Volume 2 2006
Table of Contents
To view a specific article, click on the
article title, and it will take you directly
to the story.
Priority Policy and Benefit Updates
In this redesigned issue of STAT,
the Blue Cross of California (Blue
Cross) Provider e-News, you will
find important policy updates and
new programs or services to help you
care for our members in these plans:
• Medi-Cal
• L.A. Care Health Plan
• Healthy Families Program
• Access for Infants and Mothers
• Managed Risk Medical
Insurance Program
• County Medical Services Program
Provider Tools Now Online
Your time is valuable. To make
it easier and faster for you to do
your work, we have added some
important information to our
provider website.
Prior Authorization Forms
You now can find our prior
authorization forms for the top 10
most popular provider authorization
requests − right at your fingertips!
Click here to go to the forms now.
To use these forms in the future
go to www.bluecrossca.com.
Click on Providers. Then click
on State Sponsored Plans
(Medi-Cal, Healthy Families
Program, MRMIP, AIM, CMSP).
Click on Prior Authorization
Toolkit. Then click on the plan
type of the member and select
the form. You can download and
complete the forms or follow the
instructions on where to call for
prior authorization.
Utilization Management
(UM) Guidelines
Our corporate clinical UM
guidelines now are available
online for your review. Members
also have access to these guidelines.
To view these guidelines, visit
www.bluecrossca.com. On the
home page, click on Medical
Policies and Clinical UM
Guidelines. This link is the first
bullet under the Learn More
heading at the bottom left of the
page. We have adopted these clinical
guidelines that apply to our plans.
Hard copies of these UM guidelines
are available upon request.
1
Provider Tools Now Online
2
Quality Improvement Program
Ensures Accessible Quality Care
4
Medical Record Audit Compliance
Rate Takes a Dip
Spotlight
4
Apply for NPI Now!
6
Blue Cross Receives Prestigious
EPA Award
7
Awarded NCQA Excellent Status
Operations Updates
7
Change in Address?
7
After-Hours Care
Health Improvement
8
Initial Health Assessment Reminder
8
Educate Members About the Flu
9
New Surgeon General’s Report on
Secondhand Smoke
Rx Updates
10 Formulary Available Online
10 New Formulary Updates – Second
Quarter, Third Quarter, Third Quarter
Supplement, and Fourth Quarter 2006
14 Consider Generics
14 What You Need to Know About Prior
Authorization of Benefits (PAB)
15 PAB Results Review and Notification
15 Nonformulary Medications Access
15 Quantity and Dosing
STAT Physician & Provider e-News is published by Blue Cross of California to serve our State Sponsored
Business providers. Blue Cross of California is an affiliate of L.A. Care Health Plan, providing Medi-Cal
Managed Care services in Los Angeles County. Blue Cross of California and Blue Cross of California
Partnership Plan are independent licensees of the Blue Cross Association.
1106 CA0012192 12/06
Provider e-News Vol 2 2006
1
Priority Policy and Benefit Updates
Quality Improvement Program Ensures Accessible Quality Care
An overview of processes, goals, and outcomes
Blue Cross State Sponsored Business’ Quality
Improvement (QI) Program seeks to continually
improve the quality of the clinical care and services
that its members receive through a systematic
approach. To achieve this goal, we monitor and
evaluate all aspects of the health care delivery system.
We also develop and offer quality improvement
initiatives directed at members, practitioners, and
other health care professionals.
We design our processes and procedures to ensure
all covered services are available and accessible to all
members, regardless of race, color, national origin,
creed, ancestry, religion, language, age, gender,
marital status, sexual orientation, health status, or
disability, and that all covered services are provided
in a culturally and linguistically appropriate manner.
• Protect member-identifiable health information
by ensuring that protected health information
(PHI) is released in accordance with federal,
state, and all other pertinent regulatory
requirements
• Promote collaborative activities among other
Medicaid and state-funded health care plans and
providers, including behavioral health providers
and practitioners
To thoroughly assess the system and prioritize
initiatives, we select critical monitors from the
following QI Program components that promote
quality clinical care and service.
