribal Updates
November is Native American Heritage Month
During Native American Heritage Month we would like to highlight some of our partner Tribal organizations. Each week in November, you can see our highlights on social media including Facebook, Linked in, and Twitter by searching #NativeAmericanHeritageMonth and learn about the incredible work being done by these organizations.
As part of our weekly series for Native American Heritage Month, we’re highlighting our partner Native American Reentry Services (NARS). NARS is dedicated to helping American Indian and Alaskan Native (AI/AN) people overcome the challenge of incarceration and reenter the community post-incarceration. Coordinated Care supports and works together with NARS to better understand the barriers to health care the AI/AN population faces, support care management referrals, and connect the AI/AN population to Coordinated Care teams.
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Clinical Policy Updates
National Imaging Associates, Inc. (NIA)
Two announcements regarding Prior Authorization (PA) vendor NIA:
1) The following NIA policies have been updated with changes that will be effective January 1, 2024. The policies are available on the NIA site; a link is available from the Pre-Auth Check section of our provider web page.
| Policy Number | Policy Title |
|---|---|
NIA_CG_001 | NIA - Brain (Head) MRI Brain (Head) MRI with IAC (Internal Auditory Canal) |
NIA_CG_002 | NIA - Brain (Head) CT |
NIA_CG_003 | NIA - Brain (Head) MRS |
NIA_CG_004-1 | NIA - Brain (Head) CTA |
NIA_CG_004-2 | NIA - Brain (Head) MRA/MRV |
NIA_CG_006-1 | NIA - Temporal Bone, Mastoid, Orbits, Sella, Internal Auditory Canal CT |
NIA_CG_007 | NIA - Temporomandibular Joint (TMJ) MRI |
NIA_CG_008-1 | NIA - Neck CT (soft tissue) |
NIA_CG_009 | NIA - Sinus & Maxillofacial CT Limited or Localized follow up Sinus CT - CCW version |
NIA_CG_012-1 | NIA - Neck CTA |
NIA_CG_012-2 | NIA - Neck MRA/MRV |
NIA_CG_013 | NIA - Functional Brain MRI |
NIA_CG_014 | NIA - Orbit, Face, Neck, Sinus MRI - CCW version |
NIA_CG_015 | NIA - Cerebral Perfusion CT |
NIA_CG_020 | NIA - Chest (Thorax) CT |
NIA_CG_020-1 | NIA - Low Dose CT for Lung Cancer Screening |
NIA_CG_021 | NIA - Chest (Thorax) MRI |
NIA_CG_022-1 | NIA - Chest CTA |
NIA_CG_022-2 | NIA - Chest MRA/MRV |
NIA_CG_023 | NIA - Breast MRI |
NIA_CG_024 | NIA - Myocardial Perfusion Imaging (aka Nuclear Cardiac Imaging Study) |
NIA_CG_025 | NIA - CT Heart |
NIA_CG_026 | NIA - Stress Echocardiography |
NIA_CG_027 | NIA - MUGA (Multiple Gated Acquisition) Scan |
NIA_CG_028 | NIA - Heart MRI |
NIA_CG_029 | NIA - Coronary Calcification (EBCT) |
NIA_CG_030 | NIA - Abdomen CT |
NIA_CG_031 | NIA - Abdomen MRI MRCP |
NIA_CG_033-1 | NIA - CT (Virtual) Colonoscopy Diagnostic |
NIA_CG_033-2 | NIA - CT (Virtual) Colonoscopy Screening |
NIA_CG_034-1 | NIA - Abdomen CTAngiography |
NIA_CG_034-2 | NIA - Abdomen MRA (Angiography) |
NIA_CG_035 | NIA - CTA Aortogram with Runoff |
NIA_CG_036 | NIA - Pelvis CT |
NIA_CG_037 | NIA - Pelvis MRI |
NIA_CG_038 | NIA - Pelvis CT Angiography |
NIA_CG_039 | NIA - Pelvis MRA MRV |
NIA_CG_040 | NIA - Cervical Spine MRI |
NIA_CG_041 | NIA - Cervical Spine CT |
NIA_CG_042 | NIA - Thoracic Spine MRI |
NIA_CG_043 | NIA - Thoracic Spine CT |
NIA_CG_044 | NIA - Lumbar Spine MRI |
NIA_CG_045 | NIA - Lumbar Spine CT |
NIA_CG_046 | NIA - Spinal Canal MRA |
NIA_CG_057-1 | NIA - Upper Extremity CT (Hand, Wrist, Arm, Elbow, Long bone or Shoulder CT) |
NIA_CG_057-2 | NIA - Lower Extremity CT (Foot, Ankle, Knee, Leg or Hip CT) |
NIA_CG_057-3 | NIA - Upper Extremity MRI (Hand, Wrist, Arm, Elbow, Long bone or Shoulder MRI) |
NIA_CG_057-4 | NIA - Lower Extremity MRI (Foot, Ankle, Knee, Leg or Hip MRI) |
NIA_CG_058-1 | NIA - Lower extremity MRA/MRV |
NIA_CG_058-2 | NIA - Upper Extremity MRA/MRV |
NIA_CG_059 | NIA - Bone Marrow MRI |
NIA_CG_060-2 | NIA - CT Bone Density Study |
NIA_CG_061-1 | NIA - Lower Extremity CTA/CTV |
NIA_CG_061-2 | NIA - Upper Extemity CTA/CTV |
NIA_CG_062 | NIA - CT Coronary Angiography (CCTA) |
NIA_CG_063 | NIA - Unlisted Study |
NIA_CG_064 | NIA - Low Field MRI |
NIA_CG_066 | NIA - Transesophageal Echo (TEE) |
NIA_CG_067 | NIA - Transthoracic Echo (TTE) |
NIA_CG_068 | NIA - Abdomen/Pelvis CT Combo |
NIA_CG_069 | NIA - Abdomen/Pelvis CTA |
NIA_CG_070-1 | NIA - PET SCANS |
NIA_CG_070-2 | NIA - Tumor Imaging PET - Any Site (Unlisted PET) |
NIA_CG_070-3 | NIA - Tumor Imaging PET - Any Site (Unlisted PET) |
NIA_CG_070-4 | NIA - Tumor Imaging PET - Any Site (Unlisted PET) |
NIA_CG_071 | NIA - Brain PET SCAN |
NIA_CG_072 | NIA - Heart (Cardiac) PET |
NIA_CG_079 | NIA - Heart (Cardiac) PET with CT for Attenuation |
NIA_CG_100 | NIA - Urgent/Emergent Criteria |
NIA_CG_104 | NIA - 3D Rendering (CT Multiplanar Reconstruction) |
NIA_CG_105 | NIA - CT/MRI Guidance for Needle Placement CT Guidance for Radiation Fields |
NIA_CG_110 | NIA- Fetal MRI |
NIA_CG_300 | NIA - Epidural Spine Injections |
NIA_CG_301 | NIA - Paravertebral Facet Point Injections or Blocks |
NIA_CG_302 | NIA - Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis) |
NIA_CG_305 | NIA - Sacroiliac Joint Injections |
NIA_CG_404 | NIA - Sympathetic Nerve Blocks |
NIA_CG_408 | NIA - Epidural Spine Injections & Single Injection Trials for Intrathecal Pumps |
2) Effective February 1, 2024, musculoskeletal service prior authorization will transition from TurningPoint to NIA. NIA policies and the codes requiring Prior Authorization are noted below. Please check the Pre-Auth tool on our provider website for the most current information and for a link to NIA’s site from which you can view the policies.
| Policy Number | Policy Title |
|---|---|
NIA - Cervical Spine Surgery | 22548, 22551, 22552, 22554, 22590, 22595, 22600, 22614, 22856, 22858, 22861, 22864, 63001, 63015, 63020, 63040, 63045, 63050, 63051, 63075 |
NIA - Hip Arthroplasty | 27130, 27132, 27134, 27137, 27138 |
NIA - Hip Arthroscopy | 29860-29863, 29914-29916 |
NIA - Hip Resurface | S2118 |
NIA - Knee Arthroplasty | 27438, 27446, 27447, 27486, 27487 |
NIA - Knee Arthroscopy | 27332, 27333, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 27427-27429, 27570, 29866-29868, 29870, 29873-29877, 29879, 29880-29889, G0289 |
NIA - Lumbar Artificial Disc Replacement | 22857, 22860, 22862, 22865, 0164T, 0165T |
NIA - Lumbar Spine Surgery | 22533, 22558, 22612, 22614, 22630, 22633, 62380, 63005, 63012, 63017, 63030, 63042, 63047, 63056 |
NIA - Sacroiliac Joint Fusion | 27279 |
NIA - Shoulder Arthroplasty | 23470, 23472-23474 |
NIA - Shoulder Arthroscopy | 23120, 23125, 23130, 23405, 23410, 23412, 23415, 23420, 23430, 23450, 23455, 23460, 23462, 23465, 23466, 23700, 29805-29807, 29819, 29820-29828 |
You will find the policies on the NIA Website. A link is available under “Provider Resources” on CoordinatedCareHealth.com.
Monthly Updates
The below clinical policies received updates as part of our regular monthly review in November. These policy changes are effective January 1, 2024. You will find the policies, including a description of the revisions, posted on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
WA.CP.MP.527 | Vitamin D Testing | Apple Health & Ambetter |
| CP.MP.31 | Cosmetic and Reconstructive Procedures | Apple Health & Ambetter |
| CP.MP.61 | IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures | Ambetter |
| CP.MP.101 | Donor lymphocyte infusion | Apple Health & Ambetter |
| CP.MP.108 | Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia | Apple Health & Ambetter |
| CP.MP.109 | Panniculectomy | Apple Health & Ambetter |
| CP.MP.138 | Pediatric Heart Transplant | Apple Health & Ambetter |
| CP.MP.150 | Phototherapy for Neonatal Hyperbilirubinemia | Apple Health & Ambetter |
| CP.MP.202 | Orthognathic Surgery | Apple Health & Ambetter |
The below genetic testing clinical policies received updates as part of our twice yearly review. These policy changes are effective January 1, 2024. You will find the policies, including a description of the revisions, posted on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
V1.2024 | CG Aortopathies and Connective Tissue Disorders | Apple Health & Ambetter |
V1.2024 | CG Cardiac Disorders | Apple Health & Ambetter |
V1.2024 | CG Dermatologic Conditions | Apple Health & Ambetter |
V1.2024 | CG Epilepsy Neurodegenerative and Neuromuscular Conditions | Apple Health & Ambetter |
V1.2024 | CG Exome and Genome Sequencing for DX of Genetic Disorders | Apple Health & Ambetter |
V1.2024 | CG Eye Disorders | Apple Health & Ambetter |
V1.2024 | CG Gastroenterologic Disorders Non-cancerous | Apple Health & Ambetter |
V1.2024 | CG General Approach to Genetic Testing | Apple Health & Ambetter |
V1.2024 | CG Hearing Loss | Apple Health & Ambetter |
V1.2024 | CG Hematologic Conditions Non-cancerous | Apple Health & Ambetter |
V1.2024 | CG Hereditary Cancer Susceptibility | Apple Health & Ambetter |
V1.2024 | CG Immune Autoimmune and Rheumatoid Disorders | Apple Health & Ambetter |
V1.2024 | CG Kidney Disorders | Apple Health & Ambetter |
V1.2024 | CG Lung Disorders | Apple Health & Ambetter |
V1.2024 | CG Metabolic Endocrine Mitochondrial Disorders | Apple Health & Ambetter |
V1.2024 | CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Ambetter |
WA.CP.MP.230 | Genetic Testing Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Apple Health |
V1.2024 | CG Non-Invasive Prenatal Screening | Ambetter |
WA.CP.MP.231 | Genetic Testing Non-Invasive Prenatal Screening (NIPS) | Apple Health |
V1.2024 | CG Oncology Algorithmic Testing | Apple Health & Ambetter |
V1.2024 | CG Oncology Cancer Screening | Apple Health & Ambetter |
V1.2024 | CG Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy | Apple Health & Ambetter |
V1.2024 | CG Oncology Cytogenetic Testing | Apple Health & Ambetter |
V1.2024 | CG Oncology Molecular Analysis Solid Tumors & Hematolgic Malignancies | Apple Health & Ambetter |
V1.2024 | CG Pharmacogenetics | Apple Health & Ambetter |
V1.2024 | CG Preimplantation Genetic Testing | Apple Health & Ambetter |
V1.2024 | CG Prenatal and Preconception Carrier Screening | Apple Health & Ambetter |
V1.2024 | CG Prenatal Diagnosis Pregnancy Loss | Apple Health & Ambetter |
V1.2024 | CG Skeletal Dysplasia Rare Bone Disorders | Apple Health & Ambetter |
The below policy was updated as part of our regular monthly review in November. The policy changes are effective March 1, 2024. You will find the policy, including a description of the revisions, posted on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
CP.MP.107 | Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines | Apple Health & Ambetter |
The below policies were previously announced as revised on the date noted. You will find the policies posted on the policy site.
