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Geisinger Health PlanBrieflyDecember 2012A Publication for Providers and Office PersonnelIn this issue2 Improvingquality of care3 NIA updateGeisinger Goldupdate4 Medical andpharmaceuticalpolicy updates5 Pressure ulcercodingCommercialformulary update6 Gold formularyupdateLearn more aboutGHP Family7 MedicalTransportationManagement(MTM)8 New! Medicalspine managementprogramImproving quality of careThe Consumer Assessment ofHealthcare Providers and Systems(CAHPS ) surveys are standardizedconsumer satisfaction evaluationsfor the insurance industry. Across theUnited States, members and patients aresurveyed on the quality of services theyreceive from their health insurance planand their doctors.Geisinger Health Plan’s (GHP)commercial and Medicare Advantageprograms are included in the CAHPSratings. We use the results to improvequality of care and customer service forour members.For scoring and reporting purposes,questions are combined into measures.Some of the measures include: Getting needed care Getting care quickly Doctors who communicate well Health plan customer service Getting needed prescriptiondrugs Getting information from theplan about prescription drugcoverage and costThere are also individual questions onitems such as: Rating of personal doctor Rating of health care quality Receipt of influenza vaccineBrand X Pictures/ThinkstockThe CAHPS surveys act as our reportcard, with members scoring both GHPand our providers. Public reporting of theCAHPS survey results increases awarenessabout care quality and encourages bothcarriers and participating doctors toimprove quality.GHP has targeted some measuresas areas for improvement. Theseimprovements will help create a betterhealth care experience for our members.On the next page, please review thesummary of those measures and how youcan help.Briefly is also available online at thehealthplan.comBriefly - A Geisinger Health Plan Publication - thehealthplan.com 1
Key CAHPS survey measures for GHPimprovementGetting needed careCoordination of careThis measure refers to members who receivedspecialty care within the last six months. They areasked questions regarding: The ease of scheduling an appointment The number of visits they had Their overall rating of the specialist How often their PCP was notified about theirspecialty careHow can you help? Process timely referrals PCPs should follow up with the specialist’soffice Specialists should provide their patient’s PCPoffice with an update Record all care information in your patient’smedical recordThis portion is a series of questions about how aprovider and their staff deliver ongoing care to thepatient. Questions include: Did your doctor have medical records or otherinformation about your care? Did the doctor’s office follow up to give you testresults? Did you get test results as soon as you neededthem? Did your doctor talk to you about all of yourprescription medicines? When you needed help managing your carebetween providers, did your doctor’s officeprovide you the help you needed? Was your doctor informed and up-to-date aboutyour specialty care?How can you help? Promptly follow up with your patients regardingtest results Update patient medical records regularly Ask your patients if they have questionsregarding their medicationsDoctors who communicate wellMembers who visited their PCP within the last sixmonths are asked questions related to: Ease of understanding doctors’ explanations ofcare How often their doctor listened carefully andtreated them with respect If their doctor spent enough time with them atthe appointmentHow can you help? Ask patients if they have additional questions Discuss the importance of customer servicewith your office staff Spend as much time with your patients as yourschedule allowsNot only does this category reflect on the doctor’sactions, it is also relevant to your entire practice andstaff. Patients will weigh their answers based on howthey are treated at the front desk or by the nurse, aswell as