Taking Care of Chronic Illnesses
We measure public health issues and chronic
conditions affecting our Medi-Cal member
QI Program Goals
population. We do this through the Health Plan
Blue Cross has established the following goals for our
Employer Data and Information Set (HEDIS), the
QI Program:
set of standardized performance measures designed to
ensure that consumers have information to compare
• Develop and maintain a well-integrated system
the performance of health plans. The performance
to continuously identify, measure, assess, and
measures in HEDIS include cancer, heart disease,
improve quality outcomes
smoking, asthma, and diabetes and well as access to
• Respond to the needs and expectations of the
care, and customer service. Here are results of provider
program’s internal and external customers by
and plan performance in some key categories for
evaluating performance relative to meeting those
our Medi-Cal members, as well as other awards and
needs and expectations
achievements. It is due to our collaboration with you,
• Maintain compliance with regulatory
our providers, that these results are possible.
requirements and accreditation standards
• Promote high quality of care and service and
effective utilization of service to all members,
including those with a limited proficiency
in English
• Identify the educational needs of members,
practitioners, and other health care professionals,
including behavioral health care providers and
practitioners as determined by product
• Promote processes that reduce medical errors and
improve patient safety
Asthma
What we track: The number of asthmatic Medi-Cal
members who take the appropriate medications
for asthma
What we do: Help members try to keep their asthma
under control
• We schedule appointments for our asthmatics
to see their primary care physician (PCP) if
they have not been in for a visit within the last
12 months.
Provider e-News Vol 2 2006
2
Priority Policy and Benefit Updates
• In 2005, almost 90 percent of all asthmatic
members who required medication were prescribed
the correct medication.
• Our asthma program was honored by the
state’s External Quality Review Organization
as a best practice.
• We were the only health plan to receive the U.S.
Environmental Protection Agency’s 2006 National
Leadership Award in Asthma Management based
on a series of statewide asthma projects. Read more
in “Blue Cross Receives Prestigious EPA Award.”
Diabetes
What we track: The number of Medi-Cal diabetic
members who get the required Diabetic Retinal Eye
exams, Hgb A1C tests, Nephropathy screening, and
Cholesterol screening annually.
What we do: Provide educational materials to
members, and schedule appointments for our
members to see their PCP and/or ophthalmologist
for their recommended screenings. Inform physicians
when diabetic members are not coming in for
routine exams.
How we’re doing: In 2005, 56 percent of our
diabetic members had a Diabetic Retinal Eye exam;
an increase from 2004.
Preventive Health
Childhood Immunizations
What we track: The number of Medi-Cal members
2 years of age and younger who get all required
immunizations
What we do: Send a yearly reminder to members to
let them know the vaccines doctors recommend for
children 2 years of age and younger
How we’re doing: Blue Cross beat the Medicaid
average and most health plans! In 2005, 75 percent
of our members 2 years of age and younger got the
immunizations they needed, including shots for
mumps, measles, and hepatitis.
Breast Cancer Prevention
What we track: The number of female Medi-Cal
members, ages 52 to 69, who have had a mammogram
in the current or prior year
What we do: Send a yearly reminder to our female
members identified as requiring a mammogram
How we’re doing: In 2005, more than 52 percent of our
female members, ages 52 to 69, had mammograms
Cervical Cancer Prevention
What we track: The number of female Medi-Cal members,
ages 21 to 64, who have had a cervical cancer screening
What we do: Send a reminder to our female members
identified as requiring this test
How we’re doing: In 2005, more than 67 percent of our
female members, ages 21 to 64, had a cervical cancer
screening. Blue Cross scored better than most health
plans in this category.
We Ask Our Members
We survey member opinions on the health care
they receive. Here are a few key results from our
most recent survey:
• To the question regarding how easy it is to see
the doctor when you need to, the response
“getting care quickly” was rated 3 percent
higher than last year.
• Members who had a good opinion of Blue
Cross as a health plan increased by 6.4 percent
from last year to 75.3 percent.
• Members rated more than 90 percent of the
office staff in our provider offices as courteous
and respectful.
• Members believed 85 percent of physicians
showed respect for what the member had to
say and 86 percent listened carefully to what
the member said.
Thank you for working hard to care for our
members. The survey responses show how much
your efforts are paying off and making a difference
to our members.
