Volume 15 • Issue 9 • September 2013

Preparing for Health Care Reform: What you need to know about networks When the Health Care Reform open enrollment begins this October, many of your patients will be shopping for new health insurance plans on either the Federally Facilitated Marketplace (FFM), also known as the exchange, or our Blue Cross Store. Just like today, they will want to know if their doctors participate in these health insurance plans that will be offered in 2014. Blue Cross of Northeastern Pennsylvania (BCNEPA) is committed to giving you the information you need to help you prepare for questions you may receive from your patients.

What networks do Blue Cross of Northeastern Pennsylvania’s health insurance plans use? The following charts tell you which networks our health insurance plans use. Some health insurance plans cover services only from in-network providers, unless you have prior approval. Some health insurance plans cover out-of-network providers, but your patients will have more out-of-pocket costs.

Individual Health Insurance Plans Offered in 2014

In-Network Providers

Out-of-Network Providers

myBlue® Choice myBlue Choice LP myBlue Cross, a Multi-State Plan

Providers that participate in the FPLIC PPO network or BlueCard PPO network

Out-of-network providers are covered, but your patients will have higher out-of-pocket costs.

myBlue Access myBlue Access LP myBlue Access Catastrophic myBlue Care

Providers that participate in the FPLIC Custom PPO network*

Out-of-network providers (including BlueCard PPO providers) are covered, but you will have higher out-of-pocket costs.

CHIP

Providers that participate in the FPH network

Out-of-network providers are not covered, except in emergency or with prior authorization (approval). Guest Membership is available for those living out of area for 90 days or more.

BlueCare Security

Any provider that accepts Medicare Assignment

Out-of-network providers do not accept Medicare Assignment, which may result in higher out-of-pocket costs for your patient.

FPLIC = First Priority Life Insurance Company® FPH = First Priority Health® * FPLIC Custom PPO network = Includes FPLIC PPO providers plus Geisinger Bloomsburg, Lehigh Valley, Berwick, St. Luke’s and Bon Secours providers continued on page 2

Table of Contents 3 IVR Provider Self-Service Now Available 4 Prepare for ICD-10 with “What’s Up Wednesday”

4 Medical Policy Updates 5 Utilization Management Updates 8 BCNEPA’s Prescription Drug Formulary Changes

Preparing for Health Care Reform  continued from page 1 Group Health Insurance Plans Offered in 2014 BlueCare® PPO BlueCare QHD PPO

In-Network Providers Providers that participate in the FPLIC PPO network and/or BlueCard® PPO network

Out-of-Network Providers Out-of-network providers are covered, but your patients will have higher out-of-pocket costs.

BlueCare Custom PPO BlueCare QHD Custom PPO AffordaBlueSM

Providers that participate in the FPLIC Custom PPO network*

Out-of-network providers (including BlueCard PPO providers) are covered, but your patients will have higher out-of-pocket costs. Benefits Away From Home program is available for those living out of area for 90 days or more.

BlueCare EPO

Providers that participate in the FPLIC EPO network and/or BlueCard PPO network

Out-of-network providers are not covered, except in emergency.

BlueCare HMO

Providers that participate in the FPH network

Out-of-network providers are not covered, except in emergency or with prior authorization (approval). Guest Membership is available for those living out of area for 90 days or more.

BlueCare HMO Plus

Providers that participate in the FPH network

Out-of-network providers (including BlueCard PPO providers) are covered, but your patients will have higher out-of-pocket costs. Guest Membership is available for those living out of area for 90 days or more.

Providers that participate in the FPLIC Traditional network and/ or BlueCard network

Out-of-network providers are covered, but your patients will have higher out-of-pocket costs.

Any provider that accepts Medicare Assignment

Out-of-network providers do not accept Medicare Assignment, which may result in higher out-of-pocket costs for your patient.

BlueCare Traditional BlueCare Senior

FPLIC = First Priority Life Insurance Company FPH = First Priority Health * FPLIC Custom PPO network = Includes FPLIC PPO providers plus Geisinger Bloomsburg, Lehigh Valley, Berwick, St. Luke’s and Bon Secours providers The updated alpha prefix listing for these health insurance plans can be found on our Provider Center by clicking on “Resources & Tools,” then “Reference Materials.”

Our new health insurance plans for 2014

Where can I learn more?

Rest assured, with all of our new health insurance plans

If you would like to learn more about our networks, please

for 2014, your patients will continue to get the same

feel free to contact your Provider Relations Consultant.

great value from using in-network providers for their

If you would like to learn more about Health Care Reform,

care. Encourage your patients to use in-network doctors

check out our Health Care Reform website at

and hospitals whenever possible in order to avoid higher

www.bcnepa.com/Reform.

out-of-pocket costs.

(Policy Update 1509001)

2

Integrated Voice Response Self-Service Now Available Early this September, our new Integrated Voice Response (IVR) phone system will make your benefits, claims and eligibility inquiries quicker, easier and more efficient! The provider IVR system provides an easy-to-use self-service function for providers that need customer service support and it’s available 24/7. The system will provide accumulators on your patients such as benefit limits and maximums, including: • Physical therapy • Speech therapy • Occupational therapy • Chiropractic manipulative benefit • Pulmonary therapy • Cardiac therapy • Home health care • Durable medical equipment • Primary care, well and sick office visits • Specialist well and sick office visits

Benefits

Claims

Eligibility

If the benefit you’re inquiring about is not recognized, you will be transferred to a customer service rep. The information you provided will be passed to the rep so you will not have to repeat yourself.

The IVR will ask you for the date of the service. The IVR will then provide complete claim information, including the check number or EFT information, if it was paid. If the claim was denied, you will be given the option to be transferred to a customer service rep for more information.

IVR will provide the same type of eligibility information as it currently provides through NaviNet. Member information will need to be validated before it can be provided.

When you call, you will receive a 12-digit confirmation number for documentation purposes. You will be able to choose from menu options such as claims, eligibility or benefits. After choosing an option, you will be asked for your NPI and Tax ID (for validation) as well as the patient’s UMI and date of birth. (Policy Update 1509002)

Duplicate Claims Handling for Medicare Crossover

Commonly Asked Questions:

Since January 1, 2006, all Blue Plans have been required to process Medicare crossover claims for services covered under Madigan and Medicare Supplemental products through the Centers for Medicare & Medicaid Services (CMS). This has resulted in automatic submission of Medicare claims to the Blue secondary payer, eliminating the need for the provider’s office or billing service to submit an additional claim to the secondary carrier. Additionally, this has also allowed Medicare crossover claims to be processed in the same manner nationwide. Effective since July 2013, when a Medicare claim has crossed over, providers are to wait 30 calendar days from the Medicare remittance date before submitting the claim to BCNEPA. The claims you submit to the Medicare intermediary will be crossed over to the Blue Plan only after they have been processed by the Medicare intermediary. This process may take approximately 14 business days to occur. This means that the Medicare intermediary will be releasing the claim to the Blue Plan for processing about the same time you receive the Medicare remittance advice. As a result, upon receipt of the remittance advice from Medicare, it may take up to 30 additional calendar days for you to receive payment or instructions from the Blue Plan. Providers should continue to submit services that are covered by Medicare directly to Medicare. Even if Medicare may exhaust or has exhausted, continue to submit claims to Medicare to allow for the crossover process to occur and for the member’s benefit policy to be applied. Medicare primary claims, including those with Medicare exhaust services, which have crossed over and are received within 30 calendar days of the Medicare remittance date or with no Medicare remittance date, will be rejected by BCNEPA. 3

How do I submit Medicare primary/Blue Plan secondary claims? • For members with Medicare primary coverage and Blue Plan secondary coverage, submit claims to your Medicare intermediary and/or Medicare carrier. • When submitting the claim, it is essential that you enter the correct Blue Plan name as the secondary carrier. This may be different from the local Blue Plan. Check the member’s ID card for additional verification. • Make sure to include the alpha prefix as part of the member ID number. The member’s ID will include the alpha prefix in the first 3 positions. The alpha prefix is critical for confirming membership and coverage, and key to facilitating prompt payments. When you receive the remittance advice from the Medicare intermediary, look to see if the claim has been automatically forwarded (crossed over) to the Blue Plan: • If the remittance indicates that the claim was crossed over, Medicare has forwarded the claim on your behalf to the appropriate Blue Plan and the claim is in process. There is no need to resubmit that claim to BCNEPA. (Policy Update 1509003)

Prepare for ICD-10 with “What’s Up Wednesday”

When is the next call?

An ICD-10 preparedness teleconference series from Pennsylvania’s Blue Plans (Blue Cross of Northeastern Pennsylvania, Capital BlueCross, Highmark Blue Shield, Independence Blue Cross)

Who should participate?

September 18, 2013: 2–3 p.m. Going forward, calls will take place on the third Wednesday of each month. All providers, clearinghouses, trade associations and information networks are encouraged to participate.

How do I participate?

Before the call, visit the BCNEPA ICD-10 website at www.bcnepa.com/Privacy/HIPAA/ICD-10.aspx to access the presentation. Then dial 1.800.882.3610 and enter pass code 5411307 when prompted. Be sure to dial in a few minutes early. Questions can be emailed before or during the teleconference to [email protected].

“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, 2014 compliance date.

(Policy Update 1509004)

Medical Policy Updates

Effective 10/01/13

Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing Language has been added to policy as follows: • BCNEPA will not provide coverage for genetic cancer susceptibility panels using next-generation sequencing (i.e., BreastNext, OvaNext, ColoNext and CancerNext), as these are considered investigational.

Electrical/Neuromuscular Stimulator (MPO-490-0018) Deep Brain Stimulation Policy language has been amended to include new investigational indications as follows: • BCNEPA will not provide coverage for deep brain stimulation 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: - Treatment of other psychiatric or neurologic disorders including, but not limited to, Tourette’s syndrome, depression, obsessive compulsive disorders, anorexia nervosa, alcohol addiction, chronic pain and epilepsy.

Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification The following new language has been added to policy: • BCNEPA will not provide coverage for microarray-based gene expression profile testing (i.e., MyPRS™/MyPRS Plus™ GEP70 test from Signal Genetics LLC, Little Rock, AR) for multiple myeloma, as it is considered investigational for all indications.

Experimental/Investigative Services—Radiology (MPO-490-0137)

Surgically Implanted Hearing Devices (MPO-490-0031)

Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure

Cochlear Implant Policy language has been updated as follows: • Cochlear implantation as a treatment for patients with unilateral hearing loss with or without tinnitus is considered investigational.

Genetic Testing (MPO-490-0083)

Policy language has been added as follows: • BCNEPA will not provide coverage for myocardial sympathetic innervation imaging with 123Iodine metaiodobenzylguanidine (MIBG), as this is considered investigational for patients with heart failure (i.e., AdreView™).

Genetic Testing for Statin-Induced Myopathy

Ablation Services (MPO-490-0165)

Policy language has been added as follows: • BCNEPA will not provide coverage for genetic testing for the presence of variants in the SLCO1B1 gene for the purpose of identifying patients at risk of statin-induced myopathy, as this is considered not medically necessary.

Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate or Dermatologic Tumors The revised policy statements are as follows: • BCNEPA will not provide coverage for cryosurgical ablation for the following indications, as they are considered investigational: 1. As a treatment of renal cell carcinomas in patients who are surgical candidates 2. As a treatment of benign or malignant tumors of the breast, lung, pancreas and other solid tumors or metastases outside the liver and prostate

Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies The following language has been added to policy: • BCNEPA will not provide coverage for genetic testing for the diagnosis of inherited peripheral neuropathies to confirm a clinical diagnosis, or for all other indications, as this is considered investigational.

(Policy Update 1509005)

4

updates

continued on page 3

Utilization Management Updates

New Prior Authorization Requirements BCNEPA’s Utilization Management (UM) department is continually evaluating our processes and looking for opportunities to improve appropriateness of member care and, ultimately, member outcomes. Please note: In the August 2013 Provider Bulletin, we incorrectly identified code 15830 as abdominoplasty and stated that it would require prior authorization beginning in November 2013. Code 15830 is for panniculectomy, which already requires prior authorization for all First Priority Health® (FPH) and First Priority Life Insurance Company® (FPLIC) products; therefore, there will be no changes to this requirement. As of September 1, 2013, the following services will require prior authorization:

Beginning in the spring of 2014, the following services will require prior authorization:

Services

Services

Codes

Spinal Fusion

Starting in January 1, 2014, the following services will require prior authorization:

20936, 20937, 20938, 22532, 22533, 22534, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 81.00, 81.01, 81.02, 81.03, 81.04, 81.05, 81.06, 81.07, 81.08, 81.62, 81.63, 81.64

Knee Replacement

27447

Services

Codes

Hip Replacement

27130, 81.51

Uvulopalatopharyngoplasty (UPPP)

42145

CPAP Therapy

E0601

Reduction Mammoplasty (if benefit is available)

19318

The prior authorization requirements will apply to all FPH and FPLIC products. Please check future editions of the Provider Bulletin for more details about new prior authorization requirements.

Epidural, Facet Joint Injections Facet Joint Denervation

Codes 62281, 62282, 62310, 62311, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495 64633, 64634, 64635, 64636

NaviNet Update:

Submitting Prior Authorization Requests Please note that sleep study, facet joint/epidural injection and facet joint denervation prior authorization requests should NOT be submitted via NaviNet. To begin the prior authorization process for these services, please call the Utilization Management department at the appropriate number:

BlueCare HMO plans/CHIP 1.800.962.5353 BlueCare EPO plans 1.888.345.2360 BlueCare PPO plans 1.866.262.5623 BlueCare Traditional plans 1.800.638.0505

5

updates

continued on page 5

Utilization Management Updates

Important Information for Focus PAC Prior Authorization Requests Effective July 2013, we expanded our Focus PAC list to include additional diagnosis and procedure codes as listed below. It has recently come to our attention that due to system issues, certain requests submitted through NaviNet containing these codes may not have processed properly. If any of the below codes were requested, NaviNet may not have correctly reported that the admission required prior authorization. Therefore, if you have not obtained prior authorization for an inpatient admission containing an admitting or primary diagnosis code below and a claim has not yet been submitted, please send the request and all supporting clinical documentation to the UM department for retrospective review. The UM department will temporarily waive the retrospective 5 business day limitation for these cases. If you have received a rejected claim for lack of prior authorization for any of these codes, send the documentation to the Complaint, Appeal and Grievance department as a provider appeal for further processing. Please see the section on the next page, titled “Retrospective Reviews and Provider Appeals,” for more information. Diagnosis Code Additions GI Hemorrhage

578.0, 578.1, 578.9

GI Obstruction

560.0, 560.1, 560.2

 

560.30, 560.31, 560.32, 560.39

 

560.81, 560.89

 

560.9

Otitis Media & URI

 

034.0 381.00, 380.01, 381.02, 381.03, 381.04, 381.05, 381.06 381.10, 381.19

 

381.20, 381.29

 

381.3

 

381.4

 

381.50, 381.51, 381.52

 

382.00, 382.01

 

382.1, 382.2, 382.3, 382.4, 382.9

 

465.8, 465.9

 

473.0, 473.1, 473.2, 473.3, 473.8, 473.9

 

487.1

 

Fever/Viral Infections

Diagnosis Code Additions Disorders of Biliary Tract  

574.10, 574.11, 574.20, 574.21, 574.30, 574.31, 574.40, 574.41

 

574.50, 574.51, 574.60, 574.61, 574.70, 574.71, 574.80, 574.81

 

574.80, 574.81, 574.90, 574.91

 

575.0

 

575.10, 575.11, 575.12

 

575.2, 575.3, 575.4, 575.5, 575.6, 575.8, 575.9

 

576.0, 576.1, 576.2, 576.3, 576.4, 576.5, 576.8, 576.9

Headaches Seizures

079.0, 079.1, 079.2, 079.3, 079.4

574.00, 574.01

349.0 780.31, 780.32, 780.33, 780.39

Simple Pneumonia and Pleurisy

485.

 

486.

 

487.0

 

511.0

Procedure Code Additions

 

079.50, 079.51, 079.52, 079.53, 079.59

 

079.6

 

079.81, 079.82, 079.83, 079.88, 079.89

 

56.34, 56.35, 56.39

 

079.98, 079.99

 

56.99

Kidney & Urinary Procedures for Non-Neoplasm

56.1, 56.2

We have corrected the issue and apologize for any confusion. If you have any questions, please contact your Provider Relations Consultant. 6

updates

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Utilization Management Updates

Retrospective Reviews and Provider Appeals

Important Update:

Precertification of services should be obtained before the services are rendered. However, if there were reasonable circumstances that prohibited the provider from obtaining the precertification in advance of the services, the UM department may consider a retrospective request, as long as the request is made no more than 5 business days from the initial date of the service(s).

Discharge Planning Process As mentioned in previous versions of the Provider Bulletin, the UM department is partnering with our Case Management department to start a member outreach program to assist select members with transition of care. This program is designed to ensure a safe and successful

Please note that if a claim is rejected due to lack of precertification, this will be considered a provider appeal. You may forward the provider appeal and all supporting documentation to our Complaint, Appeal and Grievance department for further processing.

discharge plan and appropriate follow-up care for our members. This will also allow us to collaborate with you to improve overall patient outcomes and help reduce the number of patient readmissions. The UM department will take an active role in managing

Regionalization of Utilization Management Staff

the discharge planning process to help transition our

We continually analyze opportunities to enhance and improve services to our members and providers. In an effort to provide optimal service, the UM department will be adopting a regional model, in which teams of staff members will be assigned to the various regions that BCNEPA services. This will allow our staff to better serve the specific needs of each region and help deliver the best possible care to our members.

we will also coordinate referring members, as appropriate,

members’ care and send referrals to Case Management/ Disease Management, as needed. Beginning January 2014, to behavioral health case management. We hope to further assist our hospital partners in reducing their readmission rates through this program. In order to best support our members with transitions in care, we’d like to remind you it is very important that discharge information includes a copy of member discharge orders, medications, durable medical equipment, home health, follow-up appointments and/

HEDIS Measures Added to HEDIS Homepage

or other directives for the discharged patient. We will be starting this transitional care program

The following HEDIS measures have been added to the HEDIS Homepage with the measure description, documentation tips and best practice information:

possibly as early as fourth quarter, 2013. Please check future editions of the Provider Bulletin for more

• Appropriate Treatment for Children with URI

information about this initiative. We would be happy

• Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

to schedule a teleconference call to discuss this new

You can access the HEDIS Homepage on our Provider Center at www.bcnepa.com by clicking on the “Providers” tab, then “Quality Management,” and then select the link to the HEDIS Hompage.

Medical Management, at 570.200.4376. Thank you for

program. Call Jill Sikorski, administrative assistant for your continued cooperation with our efforts to provide high-quality care to our members.

