Oregon |September/October 2019
Introducing our new Primary Care Coordinated Care Model for 2020

Effective December 31, 2019, Moda Health’s Synergy and Summit risk model programs will end, and will be replaced with our new Primary Care Coordinated Care Model (CCM/PCP360), which is effective October 1, 2019 for OEBB, and January 1, 2020 for PEBB. OEBB members will access care through the Connexus network, and PEBB members will access care through the Synergy network.

In addition, the Synergy and Summit networks will be combined to form a single statewide Synergy network. The Summit network may stay in existence through 2021 for employer group run-out, but the network is not expected to be maintained long-term, and will not be available for new sales after December 31, 2019.

Although the Synergy and Summit risk model programs will be sunsetting for 2020, the Synergy network of providers will continue to provide services to all non-OEBB group and ASO Synergy and Summit members.

More information about these and other networks can be found on our networks page. 
OHA issues public health warning on the hazards of vaping

The Oregon Health Authority has issued a public health warning for all individuals to stop using vaping products immediately until federal and state officials have determined the cause of serious lung injuries and deaths linked to the use of both cannabis and nicotine vaping products.

On October 9, 2019, the OHA issued a temporary emergency disease reporting rule and banned flavored vaping products for 180 days. In response to this rule, on October 17, 2019, the Oregon Court of Appeals granted a temporary stay of the OHA rule, which removed the ban of flavored vaping products.

Clinicians must, however, continue to report within one working day any patient who has been hospitalized or who died from radiographically or histologically demonstrated lung injury following a history of e-cigarette use or vaping in the preceding 90 days.
Reports may be made to the Oregon Health Authority via phone (971-673-1111) fax (971-673-1100) or online.

At Moda Health, we are also dedicated to supporting all tobacco and nicotine cessation efforts. Providers are encouraged to advise patients on their options for quitting, including counseling, FDA-approved Nicotine Replacement Therapy and other FDA-approved medications. A combination of counseling and medication can increase the chances of successfully quitting.

Additional information can be found on Youth Vaping and Quit Tobacco Your Way flyers.
Medicare Advantage-contracted providers: VSP Advantage Elements update

Moda Health Medicare Advantage plan members will also be enrolled in the VSP Advantage Elements Plan as of January 1, 2019. This benefit is a full-service plan for members who visit a VSP® Advantage network doctor. As part of routine coverage, providers should bill VSP for routine services and refraction services. The plan also features frames from the Genesis Collection by Altair®.
 
Moda Health Medicare Advantage-contracted providers should continue to send non-routine vision services to Moda Health . VSP only administers routine coverage within Moda Health’s Medicare Advantage plans. 

Participating Moda Medicare Advantage providers may join the VSP provider network by calling VSP at  800-615-1883. Joining the VSP network ensures Medicare Advantage members receive the highest routine vision and routine hardware benefit available. The benefit will be available to members who seek routine vision and routine hardware from a VSP network doctor.
2020 changes to Medicare Part B prescription drug decision timelines

Beginning Jan. 1, 2020, decision timelines for Medicare Part B prescription requests will be as follows:

  • Standard Coverage Decisions: For a Medicare Part B prescription drug, a decision will be made within 72 hours of receiving the request
  • Fast (or other similar requests, such as “Expedited,” “Urgent” or “Rush”) Coverage Decisions: For a Medicare Part B prescription drug, a decision will be made within 24 hours of receiving the request

Please note: We cannot take extended time with Medicare Part B prescription drug requests when you request a fast decision. Also, please include all necessary information when you submit a request for a Medicare Part B prescription drug. This includes relevant medical records. If we do not have the information we need to make a decision, we may have to deny the request. 
Moda Health partners with CoverMyMeds online prior authorization platform

Moda Health has partnered with CoverMyMeds to process electronic prior authorization (ePA) requests for medications covered under a member’s pharmacy benefit. CoverMyMeds is a free online platform that accepts requests from your organization’s electronic health record system, or directly through the CoverMyMeds portal.

Prescribers and staff have the option to begin using CoverMyMeds to submit ePA requests that utilize Moda’s custom criteria and question sets for all Moda Commercial, EOCCO, and Medicare Advantage members. As a reminder, please select the form specific to the line of business when submitting an ePA for your patient.

CoverMyMeds provides a convenient and streamlined PA process that supports faster determinations and an automatic PA renewal setup that supports medication adherence amongst your patients. To get started, visit www.covermymeds.com and create a free account.

Weekly webinar trainings are available by visiting www.covermymeds.com/main/support/. CoverMyMeds is also happy to schedule personalized webinars at a day and time that’s convenient for prescribers and staff. Email help@covermymeds.com, or chat live at www.covermymeds.com to request a date and time for a demo.

We appreciate your support in assuring Moda members receive quality care. If you have any questions, please call our Moda Pharmacy Customer Service team toll-free at 888-361-1610.
Prior authorization for filgrastim-sndz (Zarxio) no longer required

Beginning November 01, 2019, Moda Health’s preferred short acting granulocyte colony-stimulating factor (GCSF), filgrastim-sndz (Zarxio), will no longer require prior authorization under the pharmacy or medical benefit.

Quantity level limits and post service claims edits will still apply under the pharmacy and medical benefit, respectively. Non-preferred short acting GCSFs [i.e. filgrastim (Neupogen), filgrastim-aafi (Nivestym), tbo-filgrastim (Granix)] will continue to require prior authorization. While all long acting GCSF products will continue to require prior authorization, pegfilgrastim (Neulasta) and pegfilgrastim-cbqv (Udenyca) are Moda’s preferred products. 

To learn more about our G-CSF medical necessity requirements, please visit our medical necessity criteria page.
Prior authorization now required for Zilretta

Moda Health has partnered with Magellan Rx Management (Magellan Rx) to assist you in medical pharmacy management through the provider administered injectable drug program. To ensure our members receive quality and affordable care, we will implement updates to the review and approval processes of certain injectable medications for all Moda members.

Effective January 01, 2020, triamcinolone acetonide extended release (Zilretta®) will be added to the prior authorization list of medications in the Magellan Rx program.
 
Magellan Rx will review your prior authorization requests for the following 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 or a physician’s office.
To begin requesting prior authorizations through the Magellan Rx self-service portal, visit ih.magellanrx.com/ and select “New Access Request-Provider” on the right side of the home page. Find out which medications require prior authorization through Magellan Rx at modahealth.com/medical/injectables.

To learn more about our injectable drug program, please check out our Injectable Drug Program FAQ.
Avastin named preferred drug for ocular indications

As part of our commitment to provide members with high-quality, affordable care, Moda Health has selected intravitreal bevacizumab (Avastin®) [J9035] as the preferred product for the treatment of various covered ophthalmic indications (e.g. diabetic macular edema, diabetic retinopathy, neovascular age-related macular degeneration).

Beginning January 1, 2020, all Moda fully insured groups, ASO and individual members initiating therapy will be limited to receiving bevacizumab (Avastin), unless deemed medically inappropriate. If there is clinical documentation that bevacizumab (Avastin) is ineffective, not tolerated or contraindicated, aflibercept (Eylea®) [J0178] or ranibizumab (Lucentis®) [J2778] may be administered with a prior authorization approval by MagellanRX or Moda Health.

To learn more about our bevacizumab (Avastin), aflibercept (Eylea), and ranibizumab (Lucentis) medical necessity requirements, please visit our medical necessity criteria page.
Injectable medication updates

The following prior authorization updates have been made to the injectable medications currently in the Magellan RX 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 a n outpatient facility , a patient's home or a physician's office.

