Oregon |July/August 2019
2019 Provider Workshops are just around the corner!

Moda's 2019 Medical Provider Workshops are set to begin October 16, 2019. Join us to learn about our 2019 updates and get a glimpse of what's ahead for 2020.

To save a seat at our next workshop, be sure to visit  our workshop page .
OEBB/PEBB Coordinated Care Model (PCP360) Q & A

Earlier this year, we began rolling out what is known as our Coordinated Care Model (CCM) for our OEBB and PEBB members. Now that Open Enrollment has begun for our OEBB members, we wanted to share some quick facts about the program .

Q: What is the Coordinated Care Model?
A : Also known as CCM, the Coordinated Care Model focuses on primary care. The goal of the model is to encourage the use of high performing PCPCH providers and coordinated care management.

Q: Who does the Coordinated Care Model apply to?
A: This model was created specifically for our OEBB and PEBB members.

Q: How do I know if my practice is participating in the Coordinated Care Model?
A: Earlier this year, our contracting team worked with qualifying health systems and clinics to get CCM agreements signed. In order to qualify, a health system or clinic must be PCPCH certified and/or participating in the CPC+ program.

Q: What is a PCP 360?
A: Primary Care Providers who practice for a health system or clinic who have signed a CCM agreement are known as a ‘PCP 360’. These providers are identified in Find Care by the following ‘badge’:  
Q: How can I become a PCP 360? 
A: If you are interested in becoming a PCP 360, you will first need to be certified as a PCPCH by the Oregon Health Authority. Please visit the following website to start the certification process: https://www.oregon.gov/oha/hpa/dsi-pcpch/Pages/index.aspx
Medicare Advantage providers: important Quality Improvement Organization (QIO) updates

Led by the Centers for Medicare & Medicaid Services (CMS), the QIO Program is one of the largest federal programs dedicated to improving health quality at the local level. QIOs also help Medicare beneficiaries exercise their right to high-quality health care. Patients benefit from the QIO Program by having their quality of care complaints and appeals addressed, as well as from the QIO improvement initiatives those complaints and appeals inspire.

Beginning June 8, 2019, Medicare Advantage beneficiaries in Region 10 (Oregon, Washington, Alaska, Idaho) who are concerned about the medical care they received can contact KEPRO to obtain a free case review. KEPRO is available to assist Medicare Advantage beneficiaries who have questions about whether they are ready for discharge from a hospital or skilled nursing facility, whether they received appropriate medical care, or if they need intervention with a provider.

If your facility is located in one of these states, please take action on two important updates:

Update your Appeals Notices
To ensure your Medicare beneficiaries are able to contact KEPRO to make timely appeals, please update information you provide to them, including:

Post-Acute Care Providers
  • Update your Notice of Medicare Non-coverage with KEPRO’s phone number for your Region.
 
Acute Care Providers
  • Update your Important Message from Medicare with KEPRO’s phone number for your Region.
Complete a Memorandum of Agreement (MOA) and Provider Update Form
Visit www.keproqio.com/moa to complete the MOA and Provider Update Form and
submit it to KEPRO.
Asthma Guideline Update: Say Goodbye to SABA Monotherapy

Did you know that short-acting beta-agonist (SABA) monotherapy is no longer recommended? The Global Initiative for Asthma (GINA) guidelines now recommend that asthma be treated with low-dose inhaled corticosteroid (ICS)-containing controller therapy. Mild asthma treated with SABA monotherapy is “associated with increased risk of exacerbations and lower lung function.” Moreover, patients who use three or more canisters per year are prone to these increased risks, and those who use at least 12 canisters per year have an increased risk of asthma-related death.

These recommendations are supported by a large, double-blind, randomized, Phase 3 trial that studied as-needed SABA monotherapy versus low-dose ICS plus as-needed SABA. Secondary endpoint results showed that removal of an as-needed SABA had a decreased difference in the treatment effect between the treatment-arms.

Updated guidance in managing asthma patients is reflected in Table 1 and Table 2:

Flu season is almost here

Influenza season is approaching and it is time to guide your patients to take preventative action against the flu. Although the severity of influenza varies from year-to-year in the United States, millions of illnesses and tens of thousands of influenza deaths have occurred since 2010, according to the CDC.

In May 2019 interim estimates of vaccine effectiveness, completed by the U.S. Flu Vaccine Effectiveness Network, showed vaccination reduced the overall risk for medically attended respiratory illness by 47% over the 2018-2019 influenza season.
Even during seasons when vaccines are less effective, vaccination can offer substantial benefit and reduce the likelihood of severe outcomes including hospitalization and death. This past season’s estimates will be published later this year; however, during the 2017–18 season, vaccination significantly reduced influenza related illness, medical visits, hospitalizations and deaths in the United States by 38%.

