Provider Connections Newsletter - Spring 2011

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1199SEIU Benefit and Pension Funds 330 West 42nd Street New York, NY 10036-6977

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1199SEIU PROVIDER

Connections Spring 2011

Message from the

Executive Director

Please Participate in Our Research to Increase Colorectal Screening We work hard to help keep our 1199SEIU members healthy, and we’re continuing those efforts through our partnership with Columbia University on a research project aimed at improving the rates of colorectal cancer screening among men and women ages 50-75. We recently informed more than 47,000 1199SEIU members and retirees about the opportunity to participate in the randomized trial, which will test the effectiveness of different strategies for increasing the number of at-risk men and women who are screened for colorectal cancer. The study targets a tough-to-reach population – minorities with low income levels – and is funded by the American Cancer Society. If any of your patients are enrolled in the study, you may be contacted for a brief interview, lasting as little as 10 minutes, and we encourage your participation in this important project for the health of your patients. Please remember that we cover colon cancer screenings at no cost to members, so be sure to remind your patients if it's time to get one.

Your Key to the 1199SEIU Benefit Funds

We know that keeping our providers up to date on our Benefit Fund’s programs and policies is one of the best ways we can help you provide the highest quality care. So in this edition of Provider Connections, we are including several important updates. First, we remind you that our 1199SEIU Greater New York Benefit Fund members now have co-payments for certain services. This change does not affect our 1199SEIU National Benefit Fund members.

Make sure to check your 1199SEIU patients’ Health Benefits ID cards to determine which Fund they are in, and update their information if necessary.

You will also read about a number of changes as we continue tailoring our programs to ensure our members are receiving the most appropriate care. This spring, we will also offer new programs for smoking cessation, weight management and prenatal home nursing services to help supplement the care you provide.

Plus, we have added new classes to our Preferred Drug List, and changed some pre-authorization requirements.

As always, we value our ongoing relationship with you, and we hope you will always come to us with any questions or concerns.

We encourage you to speak to your Provider Representative, or contact our Provider Relations Department at (646) 473-7160 for any information that you need.

Mitra Behroozi, Executive Director 1199SEIU Benefit and Pension Funds

New 1199SEIU Health Coaching Programs to Lose Weight and Quit Smoking

Your 1199SEIU patients can now access intensive new smoking cessation and weight management programs through the Fund, giving them even more resources to help them quit tobacco, maintain a healthy weight and improve their overall health. The new programs were launched in March 2011, as part of our ongoing effort to combat two of the nation’s leading health problems and help improve our members’ well-being. Our smoking cessation program connects members one on one with a personal health coach and combines access to counselors, qualified support staff, print material and product discounts to help smokers become smoke-free. We also offer savings on nicotine replacement patches, gum and lozenges so that your patients can choose the method that works best for them. Your patients can still use their Fund’s prescription drug benefits to try non-nicotine medications as well.

Likewise, our weight management services put members in touch with a health coach who can help them eat more nutritiously and incorporate exercise into their routine. Of course, the Nurse Helpline and Health Coaching Services still provide members with education and support to help them manage conditions like diabetes and heart disease and to answer health-related questions 24 hours a day, 7 days a week.

If your 1199SEIU patients need additional support in these areas, encourage them to call (866) 935-1199 to talk to a personal health coach today.

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New 1199SEIU Greater New York Benefit Fund Co-Payments As of March 1, 2011, your patients enrolled in the 1199SEIU Greater New York Benefit Fund will have co-payments on prescriptions and selected services. However, there will still be no co-payments for preventive services, including annual check-ups, well-child visits and numerous health screenings and vaccinations.You can find a full list of preventive services at www.healthcare.gov. We recently informed the 1199SEIU Greater New York Fund members of these changes and have issued those members new Health Benefits ID cards. The copayments are listed on the members’ new ID cards, so be sure to ask your patients for their updated cards at their next visit. Please remember that these co-payments apply ONLY to patients covered by the 1199SEIU Greater New York Benefit Fund, not to those covered by the 1199SEIU National Benefit Fund.

Effective March 1, 2011, the co-payments for 1199SEIU Greater New York members are: • • • •

$10 for primary care visits with a general or family practitioner and pediatricians for children $15 for specialist visits $4 for generic drugs and $12 for brand-name drugs at participating pharmacies $10 for generic drugs and $20 for brand-name drugs when

• •

using mail order through The 90-Day Rx Solution for three-month supplies of long-term medication $15 for CT and PET scans, MRAs and MRIs $75 for emergency room visits (if not admitted to the hospital)

Save Time and Money – Check Claims and Verify Eligibility Online

The 1199SEIU Benefit Funds have partnered with Alere health management services to give you more resources for helping your highrisk obstetrical patients. Alere gives patients and their providers access to home services through a team of specialized high-risk OB RNs and clinical OB pharmacists. The program offers services for diabetes in pregnancy, history of spontaneous preterm birth (17P Administration), current preterm labor, nausea and vomiting, coagulation disorders and hypertensive disorders. For referrals, simply contact Alere directly at (800) 950-3963 or visit their website at www.alere.com and identify yourself as an 1199SEIU provider.