Effective January 1, 2020
 
  • Adcetris – To non-Hodgkin’s lymphoma, removed the following indications from coverage: Enteropathy-associated T-cell lymphoma, monomorphic epitheliotropic intestinal T-cell lymphoma, nodal peripheral T-cell lymphoma with TFH phenotype, or follicular T-cell lymphoma, Breast-Implant Associated Anaplastic Large Cell Lymphoma (ALCL), Adult T-Cell Leukemia/Lymphoma, Extranodal NK/T-Cell Lymphoma, Hepatosplenic Gamma-Delta T-Cell Lymphoma. To Primary cutaneous CD30+ T-Cell Lymphoproliferative Disorders, indicated use is for patients previously treated with systemic therapy and removed use as a component of CHP (cyclophosphamide, doxorubicin, prednisone). To B-Cell Lymphomas, restricted use to DLBCL only for subsequent therapy in transplant-ineligible patients and removed use as subsequent therapy for CD30+ monomorphic PTLD (B-cell type). 
  • Alimta – Removed primary central nervous system (CNS) lymphoma as a covered indication. For ovarian cancer, restricted use to platinum-resistant disease.
  • Synribo – For chronic myeloid leukemia, removed use post-allogenic stem cell transplant.
  • Tecentriq – For first-line bladder cancer/urothelial carcinoma in cisplatin-ineligible patients, removed use in patients with PD-L1 expression of ≥5% to restrict use to carboplatin-ineligible patients only. Restricted use to first-line therapy for breast cancer.

Effective February 1, 2020

  • Cyramza Gastric, Esophageal and Gastro-esophageal Junction Adenocarcinoma: To subsequent therapy, added use is after fluoropyrimidine- or platinum-containing chemotherapy.
  • Erbitux CRC: Added ‘will not be used in combination with another biologic agent’ per NCCN. To first-line or primary therapy in combination with FOLFIRI, added ‘for left sided-tumors only’. To BRAF V600E mutation positive disease, removed use in combination with dabrafenib and trametinib. SCCHN: To use in combination with radiation therapy for first-line treatment of regionally or locally advanced disease, indicated cetuximab must be used as a single agent. Created separate criteria for Cancer of the Nasopharynx to indicate use is in combination with carboplatin for first-line therapy. Squamous Cell Skin Cancer: To use for regional recurrence, inoperable positive regional lymph nodes, or distant metastases, indicated must be used as primary treatment or first-line therapy. Penile Cancer: Added ‘Patient must have received prior treatment with a paclitaxel, unless there was a contraindication or intolerance’. NSCLC: Removed indication.
  • Mylotarg – AML: To newly-diagnosed disease as a single-agent, added patient must be 60 years or older or unable to receive intensive therapy with daunorubicin and cytarabine. To post-remission therapy, added patient must have had previous therapy with gemtuzumab ozogamicin (plus daunorubicin and cytarabine if given as induction therapy). Restricted use in relapsed or refractory disease to first relapse. To re-induction therapy, indicated patient is to use the previously successful induction regimen. To acute promyelocytic leukemia, removed use in relapsed disease.
  • Vectibix CRC: Added ‘will not be used in combination with another biologic agent’ per NCCN. To first-line or primary therapy in combination with FOLFOX, added ‘for left sided-tumors only’. Removed use in combination with vemurafenib and irinotecan in patients with BRAF V600E mutation positive disease.  
Medical necessity policy updates

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

Criteria effective Nov. 1, 2019

Criteria effective January 1, 2020
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

Introducing our new Primary Care Coordinated Care Model for 2020

OHA issues public health warning on the hazards of vaping

Medicare Advantage-contracted providers: VSP Advantage Elements update

2020 changes to Medicare Part B prescription drug decision timelines

Moda Health partners with CoverMyMeds online prior authorization platform

Prior authorization for filgrastim-sndz (Zarxio) no longer required

Prior authorization now required for Zilretta

Avastin named preferred drug for ocular indications

Injectable medication updates

Medical necessity criteria updates
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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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