|
In this bulletin, we’ll share updates about our work to review and reduce requirements for Prior Approvals, how to get credentialed, coverage for nutrition therapy, the expansion of our behavioral network and virtual primary care, a few ways patients can save on prescriptions, an update on Humira biosimilars and medical benefit updates.
Cutting the Red Tape: Making it Easier to Get Prior Approvals
Getting a medical procedure can be nerve wracking enough, without the red tape of requiring referrals and Prior Approvals. Community Health Options doesn’t require referrals and uses evidence-based care guidelines to approve the care Members need. In some cases, our Utilization Management team may even deny an approval request so our clinician can work with you to offer a higher level of care.
In 2023, we dropped Prior Approval requirements for 5,000 codes primarily across three categories—ultrasounds, obstetrics ultrasounds and services related to treating fractures. The Utilization Management team’s code review committee continues to review and revise Prior Approval requirements on an ongoing basis. You can read more on our approach to Prior Approval in a recent blog.
Please contact us with any questions.
Credentialing is as Easy as One-Two-Three
You’ve submitted a credentialing application to Community Health Options, so what’s next?
- Confirm receipt of your application.
- Ensure your CAQH is up to date and Community Health Options is authorized to access the application.
- Make sure your credentialing contact is listed correctly and all supporting documentation is up to date.
We’ll send a welcome letter as soon as the application’s approved. And if we need additional information during the verification process, we will reach out using the credentialing contact listed on your application.
Community Health Options Members Have Coverage for Medical Nutritional Therapy
Community Health Options provides benefits for medical nutrition therapy visits for select conditions and for Members with specified benefits through our Chronic Illness Support Program (CISP). Members who have had a preventive visit for diet counseling, obesity screening (adult or child), prediabetes screening, Type 2 diabetes screening and preventive weight gain in pregnancy are eligible for 12 medical nutritional therapy visits at no cost. Additional visits are subject to cost sharing.
Costs are also waived for up to 12 medical nutritional therapy preventive visits for Members through CISP if they are diagnosed with diabetes, coronary heart disease or hypertension. Additional visits are subject to cost sharing.
All other Members will have a cost-share associated with medical nutritional therapy.
There is no Prior Approval required.
Community Health Options Expands Behavioral Health Support
At Community Health Options, behavioral health is treated the same as any other healthcare need. “We don’t separate the mind and the soul from the body,” says Dr. Lori Tishler, the company’s chief medical officer.
Yet the people of Maine often struggle to find the support they need. More than 37% of Maine adults reported symptoms of anxiety or depression and 65,000 went without the healthcare they needed in 2021, according to NAMI Maine, a part of the National Alliance on Mental Illness. NAMI also found Mainers are 11 times more often forced out-of-network for mental health care than for primary care.
In 2023, Community Health Options continued to restructure and expand its behavioral health network by adding 493 new providers at facilities and in private practice across the state, including counselors, psychiatrists, psychologists, therapists and social workers who can provide a range of support to youth and adults.
Virtual Options Support Members Needing Primary Care
We know providers in Maine are under pressure to meet the growing demands for care, particularly when it comes to serving those looking for a primary care provider.
Providers with little capacity to take on new patients should feel comfortable suggesting patients check out Firefly, which works with Maine-based labs, specialists and facilities to deliver in-person care when it’s necessary.
Earlier this year, for example, a Member contacted Member Services after her longtime primary care physician retired. She wasn’t feeling well and had some concerns but couldn’t find anyone who could see her without waiting eight months. Member Services suggested Firefly Health and she had an appointment that day, not only to address her immediate concerns, but to catch up on preventative screenings and begin to build a new PCP relationship. Said another Member from a remote area of the state using Firefly, “I wouldn’t have access to in-network healthcare without it.”
Any Member 18 and over can choose a Firefly virtual primary care team that includes a primary care provider, nurse practitioner, behavioral health specialist and health guide. To see what we have to say about when telehealth or virtual care might be a great choice, read our recent blog.
Pharmacy Programs Help Members to Save on Costs
Remember that the Maine-based Community Health Options care teams are specially trained to help Members save money on and manage their prescriptions. Here are a few programs your patients can benefit from:
• Through the ScriptSaver program, Community Health Options pharmacists work with providers, pharmacies and drug manufacturers to reduce a Member's costs and to explore potential coupon savings. In 2023, the program yielded $170,100 in annualized Member prescription savings.
• Price Assure, a program offered through Express Scripts® helps Members reap potential savings on generic medications when they fill prescriptions at in-network retail pharmacies accepting GoodRx. Members automatically pay the lower price when GoodRx offers a better price than Express Scripts without having to sign up for GoodRx.
• Through the voluntary Site of Care infusion program, our Utilization Management team works with Members needing infusion therapy to help determine the best place to get care, which may even be in their home based on the Member’s location and medication being prescribed. The program gained $1.04 million in annualized savings in 2023.
Humira Biosimilars Added to Express Scripts’ Formulary
With Humira’s (adalimumab) exclusivity ending in 2023, several biosimilars have emerged in the marketplace to treat and reduce the signs and symptoms of such autoimmune conditions as Crohn’s disease, rheumatoid arthritis and plaque psoriasis.
While there are currently products available from 10 different manufacturers, four have interchangeable status—providing opportunities for greater access to treatment while maintaining therapeutic effectiveness.
Express Script’s preferred biosimilar products include Hyrimoz and Cyltezo. Information about interchangeability status of biosimilar products can be found in the FDA’s Purple Book.
| 