their doctor.Advising on the use of aspirinCardiovascular disease (CVD) is the leadingcause of death in the United States. Daily aspirinuse, dosage of 81 mg, in people with moderate tosevere CVD can reduce risks associate with CVD.The U.S. Preventive Services Task Force supportsthis recommendation, and in 2009 revised theirguidelines on the use of daily aspirin therapy.How can you help?Aspirin is recommended for: Men, ages 45 to 79: when the potentialbenefit due to a reduction in myocardialinfarctions outweighs the potential harm due toan increase in gastrointestinal hemorrhage Women, ages 55 to 79: when the potentialbenefit of a reduction in ischemic strokesoutweighs the potential harm of an increase ingastrointestinal hemorrhageBriefly - A Geisinger Health Plan Publication - thehealthplan.com 2
NIA’s 2013 clinical guidelineupdatesEffective January 2, 2013, National Imaging Associates, Inc.(NIA) reviewers will begin using updated clinical guidelinesin the evaluation of requests for radiology services. The 2013annual clinical guidelines review process incorporated anextensive clinical review. All revisions to these guidelinesare the result of clinical consensus and approved by clinicalleadership at both NIA and GHP.The following 2013 NIA clinical guideline formattingchanges were made to provide consistency in all similarguidelines and to enhance usability: PET scans for oncology—The need to search fora specific cancer type and the indications that follow hasbeen eliminated. With a few exceptions, cancer types havebeen consolidated to collectively address the initial andsubsequent treatment strategy for all solid tumor types. CT/MRI—All single study upper (wrist, arm, humerus,and shoulder) and lower extremity (foot, ankle, knee,and hip) guidelines for CT/MRI were combined into fourmajor extremity guidelines. The guideline includes clinicalindications that can be generally applied to any of theextremities. Plus, sections were added within each of theupdated extremity guidelines with clinical indicationsspecific to the extremity body part. For example, withinthe lower extremity guideline, there will be a section that isspecific to the knee to address clinical conditions that onlyrelate to the knee like “physical findings of anterior cruciateligament.”You can view the current 2012 guidelines by accessingyour radmd account. NIA has also posted the 2013 advancedimaging clinical guidelines online.To access your radmd account and view the 2013guidelines (login not required): Visit www.radmd.com Click the “Solutions” tab from the main menu bar From the “Solutions” drop down list, click on “AdvancedImaging” Listed under “Document,” click on “Preview of NIA’s 2013Standard Guidelines”o The table of contents begins on page 3o Click once on the study to be viewedo To return to the table of contents, click on “TOC”in the upper right hand corner above theheading of each guidelineEffective January 2, 2013, NIA will replace current clinicalguidelines with the updated 2013 version.Creatas/ThinkstockGeisinger Gold updatesGeisinger Gold is pleased to announce thatPennsylvania Medicare beneficiaries will continue toenjoy the same great coverage and service they areaccustomed to. Members with Part D prescriptiondrug coverage will also have a new benefit, 3 drugcopays on most generics right through the coveragegap.Beginning in January, participating providers willsee a new Geisinger Gold logo on member ID cardsand Gold materials (see below). This new logo ispart of a GHP-wide change to logos for all benefitplans, as part of an effort to increase awareness of allofferings within GHP.Also beginning in 2013, Geisinger Gold ispartnering with Meridian Health to offer MedicareAdvantage plans in Monmouth and Ocean countiesin New Jersey. Several plans include HMO, PPO, andMSA, offering the same affordable, comprehensivecoverage available to Pennsylvania members.Participating providers can visit thehealthplan.comor call (800) 876-5357 for more information.If you have any patients who are interested inGeisinger Gold or have questions, they can call(800) 631-1656, 8 a.m. to 8 p.m. seven days aweek; TDD/TTY users call 711 or visit us online atGeisingerGold.com.Left: NewGeisinger GoldlogoRight: MeridianGeisinger Goldlogo for plans soldin New JerseyBriefly - A Geisinger Health Plan Publication - thehealthplan.com 3