Provider e-News Vol 2 2006
3
Priority Policy and Benefit Updates
Medical Record Audit Compliance Rate Takes a Dip
Make process improvement a priority
We want to call your attention to Blue Cross’ 2006
Medical Record Audit results. The report, presented
at the December meeting of the Blue Cross Physician
Quality Improvement Committee (QIC), focused on the
Continuity and Coordination of Care Criteria that declined
from 88.7 percent in 2005 to 83 percent in 2006.
This 6 percent decline revealed the lack of practitioner
compliance in signing the review of lab reports,
specialty consults, emergency room reports, and
hospital discharge summaries. As many as 2,198 charts
representing 791 primary care physicians were reviewed
for the audit.
Continually improving our processes and services is one
of our most important goals. By bringing this finding
to your attention, we would like to remind you to
review your office practices related to this important
documentation of member chart information prior to
filing reports in your medical records.
Spotlight
Apply for NPI Now!
Contact CMS
The Health Insurance Portability and Accountability
Act (HIPAA) requires the adoption of a standard
10-position unique identifier for health care providers,
effective May 23, 2007. The unique identifier is the
National Provider Identifier (NPI) which will replace
health care provider identifiers used in HIPAA-covered
entities. HIPAA-covered entities need to obtain NPIs
to identify themselves in HIPAA standard transactions
by May 23, 2007. Small health plans are allowed an
additional 12 months to comply. Please note: As a
participating Blue Cross provider, your practice is a
HIPAA-covered entity.
How to Get Started
With only a few months before the new NPI
requirements become effective, we encourage you
to obtain your new NPI now from the Centers for
Medicare and Medicaid Services (CMS). Visit the CMS
website at www.cms.hhs.gov/NationalProvIdentStand
or call (800) 465-3203 to get started. To apply for
an NPI online, go to the National Plan and Provider
Enumeration System website at https://nppes.cms.hhs.gov.
Please apply right away. Otherwise, you may not be able to
complete the full NPI transition with your health plans and
electronic vendors. Not having your NPI by the scheduled
effective date may disrupt services and payments.
Register Your NPI with Us
Once you receive your NPI, you need to complete our
online submission form to register your NPI at
https://npi.wellpoint.com. Registration ensures our
internal systems accurately reflect your NPI information.
If you are registering more than one NPI, please
complete one form for each NPI. If you have a large
quantity of NPIs to submit, we will implement a “bulk”
submission process soon. Please be sure to check
https://npi.wellpoint.com regularly for additional
information regarding this process.
Provider e-News Vol 2 2006
4
Spotlight
Assess System Capabilities Early
It will take time to incorporate NPI changes. You
can help by assessing any NPI impact to your
practice management systems. Consider the impact
to the following technological systems you have to
help gauge your NPI readiness:
• Applications systems such as accounting and
patient records management
• Files and databases with provider numbers
• Functions outsourced to other companies,
such as lab work or accounting
• Telephone and interactive voice response systems
Consider Your Vendors
If you use vendors such as medical supply
companies, third-party billing agencies, and
laboratory services, check and see if they are
working toward becoming NPI-compliant. Their
noncompliance may impact your operations and
hamper your ability to transition to NPI.
In addition, testing is a key component of the NPI
preparation process. You may be able to minimize
problems by testing early with electronic vendors
and Blue Cross. By preparing in advance, you
can help ensure a seamless conversion to NPI,
minimizing any potential payment disruptions
in your operations with us. Act now! Let’s work
together to ensure that when the May 23, 2007,
NPI implementation date arrives, we will be able to
continue business as usual.
Provider e-News Vol 2 2006
5
Spotlight
Blue Cross Receives Prestigious EPA Award
Addressing asthma management in a Medicaid population
Blue Cross recently received the 2006 National
Environmental Leadership Award in Asthma
Management from the U.S. Environmental Protection
Agency (EPA). This important award acknowledged our
Medicaid plan and providers for offering comprehensive
resources to help people with asthma lead normal,
active lives.
Our application, titled “Asthma, Air Quality, and
Community Health: A Health Plan’s Contribution,”
emphasized the exceptional importance and value of
community partnerships in addressing the significant
health challenges posed by asthma. “The award
honored our unique accomplishments in addressing
both indoor and outdoor environmental asthma
triggers through the Asthma Management Program
statewide, the Plan/Practice Improvement Project
Asthma Collaborative in San Francisco, and the
Valley Air Quality Project in Fresno,” says Blue Cross
State Sponsored Business Vice President and Medical
Director Dawn Wood, MD.
care, and streamline daily clinical activities, so that
evidence-based interactions between informed patients
and prepared practice teams become the norm. By
creating planned disease-management visits, maximizing
patient self-management, and teaching patients to reduce
exposure to environmental asthma triggers, patients and
physicians are better prepared to focus on chronic
illness management, and to use critical information to
make the best use of their visits. (More to come on this
innovative project in an upcoming e-Newsletter.)
Valley Air Quality Project
Through this effort, we use community partnerships
and collaborative research with public health, local
health care leaders, community agencies, and academic
researchers to help improve community responses to
environmental air pollution affecting the respiratory
health of Fresno County residents. Fresno County is an
area where asthma prevalence is high. (More to come
on this ground-breaking project as well.)
Asthma Management Program
Working with the EPA
You may be familiar with our Asthma Management
Program. It provides a wide range of educational
resources, tools, and information to members,
physicians, and pharmacists to help improve member
outcomes. Asthma education emphasizes minimizing
exposure to asthma triggers and improving patient
self-management skills.
The EPA award jumpstarted a collaboration with the
EPA. The coordinator for the EPA’s Pacific Southwest
Region Indoor Air Program, Barbara Spark, served
as a guest speaker at our Field Business Meeting, an
annual event for our field staff to share best practices.
Spark’s presentation, in turn, prompted our health
promotion consultants at Community Resource
Centers throughout California and in several other
states to organize a focused project on environmental
asthma management this year in collaboration with
local schools. This effort will augment ongoing asthma
interventions, and should help identify additional best
practices in community collaboration for improved
asthma outcomes.
Plan/Practice Improvement Project
Asthma Collaborative
Facilitated by the Center for Health Care Strategies, the
National Initiative for Children’s Health Care Quality,
and the California Health Care Foundation, this asthma
collaborative is a pilot project which involves five
practices in San Francisco. The collaborative encourages
physicians to apply the chronic care model to asthma
To learn more about our award, visit the EPA’s site at
www.epa.gov/asthma/leadership_award_winners.html.
Provider e-News Vol 2 2006
6
Spotlight
Awarded NCQA Excellent Status
Thank you to our providers
For the fourth year in a row, we have been awarded
an “Excellent” accreditation status for our California
Medicaid program.
If you’d like to review our NCQA report card, visit
www.ncqa.org. In the Hot Links! Report Cards menu
on the right, click on Health Plans.
The National Committee for Quality Assurance
(NCQA) is a nonprofit organization created to improve
patient care quality and health plan performance in
partnership with managed care plans, purchasers,
consumers, and the public sector. NCQA ratings were
calculated using results from the Health Plan Employer
Data and Information Set (HEDIS) and Consumer
Assessment of Healthcare Providers and Systems surveys
(CAHPS).
We’d like to extend our congratulations to you, our
plan providers. Without your dedication, hard work,
and commitment to our members, we could not
have received this accreditation. Thank you for your
excellent care.
Operations Updates
Change in Address?
After-Hours Care
Contact us right away
What’s expected of you
If you change your office address, telephone
numbers, capacity, or other important demographic
information, please contact us right away. Our
online Provider Change Request Form allows you to
change your tax identification number, clinic hours,
address, phone number, fax number, or hospital
privilege information. Click here to view the form.
Instructions on how to submit the form are included
on the form itself.
If you’re a primary care physician, you need to have
an after-hours system in place and give members a
telephone number to call after business hours to reach
you, the on-call physician (if not you), or a provider
in your physician group. You are responsible for being
available to determine the need for emergency and
after-hours services and to authorize care for our
members who are your patients. Providers who receive
calls after business hours need to contact the member
back within 30 minutes of receiving the call. Refer to
your Blue Cross Provider Operations Manual (POM)
for a more detailed explanation of our after-hours
procedures.
Provider e-News Vol 2 2006
7
Health Improvement
Initial Health Assessment Reminder
Meeting the requirement is an important step
If you’re a primary care physican, please be aware that
you’re responsible for getting a complete history, physical
examination, and assessment of health behaviors for all new
members. This is an “initial health assessment,” or IHA.
This critical procedure for treating patients is mandatory.
The IHA is an important part of the audit process and
providers who do not complete this assessment are out
of compliance. Just as importantly, the IHA is one of
the key ways to identify health problems early on and to
build a relationship with your patient.
You need to provide these assessments within the
following mandated time frames:
• Within 60 calendar days following enrollment
for children under the age of 18 months, or
within periodicity timelines of the American
Academy of Pediatrics (AAP) for ages 2 years and
younger, whichever is less
• Within 120 calendar days of enrollment for children
18 months of age and older (The IHA needs to
include, or you must arrange for the provision of, all
necessary immunizations and an appropriate health
education behavioral assessment.)
• Within 120 calendar days of enrollment for adults
older than 21 years of age (The assessments should
include a complete history and physical exam as well
as a health education behavioral risk assessment.)
For more information on IHAs, refer to your POM.
Helpful hint: Administer the Staying Healthy Assessment
Tool along with the IHA so you have a complete medical
record on each patient.
Educate Members About the Flu
What you can do
Flu season is in full swing. Some of your patients may
head to the emergency room unnecessarily and wait
hours for care. A new survey by the Oakland,
California-based California HealthCare Foundation
indicates that publicly insured Medi-Cal patients were
more than twice as likely as those with private insurance
to have used emergency department services in the past
year. The report shows Medi-Cal patients were less likely
to have a regular doctor and more likely to use a clinic or
emergency room for care.
We Need Your Help
You can teach our members how to get the right care for
the flu.
• Encourage your high-risk members to get a flu shot.
• Be sure members know antibiotics will not
cure the flu.
• Remind your Blue Cross members that they
can call the MedCall® 24-hour nurse help line at
(800) 224-0336 to help them figure out what to do
when they have a cold or the flu. MedCall is staffed
by registered nurses who can answer questions,
give self-care tips, and help members schedule an
appointment when they need it. However, your
members must see you for medical advice.
Flu Resources
• The Centers for Disease Control Flu Website
www.cdc.gov/flu
- Preventing the Flu
www.cdc.gov/flu/protect/preventing.htm
- What to Do if You Get Sick
www.cdc.gov/flu/symptoms.htm
- Key Facts About Influenza and the Influenza
Vaccine www.cdc.gov/flu/keyfacts.htm
• National Institute of Allergy and Infectious
Diseases’ Focus on Flu Website
www3.niaid.nih.gov/news/focuson/flu/default.htm
- Is It a Cold or the Flu?
www.niaid.nih.gov/Publications/cold/sick.pdf
Provider e-News Vol 2 2006
8
Health Improvement
New Surgeon General’s Report on Secondhand Smoke
Talk to your patients who smoke
U.S. Surgeon General Richard H. Carmona has
issued a comprehensive scientific report that
concludes no level of exposure to secondhand smoke is
risk-free. This is one more reason to ask your patients if
they smoke and to counsel them to quit smoking.
The study indicates nonsmokers exposed to
secondhand smoke at home or work increase their
risk of developing heart disease by 25 to 30 percent
and lung cancer by 20 to 30 percent. The finding
is a major public health concern because statistics
show nearly half of all nonsmoking Americans are
regularly exposed to secondhand smoke.
“The report is a crucial warning sign to nonsmokers
and smokers alike,” says U.S. Health and Human
Services Secretary Michael Leavitt. “Smoking can
sicken and kill, and even people who do not smoke
can be harmed by smoke from those who do.”
Secondhand smoke exposure also is a known cause
of sudden infant death syndrome (SIDS), respiratory
problems, ear infections, and asthma attacks in
infants and children, the report finds.
“The good news is that, unlike some public health
hazards, secondhand smoke exposure is easily
prevented,” Carmona says. “Smoke-free indoor
environments are proven, simple approaches that
prevent exposure and harm.”
You can get copies of “The Health Consequences of
Involuntary Exposure to Tobacco Smoke: A Report
of the Surgeon General” and related materials on the
Surgeon General’s website. For details, go to:
www.surgeongeneral.gov/library/secondhandsmoke.