| Policy Number | Policy Title | Effective Date | Line of Business |
|---|---|---|---|
CP.MP.129 | Fetal Surgery in Utero for Prenatally Diagnosed Malformations | 12/1/23 | Apple Health & Ambetter |
| WA.CP.MP.50 | Drugs of Abuse: Definitive Testing | 12/1/23 | Apple Health |
| CP.MP.50 | Drugs of Abuse: Definitive Testing | 1/1/24 | Ambetter |
| CP.BH.124 | ADHD Assessment and Treatment | 1/1/24 | Apple Health |
| CP.MP.123 | Laser Therapy for Skin Conditions | 1/1/24 | Apple Health |
| CP.MP.246 | Pediatric Kidney Transplants | 1/1/24 | Apple Health & Ambetter |
| CP.MP.181 | Polymerase Chain Reaction Respiratory Viral Panel | 1/1/24 | Apple Health |
| CP.MP.98 | Urodynamic Testing | 1/1/24 | Apple Health |
| CP.MP.101 | Donor Lymphocyte Infusion | 1/1/24 | Apple Health & Ambetter |
| CP.MP.209 | GI Pathogen Nucleic Acid Detection Panel Testing | 1/1/24 | Apple Health |
| CP.MP.57 | Lung Transplantation | 1/1/24 | Apple Health & Ambetter |
The below new policy was previously announced effective on the date noted. You will find the policy posted on the policy site.
| Policy Number | Policy Title | Effective Date | Line of Business |
|---|---|---|---|
CP.MP.250 | Lantidra (donislecel): Allogeneic pancreatic islet cellular therapy | 1/1/24 | Apple Health & Ambetter |
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Wellcare
EPIC Payer Platform
We are pleased to be participating in Epic Payer Platform, a platform that enables more secure, efficient bi-directional data exchange between providers and health plans, as part of our broader interoperability strategy.
How does Epic Payer Platform benefit you?
Epic Payer Platform benefits providers by reducing friction, combining knowledge to improve care, and ultimately improving the patient experience. It is available for health systems and providers on Epic.
What are the features of Epic Payer Platform and how do they help?
- In our initial work with Payer Platform, we are live with clinical data exchange, which automatically releases appropriate clinical records to health plans. This helps reduce manual record requests, reducing administrative burden for providers.
- Following our initial work on risk adjustment, we intend to focus on HEDIS/Quality use, similarly, receiving information from Epic Payer Platform to improve the accuracy of quality measurement, also reducing manual records requests.
- We plan to develop additional features and continue to refine our roadmap:
- Actionable insights (such as our members’ gaps in care and historical conditions and diagnoses) can be provided at the point of care directly into a clinician’s existing workflow. This helps our provider-partners receive a more complete picture of their patients to help improve their quality of care.
- Plans to pilot prior authorization can help streamline the process and further reduce administrative frictions involved.
How do I learn more?
- For more information on risk adjustment use cases, please contact Jennifer Holman at Jennifer.l.holman@centene.com
- For other information about Epic Payer Platform, please contact: epic_emr_integration@centene.com
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Apple Health Core Connections
Coordinated Care is the single managed care organization to administer the Integrated Managed Care Apple Health Foster Care program in collaboration with the Health Care Authority and Department of Children Youth and Families. This program serves children and youth in foster care, adoption support, alumni of foster care (ages 18-26), children reunified with their parents, and youth in the Unaccompanied Refugee Minor program. Coordinated Care’s program is named “Apple Health Core Connections.” For questions or care coordination referrals you can reach us at 1-844-354-9876 or AHCCTeam@coordinatedcarehealth.com.
