Tufts Health Public Plans FEBRUARY 2017 Provider News This issue includes information for Tufts Health Public Plans products (including Tufts Health Direct, Tufts Health Together and Tufts Health Unify). For information pertaining to Tufts Health Plan Commercial (including the Tufts Health Freedom Plan), Tufts Medicare Preferred HMO and Tufts Health Plan Senior Care Options products, refer to the Tufts Health Plan Provider Update newsletter. Contact Us 60-DAY NOTIFICATIONS Phone: 888.257.1985 Preferred Drug List Changes for Tufts Health Together Business hours: Monday through Friday, Effective April 1, 2017, there are changes to the Preferred Drug List for Tufts Health Together. 8 a.m. to 5 p.m., excluding holidays Update to prior authorization requirements for Elidel (pimecrolimus), Entresto (sacubitril/ By mail: valsartan), Gralise (gabapentin extended-release), Horizant (gabapentin enacarbil), Tufts Health Plan P.O. Box 9194 Promacta (eltrombopag) and tacrolimus ointment Watertown, MA 02471-9194 Effective for prior authorization requests submitted on or after April 1, 2017, Tufts Health Together will apply new criteria to prior authorization requirements for coverage of Elidel (pimecrolimus), Entresto (sacubitril/valsartan), Gralise (gabapentin extended- release), Horizant (gabapentin enacarbil), Promacta (eltrombopag) and tacrolimus ointment. Register Your Email for The prior authorization criteria will apply to new starts. The prescribing provider must request prior authorization through the medical review process subject to the pharmacy Provider Update medical necessity guidelines for Entresto (sacubitril/valsartan), gabapentin medications Tufts Health Public Plans is now (including but not limited to Gralise [gabapentin extended-release] and Horizant [gabapentin distributing its provider newsletter by enacarbil]), Promacta (eltrombopag) and topical immunomodulators (including but not email.* To receive Provider Update, all limited to Elidel [pimecrolimus] and tacrolimus ointment). To submit a prior authorization contracting providers and anyone else request, please fill out the Massachusetts Standard Form for Medication Prior Authorization who wishes to receive future issues Requests and fax or mail it to the pharmacy utilization management team as directed via email must complete the online on the form. registration form at tuftshealthplan.com/ provider/news. Addition of prior authorization requirements for Carafate suspension (sucralfate Please let all providers in your suspension) and Ulesfia lotion (benzyl alcohol) organization know about this change and Effective for fill dates on or after April 1, 2017, Tufts Health Together will require prior encourage each provider to register to authorization for coverage of Carafate suspension (sucralfate suspension) and Ulesfia lotion receive future issues by email. Office staff (benzyl alcohol). If you feel your Tufts Health Together members should continue taking may also register a provider on his or her Carafate suspension or Ulesfia lotion, you must request prior authorization through the behalf by using the provider’s name, email medical review process subject to the pharmacy medical necessity guidelines for Carafate address and NPI, and by indicating the suspension (sucralfate suspension) or pediculocide medications, respectively. To submit a division(s) of Tufts Health Plan with which prior authorization request, please fill out the Massachusetts Standard Form for Medication the provider participates. Prior Authorization Requests and fax or mail it to the pharmacy utilization management team as directed on the form. Please note that requests for a prior authorization will not be * To request copies of this newsletter, reviewed until the effective date of April 1, 2017. please call the provider services team at 888.257.1985. Drug moving to noncovered status Scan here with your Effective April 1, 2017, polyethylene glycol packets will no longer be routinely covered for smartphone to sign up Tufts Health Together. Please note polyethylene glycol powder will continue to be covered. and for the latest issue of If you feel your Tufts Health Together members should continue this medication, you must Provider Update: submit an exception request for coverage through our medical review process. To submit an exception request, please fill out the Massachusetts Standard Form for Medication Prior Authorization Requests and fax or mail it to the pharmacy utilization management team as directed on the form. Please note that requests for an exception will not be reviewed until the effective date of April 1, 2017. 5830 02017 continued on page 2 © 2017 Tufts Health Public Plans, Inc. tuftshealthplan.com/provider | 888.257.1985 1 Preferred Drug List Changes for Tufts Health Direct Effective April 1, 2017, there are changes to the Preferred Drug List for Tufts Health Direct. Update Your Practice Information Drugs moving to noncovered status Providers are reminded to regularly Effective April 1, 2017, Asacol HD (mesalamine delayed-release tablets) will no longer be notify Tufts Health Public Plans of any routinely covered for Tufts Health Direct. If you feel your Tufts Health Direct members should changes to their contact or member continue this medication, you must submit an exception request for coverage through our panel information, such as a change in medical review process. To submit an exception request, please fill out the Massachusetts their ability to accept new patients, street Standard Form for Medication Prior Authorization Requests and fax or mail it to the address, phone number or any other pharmacy utilization management team as directed on the form. Please note that requests change that affects their availability to for an exception will not be reviewed until the effective date of April 1, 2017. members. For Tufts Health Public Plans to remain compliant with regulatory Addition of prior authorization requirements for nonpreferred topical corticosteroids requirements, it is important that these Effective for fill dates on or after April 1, 2017,Tufts Health Direct will require prior changes be communicated in writing as authorization for coverage of nonpreferred topical corticosteroids. The prior authorization soon as possible and that members have criteria will apply to new starts. For a member to start treatment with a nonpreferred access to the most current information in topical corticosteroid, the prescribing provider must request prior authorization through the the Provider Directory. medical review process subject to the pharmacy medical necessity guidelines for topical In addition, we include, as an element corticosteroids. To submit a prior authorization request, please fill out the Massachusetts of our Provider Directory, whether a Standard Form for Medication Prior Authorization Requests and fax or mail it to the participating provider has taken cultural pharmacy utilization management team as directed on the form. Please note that requests competency training, based in part on for a prior authorization will not be reviewed until the effective date of April 1, 2017. Centers for Medicare & Medicaid Services requirements. Please go to Drugs moving to excluded status tuftshealthplan.com/provider/ Effective April 1, 2017, Ultravate X (halbetasol 0.05% cream and lactic acid 10% cream kit) cultural-form to update us when will be excluded from the pharmacy benefit for Tufts Health Direct. Exclusion from coverage you have completed any cultural means that Tufts Health Public Plans will no longer consider medical review requests for competency training. exceptions, and coverage will not be available for Ultravate X (halbetasol 0.05% cream and lactic acid 10% cream kit). How to update your information: You can check your current practice Continuing Coverage During an Appeal information by going to the Find a Effective for dates of service on or after April 1, 2017, Tufts Health Public Plans will Doctor, Hospital, or Pharmacy tool. If that define “continuing care” for Tufts Health Together members as care that has previously information is not correct, please update been authorized with an initial date and a last-covered date. A request for authorization it as soon as possible by completing for coverage beyond the last-covered day is a new request and will not be eligible for the Medical Provider Information reimbursement during an appeal. Form or Behavioral Health Provider Information Form. Provider information This decision is based in part on guidance provided by CMS. See 81 Fed. Reg. 27497, 27636 forms are available in the forms section (May 6, 2016). of the Provider Resource Center at Changes to Medical Necessity Guidelines tuftshealthplan.com/provider. Send your form via fax to 857.304.6311 or via email to Effective April 1, 2017, there are changes to the medical necessity guidelines referenced [email protected] below. Refer to the Provider Resource Center at tuftshealthplan.com/provider as noted on the form. (select: Tufts Health Public Plans, Guidelines, Medical Necessity Guidelines) for more information about each guideline. Therapeutic lenses Tufts Health Public Plans will require a change in prescription for therapeutic lenses to be covered with the current qualifying conditions. Clarifying language for coverage frequency of therapeutic lenses has also been added to the coverage guidelines section of the medical necessity guidelines for Therapeutic Lenses. This change applies to Tufts Health Direct and Tufts Health Together. Laser