Provider Connections — Summer/Fall 2016

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

Non-Profit U.S. Postage PAID New York, NY Permit No. 3700

1199SEIU PROVIDER

Connections

Your Key to the 1199SEIU Benefit Funds

Summer/Fall 2016

Message from the Executive

Director

In this issue of Provider Connections, we are pleased to introduce Dr.Van H. Dunn, the Funds’ new Chief Medical Officer (CMO). Dr. Dunn’s impressive background makes him uniquely qualified to take the reins as CMO, having begun his long career as a primary care physician in Boston before most recently serving as CMO for MetroPlus Health Plan in New York City. You can learn more about his vision and insights in his column on page 2.

We are pleased to introduce Dr. Van H. Dunn, the Funds’ new Chief Medical Officer (CMO).

This issue of Provider Connections also includes details of our expanded partnership with eviCore healthcare, which will help ensure that your 1199SEIU patients’ cancer care is as effective as possible and is driven by a patient-centered approach that uses evidence-based clinical pathways to support your treatment recommendations. The expanded partnership is designed to maintain consistency in diagnoses and treatment methodology, and to reduce disparities in outcomes.

In addition, we share with you recent changes to our Preferred Drug List (PDL) that affect your 1199SEIU patients who are being treated for diabetes. Prescribing preferred drugs from our PDL helps your 1199SEIU patients avoid unnecessary out-of-pocket costs.

We hope you find this edition of Provider Connections informative. If you have any comments, questions or concerns, please contact your designated Provider Relations Representative or call our Provider Relations Call Center at (646) 473-7160, and a staff member will be happy to assist you.

Sincerely,

Mitra Behroozi, Executive Director 1199SEIU Benefit and Pension Funds

Coming Soon!

A New Look for the Funds’ Website

www.1199SEIUFunds.org

The Benefit Funds’ website, www.1199SEIUFunds.org, is getting a major makeover, which will improve both ease of use and functionality for our participating providers and our members. We are updating the site with searchable provider documents, including participating pharmacies and our Preferred Drug List (PDL), which will save you time and put the information you need at your fingertips when you need it. Watch for more details in the fall.

www.1199SEIUFunds.org

Plan and Program News

Claims News

A Message from Our Chief Medical Officer:

Dr. Van H. Dunn Partnership with eviCore healthcare Is Expanded To help ensure your 1199SEIU patients receive the highest, most consistent standard of cancer treatment, the 1199SEIU Benefit Funds have expanded our partnership with eviCore healthcare, effective April 1, 2016. Using established, evidencebased clinical pathways, eviCore supports clinicians in pursuing the most effective course of action for medical oncology treatment by reviewing pre-service elective radiation therapy and medical oncology services, as well as outpatient hightech radiology and nuclear cardiology studies. This expanded partnership will help maintain consistency in diagnoses and treatment methodology, and reduce disparities in treatment and outcomes for 1199SEIU cancer patients. The partnership and prior authorization process will also help limit patients’ exposure to potentially harmful treatments and encourage a more holistic and patient-centered approach to healthcare delivery. For more information, visit www.1199SEIUFunds.org.

In my first message to you, our participating providers, let me begin by saying that I am honored to serve as the Chief Medical Officer of the 1199SEIU Benefit Funds. The Benefit Funds administer healthcare coverage to our members and their families in a manner that not only helps ensure they receive quality care but also helps them avoid unnecessary out-of-pocket costs. Removing financial barriers to medical care is integral to our mission of providing our more than 400,000 covered lives with the care they need when they need it, and I applaud the role you play in delivering that care.

All health plans have rules that their covered participants need to follow, but at the Funds we have developed our rules and programs with these two objectives in mind: providing quality care while minimizing members’ out-of-pocket costs. When our members follow plan rules, with your support, they may have no cost at all. So when you read about plan requirements in Provider Connections, such as adhering to the Preferred Drug List (PDL) or obtaining prior authorization for medical oncology, we hope you will see the benefit to our members.

We value our partnership with you, and we appreciate your professionalism and dedication to our shared mission. I look forward to working with you and building a relationship that will continue to support our members’ health and well-being.