Health Care for Youth Entering Foster Care
EPSDT: When youth are removed from their home, they need to have an EPSDT exam completed within 30 days. The appointment must be billed as an EPSDT exam, not as establishing care or office visit. Coordinated Care has NO benefit maximum on EPSDT exams. If asked to schedule an EPSDT, please set the appointment even if the patient has had an EPSDT recently. Payment for the EPSDT will be made even if the provider is not the assigned PCP. An EPSDT exam may also be needed after a child changes placement (moves from one caregiving home to another).
Interim Voucher: Sometimes health care services are needed and the AHCC Member ID or ProviderOne number is not available because the child’s medical coverage is being processed by Foster Care Adoption Support Team (FCAS) at HCA. Providers will receive an Interim Voucher that serves as proof of the youth’s eligibility as a Coordinated Care enrollee. Please do not withhold health care services, including filling prescriptions, based on lack of verified eligibility in ProviderOne or Coordinated Care’s Provider Portal for a youth in foster care. If the youth in foster care is ultimately determined not to be a Coordinated Care enrollee and remains on the Apple Health (Medicaid) coverage without a Managed Care Plan (aka fee-for-service program), we will inform you how to submit for payment to the Health Care Authority for services provided. The Interim Voucher can be found on our website.
CHET Report: Additionally, the Department of Children, Youth, and Families (DCYF) has a team of Child Health Education and Tracking (CHET) Screeners in every region who are authorized to collect health information for the CHET report.
- Due 30 days from the day a youth enters foster care, the CHET report must include the record from the EPSDT well-child exam
- Exam must be billed only as EPSDT to meet the legal requirements
- CHET Screeners will send a fax or email request noting WAC 182-502-0020 – Health Care Record Requirements, authorizing them to receive records.
It’s critical to send the EPSDT record as soon as possible; please consider an office process and a single point of contact to ensure copies are sent promptly for youth in foster care. A complete EPSDT record that fulfills the state requirement must include:
- Vitals
- Review of symptoms
- Include any abnormal findings
- Recommendations/Referrals
- Including anticipatory guidance
Make sure all referrals are in Coordinated Care's network. Please note that most Tribes do not use the CHET process.
Reminder for Billing Teams: Please use the TJ modifier for youth in foster care to receive the increased rate for EPSDT visits.
Washington State Health Care Authority (HCA)
EPSDT Fee Schedule
Effective July 1, 2022
For all other payable procedure codes, refer to the Physician-Related Services Fee Schedule.
For all payable drugs and biologicals, refer to the Professional Administered Drugs Fee Schedule.
| Code Status Indicator | Code | Modifier | Maximum Allowable NFS Fee | Maximum Allowable FS Fee | Foster Care Clients - Must use Mod TJ |
|---|---|---|---|---|---|
| R | 99381 | $80.60 | $54.71 | $120.00 | |
| R | 99382 | $84.27 | $58.13 | $120.00 | |
| R | 99383 | $87.44 | $61.80 | $120.00 | |
| R | 99384 | $97.94 | $72.54 | $120.00 | |
| R | 99385 | $95.26 | $69.61 | $120.00 | |
| R | 99391 | $72.54 | $49.58 | $120.00 | |
| R | 99392 | $77.43 | $54.71 | $120.00 | |
| R | 99393 | $77.18 | $54.71 | $120.00 | |
| R | 99394 | $84.27 | $61.80 | $120.00 | |
| R | 99395 | $85.98 | $63.51 | $120.00 |
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Training/Education
Resiliency: Coordinated Care’s Resilience Training provides information on how to foster resilience in children. It reviews research from Ann Masten and Laurence Gonzales to guide discussion. This training looks at factors that affect resilience, the human adaptive process, ways to successfully cope with trauma, and the 12 steps of successful survivors. The training ends with a discussion around how caregivers can help their children feel safe, capable, and loveable. December 7, 2023 - Register Here.
