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1199SEIU Benefit and Pension Funds 330 West 42nd Street New york, NY 10036-6977
Non-Profit U.S. Postage PAID New York, NY Permit No. 3700
1199SEIU PROVIDER
Connections
Your Key to the 1199SEIU Benefit Funds
Fall 2010
ADDRESS SERVICE REQUESTED
Reminder: Message from the
Executive Director
COMING SOON: Personalized Patient, Coverage and Claims Information at the Click of a Button In just a few months, 1199SEIU providers will have access to a new, online system that will provide the detailed, personalized information you need from the Funds.You will be able to check your 1199SEIU patients’ eligibility and benefit coverage, as well as claims status, remittance statements and Explanations of Payment with the click of a button. This service will be provided through Navinet, a system that many of our 1199SEIU Benefit Funds’ providers already use for other payers. If you already have a Navinet account, you won’t need to make any changes at all. A single log-in will allow you to access information from all your contracted payers, including the Funds.
Utilization Review for Radiology Services The Benefit Funds have contracted with a new vendor, Care to Care, to provide utilization review for our members’ non-emergent, outpatient MRA, MRI, PET and CAT scans beginning January 1, 2011. Care to Care will add an extra level of review to ensure that our members receive the highest quality and most appropriate radiology services. If your 1199SEIU patients need any of these services, please continue to call (888) 910-1199 to request prior authorization. MedFocus remains our preferred radiology provider network, so you can still refer our members to the same imaging sites and providers.
We know that in order for you to continue providing highquality care to our members, you need accurate, up-to-date information on our 1199SEIU Benefit Funds’ coverage and policies. In this issue of Provider Connections, we let you know about several important changes. First, under the new healthcare reform law, we will extend coverage of dependents to age 26 and eliminate lifetime and newborn benefit maximums beginning January 1, 2011.We have also made several updates to our prescription benefit program that may require some changes in the way your 1199SEIU patients access certain medications. And we have included information about an exciting new service that we will soon be providing to you – an online provider portal that will give you electronic access to detailed eligibility and claims information whenever you need it. As always, we value our ongoing relationship with you and hope you find the information in this newsletter helpful. If you have any questions or concerns, we encourage you to speak to your Provider Representative, or contact our Provider Relations Department at (646) 473-7160.
Keep an eye out for more details! Mitra Behroozi
No Separate Facility Charge for Office-Based Surgeries If your 1199SEIU patient undergoes a surgical procedure at an office-based surgery center, the Benefit Funds will reimburse the practitioner at the full office-based rate but will not pay a separate facility charge. Any facility charges billed on a CMS 15 or UB04 form will be denied. If you have any questions about our reimbursement policies, please contact our Provider Representatives at (646) 473-7160.
Remember: LabCorp and Quest Are the Funds’ Preferred Labs When you need to refer your 1199SEIU patients for any lab services, we want to remind you to be sure to use only our preferred labs – LabCorp and Quest Diagnostics. Referring our members to the Funds’ preferred labs helps them get the quality care they’ve earned with no unnecessary out-of-pocket costs. Of course, for specialized lab tests, be sure to first contact the Funds at (646) 473-7160 to determine if prior authorization is required.
Pre-Authorization Now Required for Certain Oral and Spinal Surgeries Beginning in 2011, our list of ambulatory surgical procedures that require pre-certification will be expanded to include certain oral surgeries and certain spinal surgeries. If your 1199SEIU patient requires such a procedure, you or the member must call CareAllies at (800) 227-9360 to receive pre-authorization. Please watch for further announcements.
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Health Reform Changes: Dependent Coverage Extended to Age 26; Maximums for Lifetime, Newborn and Biotech Drug Coverage Eliminated as of January 1, 2011 The recent passage of the Patient Protection and Affordable Care Act brings good news for 1199SEIU members. Effective January 1, 2011, coverage for dependents will be extended to age 26. The Funds are currently in the process of enrolling eligible dependents and will be issuing new 1199SEIU Health Benefits ID cards to these members and their children before the beginning of the new year. We are also eliminating the maximum lifetime benefit (currently $1 million for National Benefit Fund members in the Member Choice program, or $500,000 for NBF members not in Member Choice and for Greater New York Benefit Fund members). In addition, the $100,000 maximum on newborn coverage will be removed, as will the $100,000 maximum for biotechnology drugs for medically necessary treatment. If any of your 1199SEIU patients are affected by these changes or have questions about what the changes will mean to them, please refer them to our Member Services Representatives at (646) 473-9200.
Prescription Benefit Updates: New Medications Added to Dose Optimization and Specialty Care Pharmacy Programs As part of our ongoing effort to maintain a cost- and clinically effective prescription drug program, the Funds are making several updates to our prescription benefit program.
Dose Optimization Program Effective November 2, 2010, we will add nine new drug classes to our Dose Optimization Program, including those for rheumatoid arthritis, osteoporosis, Parkinson’s treatment and others.This means that we will no longer cover prescriptions for two tablets or capsules of these drugs per day if they are available in a higher strength and may be prescribed once a day. Of course, the Funds base these decisions on whether or not the dose has the same therapeutic effect, based on FDAapproved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective. If you feel that twice-a-day dosing is necessary for your 1199SEIU patients, you may contact Medco for a coverage review at (800) 417-1764.
Category
Affected Drugs
1) Selective Aldosterone Blockers
Inspra 25mg tablet, generic Eplerenone
2) Anticonvulsants
Gabitril 2mg tablet
3) Antinarcolepsy
Provigil 100mg tablet
4) Rheumatoid Arthritis
Arava 10mg tablet, generic Leflunomide
5) Osteoporosis
Fosamax 5mg tablet, generic Alendronate sodium
6) Parkinson Agents
Azilect 0.5mg tablet
7) Beta Blockers
Coreg CR 10mg, 20mg, 40mg capsule
8) Anti-viral (chronic Hepatitis B infection)
Baraclude 0.5mg tablet
9) Calcium Channel Blockers
Cardizem CD 120mg, 180mg; Cardizem LA 120mg, 180mg (generic Diltiazem SR tablets); Cartia XT 120mg; Dilacor 120mg
Questions about Our Prescription Program? You Can Get Answers 24/7 at www.1199SEIUBenefits.org The fastest, most convenient way to find details on our prescription programs is right at your fingertips when you visit www.1199SEIUBenefits.org. You’ll find our latest Preferred Drug List, details of our plan design, our participating pharmacies and all of the medications requiring prior authorization or special handling. And while our Provider Representatives are always happy to answer your questions by phone from 9:00 am to 5:00 pm, Monday through Friday, our website is available 24 hours a day, seven days a week. Log on today!
Fifteen Drugs Added to Specialty Care Pharmacy The Benefit Funds have added 15 drugs to our specialty care pharmacy, Accredo.The specialty care pharmacy is a reliable and safe way for members to access medications that may require special handling, such as refrigerated or injectable drugs. Members using these medications must have them delivered through Accredo rather than pick them up at a pharmacy. If your 1199SEIU patient requires one of these medications, you will need to call Accredo at (800) 987-4904 and provide the member’s 1199SEIU Member ID number.The Accredo specialty pharmacist will arrange for the medication to be delivered directly to your patient. The new specialty medications are: • Actemra • Istodax • Ampyra • Myobloc • Botox • Prolia • Dysport • Qutenza • Epoprostenol • Revatio for injection for injection • Vpriv • Hizentra • Wilate • Iprivask • Xiaflex A full list of specialty care drugs is available on our website at www.1199SEIUBenefits.org.