Provider e-News Vol 2 2006
9
Rx Updates
Formulary Available Online
Blue Cross formulary is available on our website at
www.bluecrossca.com under the Learn More section.
Select Pharmacy. Select the Formulary – PDF Format
link on the left navigation bar if you want to print a
full copy of the formulary.
Other information available online includes:
• Searchable drug formulary which can be obtained
by selecting Formulary on the left navigation bar
• Lists of preferred pharmaceuticals or formularies for
various Blue Cross benefits
New Formulary Updates
Second Quarter 2006
The following table lists the outcomes of the second quarter 2006 WellPoint Pharmacy and
Therapeutics Committee meeting held on May 31, 2006.
Drug Name
Active Ingredient
Formulary Status
Generic
Available
Abilify
aripiprazole
Add
No
Aerobid/M
flunisolide
Add
No
Aerospan HFA
flunisolide
Add
No
Asmanex
mometasone
Add
No
Eligard
leuprolide acetate
Self-Injectable Benefit*
Yes
Fazaclo ODT
clozapine
Add
No
Geodon
ziprasidone
Add
No
Leukine
sargramostim
Self-Injectable Benefit*
No
Generic Lupron
leuprolide acetate
Self-Injectable Benefit*
Yes
Neulasta
pegfilgrastim
Self-Injectable Benefit*
No
Neupogen
filgrastim
Self-Injectable Benefit*
No
Synarel
narfarelin
Delete
No
Twinject
epinephrine
Self-Injectable Benefit*
No
*Self-Injectable Benefit: Members should refer to our Member Handbook for benefit details regarding applicable copayments or coinsurance.
Please Note
These pharmacy updates are not applicable to County Medical Services Program
(CMSP) members. CMSP members have pharmacy benefits through MedImpact.
See www.cmspcounties.org for more information.
Provider e-News Vol 2 2006
10
Rx Updates
Third Quarter 2006
This table lists the outcomes of the third quarter 2006 WellPoint Pharmacy and Therapeutics
Committee meeting held on Aug. 31, 2006.
Drug Name
Active Ingredient
Formulary Status
Generic
Available
Akne-Mycin
erythromycin
Nonformulary
No
Ala-Scalp lotion 2%
hydrocortisone
Nonformulary
No
Ancobon
flucytosine
Nonformulary
No
Apidra
insulin glulisine
Nonformulary
No
Benzaclin gel
benzoyl peroxide/clindamycin
Nonformulary
No
Capex shampoo
fluocinolone acetonide
Nonformulary
No
Cloderm
clocortolone pivalate
Nonformulary
No
Colazal
balsalazide
Formulary
No
Dermatop
prednicarbate
Nonformulary
No
Diprolene lotion
augmented betamethasone
dipropionate
Nonformulary
No
Elidel 1% cream
pimecrolimus
Formulary
No
Entocort EC
budesonide
Formulary
No
Exubera
insulin
Nonformulary
No
Finacea gel 15%
azelaic acid
Nonformulary
No
Grifulvin V
griseofulvin microsize
Nonformulary
No
Gris-PEG
griseofulvin ultra microsize
Nonformulary
No
Infergen
interferon alfacon-1
Self-Injectable Benefit*
No
Locoid lipocream
hydrocortisone butyrate
Nonformulary
No
Loprox gel
ciclopirox
Formulary
No
Oxistat cream
oxiconazole
Nonformulary
No
Oxistat lotion
oxiconazole
Nonformulary
No
Pandel
hydrocortisone probutate
Nonformulary
No
Pegasys
peginterferon alfa-2a
Self-Injectable Benefit*
No
Peg-Intron
peginterferon alfa-2b
Self-Injectable Benefit*
No
* Self-Injectable Benefit: Members should refer to our Member Handbook for benefit details regarding applicable copayments or coinsurance.
