Presorted Standard U.S. POSTAGE PAID New York, NY Permit No. 3700 330 West 42nd Street New York, NY 10036-6977
Your Key to the 1199SEIU Benefit Funds
Are You Prescribing Medications From the New 1199SEIU Preferred Drug List? You can help your 1199SEIU patients avoid unnecessary out-ofpocket prescription costs by prescribing preferred medications from the Fund’s revised Preferred Drug List (PDL), which went into effect October 1. We’ve included a copy of the full PDL in this edition of 1199SEIU Provider News for you to keep on hand.
Online Live Directory Coming This Fall Beginning this fall, the Fund will be introducing a live directory on our website at www.1199SEIUFunds.org. The live directory will allow us to update provider information more frequently, making sure that our members and referring providers have the most current information on our network. You can help us by checking the Fund’s website now to make sure your information is accurate. If it needs to be updated, let us know by emailing us at Providers@1199Funds.org.
The Fund’s clinicians and Medco expanded the PDL by adding 16 new drug categories. Each drug category contains generic and sometimes brand-name options. If you prescribe any medication in these categories, your 1199SEIU patients won’t incur costs for their medication. If you prescribe non-preferred medications, members will be responsible for the full difference in price between preferred and non-preferred and this can be very costly.
Oral Pe nicillins
SECTIO N I: T 1199SEIU HERA PEUT DRUG C Preferred Drug ICList ATEGO RIES (Antibio tics)
amoxici amoxici llin trihyPlease guide drate take this Ora l Tetracy potassiullin trihydrate G with/ you the next time clines G ampicilli m clavulan G ate doxycy dicloxacin trihydrate you visit yourGGdoctor. do cli G xycy ne hyclate Ora pe nicilli llin sodium P doxycy cline hyclate capsule Mac l Erythrom G Augmenn v potassiu rolides ycins an minocy cline monohytablet G d othe 125 - 31 tin Chewab m G cli drate r tet le .25 azithrom racyc ne HCl Ta blet Oral Ce 250 - 62 mg, G P .5mg phalosp line HCl clarithro ycin Augmen G G erythro mycin cefaclor orins 125 - 31 tin Suspensio G G my n erythro cin base cefadro 250 - 62 .25mg/5, G G mycin xil hydr .5mg/5 er eth yth ce fdinir yls ate ro G sulfisox mycin ethyls uccinate cefpodo G G azole uccinate cefproz xime proxe / tyl G Oral Q erythromycin ace til tablet stearate cefurox il uinolone G G cephale ime axetil tab G ciproflo s G xacin HC cephradxin monohy let P ofl dr ox P ine ate l tablet aci Ceftin Avelox n Suspen P PSYCH sion Cipro OTHE P Suspen RAPE Cipro Ta sio UTIC blet 10 n S (Anx Hypnot 0mg iety/Dep ic Agen ression) G ts � chlor G al � estazohydrate G Anxiolyt ics � fluraz lam G G � temazeepam HCl G � alpraz G pam � triazo G � alp olam G P lam buspiro razolam ER Fazaclo Miscell � zolpidem G P ne aneous Geodon � chlor HCl G P © 2007 Medco Health Solutions,GInc. All rights reserved. Antidep Haldo � clorazdiazepoxide �amitr G P reInc. ssa Medco is a registered trademark G of Medco� Healthipt Solutions, nt s Mobanl Deconate � diaze epate dipot HCl G P amoxap yline HCl G pam assium Or ine � � ap G P lorazepa budrug propio If you have questions about yourG prescription benefit, Risperd n HCl � bupro P SSRI An � oxazepamm tablet pion HC Risperd al visit www.medco.com or call Medco Member at 800-818-6720. P tidepre sustaServices G l G Risperd al Consta ssants �clomi ined action tablet, P G � citalo pram G Seroqu al M For questions about your 1199SEIU benefits, 1199SEIU pr �desipcall ine HC Member Services P am G � fluox HBr G Seroqu el �doxe ramine HCl l P at 646-473-9200. G � fluvo etine HCl pin G Zyprex el XR P �imipr HCl G � paro xamine malea amine Zyprex a xe � mapro G HC a Zydis suspen tine HCl tabte G � mirta tiline HCl l sion let, G Antipsy sertraline HCl � mirta zapine tablet zapine ch ot ics G tablet, disso G MG918654 rapid O chlorpro �nortr lve (Ed. 8/07) G G clozapinemazine � trazo iptyline HC G G l do fluphen � venla ne HCl G P haloperiazine � Cymbfaxine HCl G P loxapine dol � Nard alta G P perphe � Well il G butrin thiothixnazine XL 150m G g trifluop ene P Clozari erazine HCl l
Key: G = Preferr ed P = Preferr generic medic ed brandatio name me n. dication.
� = A dos � = Use e lower tha n the ma by peo nuf ple safe
acture r alterna 65 and old tives ma = Weig er is ass r’s guidelines y h is d, the dos sed risk s or oth d for peo in pregna ; er advers age ple 65 ncy. and old e outcom should genera er. lly be low es. ered.
be availab ociated risk of = Do with inc often recomme Medco manages your prescription drug benefit for the 1199SEIU Benefit Funds le. health th defect not use bir If useplan. rea nde
If you are prescribing a medication from a category that the Fund covers, but it is not included on the PDL, simply prescribe any generic or single source brand in that category. If you believe your patient needs a non-preferred drug in a covered category, or a brand-name drug when a generic is available, you will need to demonstrate that the preferred medications are not appropriate for a particular patient for the Fund to cover it. We encourage you to discuss the new PDL with your patients. All Fund members have received information on these prescription drug benefit changes and may have questions about new medications. If you have any questions, email us at Providers@1199Funds.org or call our Provider Hotline at (646) 473-7160 Coming January 1 – Check Claims Status Automatically, 24 Hours a Day Many of our providers already use the Fund’s Interactive Voice Response system (IVR) to quickly verify their 1199SEIU members’ eligibility 24 hours a day, 7 days a week. Coming in January, you’ll also be able to check the status of your Fund claims automatically at any time that’s convenient for you. To check eligibility, just call (888) 819-1199 and enter your tax ID number, the member’s ID number and date of birth. The system allows you to check an unlimited number of members in one call. You’ll receive more information on checking claims status later in the year. It’s another way we’re improving our service to you.
Message From the Executive Director Dear Provider: At the Benefit Fund, our priority is to ensure that our members receive the highest quality care. And we know that the best way to do this is by making sure our providers have the tools and information they need to deliver that care. In this edition of Provider News, you’ll learn about several ways that you can help your 1199SEIU patients avoid paying outof-pocket for prescriptions and care and about new prior authorization requirements for certain imaging services. And you’ll read about changes in Durable Medical Equipment reimbursement procedures, as well as the addition of Quest to our preferred lab network. We’re also looking for your help in strengthening our provider network. The Fund is currently credentialing our providers, and part of that process is making sure we have your full provider history on file. We’ve contracted with MedAdvantage to help us gather this information, so please respond promptly if the company contacts you. You can also help in the credentialing process by participating on our Credentialing committee as a peer reviewer. You’ll read more about how you can become involved in this newsletter. We hope you find this provider newsletter a helpful resource. We encourage you to contact us if need further information, and remember to visit our new website for forms and updates at www.1199SEIUFunds.org. You can get all the information you need about our programs and policies with just one click! Sincerely, Mitra Behroozi Executive Director 1199SEIU Benefit and Pension Funds
Contacting the Fund Just Got Easier With Extended Phone Hours To make contacting the Benefit Fund easier than ever, we’re offering extended phone hours Monday through Friday, from 8:00 AM through 6:00 PM. Simply call our Provider Hotline at (646) 473-7160 at any time during those hours to speak with one of our representatives. Remember, you can also check your 1199SEIU patient’s eligibility automatically, 24 hours a day by calling (888) 819-1199.
Are You Using the Most Updated Procedure Codes? You can help ensure your claims are being paid accurately by using the most current procedure codes. If you submit claims with old codes, or codes that are no longer used, your claims may be denied. Remember to double-check all of your codes before you submit claims for 1199SEIU patients. Questions? Call (646) 473-7160 or email us at Providers@1199Funds.org.
Provider Credentialing Helps Us to Help You When the Fund has your full provider history on file, it simplifies all your Fund transactions from claims processing to eligibility and referrals. Right now, we’re in the process of recredentialing our providers. To help us through the process, we’ve contracted with MedAdvantage to help us gather the data we need on our participating providers’ history. If you are contacted by MedAdvantage and asked for Fund recredentialing information, please respond promptly. Doing so will ensure we have all the information we need to process your claims quickly and accurately. Questions? Email us at Providers@1199Funds.org or call our
Expanded Wellness Program Supports Your Care The Benefit Fund has introduced two new additions to our Wellness Program that will support the care you provide to members — a 24-Hour Nurse Helpline and a Health Coaching Service for members with chronic conditions. Now, members with diabetes, asthma, high blood pressure or obesity will have access to voluntary, personalized health coaching by phone to help them keep their disease under control. And members with more general questions on their overall health have access to a 24Hour Nurse Helpline to discuss their concerns with a trained professional. We encourage you to refer your 1199SEIU patients to these two valuable resources. Members can access either the Health Coaching Service or the Nurse Helpline by calling the same number: (866) 935-1199. Pullout: These programs are not a substitution for a doctor’s care. They are designed to support the care members receive from their primary health providers, as well as promote the benefits of adopting the healthy lifestyle habits encouraged through our existing Wellness and Protecting Our Health programs.
New Prior Authorization Requirements for Imaging Services As of October 1, the Fund requires prior authorization for certain imaging services including PET scans, CAT scans, MRIs and MRAs. If you prescribe these tests for an 1199SEIU member, you must call MedFocus at (888) 910-1199 first for prior authorization and a participating imaging location.
Make Sure 1199SEIU Patients Avoid Out-of-Pocket Cost By Referring Them To a Participating Specialist Effective October 1, 2007, the Fund will only reimburse non-radiology physicians for services within their specialty for all imaging tests in the 70000 cpt code series. If members need imaging services that are not indicated for your specialty, you must refer them to the appropriate specialist or radiologist. To help your patients avoid outof-pocket costs, please make sure you refer them to a participating provider. You can find a list of participating providers, as well as the Fund’s list of Radiology Privileging specialties and guidelines, online at www.1199SEIUFunds.org.
Only Durable Medical Equipment Providers Will Be Reimbursed for DME Supplies Beginning October 1, the Fund will no longer reimburse physicians for DME supplies, even if an 1199SEIU member presents a DME authorization. The Fund will only reimburse Durable Medical Equipment Providers for these supplies. If your 1199SEIU patients have an authorization for DME, please refer them to a participating provider. A list of approved DME providers is available on the Fund’s website at www.1199SEIUFunds.org.
Quest Joins The Fund’s Preferred Lab Network On October 1, Quest Diagnostics joined the Benefit Fund’s preferred laboratory network. Now, in addition to LabCorp, Dianon (a LabCorp subsidiary), Bendiner & Schlesinger, Centralized Lab and members’ own Member Choice hospital-based labs, you may also send your 1199SEIU patient’s lab work and tests to Quest.
Help Us Strengthen Our Provider Network Fund’s Credentialing Committee Seeks Board Certified Physicians
For a full list of participating labs, visit www.1199SEIUFunds.org.
The Benefit Fund is inviting all board certified participating providers to join our Credentialing Committee as peer reviewers. To join the Committee or for more information, contact Stephanie Price in the Fund’s Credentialing Department at SPrice@1199Funds.org
In order to safeguard our members’ personal information, the Benefit Funds will be changing our participant ID numbers over to unique, 10-digit numbers this winter. In December, members will all receive new Health Service ID Cards with their new ID.
New 1199SEIU Member ID Numbers are Coming This Winter
Be sure to ask your 1199SEIU patients for their new cards, and keep the new ID numbers on file. By January 3, you’ll need to submit all claims using the new member ID. Keep an eye out for more information later in the fall.