We know how important it is for providers to have access to real-time information on their 1199SEIU patients’ claims or eligibility. That’s why in addition to our Fund’s automated line, we also offer you a quick and convenient way to view eligibility and claims information online, through NaviNet. Please visit www.navinet.net to sign up and view patient information including eligibility, benefits and claim status. Of course, you can always call the Fund’s automated line at (888) 819-1199 to check your 1199SEIU patients’ eligibility and claims status.

As of January 1, 2011, pre-authorization is no longer required for home hospice services of up to 210 days in a patient’s lifetime. Your 1199SEIU patients also no longer need pre-authorization for orthotics services billed with HCPC codes L3000, L3002, L3010, L3020 and L3030. Adult members may receive inserts once every two years and children may receive inserts once a year.

Care to Care Now Reviews Radiology Services Care to Care now provides the utilization review for our 1199SEIU members’ non-emergency, outpatient MRA, MRI, PET and CAT scans. The prior authorization number will remain the same, so if your 1199SEIU patients need any of these services, the referring physician’s office should continue to call (888) 910-1199. MedFocus remains our preferred radiology provider network, so be sure to keep referring our members to the same MedFocus imaging sites and providers that you do now.

The Benefit Funds’ specialty care pharmacy, Accredo, has added 14 new drugs to its list of available medicines. The specialty care pharmacy is the safest and most reliable option for members who need medications that require special handling, like refrigerated or injectable drugs. These medications must be delivered through Accredo directly to the patient, so if you’re prescribing any of these drugs to your 1199SEIU patients, please call Accredo at (800) 987-4904 and provide them with the patient’s 1199SEIU Member ID number. A full list of specialty care drugs is available at www.1199SEIUBenefits.org under “For Providers.”

Submit Claims Using New Dental Codes Make sure your dental practice doesn’t face payment delays by submitting all your claims on an ADA form using current CDT codes. We recently sent you the updated CDT codes as well as a letter listing the 17 codes that have been eliminated, effective February 1, which included primary filling codes. The new CDT codes now cover both primary and adult teeth, so please make sure to use the new codes for all your claims.

Remember to Refer Your 1199SEIU Patients in Network Referring your 1199SEIU patients within our network of credentialed providers helps our members get the high-quality care they deserve with no balance billing. So when you refer our members to a medical specialist or a facility for radiology, lab services or any other ancillary services, be sure to send them to an 1199SEIU participating provider.

A complete list of our participating specialists, lab and radiology providers is available at www.1199SEIUBenefits.org.

New Drug Classes Added to The 90-Day Rx Solution Mail Order Program The Benefit Funds’ 90-Day Rx Solution requires 1199SEIU members to get their long-term medications in 90-day supplies by mail, either delivered to their home or a local Rite Aid. We’ve added six new drug categories to the mail order service effective March 1, 2011, so make sure to write your 1199SEIU patients three-month prescriptions when you prescribe from the drug categories listed below – otherwise, they will end up paying more money out of pocket for their medications.

• • • • • •

The easiest way to know which Fund covers your 1199SEIU patients is to check their Health Benefits ID card: the Greater New York Fund card is red, with co-payments listed on the back. (The National Benefit Fund card is blue.) You can also call the Funds’ automated eligibility system at (888) 819-1199, or log on to www.navinet.net if you are a NaviNet user. Our Provider Services representatives are also available to answer your questions during regular business hours at (646) 473-7160.

In-Home Nursing Care Is Available for High-Risk Obstetrical Patients

No Pre-Authorization for Home Hospice Services or Orthotics

Specialty Care Pharmacy Adds New Drugs

Oral breast cancer drugs Oral/topical overactive bladder drugs Oral prostatic cancer drugs Miscellaneous pulmonary agents Ophthalmic allergy eye drops Oral drugs to treat elevated platelets

New Drug Classes Added to Our Preferred Drug List Also effective March 1, 2011, the Benefit Fund has added seven new Preferred Drug List (PDL) drug classes and two modified PDL drug classes.

The new specialty medications are: • • • • • • • • • • • • • •

Botox (requires prior authorization), prescribed for non-cosmetic use, e.g., spasmodic torticollis) Carbaglu Egrifta (requires prior authorization) Enoxaparin sodium Gammaplex (requires prior authorization) Ganciclovir Gilenya (requires prior authorization) Glassia Halaven Iprivask Jetvana (requires prior authorization) Krystexxa (requires prior authorization) Lumizyme (requires prior authorization) Xgeva

For more information, physicians can call Medco’s Prior Authorization Department at (800) 753-2851 from 8:00 am to 6:00 pm, Monday through Friday.

Providers who want additional information about the Fund’s prescription drug benefit plan can call Medco’s Physician Service Center at (800) 211-1456 from 8:00 am to 6:00 pm, Monday through Friday.

The new PDL drug classes are: • Multiple sclerosis (new users only; specialty drug class) • Gout therapy (all users) • Antiandrogens (new users only) • Adrenal hormones (all users) • Antipsoriatic/antiseborrheic (all users) • Ophthalmic steroid-antibiotic combinations (all users) • Miscellaneous ophthalmic/anti-inflammatories (new users only) The modified PDL drug classes are: • Estrogens (all users) • Miscellaneous ophthalmic/antihistamines and mast cell stabilizers (all users) Remember to visit www.1199SEIUBenefits.org regularly to review the most up-to-date Preferred Drug List.