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Tier Changes to TRICARE Formulary Drugs
The Department of Defense Pharmacy &Therapeutics (DoD P&T) Committee oversees the TRICARE Management Activity drug formulary. The DoD P&T has recommended changes to certain prescription drugs that will move them to the non-formulary level (Tier 3) or will require prior-authorization.
Please be mindful that the step-therapy requirement for Nexium is applicable to members new to therapy and those currently on therapy. Members new to therapy and currently on therapy are required to try formulary drugs, however, you may submit a prior-authorization request if your patient meets any of the following criteria:
- Use of ALL formulary agents is contraindicated
- Patient has experienced significant adverse effects from ALL formulary agents
- All formulary agents result in therapeutic failure
For more information or if you have questions, please contact Customer Service at 1-800-808-7347.
Provider Outreach and Education Seminar
Part 1: "The Inside Story: Coding and Introduction to Risk"
Risk adjustment is an essential component in the health care industry, affecting both providers and health plans. We will discuss how accurate medical record documentation and coding practices impact auditing, claims reimbursement, and regulatory requirements. Using ICD-10, CPT, Hierarchical Conditions Categories (HCC) and other metrics, we will provide best practices to appropriately capture provider and patient interactions for quality documentation and complementary coding.
Register for one of the Part I dates below by calling 888-895-4998 or emailing email@example.com by April 5. For both dates, registration begins at 8:30 a.m. and lunch is served at 12 p.m.
Wednesday, April 19
9 a.m.-12 p.m.
Spring Hill Suites
7544 Teague Road
Hanover, MD 21076
Thursday, June 8
9 a.m.-12 p.m.
Holiday Inn Columbia
7900 Washington Blvd.
Jessup, MD 20794
Johns Hopkins Advantage MD Pre-Authorization Guidelines Update
Based on your feedback, we have updated the pre-authorization guidelines for the Johns Hopkins Advantage MD programs. The updates are in alignment with industry standard and will be effective April 15.
Summary of updates:
Effective April 15, the following procedures no longer need pre-authorization:
- Carpal Tunnel Surgical Decompression
- Routine Outpatient Mental Health Services
- Sleep Studies
- Sacroiliac Joint Injections
- Transformaminal Epidurals
- Wound Clinic
Effective April 15, the following procedures have revised pre-authorization requirements:
- CT – CTA of Heart only
- MRI – Breast only
- Outpatient Surgery* (Ambulatory Surgical Center or Hospital-based)
*Specified surgeries continue to have pre-authorization requirements.
Emergency Room Facility Update
Effective March 23, 2017, EHP will follow the ER sudden and serious auto pay list for facility emergency services for members covered under the EHP medical plans for Johns Hopkins Hospital, Johns Hopkins Bayview and Johns Hopkins Health System with group numbers: E00090, E00091, E00092, E00093, E00190, E00192, E00194, E00198, E00006, E00007.
The ER sudden and serious list includes the ICD-10 codes designating an emergency room visit requiring immediate medical attention. The ER sudden and serious list will automatically adjudicate the hospital claims.
Diagnoses listed on the ER sudden and serious list will automatically adjudicate based on the principal diagnosis submitted and billed. This applies for hospitals billing with revenue codes 451/452.
Emergency services claims in which the principal diagnosis is not on the ER sudden and serious list will be subject to medical record review and possible denial of payment for services by EHP
Please refer to the Emergency Department Review Process, Policy: APL.009 for additional information.
If you have questions or need assistance with any other item, please contact Provider Relations at (888)-895-4998.
Johns Hopkins Advantage MD Influenza "Flu" Vaccinations
People 65 years and older are at greater risk of serious influenza (flu) disease. Immunosenescence (decline in immune function) is a normal part of aging, increasing the susceptibility of flu-related hospitalizations and deaths among people in this age group. We strongly encourage our seniors and their caregivers to get their flu vaccinations during this season.
According to the Centers for Disease Control and Prevention, there are two vaccines designed specifically for people 65 and older:
- The “high-dose vaccine” is designed specifically for people 65 and older and contains four times the amount of antigen as the regular flu shot. It is associated with a stronger immune response following vaccination (higher antibody production). Results from a clinical trial of more than 30,000 participants showed that adults 65 years and older who received the high dose vaccine had 24% fewer influenza infections as compared to those who received the standard dose flu vaccine. The high dose vaccine has been approved for use in the United States since 2009.
- The adjuvanted flu vaccine, Fluad, is made with MF59 adjuvant, which is designed to help create a stronger immune response to vaccination. In a Canadian observational study of 282 persons aged 65 years and older conducted during the 2011-12 season, Fluad was 63% more effective than regular-dose unadjuvanted flu shots. There are no randomized studies comparing Fluad with Fluzone High-Dose. This vaccine will be available for the first time in the United States during the 2016-2017 season.
The high-dose and adjuvanted flu vaccines may result in more of the mild side effects that can occur with standard-dose seasonal shots. Mild side effects can include pain, redness or swelling at the injection site, headache, muscle ache, and malaise.
In addition, it is important that people 65 years and older are up to date with pneumococcal vaccination to protect against pneumococcal disease, such as pneumonia, meningitis, and bloodstream infections. The annual focus on influenza vaccination is an ideal time to ensure that your patients are also up to date on their pneumococcal vaccination.
Johns Hopkins HealthCare (JHHC) will reimburse providers who administer pneumococcal and flu vaccinations for Advantage MD members.
- Pneumococcal and influenza (flu) virus vaccines are covered by Medicare Part B
- Member may receive the vaccine at a participating network pharmacy or at the provider’s office
- Member’s responsibility is $0
The provider must bill the appropriate CPT code, which includes the vaccine and administration of the vaccine, to be reimbursed for this service.
If an Evaluation and Management code (E&M code) is billed with the flu vaccine, it implies an examination has been completed and the applicable copay will be applied.
If you have questions, please contact the JHHC Provider Relations department at 888-895-4998.
Consistent with current standards of practice in mental health and addiction medicine, these changes will reduce administrative barriers and improve access for mental health and substance use disorder treatment.
The following services no longer have quantitative limits, however all other requirements remain unchanged:
- Partial hospitalization and intensice outpatient programs (must still be pre-authorized and reviewed for medical necessity)
- Substance use disorder rehabilitation facility (must still be pre-authorized and reviewed for medical necessity)
- Outpatient individual, family, and group psychotherapy (8 yearly unmanaged visits before submission of a treatment plan is required; outpatient services performed in a hospital or facility setting require referral)
- Psychological testing (must still be pre-authorized and reviewed for medical necessity)
- Smoking cessation quit attempts
- Smoking cessation counseling sessions per attempt
As a result of these changes, mental health and substance use disorder services, regardless of the length or quantity, may be covered as long as the care is authorized and considered medically or psychologically necessary and appropriate. The current benefit of not requiring a referral or authorization for the first eight outpatient mental health visits in a fiscal year remains unchanged.
Also effective October 3, 2016, copays for mental health and substance abuse services will be changed as follows:
|Prior to 10/3/16||On and after 10/3/16|
|Individual Outpatient Psychotherapy||$25||$12/visit|
|Inpatient Mental Health||$40/day||$11/day ($25 minimum per visit)|
Download the Uniform Treatment Plan form to be submitted for purposes of treatment authorization.
Please contact the customer service department at 410-424-4528 or 800-808-7347 with questions.
Did you know that NCQA rates the Johns Hopkins Health Plans each year? All of the John’s Hopkins health plans rated as high performance plans in 2016. NCQA’s Health Insurance Plan Ratings are based on quality measures (HEDIS), member satisfaction (CAHPS) and NCQA Accreditation standards scores. NCQA’s uses a rating methodology which classifies plans into scores from 1-5 in 0.5 increments–-a system similar to CMS’ Five-Star Quality Rating System. You can view each plan’s report card on the NCQA website.
The 2016 NCQA ratings are as follows:
- EHP – High performance (4.0) with Accredited Accreditation
- PPMCO – High performance (4.0) with Commendable Accreditation
- USFHP – High Performance (5.0) with Excellent Accreditation
The Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) features many required health care services for children on Medicaid. To help you stay informed about the requirements of EPSDT, we have created a webpage with helpful information and links to periodicity schedules, immunization recommendations, and additional resources. Visit the EPSDT webpage for more information.
Thank you for providing great health care to our Priority Partners child members, and we hope this information helps you to continue this great care.
Per the Provider Notice letter you should have received, the 2016 Outpatient Referral & Pre-Authorization Guidelines for EHP, Priority Partners, and USFHP are now up on the JHHC website. To view these guidelines, please click the links below: