Provider Connections Newsletter - Fall 2008

Presorted Standard U.S. POSTAGE PAID New York, NY Permit No. 3700 330 West 42nd Street New York, NY 10036-6977

FALL 2008

Your Key to the 1199SEIU BeneďŹ t Funds New Classes Added for the Preferred Drug List, Step Therapy Program and Quantity Duration Rules "EGINNING *ANUARY

WE WILL BE ADDING NEW CLASSES TO OUR 0REFERRED $RUG ,IST AND SEVEN NEW CLASSES TO BOTH OUR 3TEP 4HERAPY 0ROGRAM AND 1UANTITY $URATION 2ULES 4HE "ENElT &UND S 0REFERRED $RUG ,IST 3TEP 4HERAPY 0ROGRAM AND 1UANTITY $URATION 2ULES HAVE BEEN SUCCESSFUL TOOLS IN SAFEGUARDING OUR MEMBERS HEALTH WHILE PROVIDING THEM ACCESS TO THE MEDICATIONS THEY NEED

Preferred Drug List Adds 10 New Drug Classes Prescribing medications on our Preferred Drug List saves members out-of-pocket expenses and ensures they are getting the most clinically effective medication. Please be sure to check the updated list when prescribing one of these medications: s )NHALED #ORTICOSTEROIDS

s /PHTHALMIC !NTIBIOTICS

s 4RIPTANS

s -ISCELLANEOUS /PHTHALMOLOGICS

s -ISCELLANEOUS !NALGESICS

s 6ITAMINS

s #OUGH #OLD

s Vitamin B complex used for growth and development s Prenatal vitamins used during pregnancy s Multivitamins used as a dietary supplement s Iron preparations used as a supplement for anemia

s !CNE 4HERAPY

Do We Have Your Current Information on File?

s %STROGENS s 4OPICAL !NTIVIRALS

Seven New Medications Added Requiring Step Therapy

We’re always working to make sure our

members

have

access

to

the

most accurate and complete information on our participating provider network. Check our online directory at WWW 3%)5&UNDS ORG to verify your

Like most other health payers, the BeneďŹ t Funds introduced step therapy for certain medications. The program was introduced last fall to encourage members to try a less-costly alternative for the popular drug Nexium, and most members and their doctors found it worked just as well. To build on this success, the BeneďŹ t Funds will add seven new medications requiring step therapy on January 1, 2009. These are for new users only and will not affect members who are already stabilized on the following medications for these conditions. Please note that in order to safeguard our members’ health, these medications will only be covered for their FDA-approved use. s 'ABITRIL for epilepsy drug treatment

s "YETTA for diabetes drug treatment

s 4/") for cystic ďŹ brosis treatment

s #/8 )) #ELEBREX for arthritis drug treatment

s %LIDEL 0ROTOPIC for eczema treatment

s !CTIQ &ENTORA for pain management treatment

s 4OPAMAX :ONEGRAN for epilepsy drug treatment

information. If we do not have your current information, complete a Provider Demographic Change Request form, which is

Seven New Quantity Duration Rules Added for New and Existing Users Based on FDA-recommended prescribing and safety information, our Quantity Duration Rules help ensure that the most clinically appropriate dosages of medication are being prescribed for members for the appropriate length of time. We are applying these rules to the following drugs:

also available on our website under Forms

s 4/")

s !NTIVIRAL

and Resources.

s "YETTA

s !CTIQ &ENTORA

s !NTIFUNGAL (onchomycosis, NoxaďŹ l, Vfend)

You should be receiving an updated Preferred Drug List in the mail, or feel free to check our website at www.1199SEIUFunds.org for the most updated version.

-ESSAGE FROM THE %XECUTIVE $IRECTOR Our goal at the Benefit Funds is to provide our members with access to the highest level of quality care. We know that a big part of that is making sure our providers have all the information you need to provide that care and help members use their benefits wisely.

In this edition of Provider Connections, you’ll learn about important new prescription drug benefit rules that take effect in January 2009. These programs will help ensure our members are receiving the most appropriate, safe and clinically effective medications available. You’ll also read about our prior authorization rules concerning genetic testing by specialized laboratories. And, we’ve included some updates and reminders about providing after-hours coverage for members, our fraud and abuse tipline and our automated line for checking claim status and member eligibility.

We hope you find this provider newsletter a helpful resource. We look forward to a continued relationship to provide our members with the best care. And of course, if you have any questions about the Benefit Fund’s policies or services, please contact our Provider Relations representatives at (646) 473-7160 or visit our website at www.1199SEIUFunds.org.

Mitra Behroozi

Help Us Protect Your Patients’ Benefits As a Benefit Fund provider, you can help us protect our members’ benefits by keeping an eye out for suspected fraud or abuse. Our Fraud and Abuse Department works hard to monitor members’ utilization and providers’ billing patterns, but if you suspect a patient or fellow provider is using the Funds’ benefits fraudulently, please email our tipline – benefitfraud@1199funds.org – or call our Fraud and Abuse Hotline at (646) 473-6148. You can report suspected fraud anonymously if you wish.

Special Laboratory Testing – Be Sure to Check for Prior Authorization The Benefit Fund requires medical necessity review and prior authorization approval for any advanced genetic testing performed by a specialized laboratory, such as BRCA genetic testing for susceptibility to breast and ovarian cancer or genetic testing for susceptibility to colorectal cancer. In fact, it’s recommended that you contact the Ben-

Reminder to Primary Care Physicians: Provide 24-Hour Coverage for Your 1199SEIU Patients As an 1199SEIU Benefit Fund primary care physician, you are responsible for providing 24-hour access for 1199SEIU members. After normal office hours, you must provide a live answering service or alternative physician to contact. This goes a long way toward helping members get the care they need and avoiding unnecessary emergency room visits.

efit Fund for any other proprietary advanced genetic testing or SPECIALIZED LAB TEST to determine if prior authorization is required.

And, please remember to save your 1199SEIU patients unnecessary out-of-pocket costs by referring them to participating specialists and facilities, including ambulatory surgery centers. To verify participation status, visit our online directory at www.1199SEIUFunds.org or contact our Provider Services Department at (646) 473-7160.

Need to Check Claim Status or Eligibility?

Use our Automated System 24 Hours a Day With the Benefit Funds’ automated Interactive Voice Response (IVR) system, you have claim status and member eligibility at your fingertips 24 hours a day, 7 days a week. Just call (888) 819-1199 and have your tax ID number, member ID number and the member’s date of birth on hand.

Reminder: If You Disagree With a Payment Our recently upgraded claims system has enabled us to improve our claims processing and accuracy. But if you feel there’s been an error in your payment, we want to remind you that you have 180 days from the date of the Explanation of Payment to dispute it. For more information on the process, call our Provider Relations Department at (646) 473-7160.