Connection supplemental articles and policies - November 2006

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Connection - November 2006 (pdf, 318 KB)

supplemental articles

an important message about MassHealth benefits
the inside scoop on outside authorizations
formulary updates
annual icd-9-cm updates

policies and forms

an important message about MassHealth benefits

Effective July 1, 2006, MassHealth benefits were expanded to include the services below for eligible adults. Certain conditions and limitations may apply as some services require prior approval.

Dental services. MassHealth covers medically necessary dental services including checkups, cleanings, fillings, certain endodontics (like root canals) and dentures. Some of these services need prior approval. