INSIDE THIS ISSUE

YOUR PROVIDER NEWSLETTERImportant information for contracted providers caring for business-sponsored

and exchange health plan membershipINSIDE THIS ISSUE

Spring 2016

Look for HEDIS Reminder

check marks .......................................2

Access to care and

case management .............................2

Affirmative statement

regarding incentives ..........................2

Recent additions to the

existing PHP formulary ......................3

Quality Improvement Program ..........4

Supporting follow-up

treatment after behavioral

health hospitalization ........................4

Prenatal and postpartum care ..........5

Colorectal cancer prevention

starts with screening .........................5

Appropriate testing for children

with pharyngitis .................................5

Reminder – PHP member support

from Accolade® .................................6

Telemedicine services provided by Teladoc™

Prominence Health Plan commercial members now have access to U.S. board-certified doctors and pediatricians by phone, 24 hours a day, 365 days a year.

What is Teladoc?Teladoc is the first and largest telehealth provider of medical consults in the nation. This service will provide Prominence members with access to quality medical care via phone or mobile app.

Does Teladoc replace a primary care provider?Teladoc does not replace a primary care provider (PCP). When the member is unable to see their PCP and needs immediate care for non-emergent medical issues, Teladoc is an affordable, convenient alternative to urgent care and ER visits. Members can talk to a doctor who can diagnose, recommend treatment and prescribe medication, when appropriate, for many medical issues including sinus problems, bronchitis, cold and flu symptoms and ear infection.

Will Teladoc communicate with the PCP?Each time a consultation is provided, Teladoc will ask the patient to whom they should send a continuity of care communication.

Who are Teladoc doctors?Teladoc doctors are U.S. board certified in Internal Medicine, Family Practice or Pediatrics. They average 15 years practice experience and are licensed.

How does Teladoc work?Prominence members can register at www.teladoc.com, call Teladoc directly (1.800.TELADOC) or use the Teladoc mobile app to register and complete a medical history questionnaire. Once an account is established, members can contact Teladoc anytime. Members can request a consultation immediately following the registration process.

For more information about Teladoc services, visit www.prominencehealthplan.com or call Prominence Health Plan at 866.500.2741.

Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulations and may not be available in certain states. Teladoc does not prescribe DEA-controlled substances, non-therapeutic drugs and certain other drugs that may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. Teladoc phone consultations are available 24 hours, seven days a week. Video services not eligible to health plan residents in Texas. Prominence Health Plan members are not eligible for behavioral health or dermatology services provided by Teladoc.

Access to care and case managementThe Utilization Management (UM) Department provides telephone coveragefrom 8 a.m. to 5 p.m. PST, Monday through Friday. Your patients and Prominence Health Plan members can call 775.770.9350 24 hours a day/seven days a week with questions about the UM process and care management/case management services provided by the health plan at no cost to our members who qualify. Messages received after midnight Monday through Friday will be returned the same day. Messages received after normal business hours will be returned the next business day. Confidential fax is also available at 775.770.9364.

Telecommunications device for the deaf or hard of hearing and telephone typewriter for the speech impaired are offered. Language assistance is also available free of charge for members to discuss UM issues.

Urgent care and emergency care services do not require prior authorization.

Prominence Health PlanPage 2

Look for HEDIS Reminder check marksThroughout this newsletter, you may find check marks indicating HEDIS Reminders. These note information about the standards and specifications for HEDIS measures, as well as strategies designed to help practitioners and providers improve the quality of care and service provided to Plan members.

Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standardized performance measures designed to facilitate the reliable comparison of managed healthcare plans. Prominence HealthFirst collects and reports HEDIS data annually as part of the Plan’s National Committee for Quality Assurance (NCQA) Accreditation process, and in support of quality initiatives and our QualityConnect clinical excellence program.