(Policy Update 1509006)

(Policy Update 1509007)

7

Facility Provider Claims for Services that Are Statutorily Excluded by Medicare for BlueCard Members

submitted first to Medicare for consideration and must include the GY modifier for the excluded services. The claims will be handled via the crossover process. But if you are able and wish to separate the statutorily excluded services claims, you may file them separately.

When submitting the GY modifier on your claims, You Can report it On:

Effective with claims processed on July 13, 2013 and beyond, Blue Cross of Northeastern Pennsylvania (BCNEPA) will recognize the GY modifier as part of a plan to implement a standardized approach to accept and process claims that: • Have already crossed over from Medicare and • Are for services statutorily excluded by Medicare (e.g., hearing aids). In some cases, these services may be covered under the member’s benefits and could be eligible for payment. Beginning October 2013, all Blue Plans will be required to react to the GY modifier in the same manner as explained below. In the past, secondary claims for services statutorily excluded from Medicare were handled via the crossover process. Beginning July 13, 2013, BlueCard® claims that include only services statutorily excluded from Medicare should be submitted to BCNEPA along with the GY modifier. BCNEPA will route the claim to the member’s home Blue Plan for consideration. Claims that include services covered by Medicare and those that are statutorily excluded should be

• The line level procedure code modifier fields in position 1, 2, 3 or 4 • The paper UB-04 form in field 44 • The 837I at level 2400, Service Line Loop in SV202-3, SV202-4, SV202-5 or SV202-6 When reported for BlueCard claims, the GY modifier will be included with the claim information submitted to the member’s Blue Plan for consideration. However, until October 2013 when all Blue Plans are handling such claims similarly, the claim response could vary by Blue Plan. There will be no change to how claims for services statutorily excluded by Medicare are processed today for BCNEPA members. Claims for BCNEPA members with the GY modifier will be considered for payment under the member’s benefits. Claims reporting services that are covered by Medicare and those that are statutorily excluded should be filed first with Medicare, and BCNEPA will then receive them via the crossover process for benefit determination. (Policy Update 1509008)

Blue Cross of Northeastern Pennsylvania’s Prescription Drug Formulary Changes Medications

Moving to Tier 3

Drugs Covered Under the Medical Benefit

Antineoplastic/Immunosuppressant Medications Antineoplastic/ Cometriq2,3,4,8 Immunosuppressant (cabozanitinib s-maleate) Medications Iclusig2,3,4,8 (ponatinib HCl)

Jetrea (ocriplasmin/PF)

Autonomic/Central Nervous System Medications Relpax1,2,8 (eletriptan HBr) Cardiovascular Medications Hypolipoproteinemics

Juxtapid2,3,4,8 (lomitapide mesylate)

Cystaran (cysteamine) Prior Authorization Criteria

Cystaran is a cystine-depleting agent which lowers the cystine content of cells in patients with cystinosis. Cystaran acts to reduce corneal cystine crystal accumulation. The following criteria must be met for consideration of coverage of Cystaran Eye Drops: (1) Documented diagnosis of cystinosis; (2) Presence of corneal cystine crystal accumulation. When approved, this medication must be obtained through our specialty pharmacy.

Invokana (canaglifozin) Prior Authorization Criteria

Invokana is a new SGLT2 Inhibitor (sodium-glucose co-transporter 2 inhibitor) indicated as an adjunct to diet and exercise in adults with type-2 diabetes mellitus. The following prior authorization criteria must be met for approval of coverage of Invokana: (1) Adult with type-2 diabetes mellitus; (2) Prescription claims history shows current use of metformin, at a dose of 1500 mg/day and/or a sulfonylurea at ½ of the maximum allowed daily dose.

Vascepa2,8 (icosapent ethyl)

Nutrition and Blood Other Drugs Affecting Coagulation

Jetrea is a proteolytic enzyme indicated for the treatment of Symptomatic Vitreomacular Adhesion (VMA). Jetrea is an intravitreal injection; it is given as a single dose. Repeat administration into the same eye is not recommended or covered. Although it does not need a prior authorization, claims are retrospectively reviewed for a VMA diagnosis only.

New Pharmacy Prior Authorization/Step Therapy Criteria

Kynamro2,3,4,8 (mipomersen sodium)

Immunologicals and Vaccines Immunomodulators

Effective 10/01/13

Xeljanz2,3,4,8 (tofacitinib citrate) Eliquis2,8 (apixaban)

Key: 1 Step Therapy, 2 Quantity Limit, 3 Prior Authorization, 4 Specialty Pharmacy, 5 Tier Zero, 6 Tier One, 7 Tier 2, 8 Tier 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. 8

Blue Cross of Northeastern Pennsylvania’s Prescription Drug Formulary Changes

Effective 10/01/13

New Medical Prior Authorization/Step Therapy Criteria Avastin (bevacizumab) Prior Authorization Criteria

Avastin will now require a prior authorization. Medical record documentation of 1 of the following diagnoses must be received for consideration of coverage of Avastin: (1) Agerelated macular degeneration (AMD) and diabetic macular edema; (2) Metastatic colorectal cancer (adenocarcinoma) when given in conjunction with fluorouracil-based chemotherapy; (3) Glioblastoma or ependymoma that has progressed after at least 1 prior therapy; (4) Unresectable, locally advanced, recurrent or metastatic non-squamous cell lung cancer when the patient has not had prior chemotherapy AND the bevacizumab is being administered in combination with carboplatin and paclitaxel; (5) Metastatic renal cell carcinoma when the tumor has clear cell histology and treatment with a Tyrosine Kinase Inhibitor (TKI) has been ineffective, contraindicated or not tolerated; (6) Persistent or recurrent ovarian cancer when 2 prior chemotherapy regimens have been ineffective or are not tolerated. This medication is covered under the medical benefit; it cannot be selfadministered. Prior authorization is needed for new starts as well as for those members who are currently receiving this medication.

Erbitux (cetuximab) Prior Authorization Criteria

Erbitux will now require a prior authorization. The following criteria must be met for consideration of coverage of Erbitux: (1) A diagnosis of advanced (unresectable) or metastatic colorectal cancer (CRC) when no KRAS mutation is present (for use with KRAS wild type tumors only—must provide documentation); OR (2) A diagnosis of advanced (unresectable), metastatic or recurrent squamous cell carcinoma of the head and neck (SCCHN); OR (3) A diagnosis of advanced (stage IIIb or IV) non-small cell lung cancer (NSCLC) when documentation is provided that the tumor expresses Epidermal Growth Factor Receptor (EGFR). This medication is covered under the medical benefit; it cannot be self-administered. Prior authorization is required for new starts as well as for those members who are currently receiving this medication.

Gemcitabine (Gemzar) Prior Authorization Criteria

Gemcitabine will now require a prior authorization. Medical record documentation of 1 of the following diagnoses must be received for consideration of coverage of gemcitabine: (1) Breast cancer; (2) Non-small cell lung cancer; (3) Ovarian cancer; (4) Pancreatic cancer; (5) Bladder cancer; (6) Bone cancer—Ewing’s sarcoma, Mesenchymal chondrosarcoma osteosarcoma, dedifferentiated chondrosarcoma; (7) Head and neck cancers-cancer of the nasopharynx; (8) Hepatobiliary cancers, including gallbladder cancer; (9) Hodgkin lymphoma; (9) Malignant pleural mesothelioma; (10) Non-Hodgkin lymphoma; (11) Occult primary; (12) Small cell lung cancer; (13) Soft tissue sarcoma; (14) Testicular cancer; (15) Thymic malignancies; (16) Uterine malignancies. This medication is covered under the medical benefit; it cannot be self-administered. Prior authorization is required for new starts as well as for those members who are currently receiving this medication.

Herceptin (trastuzumab) Prior Authorization Criteria

Herceptin will now require a prior authorization. Medical record documentation of 1 of the following diagnoses must be received for consideration of coverage of Herceptin: (1) In breast cancer—lab results documenting a positive result for HER-2/neu protein overexpression** have been submitted AND 1 of the following: Treatment of metastatic breast cancer, as a single agent or in combination with chemotherapy (any chemotherapy approved for use in breast cancer) either in treatment-naive individuals or individuals who have received 1 or more chemotherapy regimens for their metastatic disease OR in combination therapy with pertuzumab and docetaxel for patients with metastatic breast cancer whose tumors overexpress the HER2 protein and who have not received chemotherapy for their metastatic disease OR as an adjuvant in combination with other chemotherapeutic agents for patients with early-stage breast cancer. (2) In gastric cancer—lab results documenting a positive result for HER-2/neu protein overexpression** have been submitted AND presence of documented metastatic gastric cancer or gastroesophageal junction adenocarcinoma. This medication is covered under the medical benefit; it cannot be self-administered. Prior authorization is required for new starts as well as for those members who are currently receiving this medication.

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. 9

Blue Cross of Northeastern Pennsylvania’s Prescription Drug Formulary Changes

Effective 10/01/13

New Medical Prior Authorization/Step Therapy Criteria Neupogen (filgrastim)/ Neulasta (pegfilgrastim) Prior Authorization Criteria

Neupogen and Neulasta will now require a prior authorization. Both of these medications are covered for primary prophylaxis, secondary prophylaxis, therapeutic use in specified high-risk, febrile, neutropenic members, as well as several other diagnoses. Prior authorization is needed for new starts as well as for those members who are currently receiving this medication. This medication is covered under both the pharmacy and the medical benefits. When covered under the pharmacy benefit, the medication must be obtained through our specialty pharmacy.

Oxaliplatin (Eloxatin) Prior Authorization Criteria

Oxaliplatin will need a prior authorization. Medical record documentation of 1 of the following diagnoses must be received for consideration of coverage of oxaliplatin: (1) Adenocarcinoma of the pancreas and ampullary and periampullary carcinomas; (2) Advanced carcinoma of the colon or rectum, including use as adjuvant treatment in persons who have undergone complete resection of their primary tumor; (3) Advanced epithelial ovarian carcinoma/fallopian tube carcinoma/primary peritoneal cancer; (4) Advanced esophageal carcinoma; 5) Advanced gastric carcinoma; (6) Advanced small bowel carcinoma; (7) Advanced testicular cancer; (8) Cholangiocarcinoma (intrahepatic or extrahepatic); (9) Advanced pancreatic adenocarcinoma; (10) Relapsed or refractory chronic lymphocytic leukemia/small lymphocytic lymphoma; (11) Relapsed or refractory nonHodgkin’s lymphoma (diffuse large B-cell lymphoma, follicular lymphoma, nodal marginal zone lymphoma, MALT lymphoma, mantle cell lymphoma, splenic marginal zone lymphoma, peripheral T cell lymphoma, primary cutaneous B-cell lymphoma) as a second-line agent; (12) Unresectable or metastatic gallbladder cancer. This medication is covered under the medical benefit; it cannot be self-administered. Prior authorization is needed for new starts as well as for those members who are currently receiving this medication.

Rituxan (rituximab) Prior Authorization Criteria

Rituxan will now need a prior authorization for any indication. Medical record documentation of 1 of the following diagnoses must be received for consideration of coverage of Rituxan: (1) B-cell non-Hodgkin Lymphoma (NHL); (2) B-cell Chronic Lymphocytic Leukemia (CLL); (3) Thrombocytopenic purpura, immune or idiopathic; (4) Wegener’s Granulomatosis (WG) and Microscopic Angiitis (MPA); (5) Rheumatoid Arthritis. This medication is covered under the medical benefit; it cannot be self-administered. Prior authorization is needed for new starts as well as for those members who are currently receiving this medication.

Zoledronic Acid (Zometa, Reclast) Prior Authorization Criteria

Zoledronic acid in both forms, Reclast equivalent and Zometa equivalent, will now need a prior authorization. Reclast equivalent criteria will remain the same as previously determined. Medical record documentation of 1 of the following diagnoses must be received for consideration of coverage of zoledronic acid (Zometa equivalent): (1) Hypercalcemia of malignancy; (2) Treatment of multiple myeloma; (3) Treatment of bone metastases from solid tumors in conjunction with standard antineoplastic therapy, including bone metastases from multiple myeloma, breast carcinoma, prostate carcinoma and other solid tumors. Prostate cancer should have progressed after treatment with at least 1 hormonal therapy. This medication is covered under the medical benefit; it cannot be self-administered. Prior authorization is needed for new starts as well as for those members who are currently receiving this medication.

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. For complete criteria, quantity limits and additional information visit our website at www.bcnepa.com and click on the “Providers” tab. Then choose the “Pharmacy Benefits” link on the right and select the link for “Utilization Management” on the right. 10

Blue Cross of Northeastern Pennsylvania’s Prescription Drug Formulary Changes

Effective 10/01/13

Revised Pharmacy Prior Authorization/Step Therapy Criteria Arcalyst/Ilaris Prior Authorization Criteria

This policy has been revised to include criteria for coverage of a new indication for Ilaris. Ilaris is now indicated for the treatment of active Systemic Juvenile Idiopathic Arthritis (SJIA). The following criteria must be met for consideration of coverage of Ilaris in the treatment of SJIA: (1) Member is 2 years of age or older; (2) Diagnosis of systemic juvenile idiopathic arthritis (SJIA) with disease activity greater than 6 months documented by a rheumatologist; (3) Treatment with at least 1 oral systemic agent for SJIA was ineffective or not tolerated. When approved, this medication must be obtained through our specialty pharmacy.

Multiple Sclerosis Oral Disease Modifying Agents Prior Authorization Criteria

Criteria for consideration of approval of Tecfidera (dimethyl fumarate), a new oral Multiple Sclerosis Disease Modifying Agent, has been added to this policy. The following criteria must be met for consideration of coverage of Tecfidera: (1) Documented diagnosis of relapsing-remitting or secondary progressive multiple sclerosis by either a neurologist or a multiple sclerosis specialist; (2) Tecfidera requested by a neurologist or multiple sclerosis specialist; (3) Trial and intolerance to/failure to respond to 2 of the following: Avonex, Betaseron, Copaxone, Rebif or Extavia; (4) Results from a recent CBC (within the past 6 months) to identify members with low lymphocyte counts. When approved, this medication must be obtained through our specialty pharmacy.

Serotonin 5-HT-1 Receptor Agonists (“triptans”) Step Therapy Criteria

Generic formulations of Zomig (zolmitriptan) and Maxalt (rizatriptan benzoate) are now available and are 1st-step medications in the step therapy policy. 1st-step medications are now naratriptan, sumatriptan, zolmitriptan and rizatriptan. Relpax (eletriptan HBr) is now a 2nd-step medication. Two 1st-step medications must be given a trial and appear on the member’s prescription claims summary in the past 130 days before a 2nd-step medication will be covered.

Immunomodulators in the Treatment of Inflammatory Disease (Simponi) Prior Authorization/Step Therapy

This policy has been revised to include criteria for coverage of a new indication for Simponi. Simponi is now indicated in the treatment of ulcerative colitis. The following criteria must be met for consideration of approval of Simponi in the treatment of ulcerative colitis: (1) Documented diagnosis of moderate to severe ulcerative colitis; (2) Inadequate response to prior treatment OR requires continuous steroid therapy. Prescription claims history, as well as submitted medical records, must document these treatments. When approved, this medication must be obtained through a specialty pharmacy. Revised Medical Prior Authorization/Step Therapy Criteria

Actemra (tolicilizumab) Prior Authorization Criteria

This policy has been revised to include prior authorization criteria for a new indication, polyarticular juvenile idiopathic arthritis. The following criteria must be met for consideration of approval of Actemra: (1) Member is 2 years of age or older; (2) Diagnosis of Polyarticular Juvenile Idiopathic Arthritis (PJIA) with disease activity for greater than 6 months’ documented by a rheumatologist; (3) Treatment with at least 1 oral systemic agent for PJIA was ineffective or not tolerated.

Denosumab (Prolia/Xgeva) Prior Authorization Criteria

This policy has been revised to include prior authorization criteria for Xgeva. Previously, prior authorization was only required for Prolia. The criteria which must be met for approval of Xgeva are: (1) Must be prescribed by an oncologist AND documented presence of secondary malignant neoplasm of the bone and bone marrow OR; (2) Presence of giant cell tumor of the bone (GCTB). For those members with GCTB, if an adolescent, bones must have matured, the GCTB cannot be surgically removed or surgery is likely to result in severe morbidity. Prior authorization is needed for new starts as well as for those members who are currently receiving this medication.

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. For complete criteria, quantity limits and additional information visit our website at www.bcnepa.com and click on the “Providers” tab. Then choose the “Pharmacy Benefits” link on the right and select the link for “Utilization Management” on the right. (Policy Update 1509009)

11

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Address Service Requested

Editors: Jennifer Sensky Ann Poepperling Blue Cross of Northeastern Pennsylvania administers health plans for Blue Cross of Northeastern Pennsylvania, Highmark Blue Shield, First Priority Health® and First Priority Life Insurance Company.®

Provider Relations Department: 1.800.451.4447

BCNEPA Provider Relations Consultants

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—1.866.262.5635 • BlueCare Traditional—1.888.827.7117 • BlueCare EPO—1.888.345.2353 Valuable Health Resources: Refer your BlueCare patients to the following Blue Health Solutions health and wellness resources: SM

• Personalized health management and wellness programs, care management resources and much more—1.866.262.4764

Odette Ashby • 570.200.4658 [email protected]

Important Fax Numbers:

Cheryl Grimm • 570.200.4669 [email protected]

BC Claims Department................ 570.200.6790 (For claims adjustments, BlueCare Senior, FEP)

Cheryl Hashagen • 570.200.4670 [email protected]

BC Precertification Department.... 570.200.6788

Louise LoPresto • 570.200.4674 [email protected]

BlueCard® ITS Claims.................. 570.200.6790 FPH Claims Department.............. 570.200.6790

Jean Wiernusz • 570.200.4682 [email protected]

(For Maternity Precertification Forms, adjustments, Claims Research Request Forms, etc.)

Tracie Wyandt • 570.200.4647 [email protected]

Provider Relations........................ 570.200.6880

Senior Manager, Provider Relations

Provider Customer Service......... 570.200.6868 FPH Complaint/Grievance Department..................................... 570.200.6770

• 24/7 Nurse Now health care information— 1.866.442.BLUE and available online at www.bcnepa.com. Login to Self-Service, click on the “Health & Wellness” tab and then select “24/7 Nurse Now.”

FPH Non-par Referral Requests.... 570.200.6840

Report Fraud: Call our Fraud Hotline at 1.800.352.9100, or email our Special Investigations Unit at [email protected].

Other Party Liability (OPL)......... 570.200.6790

FPH Pharmacy Department........ 570.200.6870 FPH Precertification Department..................................... 570.200.6799

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. 2013.