Provider e-News Vol 2 2006
11
Rx Updates
Drug Name
Active Ingredient
Formulary Status
Generic
Available
Protopic 0.03% &
0.1% ointment
tacrolimus
Formulary
No
Rebetol solution
ribavirin
Nonformulary
Yes
Relenza
zanamivir
Nonformulary
No
Roferon-A
interferon alfa-2a
Self-Injectable Benefit*
No
Sporanox oral
solution
itraconazole
Nonformulary
No
Tamiflu
oseltamivir
Nonformulary
No
Tazorac cream 0.05%,
0.1%; gel 0.05%, 0.1%
tazarotene
Nonformulary
No
Vfend
voriconazole
Nonformulary
No
Zocor
simvastatin
Nonformulary
Yes
* Self-Injectable Benefit: Members should refer to our Member Handbook for benefit details regarding applicable copayments or coinsurance.
Third Quarter Supplement 2006
The following table lists the outcomes from the third quarter 2006 Supplemental WellPoint Pharmacy and
Therapeutics Committee meeting held on Sept. 6, 2006.
Drug Name
Active Ingredient
Formulary Status
Generic
Available
Cleocin 75 mg
clindamycin HCl
Nonformulary
No
Cleocin Pediatric
clindamycin palmitate
Nonformulary
No
Miacalcin Injectable
salmon-calcitonin
Self-Injectable Benefit*
No
Neumega
oprelvekin
Self-Injectable Benefit*
No
Pulmozyme
dornase alfa
Nonformulary
No
Sumycin
tetracycline oral
suspension and tablets
Nonformulary
No
Suprax
cefixime oral suspension
Nonformulary
No
Zyvox
linezolid
Nonformulary
No
Zavesca
miglustat
Formulary
No
* Self-Injectable Benefit: Members should refer to our Member Handbook for benefit details regarding applicable copayments or coinsurance.
Provider e-News Vol 2 2006
12
Rx Updates
Fourth Quarter 2006
The following table lists the outcomes of the fourth quarter 2006 WellPoint Pharmacy and Therapeutics
Committee meeting held on Nov. 2, 2006.
Drug Name
Active Ingredient
Formulary Status
Generic
Available
Acular PF
ketorolac tromethamine
Nonformulary
No
Androgel
testosterone gel 1%
Formulary
No
Anadrol-50
oxymetholone
Nonformulary
No
Avodart
dutasteride
Nonformulary
No
Cyclomydril
cyclopentolate/phenylephrine
Nonformulary
No
Emend
aprepitant
Nonformulary
No
Estrostep FE
norethindrone 1 mg/esthinyl
estradiol 20 mcg, 30 mcg, or 35 mcg
Nonformulary
No
Flarex
fluorometholone
Nonformulary
No
Forteo
teriparatide
Self-Injectable Benefit*
No
Inspra
eplerenone
Nonformulary
No
Isopto Carbachol
carbachol
Nonformulary
No
Isopto Hyoscine
scopolamine
Nonformulary
No
Kytril Solution
granisetron
Formulary
No
Oxandrin
oxandrolone
Nonformulary
No
NuvaRing
etonogestrel 0.12 mg/ethinyl
estradiol 0.015 mg
Nonformulary
No
Patanol
olopatadine
Nonformulary
No
Phospholine Iodide
phospholine iodide
Nonformulary
No
Pilopine HS
Nonformulary
No
Nonformulary
No
Razadyne/ER
pilocarpine HCL
micronized progesterone vaginal
gel
galantamine
Nonformulary
No
Sensipar
cinacalcet
Nonformulary
No
Seasonique
levonorgestrel 0.15 mg/estradiol
0.03 mg/ethinyl estradiol 0.01 mg
Nonformulary
No
Testim
testosterone gel 1%
Formulary
No
Tracleer
bosentan
Nonformulary
No
Prochieve
* Self-Injectable Benefit: Members should refer to our Member Handbook for benefit details regarding applicable copayments or coinsurance.
Provider e-News Vol 2 2006
13
Consider Generics
Rx Updates
An affordable alternative
With today’s rising health care costs, substituting
generic products approved by the Food and Drug
Administration (FDA) helps reduce medication
costs. Generic drugs provide a safe, effective, and less
expensive alternative for patients, when medically
appropriate. With an FDA-approved generic drug,
the strength, dosage form, route of administration,
and intended usage are identical to the brand-name
counterpart. Both brand-name and generic drugs must
complete a rigorous approval process successfully.
Patients and providers should expect that the generic
product will produce the same clinical effect and safety
profile as the brand-name drug.
For a copy of the Blue Cross formulary, please go
to our website at www.bluecrossca.com and select
Pharmacy, or contact WellPoint NextRx at
(800) 227-3032.
What You Need to Know About Prior Authorization of Benefits (PAB)
How it works
The PAB process for Blue Cross prescription drug
benefits alerts prescribers about safe and less costly
alternatives on the formulary, as well as prescribed
drugs that may not be clinically recommended for
the condition for which they are prescribed. Keep in
mind that certain medications on the formulary and all
nonformulary medications require written PABs.
Here are clarifications about our PAB requirements:
• Blue Cross covers medications that are medically
necessary. We defer to the prescribing physician’s
decision so long as the physician supplies medical
evidence that the drug is appropriate for a patient’s
condition.
• We cover medication that requires PAB and is
prescribed for off-label use in the treatment of
an illness if there is supporting medical evidence.
Supporting medical evidence validates a drug
when it has been recognized for treatment of that
condition by one of the following:
• The American Medical Association
drug evaluations
• The American Hospital Formulary Service
drug information
• The United States Pharmacopoeia Dispensing
Information, Volume 1, “Drug Information for
the Health Care Professional”
• Two articles from major peer-reviewed medical
journals that present data supporting the
proposed off-label use or uses as generally
safe and effective unless clear and convincing
contradictory evidence is presented in a major
peer-reviewed journal
If we receive a request without the information necessary
to make a decision, we will ask the prescribing physician
to provide us with additional medical information in
order to proceed with the review.
Provider e-News Vol 2 2006
14
PAB Results Review and Notification
Rx Updates
Standards for turnaround time
We review and make determinations on nonurgent
PAB requests within 24 hours. In emergency cases or
life-threatening situations, the pharmacy may proceed
with dispensing a 72-hour supply of a medication
by calling WellPoint NextRx. We notify prescribing
physicians within one working day of the determination.
If the determination results in a denial, we will notify
both the member and the physician in writing within
two working days and give them information on the
Blue Cross grievance and appeals process. We will send a
letter to the prescribing physician explaining the medical
reasons for the denial, along with the name of the Blue
Cross physician who issued the denial. We monitor the
PAB process regularly to ensure timely outcomes.
To Reach the PAB Center
When you need help with PAB, call the WellPoint
NextRx PAB Center at (866) 302-7166. We can
help you:
• Submit a PAB request
• Obtain the status of a PAB request
• Get a PAB Request Form
Please fax completed PAB Request Forms to
(866) 302-7167.
Nonformulary Medications Access
Medi-Cal PAB
Healthy Families Program DUR
The Blue Cross Medi-Cal program has implemented
a PAB program for nonformulary medications. The
“dispense as written” (DAW-1) or “do not substitute”
(DNS) override has been replaced with this PAB
program for all nonformulary medications.
The Drug Utilization Review (DUR) exception process
provides access to most nonformulary medications,
therapeutic interchanges, and step therapy procedures.
It is still available for our Healthy Families Program.
Consequently, when the prescribing physician
denotes “do not substitute” or “dispense as written”
on the prescription for a Healthy Families Program
member, the pharmacist transmits the claim using the
appropriate DUR code to allow claim adjudication.
Quantity and Dosing
30-Day Quantity Supply Limits
Dose Optimization Program
The pharmacy benefit program allows up to a 30-day
supply of most medications with the new exception
of select maintenance medications on the 90-day
supply list. This program defines a quantity limit
based on FDA dosing recommendations. If a medical
condition warrants a greater supply than what has
been recommended, then PAB is required in order
to ensure access to a medically appropriate quantity.
Medications in this program require an internal review
by Blue Cross prior to dispensing.
The Dose Optimization Program helps increase
patient adherence to drug therapies. This program
works with the member, the member’s physician or
health care provider, and the pharmacist to replace
multiple doses of lower-strength medications where
clinically appropriate with a single dose of a
higher-strength medication (only with the prescribing
physician’s approval). If you have questions, please
contact WellPoint NextRx at (800) 227-3032.
Provider e-News Vol 2 2006
15