Medical and pharmaceutical policy updatesThe following is a summary of new, revised and recently reviewed medical and pharmaceutical policies. Please consult the full text ofthese policies online at thehealthplan.com. Printed copies are available by contacting your provider relations representative. More details willbe available in future issues of Briefly. New and revised policies are effective January 1, 2013.*Coverage requires prior authorization (PA)New PoliciesMP270 Ocular Photoscreening GHP does NOT provide coverage for ocular photoscreeningas a tool to detect amblyogenic factors, or any otherindications, because it is considered experimental,investigational or unproven. There is insufficient evidencein the peer-reviewed published medical literature to establishthe effectiveness of this treatment on health outcomes whencompared to established treatments or technologies.MBP96.0 Voraxaze (glucarpidase) Voraxaze (glucarpidase) may be considered medicallynecessary for the treatment of toxic plasma methotrexateconcentrations ( 1 micromole per liter) in patients withdelayed methotrexate clearance due to impaired renalfunction.MBP97.0 Kyprolis (carfilzomib)* Kyprolis (carfilzomib) is considered medically necessary forthe treatment of insured individuals with a diagnosis ofmultiple myeloma when all of the following criteria are met:- Krypolis (carfilzomib) is prescribed by a hematologist/oncologist- Documentation of a diagnosis of multiple myeloma- Physician documentation of therapeutic failure on intoleranceto or contraindication to: Bortezomib (Velcade); and An immunomodulatory agent (e.g., Thalidomide [Thalomid]or Lenalidomide [Revlimid])MBP98.0 : Perjeta (pertuzumab)* Perjeta (pertuzumab) is considered to be medically necessaryfor the treatment of HER2 positive metastatic breast cancerwhen all of the following criteria are met:- Physician documentation of a diagnosis of HER2 positivebreast cancer naïve to prior anti-HER2 therapy (e.g., Herceptin[trastuzumab], Tykerb [lapatinib] ) or chemotherapy formetastatic disease- Physician documentation of a plan to use Perjeta incombination with Trastuzumab and Docetaxel/PaclitaxelRevised PoliciesMP214 - IontophoresisAdded Indications Iontophoresis for the treatment of musculoskeletalinflammation resulting in pain and/or edema is considered tobe medically necessary when used as part of anoverall treatment protocol in any of the following conditions:- Epicondylitis- Patellofemoral syndrome- Tendonitis (except Achilles tendonitis)- Rotator cuff syndrome- Plantar fascitisMBP 31.0 Erbitux*Added indication Erbitux being used in combination with FOLFIRI ( Irinotecan,5-Fluorouracil, Leucovorin) for first line treatmentMP 48 - Ablation Therapies for Treatment of Benign ProstaticHypertrophyCriteria for coverage: all must be met Diagnosis of symptomatic BPH with duration of symptomsgreater than 3 months Failed trial or intolerance to medication therapy for a minimumof 6 months (alpha-blocker and/or finasteride) Recent PSA that resulted in a value of 2.5 ng/ml or less forinsured individuals up to age 60 ; 4.0 ng/ml or less for membersover age 60 Peak urine flow rate (Qmax) less than 15 cc on a voided volumeof greater than 125ccReviewed PoliciesThe following policies were reviewed. No changes were madeto the clinical content. References updated.MP 146 - Sympathetic TherapyMP 147 - Artificial Intervertebral DiscMP 120 - Intravacitary Balloon Brachytherapy for Breast CancerMP 118 - Quantitative Sensory TestingMP 117 - Dry HydrotherapyMP 116 - HippotherapyMP 112 - Wireless Capsule EndoscopyMP 79 - Donor HLA TypingMP 69 - UltrafiltrationMP 166 - MR Ultrasound Ablation of Uterine FibroidsMP 161 - Thermal CapsulorraphyMP 258 - HyperhidrosisMP 195 - Functional Magnetic Resonance Imaging (Retired)MP 181 - Suit TherapyMP 65 - Obesity Surgery*MP 38 - Oral Health*MP20 - Transplant Services*MP217 - Polysomnography and Sleep StudiesMP232 - Autism Spectrum Disorder Evaluation and MedicalManagementMP244 - Pelvic Floor StimulationMP243 - Anorectal Fistula Repair Using an Acellular PlugMP201 - Obstructive Sleep ApneaMP187 - CryoablationMP242 - Genetic Testing for Tamoxifen MetabolismMP 155 – Cooling DevicesMP 47 – Hyperbaric Oxygen TherapyMP 50 – Surgical Correction of Chest Wall DeformitiesMP 66 – Extracorporeal Shock Wave treatment forMusculoskeletal indicationsContinued on page 5Briefly - A Geisinger Health Plan Publication - thehealthplan.com 4
Revised Policies continuedMP 29 – Bone Growth Stimulator*MP 159 – Voice TherapyMP 58 – Negative Pressure Wound Therapy*MP 104 – Continuous Subcutaneous InsulinInfusion Pump*Clinical Guideline ReviewHemera/ThinkstockGHP continues to solicit physician and non-physicianprovider input concerning clinical guidelines. The followingclinical guidelines are currently being reviewed:Coding for pressure ulcersProviders are reminded that pressure ulcers should beclearly documented in the progress notes indicating bothlocation and stage of the ulcer.Example: Pressure ulcer - hip - Stage 1When coding for pressure ulcers, use one of the fourstages or the “unstageable” designation defined below: Stage I – Healing pressure ulcer Stage II – Pressure ulcer with full thickness skin loss Stage III – Pressure ulcer with full thickness tissueloss—bone, tendon or muscle are not exposed Stage IV – Pressure ulcer with full thickness tissueloss—exposed bone, tendon, or muscle Unstageable – Pressure ulcer with full thickness tissueloss in which the base is covered in slough/eschar inthe wound bed. Until removed, the stage cannot bedetermined Adult sinusitis Adult UTI Hyperlipidemia Asthma COPD HypertensionYour feedback is encouraged and appreciated. Commentsshould be sent to Phillip Krebs at pkrebs@thehealthplan.com.Please provide your feedback by March 15, 2012.The complete list of clinical guidelines is available online atthehealthplan.com. Providers are encouraged to contact theirprovider relations representative for assistance in accessingthe guidelines online or to request hard copy. Comments canbe sent to pkrebs@thehealthplan.com.Commercial formulary updatesThe table below represents recent updates to GHP’s formulary. For questions or to request a hard copy of the entire formulary, pleasecontact the pharmacy customer service team at (800) 988-4861, Monday through Friday, 8 a.m. to 5 p.m. You may also view the entireformulary at thehealthplan.com. *Indicates prior authorization is required.Brand NameTieredFormularyStatus4th uantityLimitDetailedLimitsFormulary psulesper 30 daysDymistaFormulary3No2YesNoazelastine hydrochloride,fluticasone propionateBosulifFormulary3Yes2YesNoGleevec, Sprycel*, Tasigna*OnfiFormulary3No2YesNolamotrigine, topiramate,felbamate, Banzel,StivargaFormulary3Yes2YesYes120 tablets Noneper 30 daysSkliceFormulary3No2YesNolindane shampoo, Formulary2No2NoNoNonespinosadFormulary changes effective January 1, 2013:- Crestor will require prior authorization for new starts only. Alternatives include simvastatin, pravastatin and atorvastatin.- Zolpidem CR will move from Tier 1 to Tier 2. The quantity limit of 15 tablets per copay/coinsurance will remain. Alternatives include immediaterelease zolpidem and zaleplon.Briefly - A Geisinger Health Plan Publication - thehealthplan.com 5