Affirmative statement regarding incentivesProminence Health Plan distributes annually an affirmative statement regarding incentives to all members and to all

practitioners, providers and employees who make utilization management decisions, affirming the following:

Utilization Management (UM) decision-making is based only on appropriateness of care and services and existence of coverage.

The organization does not specifically reward practitioners or other individuals for issuing denials of coverage or service care.

Financial incentives for UM decision makers do not encourage decisions that result in under-utilization.

Incentives, including compensation, for any person are not based on the quantity or type of denial decisions rendered.

For questions regarding this statement, please call the Prominence Health Plan Utilization Management Department at 775.770.9350.

www.prominencehealthplan.com Page 3

Recent additions to the existing PHP formularyTo help members get the most out of their pharmacy benefits, it’s important to understand what is available to them. The most current Formulary Reference Guide can be found on www.prominencehealthplan.com, and a list of recent drug additions is noted below.

Questions regarding Prominence Health Plan prescription drug coverage should be directed to the MedImpact Help Desk at 844.282.5339. MedImpact customer services representatives are available 24/7 to assist.

FORMULARY UPDATES

Drug Name Tier Status

Belsomra Tier 4 with step therapy of at least 2 other sleep disorder agents: Zolpidem IR, Zolpidem CR and Eszopiclone (Lunesta) in the past 365 days.

Cholbam Tier 5 Prior Authorization Required

Corlanor Tier 3 Prior Authorization Required

Coumadin Tier 4

Dilantin Tier 4

Evotaz Tier 5 Quantity Limit of 1 per day

Fuzeon Tier 5 Prior Authorization Required

Isentress Tier 4

Natpara Tier 5 Prior Authorization Required

Neoral Tier 4

Pradaxa Tier 3 Quantity Limit of 2 per day with a max day supply of 34 and only dispense 1 per 6 months.

Drug Name Tier Status

Prezcobix Tier 5 Quantity Limit of 1 per day

Selzentry 150mg Tier 5 Prior Authorization and 300mg Required

Spiriva Tier 3

Stiolto Tier 3 with step therapy using LAMA = Long acting muscarinic antagonist or LABA = Long acting beta agonist

Stribild Tier 5 Quantity Limit of 1 per day

Striverdi Tier 3

Synthroid Tier 4

Tivicay Tier 5 Quantity Limit of 1 per day

Triumeq Tier 5 Quantity Limit of 1 per day

Unituxin Tier 5 Prior Authorization Required

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Quality Improvement ProgramProminence Health Plan’s Quality Improvement (QI) Program is designed to assess and improve the quality of care and service delivered to Plan members. The goal of the QI Program is to monitor the quality and appropriateness of patient care and service and to meet or exceed established local, state and national standards. Methods to achieve this include establishing standards and performance goals for the delivery of care and services, measuring performance outcomes, and development and implementation of action plans to improve outcomes. The Quality Improvement operational functions are under the direct supervision of the Plan Chief Medical Officer.

The focus of the QI Program is to improve the overall health status of Plan members through systematic identification of opportunities for improvement and evaluation of processes to achieve improvement. The comprehensive QI Program provides the framework for determining indicators for recommended levels of care and service. Opportunities for improvement are selected through the monitoring of identified quality and performance indicators.

The QI Program reflects the Plan’s mission, vision and values. It is designed to develop, implement, monitor, evaluate and improve standards of healthcare

quality of service and care on an ongoing basis. Quality Improvement functions in conjunction with the Plan’s Organizational Structure to promote appropriate system development and implementation to meet the requirements of Plan members, employers, employees and the practitioner/provider network.

Additional information regarding the Plan’s QI Program and/or program activities is available upon request by accessing Prominence Health Plan’s website at www.prominencehealthplan.com.

Supporting follow-up treatment after behavioral health hospitalizationTimely follow-up treatment after discharge from inpatient behavioral health hospitalization is crucial toward supporting a member’s ongoing recovery. Early aftercare treatment (within seven days of discharge) with a behavioral health provider has been demonstrated to improve outcomes and prevent readmission. By contrast, lack of ongoing follow-up has been identified as a predictor of poor outcomes.