Recommendations:
  • Influenza vaccines are recommended for all persons 6 months and older.
  • Emphasis should be placed on high-risk groups, including but not limited to:
  • Children aged 6-59 months, adults aged > 50 years, women who are or will be pregnant during the influenza season, and persons with chronic conditions, who are immunocompromised, or who are extremely obese.
  • Live Attenuated Influenza Vaccine (LAIV) versus inactivated influenza vaccine (IIV)
  • The American Academy of Pediatrics (AAP) recommends the flu shot (inactivated influenza vaccine [IIV3/4]) as the primary choice for all children for the 2019-20 season. However, with the new formulation of LAIV (nasal spray flu vaccine) that suggest better antibody response than previous LAIV, AAP stated that LAIV may be used in children who would not otherwise receive a vaccine.
  • The CDC's Advisory Committee on Immunization Practices (ACIP) did not express preference for any one vaccine over another.
Reminders:
  • Influenza vaccines are typically covered under the pharmacy benefit.
  • Pharmacists are able to administer flu shots to patients seven years and older.
  • The majority of members may qualify for a $0 copay.
Ultomiris named preferred product for the treatment of Paroxysmal Nocturnal Hemoglobinuria (PNH)

As part of our commitment to provide members with high-quality, affordable care, Moda Health has selected ravulizumab-cwvz (Ultomiris®) [J1303] as the preferred product for the treatment of Paroxysmal Nocturnal Hemoglobinuria (PNH).

Beginning Nov. 1, 2019, all Moda fully insured groups, ASO, and Individual members initiating therapy will be limited to receiving ravulizumab-cwvz (Ultomiris), unless deemed medically inappropriate. If there is clinical documentation that ravulizumab-cwvz (Ultomiris) is ineffective, not tolerated, or contraindicated, eculizumab (Soliris®) [J1300] may be administered with a prior authorization approval by MagellanRX or Moda Health.

To learn more about our ravulizumab-cwvz (Ultomiris) and eculizumab (Soliris) medical necessity requirements, please visit our medical necessity criteria page at modahealth.com/medical/medical_criteria.shtml .

We appreciate your support in assuring our members receive quality care. If you have questions, please call our Customer Service team toll-free at 877-605-3229.
Bendamustine named preferred drug for the treatment of oncology indications

As part of our commitment to provide members with high-quality, affordable care, Moda Health has selected bendamustine (Bendeka®) [J9034] and bendamustine ready-to-dilute (Belrapzo®) [J9036] as the preferred bendamustine products for the treatment of various oncology indications.

Beginning Nov. 1, 2019, all Moda fully insured groups, ASO, and Individual members initiating therapy will be limited to receiving bendamustine (Bendeka) or bendamustine ready-to-dilute (Belrapzo), unless deemed medically inappropriate. If there is clinical documentation that bendamustine (Bendeka) or bendamustine ready-to-dilute (Belrapzo) are ineffective, not tolerated, or contraindicated, bendamustine (Treanda®) [J9033] may be administered with a prior authorization approval by MagellanRX or Moda Health.

To learn more about our bendamustine medical necessity requirements, please visit our medical necessity criteria page at modahealth.com/medical/medical_criteria.shtml .

We appreciate your support in assuring our members receive quality care. If you have questions, please call our Customer Service team toll-free at 877-605-3229.
Site of Care expansion

Effective November 1, 2019, the Site of Care program medication list will include ravulizumab-cwvz (Ultomiris) and Patisiran (Onpattro
Background/additional information:
We work with Magellan Rx for medical pharmacy management and for our provider administered injectable medication and claim edit programs to ensure our members receive quality and affordable care.

On Oct. 1, 2017, our partnership with Magellan Rx expanded to include a Site of Care program that directs members to the most cost-effective, yet clinically appropriate location, to receive their infusion(s) of the select specialty medications. The Site of Care program applies to all fully insured Commercial members and to all EOCCO members who began using these medications on or after Oct. 1, 2017. 

The medications included in the Site of Care program already require prior authorization through Magellan Rx. The Site of Care program requirements are administered as part of the existing prior authorization program. Through the program, infusion requests for a hospital outpatient setting for the medications included in the Site of Care program are redirected to a preferred site of service (e.g. home infusion, professional office setting). Infusions for these medications will not be covered when administered in a hospital outpatient infusion center.

To prevent a delay in care and allow adequate transition time for Moda members to an alternate infusion site, Site of Care program requirements will be waived for the first sixty (60) days only after prior authorization approval so that members can transition to a different infusion site.

Making sure our members receive the best possible care at the most affordable price is why we come to work each day. We know we cannot do this alone. We appreciate your support in helping us deliver high quality, affordable care to Moda Health and EOCCO members.

To learn more about the Site of Care program and view the current medication list, please go to modahealth.com/medical/siteofcare.shtml.