Do Not Use Unlisted Billing Codes When a Valid CPT Code Exists Please avoid submitting claims with unlisted billing codes unless you are certain a corresponding Current Procedural Terminology (CPT) code is not available. Using unlisted codes will delay the processing of your claim and may result in a denial of payment. If you have questions about which CPT billing code to file with your claim, please call (646) 473-7160, and a Provider Relations Representative will assist you.

Prescription Drug Coverage News

New Diabetes Drug Class Added to Preferred Drug List Our clinical pharmacists regularly review our Preferred Drug List (PDL) to help ensure that our members have access to the most cost-effective and clinically proven medications.

Effective July 1, 2016, the Benefit Funds have added a new PDL class for diabetes drugs: •

Basal insulin

We have also made changes to eight additional drug classes: • DPP-4 inhibitors • GLP-1 receptor agonists • SGLT2 inhibitors • Blood glucose test strips • Antipsychotics • Hyaluronic acid derivatives • Ulcerative colitis agents • Testosterone replacement agents

Sincerely, Dr. Van H. Dunn Chief Medical Officer

2

Provider Connections

Summer/Fall 2016

Before prescribing medications for your 1199SEIU patients, please review the most recent PDL, effective July 1, 2016, at www.1199SEIUFunds.org/Providers.

Reminder: Electronic Prescribing of Medications Is Mandatory in New York If you provide medical care in New York State, remember to submit prescriptions for your 1199SEIU patients electronically.

Effective March 27, 2016, the state began requiring that providers electronically send prescriptions for both controlled and non-controlled substances directly to pharmacies, with limited exceptions. The law is aimed at reducing fraud, improving efficiency, limiting dispensing errors by avoiding illegible handwriting and promoting greater accountability of provider prescribing habits. The mandate is an extension of the state’s Internet System for Tracking Over-Prescribing Act (I-STOP), enacted in 2013, which required all New York prescribers to consult the Prescription Monitoring Program Registry when writing a prescription for a Schedule II, III, IV or V controlled substance. For more information, please visit www.health.ny.gov/professionals/narcotic/electronic_ prescribing/docs/epcs_faqs.pdf.

Provider Connections

Summer/Fall 2016

3

Plan and Program News

Claims News

A Message from Our Chief Medical Officer:

Dr. Van H. Dunn Partnership with eviCore healthcare Is Expanded To help ensure your 1199SEIU patients receive the highest, most consistent standard of cancer treatment, the 1199SEIU Benefit Funds have expanded our partnership with eviCore healthcare, effective April 1, 2016. Using established, evidencebased clinical pathways, eviCore supports clinicians in pursuing the most effective course of action for medical oncology treatment by reviewing pre-service elective radiation therapy and medical oncology services, as well as outpatient hightech radiology and nuclear cardiology studies. This expanded partnership will help maintain consistency in diagnoses and treatment methodology, and reduce disparities in treatment and outcomes for 1199SEIU cancer patients. The partnership and prior authorization process will also help limit patients’ exposure to potentially harmful treatments and encourage a more holistic and patient-centered approach to healthcare delivery. For more information, visit www.1199SEIUFunds.org.

In my first message to you, our participating providers, let me begin by saying that I am honored to serve as the Chief Medical Officer of the 1199SEIU Benefit Funds. The Benefit Funds administer healthcare coverage to our members and their families in a manner that not only helps ensure they receive quality care but also helps them avoid unnecessary out-of-pocket costs. Removing financial barriers to medical care is integral to our mission of providing our more than 400,000 covered lives with the care they need when they need it, and I applaud the role you play in delivering that care.

All health plans have rules that their covered participants need to follow, but at the Funds we have developed our rules and programs with these two objectives in mind: providing quality care while minimizing members’ out-of-pocket costs. When our members follow plan rules, with your support, they may have no cost at all. So when you read about plan requirements in Provider Connections, such as adhering to the Preferred Drug List (PDL) or obtaining prior authorization for medical oncology, we hope you will see the benefit to our members.

We value our partnership with you, and we appreciate your professionalism and dedication to our shared mission. I look forward to working with you and building a relationship that will continue to support our members’ health and well-being.

Do Not Use Unlisted Billing Codes When a Valid CPT Code Exists Please avoid submitting claims with unlisted billing codes unless you are certain a corresponding Current Procedural Terminology (CPT) code is not available. Using unlisted codes will delay the processing of your claim and may result in a denial of payment. If you have questions about which CPT billing code to file with your claim, please call (646) 473-7160, and a Provider Relations Representative will assist you.

Prescription Drug Coverage News

New Diabetes Drug Class Added to Preferred Drug List Our clinical pharmacists regularly review our Preferred Drug List (PDL) to help ensure that our members have access to the most cost-effective and clinically proven medications.

Effective July 1, 2016, the Benefit Funds have added a new PDL class for diabetes drugs: •

Basal insulin

We have also made changes to eight additional drug classes: • DPP-4 inhibitors • GLP-1 receptor agonists • SGLT2 inhibitors • Blood glucose test strips • Antipsychotics • Hyaluronic acid derivatives • Ulcerative colitis agents • Testosterone replacement agents

Sincerely, Dr. Van H. Dunn Chief Medical Officer

2

Provider Connections

Summer/Fall 2016

Before prescribing medications for your 1199SEIU patients, please review the most recent PDL, effective July 1, 2016, at www.1199SEIUFunds.org/Providers.

Reminder: Electronic Prescribing of Medications Is Mandatory in New York If you provide medical care in New York State, remember to submit prescriptions for your 1199SEIU patients electronically.

Effective March 27, 2016, the state began requiring that providers electronically send prescriptions for both controlled and non-controlled substances directly to pharmacies, with limited exceptions. The law is aimed at reducing fraud, improving efficiency, limiting dispensing errors by avoiding illegible handwriting and promoting greater accountability of provider prescribing habits. The mandate is an extension of the state’s Internet System for Tracking Over-Prescribing Act (I-STOP), enacted in 2013, which required all New York prescribers to consult the Prescription Monitoring Program Registry when writing a prescription for a Schedule II, III, IV or V controlled substance. For more information, please visit www.health.ny.gov/professionals/narcotic/electronic_ prescribing/docs/epcs_faqs.pdf.

Provider Connections

Summer/Fall 2016

3

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

Non-Profit U.S. Postage PAID New York, NY Permit No. 3700

1199SEIU PROVIDER

Connections

Your Key to the 1199SEIU Benefit Funds

Summer/Fall 2016

Message from the Executive

Director

In this issue of Provider Connections, we are pleased to introduce Dr.Van H. Dunn, the Funds’ new Chief Medical Officer (CMO). Dr. Dunn’s impressive background makes him uniquely qualified to take the reins as CMO, having begun his long career as a primary care physician in Boston before most recently serving as CMO for MetroPlus Health Plan in New York City. You can learn more about his vision and insights in his column on page 2.

We are pleased to introduce Dr. Van H. Dunn, the Funds’ new Chief Medical Officer (CMO).

This issue of Provider Connections also includes details of our expanded partnership with eviCore healthcare, which will help ensure that your 1199SEIU patients’ cancer care is as effective as possible and is driven by a patient-centered approach that uses evidence-based clinical pathways to support your treatment recommendations. The expanded partnership is designed to maintain consistency in diagnoses and treatment methodology, and to reduce disparities in outcomes.

In addition, we share with you recent changes to our Preferred Drug List (PDL) that affect your 1199SEIU patients who are being treated for diabetes. Prescribing preferred drugs from our PDL helps your 1199SEIU patients avoid unnecessary out-of-pocket costs.

We hope you find this edition of Provider Connections informative. If you have any comments, questions or concerns, please contact your designated Provider Relations Representative or call our Provider Relations Call Center at (646) 473-7160, and a staff member will be happy to assist you.

Sincerely,

Mitra Behroozi, Executive Director 1199SEIU Benefit and Pension Funds

Coming Soon!

A New Look for the Funds’ Website

www.1199SEIUFunds.org

The Benefit Funds’ website, www.1199SEIUFunds.org, is getting a major makeover, which will improve both ease of use and functionality for our participating providers and our members. We are updating the site with searchable provider documents, including participating pharmacies and our Preferred Drug List (PDL), which will save you time and put the information you need at your fingertips when you need it. Watch for more details in the fall.

www.1199SEIUFunds.org