Gold formulary updatesThe table below represents recent updates to Geisinger Gold’s formulary. For questions or to request a hard copy ofthe entire formulary, please contact the pharmacy customer service team at (800) 988-4861, Monday through Friday, 8a.m. to 8 p.m. You may also view the entire formulary at thehealthplan.com/Gold under “Pharmacy and Covered Drugs.”Brand NameBosulifStatusFormulary 0 DeductibleFormularySpecialtyStandardPriorFormulary Formulary AlternativesGleevec, Sprycel, Tasignaazelastine, flunisolide, fluticasone,triamcinolone, Nasacort AQ, Nasonex,Rhinocort pecialtyBrandYesNoCeredase, Cerezymelindane shampoo, malathion, spinosad120 tabletsper 30 daysNoneAll antiretrovirals are covered on theMedicare Part D formularies excludingbrand antiretrovirals with a generic. Ifa brand antiretroviral has a generic version, then only the generic is covered.120Zytigacapsules per30 daysNoneLearn more about GHP FamilyBeginning March 1, 2013, the PennsylvaniaCommonwealth’s Department of Public Welfare(DPW) will expand its Medical Assistance managedcare program, HealthChoices, into northeasternPennsylvania. DPW has recognized GHP as one ofthe three health plans best equipped to serve theHealthChoices New East Zone. This new plan willbe called GHP Family, reflecting our commitment toproviding high-quality access to affordable healthcare for Medical Assistance recipients.The New East Zone is home to over 210,000Medical Assistance recipients and includesthe following 22 counties: Bradford, Carbon,Centre, Clinton, Columbia, Juniata, Lackawanna,Luzerne, Lycoming, Mifflin, Monroe, Montour,Northumberland, Pike, Schuylkill, Snyder, Sullivan,Susquehanna, Tioga, Union, Wayne, and Wyoming.GHP’s provider relations staff will hold GHPFamily orientation webinars starting in January2013. If you have already expanded yourparticipation to include GHP Family and wouldlike to learn more about GHP’s approach to theHealthChoices program, register for one of thescheduled webinars below: January 11, 2013 - 9:00 a.m. January 15, 2013 - 3:00 p.m. January 21, 2013 - 10:00 a.m. January 29, 2013 - 2:00 p.m. February 7, 2013 - 10:00 a.m. February 15, 2013 - 1:00 p.m. February 18, 2013 - 10:00 a.m. February 21, 2013 - 10:00 a.m. February 25, 2013 - 11:00 a.m. February 27, 2013 - 3:00 p.m.To register, please call (717) 909-3340.Webinars will run approximately 60 minutes. Ifyou are unable to attend one of the webinarslisted above, please contact your provider relationsrepresentative at (800) 876-5357 to scheduleBriefly - A Geisinger Health Plan Publication - thehealthplan.com 6
another time to discuss your participation with GHPFamily.If your office or facility provides care to MedicalAssistance recipients residing within the 22-countyNew East Zone and you have not already expandedyour participation to include GHP Family, we encourageyou to do so. Your commitment to care for GHP Familymembers is essential to the development of a highperformance provider network that can fulfill the healthcare needs of members.If you have questions concerning potentialparticipation with the new GHP Family product, pleasecontact your county’s network development associatebelow at (800) 876-5357, option 3. Mark Thomas—Centre, Juniata, Mifflin Amy Hornberger—Clinton, Columbia, Lycoming,Montour, Northumberland, Schuylkill, Snyder,Sullivan, Tioga, Union Paul Forlenza—Bradford, Carbon, Lackawanna,Luzerne, Monroe, Pike, Susquehanna, Wayne,WyomingRequesting non-emergent ambulance transportationthrough MTMOn November 1, 2012, Medical TransportationManagement, Inc (MTM) became the new administratorof ambulance transport services for GHP members. MTMis an industry leading medical transportation managerscheduling over 4 million trips a year throughout 29states and the District of Columbia.MTM now coordinates prior authorization for all nonemergent ambulance transportation requests for yourGHP patients* and reimburses ambulance providersfor all approved ambulance claims, including claims foremergency 911 calls. Discharge planners now have asingle point of contact when seeking prior authorizationfor non-emergent ambulance transportation andcoordinating pickup times.The process for requesting a non-emergencyambulance through MTM for your GHP patients is easy.Simply complete the MTM Ambulance CertificationStatement (ACS) form online at www.ambulance.mtm-inc.net, or print and fax it back to MTM at (866)453-0247. Contact MTM’s call center at (888) 409-6881 ifyou need MTM to fax an ACS form to you or if you haveany questions.Once the form data is processed, an MTM care managerwill contact you with information about the assignedambulance provider or the reason prior-authorization wasdenied.So far, the response to MTM among the participatingprovider community has been positive. In the short timeMTM has managed ambulance transport services for GHPmembers, we’ve identified and addressed ways to furtherstreamline the non-emergent ambulance request process.To this end, the ACS form has recently been updated.iStockphoto/ThinkstockPlease be sure to fill out all applicable fields andcomplete the entire ACS form. By completing the ACSform thoroughly, you will expedite the authorizationprocess and avoid having to resubmit the form withadditional information.Tips for completing the ACS form: The ordering provider must sign the ACS for it to beconsidered complete The patient weight is needed in pounds The date is needed in mm/dd/yyyy format Time is needed in 12-hour format with AM or PMspecified*MTM does not handle non-emergent ambulance requestsfor Life Geisinger members, Geisinger Gold Reserve(MSA) members, and Gold plans available in Ocean andMonmouth counties in New Jersey (i.e., Gold Classic 100,Gold Classic 300, Gold Secure 200, Gold Preferred 100, andGold Preferred 200).Briefly - A Geisinger Health Plan Publication - thehealthplan.com 7
100 North Academy AvenueDanville, PA 17822-3240Non-Profit Org.U.S. PostagePaidGeisingerNEW! Medical spine managementprogramStarting April 1, 2013, all GHP andGeisinger Choice members* will acquire anew medical spine management programbenefit upon their renewal.This new initiative requires thatpatients with spine or back pain receivean evaluation from a GHP-designatedmedical spine specialist (MSS) prior to theirfirst consultation with pain managementiStockphoto/Thinkstockor a spine surgeon, unless there is anemergency.The MSM program can be explained in three steps:Step 1: Primary care physician (PCP)—First line of care for the member. If a higher levelof care is needed, the PCP will recommend and coordinate a medical spine evaluation witha GHP-designated MSS.Step 2: Medical spine specialist (MSS)—Completes evaluation, confirms a diagnosis andworks together with the member to develop a plan of care. A copy of the treatment planwill be sent to the member’s PCP. The MSS may also order GHP’s new physical therapy (PT)bundle*, in which the member can obtain five PT visits for one copay.Step 3: Spine surgeon or pain management – If the member continues to see painmanagement or a spine surgeon for their back pain, the first office visit will require priorauthorization.GHP’s new MSM program will provide the most appropriate, effective and high-qualitycare to all members with back pain, improving their quality of life and enhancing memberand provider satisfaction. If you have additional questions regarding the MSM program,please contact your provider relations representative at (800) 876-5357.*The MSM program and PT bundle are not available to Geisinger Gold and Geisinger Health Options members.Briefly is published quarterlyby Geisinger Health Plan, andserves as an informationalresource for participating providers and office personnel.Duane E. Davis, M.D.President,Chief Executive Officer,Geisinger Health PlanJason RenneVice President,Network Innovations,Geisinger Health PlanPlease forward comments orrequests for additional copiesto: briefly@thehealthplan.comGHP Marketing100 North Academy AvenueDanville, PA 17822-3240(570) 271-8135A copy of this newsletter canalso be found atthehealthplan.comHPM50 ad Dec 2012 11/19/12Geisinger Health Plan, Geisinger Goldand Geisinger Choice shall be collectivelyreferred to as the Health Plan or GHP.
Briefly - A Geisinger Health Plan Publication - thehealthplan.com 1 Geisinger Health Plan Briefly A Publication for Providers and Office Personnel December 2012 In this issue 2 Improving quality of care 3 NIA update Geisinger Gold update 4 Medical and pharmaceutical policy updates 5 Pressure ulcer coding Commercial formulary update 6 Gold .