Trauma 101 What is Trauma? This training answers this question by defining trauma, how trauma affects children, and what caregivers can do to assist children. The presentation will heighten the caregiver’s awareness of children’s cues so they will know what to expect and how to respond when a child experiences trauma triggers. December 8, 2023 - Register Here.
Building protective factors using the Social Development Strategy: To prevent substance misuse among our youth, we must enhance protective factors and reduce risk factors. Join this webinar to learn how to build protective factors in the youth in a straight-forward, easy to implement way using the Social Development Strategy. December 5, 2023 - Register Here.
Integrated Care Conference June 6 & 7, 2024: We are pleased to announce the 3rd Annual Integrated Care Conference. Our theme this year is Cultivating Integrated Care within the Behavioral Health Ecosystem. We are also soliciting ideas for sessions and presentations. If you would like to share your perspective, your current work, or something related to the theme, please consider submitting your idea. Our call for presentations will be open until December 15, 2023. We look forward to seeing you at the DoubleTree SeaTac on June 6 and 7, 2024. More information.
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Pharmacy Updates
Physician Administered Drug Prior Authorization Change
| Procedure | Description | PA Rule | Effective Date |
|---|---|---|---|
J1746 | INJECTION HPC 10 MG (MAKENA) | Prior authorization required for all providers | 1/28/2024 |
Please verify eligibility and benefits prior to rendering services for all members.
2023/2024 Synagis Season
The Health Care Authority and Managed Care Organizations (MCOs) have updated the 2023/2024 Synagis Season to allow a total of five (5) doses between November 07, 2023 and April 30, 2024.
January 1, 2024 Apple Health Preferred Drug List (AHPDL) Changes
Effective January 1, 2024, the following drug will no longer be preferred.
| Effective Date | Drug Name | Preferred Alternative |
|---|---|---|
01/01/2024 | Canasa Suppository (Brand) | Mesalamine Suppository (Generic for Canasa) |
Effective January 1, 2024, the following drugs below will need to be billed to the Health Care Authority (HCA). For drugs that currently require prior authorization (PA), please submit PA requests to the HCA on or after January 1, 2024. For more information, please contact the HCA at 800-562-3022.
- Carglumic Acid (Carbaglu®)
- Carglumic Acid (Carglumic Acid)
- Sparsentan (FilspariTM)
- Amifampridine Phosphate (Firdapse®)
- Omidubicel-ONLV (Omisirge®)
- Afamitresgene Autoleucel (MAGE-A4 TCR)
- Apadamtase Alfa-Cinaxadamtase Alfa (TAK-755)
- Crovalimab (RG6107)
- Danicopan (Danicopan)
- Debamestrocel (Nurown)
- Eculizumab (ABP 959)
- Eplontersen (AKCEA-TTR-LRX)
- Fidanacogene Elaparvovec (Fidanacogene Elaparvovec)
- Givinostat (Givinostat)
- Iptacopan (Iptacopan)
- Lovotibeglogene Autotemcel (LOVO-CEL)
- Nirogacestat (Nirogacestat)
- Troriluzole (BHV-4157)
- Zilucoplan (RA101495)
2024 Wellcare Formulary Changes
On January 1, 2024, some drugs will no longer be covered on our Medicare Part D Plan formulary (ies). To assist our providers, we have included the list below of the most commonly prescribed drugs being removed along with the drug’s 2024 formulary alternative(s). Please refer to the list to identify the appropriate options for your patients.
| Product Name | Formulary Alternative |
|---|---|
Lantus vial, Lantus SoloStar | Basaglar KwikPen, Toujeo SoloStar, Toujeo Max SoloStar, Tresiba vial, Tresiba FlexTouch |
Levemir vial, Levemir FlexPen | Basaglar KwikPen, Toujeo SoloStar, Toujeo Max SoloStar, Tresiba vial, Tresiba FlexTouch |
Victoza pen injector | Bydureon Bcise auto-injector*, Mounjaro pen injector*, Ozempic pen injector*, Rybelsus tablet*, Trulicity pen injector* |
Byetta pen injector | Bydureon Bcise auto-injector*, Mounjaro pen injector*, Ozempic pen injector*, Rybelsus tablet*, Trulicity pen injector* |
Flovent Diskus, Flovent HFA inhaler (Discontinued by manufacturer) | Arnuity Ellipta, Pulmicort Flexhaler |
Kevzara pen injector, Kevzara syringe | Diagnosis dependent: Enbrel injection*, Humira injection*, Rinvoq tablet*, Xeljanz tablet*, Xeljanz XR tablet* |
Ingrezza capsule | Austedo tablet*, Tetrabenazine tablet* |
Betoptic-S suspension eye drops | Alphagan P 0.1% eye drops, Brimonidine Tartrate eye drops, Combigan eye drops |
*Prior authorization required.
