| |
|
|
| Medicare Offerings |
|
Update:
Opioid Prescription Policy
|
|
The opioid addiction epidemic is one of America’s
foremost health crises. According to the most recent statistics from
the Centers for Disease Control and Prevention (CDC), opioids kill more
than 33,000 people annually, and opioid abuse/overdose is considered a
leading cause of shortened life expectancy in the U.S.
The nation’s opioid epidemic reflects a complex set of circumstances.
The pattern of opioid prescription—including dose and duration—and risk
factors of age, gender, and condition are major determinants of whether
a patient becomes dependent.
In response to this growing crisis, Capital BlueCross has developed a
comprehensive strategy to ensure safer drug use in our network
including changes to our prescription drug formulary. We continue to
notify all impacted members of the modified commercial (not Medicare)
formulary changes:
- Opioid
prescriptions have new quantity level limits (QLLs) and daily
dosage limits.
- These
limits are in effect for off-exchange members and will apply
to exchange members effective January 1, 2018.
- Prior
authorization for long-acting or extended release opioid
preparations is required.
- Prescriber
justification for non-cancer and non-terminal conditions will be
reviewed to assess medical necessity.
- Prior
authorization is now required for oral fentanyl, methadone,
and medication-assisted treatments (MATs)—namely Suboxone,
Bunavail, Zubsolv, buprenorphine, buprenorphine/naloxone, and
immediate-release sublingual or mucosal absorption preparations.
|
- Can a member get additional quantities of
medication above the new limits to reflect the original
prescription?
Possibly, when the
member’s doctor completes a QLL review. If approved,
the approval for the additional number of medications will be
input into CVS’ Caremark Pharmacy system to allow the pharmacy to
fill the extra supply.
- Can a member and/or provider appeal to allow up to
the original quantity of medication on his or her prescription? Yes, the member has appeal rights.
Proper appeal documentation, medical records, and/or letters of
medical necessity and diagnosis can be sent to our pharmacy
appeals area. Note: There are no guarantees of the outcome of
the appeal; however, the pharmacy appeals department will mail the
letter to the member and if necessary, contact the member for
further explanation.
- Was this formulary change a Capital BlueCross
decision or a federal- or state- imposed change? The
over-utilization of opioids and associated deaths have reached
epidemic proportions. As a result, federal, state, and local
authorities have partnered to ensure judicious use and monitoring
of these medication quantities. As part of this initiative, payer
organizations like Capital BlueCross are able to utilize data that
will identify potentially harmful doses and quantities which
warrant further review by a qualified health care professional.
- May a member purchase medication outside of the
insurance restrictions?
Yes, a member with a valid prescription from his or her
doctor can fill all or the remainder of his or her prescription
outside of the insurance quantity limits.
- If a member purchases medication outside the limits
of the insurance restrictions, can he or she file a paper claim
for reimbursement?
1) If the script was outright filled outside the insurance
restriction, then a member can file a paper claim; however, the
only level of reimbursement will be up to the new restricted
limit. 2) If the member fills the script for the new quantity
level and his or her doctor does a QLL for an additional amount,
then any amount prescribed over the new limits will not be
eligible for reimbursement because the maximum benefit limit has
already been obtained.
|
|
|
We're committed to making this newsletter valuable to
you and the way you do business.
If you haven't already, let us know how we're doing by completing this
quick survey:
|
|
We now have one consolidated mailing address for all
segments:
|
|
First
Class Mail
Payment Processing
PO Box 371482
Pittsburgh, PA 15250-7482
|
|
Overnight
Courier
Payment Processing
Attn: 371482
500 Ross St. 154-0470
Pittsburgh, PA 15262-0001
|
|
|
|
Changes
to Group Application
|
|
Several changes have been made to the Application for
Group Benefits (C-70), available on your online producer portal.
The updated application should now be used and is required for January
1, 2018 effective dates and beyond. No exceptions will be made for use
of older applications due to PID filing and legal language updates. All
versions of the previous form that may have been saved electronically
or in paper form must be destroyed.
Specific changes include:
- The
form name submitted to the PID has been updated.
- The
group policy maker signature section has been replaced by an
authorized group signature section, including language about
authorized group representatives. Producers cannot sign this
section.
- A
Capital BlueCross representative signature is no longer required,
and that section has been removed.
- The
domestic partner question has been removed. All 2018 groups will
be set up to allow domestic partner coverage with no rate impact
to groups. It is up to group administrators to determine company
policies.
- Groups
with Capital BlueCross coverage within the past 12 months who were
terminated delinquent are now required to pay their past due
balance prior to new setup. This is effective for past review,
beginning with groups applying for January 1, 2018 effective
dates.
|
|
|
|
|
|
|
|