Questions?
We’re here to help. Just email medical@modahealth.com or call us toll-free at 800-258-2037.
Injectable medication updates

The following prior authorization updates have been made to the injectable medications currently in the MagellanRX program. Magellan Rx will review all prior authorization requests for these specialty injectable medications, along with other specialty medications that are already part of the program when administered in:

  • An outpatient facility
  • A patient's home
  • A physician's office

Effective Nov. 1, 2019

  • Arzerra – Use as a substitute for rituximab in patients experiencing rare complications was removed
  • Gazyva – For follicular lymphoma, removed use as first-line consolidation therapy, second-line consolidation therapy, and as a substitute for rituximab in patients experiencing rare complications. For NLH, removed use as a substitute for rituximab in patients experiencing rare complications.
  • Rituxan – Use in relapsed or refractory ALL was removed as a covered indication. For CNS cancer, removed use in leptomeningeal metastases from lymphomas, use in combination with methotrexate as a component of consolidation therapy, and use as a single agent or in combination with lenalidomide or high-dose methotrexate for relapsed or refractory disease. For relapsed/refractory CLL/SLL, removed use in combination with alemtuzumab and high-dose methylprednisolone and removed use in combination with chlorambucil and combination with pentostatin and cyclophosphamide (without del17p only)

Effective Dec. 1, 2019

  • Bendamustine – The following indications will no longer be covered: AIDS-related B-cell lymphomas, monomorphic post-transplant lymphoproliferative disorder, adult T-cell leukemia/lymphoma, mycosis fungoides/Sezary syndrome, primary cutaneous CD30+ T-cell lymphoproliferative disorder indications, and hepatosplenic gamma-delta T-cell lymphoma
  •  Beleodaq – To PTCL, restricted use in anaplastic large cell lymphoma to ALK-negative disease only and removed use in enteropathy-associated T-cell lymphoma, monomorphic epitheliotropic intestinal T-cell lymphoma, nodal peripheral T-cell lymphoma with TFH phenotype, and follicular T-cell lymphoma. Also removed adult T-cell leukemia/lymphoma, mycosis fungoides/Sezary syndrome, extranodal NK/T-cell lymphoma (nasal type), hepatosplenic gamma-delta T-cell lymphoma, and primary cutaneous CD30+ T-cell lymphoproliferative disorder indications
  • Empliciti – For multiple myeloma when used in combination with bortezomib and dexamethasone, use is indicated after failure of one to three prior therapies.
  • Kyprolis - When used in combination with dexamethasone and cyclophosphamide for previously treated multiple myeloma, at least one prior regimen for relapsed/refractory disease must have been used. For Waldenström’s Macroglobulinemia, removed use in relapsed disease as a covered indication.
  • Poteligeo – Primary treatment as systemic therapy removed as a covered indication.

Learn more about the injectable medication program and view the  current medication list  .
Medical necessity policy updates

We've recently updated our medical necessity criteria. You can find the following changes at our  medical necessity criteria page.

  • Air ambulance
  • Medical Nutrition Therapy/Nutritional Counselling
  • Push-rim activated power assist device (to be posted 9/3/19)
  • Ankle-foot (AFO)/Knee-Ankle-Foot (KAFO)/Hip-Ankle-Foot-Foot (HKAFO) orthoses (to be posted 9/3/19)
  • Upper extremity orthoses (shoulder, elbow, wrist, hand, finger) (to be posted 9/3/19)

Behavioral Health Medical necessity policy updates:


Learn more on our   medical necessity criteria page.
Moda Contact Information

Moda Medical Customer Service
For claims review, adjustment requests and/or billing policies, please call 888-217-2363 or email  medical@modahealth.com.

Moda Provider Services
For escalated claim inquiries, contract interpretation, educational opportunities or onsite visit requests please email providerrelations@modahealth.com.

Medical Professional Configuration
For provider demographic and address updates, please email providerupdates@modahealth.com.

Credentialing Department
For credentialing questions and requests, please email credentialing@modahealth.com.
In this Issue

2019 Provider Workshops are just around the corner!

OEBB/PEBB Coordinated Care Model (PCP360) Q & A

Medicare Advantage Quality Improvement Organization (QIO) program

Asthma Guideline Update: Say Goodbye to SABA Monotherapy

Flu season is almost here

Ultomiris named preferred product for the treatment of Paroxysmal Nocturnal Hemoglobinuria (PNH)

Bendamustine named preferred drug for the treatment of oncology indications

Site of Care expansion

Injectable medication updates

Medical necessity policy updates
Go digital today!

If you want to start exchanging information electronically with Moda, please contact the Moda Electronic Data Interchange team at edigroup@modahealth.com
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Help us keep your practice details updated

To make sure we provide high-quality service to our members, Moda's Findcare online search tool helps members connect with our extensive network of contracted providers. To meet the CMS requirement of having updated information about your practice or facility for our members, please email our provider updates team at
providerupdates@modahealth.com when any of the following changes occur, including the effective date:

  • New street address, phone number or office hours
  • Changes in the "When you are accepting new patients" status for all contracted Moda lines of business
  • Changes that affect the availability of providers in your practice

This will help make sure our members can find providers that are available and best suit their needs.

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