If you determine that it is necessary for your patient to continue to receive the non-formulary drug in 2023, you will need to submit a Coverage Determination request on or after December 15, 2023.
Request forms are located on our website on the Coverage Determinations and Redeterminations for Drugs page or you can call to request authorization.
If you have any questions, please contact Medicare Pharmacy Services at 1-800-867-6564.
Important Pharmacy Claims Processing Change, Effective January 1, 2024
We are pleased to announce that, effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.
Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.
Members have been notified in advance and will receive a new ID card with updated pharmacy information, so that they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.
Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change.
Please contact your Provider Relations Representative with any additional questions. Thank you for the care you provide to our members.
Express Scripts Transition: Frequently Asked Questions
This FAQ provides additional information on the migration of our Pharmacy Benefit Manager (PBM) services from CVS® to Express Scripts®, effective January 1, 2024.
What is changing?
As of 01/1/2024, we will be moving to directly being contracted with Express Scripts (ESI) vs. CVS.
Who is Express Scripts?
Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.
What is the rationale for changing PBM vendors?
Express Scripts as our PBM will bring increased levels of transparency and value, positioning us to provide the highest level of quality at the lowest possible cost to our members.
What PBM services will Express Scripts be providing?
Express Scripts will be the PBM of record providing pharmacy claims adjudication, pharmacy network administration and rebate administration on behalf of our health plan.
How will this PBM transition impact our members?
There will be no immediate change in service for our members, although they will receive new ID cards. We will continue to provide the same member-focused care and support as we do today.
Our highest priority continues to be serving all our members, and we remain committed to providing affordable quality healthcare services. Our team is working closely with both CVS and Express Scripts to ensure a seamless migration.
Will there be significant changes to the pharmacy network?
No. Minimal changes have been made to limit disruption. Any member affected by changes in the pharmacy network will receive a notification. Members may call member services or check our website if they have any questions or need assistance with finding an in-network pharmacy.
Is Amazon part of the Express Scripts Network?
Yes, Amazon is part of the Express Scripts network.
Can members still use CVS Caremark for their mail orders?
No, CVS Caremark Mail Service Pharmacy will be out of network, effective January 1, 2024. If members wish to continue using mail order in 2024, they must switch to Express Scripts Pharmacy.
Do members have a choice besides Express Scripts for mail order services?
Members have a choice to use other pharmacies that offer home delivery, but Express Scripts Pharmacy is the preferred mail order pharmacy for our health plan.
Are we communicating this mail order change to members?
Yes. Impacted Medicaid members will receive a Mail Order Change notification letter.
How will members get started with mail order at Express Scripts?
For existing mail order users:
- Most open prescription refills will be automatically transferred to Express Scripts
- Refills for controlled drugs, such as Alprazolam, Clonazepam, Pregabalin, Tramadol, Zolpidem, etc., will not automatically transfer to Express Scripts Pharmacy; members must request a new prescription from their provider
For new mail order prescriptions on or after January 1, 2024, members may do one of the following:
- Ask their provider to electronically submit or fax a new prescription to Express Scripts Pharmacy, as listed on their medical ID cards
- Visit express-scripts.com/rx to register or sign in, then follow the guided steps to request a prescription
- Call Express Scripts Pharmacy, who will contact their provider for a new prescription to be filled via mail order
- Mail a Home Delivery Order Form (available at express-scripts.com/rx) directly to Express Scripts Pharmacy
Does Express Scrips offer a mail order app?
Yes, members will be able to download the Express Scripts Pharmacy app, available on the App Store and Google Play. Members with a mail order benefit can order medications, track delivery and more.
Does this change where providers would submit PA requests for medications?
No, Prior Authorization will stay the same.