Winter 2017
Prescription Drug Program updates go into effect Jan. 1

Information regarding our Prescription Drug Program can be found on our website under the Arise Drug Formulary page. Specifically, you can access:
  • Our Drug Program Policy, which includes how the formulary is developed and maintained, the prior authorization program, how to pursue an exception, and information on generic substitution and quantity limits
  • The Drug Prior Authorization List, which identifies the applicable medications as well as who to contact to initiate the process; please note that prior authorization has been extended to all injectable chemotherapy (most chemo already requires prior authorization) and antiemetics, such as Aloxi and Emend
  • Formulary/Preferred Drug List
FORMULARY/PREFERRED DRUG LIST CHANGES FOR JAN. 1, 2018

Preferred Drug List Additions*
Estring
Phoslyra
Velphoro
 
Preferred Drug List Exclusions with Alternatives**
Drug names listed in CAPITALS are BRAND NAME DRUGS. Drug names listed in lowercase are generic drugs.
 
Preferred Drug List Exclusion
Preferred Alternatives
ACIPHEX SPRINKLE
esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, NEXIUM Packets
ACTOPLUS MET XR
pioglitazone-metformin, metformin, pioglitazone
AZASAN
azathioprine
BASAGLAR KWIKPEN
LANTUS/SOLOSTAR, LEVEMIR/FLEXTOUCH, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH
BUTRANS
fentanyl patch
CONDYLOX 0.5% GEL
podofilox, imiquimod
EPINEPHRINE AUTO-INJECTOR (by A-S Medications, Impax & Lineage)
EPINEPHRINE AUTO-INJECTOR (by Mylan), EPIPEN, EPIPEN JR.
FEMRING
estradiol patches, estradiol tablets, yuvafem, ESTRACE Cream, ESTRING, PREMARIN Cream, PREMARIN Tablets
FML S.O.P.
dexamethasone sodium phosphate, fluorometholone, prednisolone sodium phosphate, LOTEMAX
FORTEO
alendronate sodium, ibandronate sodium, risedronate sodium, zoledronic acid, TYMLOS
FOSRENOL
sevelamer, PHOSLYRA, VELPHORO
KALBITOR
FIRAZYR
LAZANDA
fentanyl citrate lozenges
NEUPOGEN
GRANIX, ZARXIO
NEVANAC
bromfenac sodium, diclofenac sodium, ketorolac tromethamine, ILEVRO, PROLENSA
OXYCODONE HCL ER
hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OXYCONTIN
PRADAXA
ELIQUIS, XARELTO
PRED MILD
dexamethasone sodium phosphate, fluorometholone, prednisolone sodium phosphate, LOTEMAX
PREVACID SOLUTAB
esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, NEXIUM Packets
PRILOSEC SUSPENSION
esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, NEXIUM Packets
PROCTOFOAM-HC
hydrocortisone-pramoxine, pramcort
PROTONIX SUSPENSION
esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, NEXIUM Packets
RENAGEL
sevelamer, PHOSLYRA, VELPHORO
SANDOSTATIN LAR/ DEPOT
SOMATULINE DEPOT
SIGNIFOR LAR
SOMATULINE DEPOT
SUMAVEL DOSEPRO
sumatriptan injection
TEKAMLO
amlodipine, amlodipine-valsartan, benazepril, lisinopril, losartan, telmisartan-amlodipine
TIMOPTIC OCUDOSE
timolol, betaxolol, levobunolol, ALPHAGAN P, COMBIGAN
TREXALL
methotrexate
TRULANCE
AMITIZA, LINZESS
TUSSICAPS
hydrocodone-chlorpheniramine, promethazine w/codeine
ZORVOLEX
diclofenac potassium, diclofenac sodium
 
If you would like a copy of this information, please contact our Provider Contact Center at
888-711-1444.

* May be subject to prior authorization requirements.
**Arise has a pharmacy exception process. Exceptions must be approved in advance for coverage.
Frequently asked question about viscosupplementation

In our Summer issue, we shared the change in coverage for viscosupplementation. That has resulted in questions regarding prior authorization of service. Because the service is no longer covered, we don't advise providers to submit prior authorization requests.
 
Prior authorization requests for the following will be returned as not approved : 

Viscosupplement injections including, but not limited to:

Hyaluronan or derivative
Genvisc 850
Orthovisc
Euflexxa
Hyalgan
Synvisc
Gel-one
Hymovisc
Synvisc-One
Gel-syn
Monvisc
Supartz


 
Note : Although injection, aspiration, and biopsy of large joints such as knee, hip, shoulder, and other limb joints does not require prior authorization, coverage of, and the need for, prior authorization of the substance being injected should be verified.

Questions and comments may be sent to the Medical Policy Committee at [email protected] . For questions regarding medical coding related to Medical Policies, please contact the Code Governance Committee at  [email protected] .
Provider Manual revised for 2018

In the first quarter of 2018, please watch our website for our updated 2018 Provider Manual with new information you need to know. Our Provider Manual is designed and produced for our participating providers to promote a clear understanding of our policies and procedures, including provider services, prior authorizations, claims, and eligibility. Participating providers are required to participate, cooperate, and comply with the program as outlined in this Provider Manual.
 
View the current 2017  Arise Provider Manual on our website.
Coordination of care is crucial among behavioral health and primary care practitioners

Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment, and referral. The importance of communicating with the customer's other health care practitioners cannot be overstated. This includes primary care practitioners (PCPs) and medical specialists, as well as behavioral health practitioners.
Coordination of care is especially important for customers with complex medical care needs and those referred to a behavioral health specialist by another health care practitioner. All practitioners should obtain the appropriate permission from these customers to coordinate care among behavioral health and other health care practitioners at the time treatment begins.
 
We expect all health care practitioners to have a mechanism in place to:
  • Discuss with the customer the importance of communicating with other treating practitioners
  • Obtain a signed release from the customer and file a copy in the medical record
  • Document in the medical record if the customer refuses to sign a release
  • Document in the medical record if you request a consultation
  • If you made a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner
  • Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
    • Diagnosis
    • Treatment plan 
    • Referrals
    • Psychopharmacological medication (as applicable)
With this collaborative approach, we can achieve excellent coordination of care and help improve health outcomes.
Radiology benefit management updates   

We continue to use NIA Magellan (National Imaging Associates Magellan), an accredited leader in the management of outpatient radiology benefits in the utilization management (UM) process. Updated NIA Radiology guidelines become effective in January 2018.
 
As of Dec. 4, 2017, providers can preview the complete set of the updated 2018 advanced imaging clinical guidelines through the RadMD portal prior to the implementation date of Jan. 2, 2018. You can continue to view all the current guidelines by accessing your RadMD account.
 
Highlights of the guideline changes to be implemented in January 2018 are as follows:
 
 Global change to applicable guidelines
  • A follow-up study may be needed to help evaluate a patient's progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested. This was moved from the "Additional Information" section to be included as an approvable indication. 
PET scan (oncology) guideline
  • Clinical indications were added to cover an oncological Gallium 68 Dotatate PET/CT scan.
  Cardiac guidelines (Heart (Cardiac) CT, Heart (Cardiac) MRI, Stress Echo, TTE, TEE)
  • Clinical indications added to several of our cardiac guidelines to address valvular heart disease, supported by JU Doherty et al, ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease, JACC, 2017.
On Dec. 4, 2017, NIA will place a link on RadMD so that you can preview the complete set of the 2018 advanced imaging clinical guidelines prior to their implementation on Jan. 2, 2018, by following the instructions below. Meanwhile, you can continue to view all your current guidelines by accessing your RadMD account.
 
To access the link on RadMD, please follow these steps (sign in is not required):
  • Go to the RadMD home page at radmd.com
  • Click on the Solutions tab from the home page's main menu bar
  • From the Solutions drop-down list, click on Advanced Imaging
  • Click on the link for Preview of NIA's 2018 Standard Guidelines, listed under the Document section.
    • The Table of Contents begins on page 3 of the PDF document
    • Click once on the study to be viewed
    • To return to the Table of Contents, click on "TOC" in the upper right-hand corner above the heading of each guideline
Remember, effective Jan. 2, 2018, NIA will replace the current clinical guidelines with the updated 2018 version. Check your RadMD portal and our website for additional information, coming soon.
Quarterly Medical Policy Updates

The Medical Policy Committee met this quarter and approved the medical policies due for annual review. The policy updates were emailed to providers Oct. 30, 2017, and we have included them in this issue for your convenience .
 
 
Please be sure all doctors, other clinical staff, and office staff are aware of these changes before submitting requests for coverage. We ask that you share these policy changes with providers who may be ordering or performing services and clinicians who may be referring patients for services.
 
The complete library of our medical policies can be found at Arise Medical Policies. Our Prior Authorization list can be found at Arise Prior Authorization List . No password required!
 
Specific questions or comments regarding development of policy content may be directed to the Medical Policy Editor [email protected] or 800-333-5003, ext. 64133.
Do you know your practitioner credentialing rights?

Credentialing of practitioners is performed by our Credentialing Department upon initial contracting of practitioners and every three years thereafter. Practitioners undergoing the credentialing process have the following rights:
  • You have the right to review a summary of outside information obtained by the Credentialing Department for the purpose of evaluating your application.
    • Requests to review a file shall be made to the Credentialing Manager. The review will take place on site during normal office hours.
    • Providers shall not have access to references from other practitioners/health care facilities, recommendations, or peer-review protected information received as part of the credentialing process.
    • Providers may receive a copy of only those documents provided by or addressed personally to the provider. A written summary of all other information shall be provided to the practitioner by the Medical Director or his/her designee.
  • You will be promptly notified of information that varies significantly from the information you have provided and be given the opportunity to submit updated/additional documentation or corrections to the Credentialing Department. The correction of erroneous information must be done in writing within 10 days of being notified of the varying information. The Credentialing Department is not obligated to reveal the source of information if disclosure is prohibited by law.
  • You have the right, upon request, to be informed of the status of your application at any time. Requests shall be directed to the Credentialing Manager. Credentialing Manager shall promptly provide applicant with information regarding date of application receipt, general category of items outstanding, and target approval date.
  • You will be notified of the Credentialing Department's decision regarding your application via written letter within 60 calendar days of the department's credentialing or recredentialing decision.
If you have any questions regarding the credentialing process, please contact the Credentialing Manager at 920-490-6952.
Arise Health Plan | P.O. Box 11625 | Green Bay, WI | arisehealthplan.com
JO6505
27886-085-1712
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