When a member is hospitalized, it is important to begin aftercare planning as soon as possible after admission. Prior to discharge, key activities that support an effective aftercare plan are:

• Scheduling the first follow- up appointment to occur within 7 days of the member’s discharge

• Explaining the benefits of aftercare to the member, so he or she is aware of the importance of keeping follow-up appointments

• Verifying the aftercare plan is a good fit for the member

• Involving the member’s family to support the aftercare plan

• Explaining the importance of taking medication and notifying their provider of any side effects

For information and support 24 hours/ 7 days a week, please call Magellan Behavioral Health at 800.245.7013. Additional information, self-help tools and other resources are also available online at www.magellanassist.com.

www.prominencehealthplan.com Page 5

Appropriate testing for children with pharyngitisChildren who are treated as outpatients for acute pharyngitis, acute tonsillitis or streptococcal sore throat

and are dispensed antibiotics on or up to three days after the date of the diagnosis need to have a group A streptococcus test for each diagnosed episode.

In order to expedite timely and accurate reimbursement, please include the applicable group A streptococcus test code on the member’s encounter form. Codes to identify a group A streptococcus test include:

* CPT Codes: 87070, 87071, 87081, 87430, 87650 – 87652, 87880

* LOINC Codes: 626-2, 5036-9, 6556-5, 6557-3, 6558-1, 6559-9, 11268-0, 17656-0, 18481-2, 31971-5, 49610-9, 60489-2, 68954-7

For more information about the treatment of children with pharyngitis, refer to Centers for Disease Control and Prevention recommendations available at www.cdc.gov.

Prenatal and postpartum careThis HEDIS measure assesses timeliness of prenatal care and postpartum care by measuring the following:

• Timeliness of Prenatal Care measures the percentage of OB deliveries that received a prenatal visit in the first trimester or within 42 days of enrollment in the Plan.

• Postpartum Care measures the percentage of OB deliveries that had a postpartum visit on or between 21 and 56 days after delivery.

Prenatal and postpartum visits that fall outside these time ranges cannot be used to demonstrate compliance with these measures. You can help by scheduling postpartum visits between 21 and 56 days after delivery as well as encouraging your patients to keep these important appointments – for their good health!

Colorectal cancer prevention starts with screeningAs recommended by the U.S. Preventive Services Task Force, Prominence Health Plan encourages members ages 50 through 75 to have periodic colorectal cancer screenings using stool occult blood testing, sigmoidoscopy or colonoscopy. Because the risks and benefits of these screening methods vary, members are encouraged to discuss this recommendation with their clinical practitioner.

Now is the ideal time to discuss this very important screening with your patients.

For questions related to members’ benefits or information on plan physicians that provide colonoscopy or sigmoidoscopy, please contact Prominence Health Plan Customer Service through the dedicated phone line for plan providers at 775.770.9311 or 866.500.2741.

FPO

1510 Meadow Wood LaneReno, Nevada 89502

Page 6www.prominencehealthplan.com

Reminder – PHP member support from Accolade®

Accolade’s Clinical Health Assistants and Health Assistants work in tandem to help support Prominence Health Plan members and their families with anything related to their healthcare, including:

CARE AND CONDITION SUPPORT

• Health questions and treatment options

• Medication questions

• Condition management and lifestyle improvement

PROVIDER SEARCHES

• Doctor, specialist, facility and clinic

• Other care options

• Appointment assistance

• Visit preparation

For questions regarding patient claims, benefits or eligibility, call Prominence Health Plan Customer Service at the dedicated phone line for plan providers at 775.770.9311 or 866.500.2741.

BENEFITS AND CLAIMS SUPPORT

• Eligibility and coverage

• Billing questions

• Benefit enrollment options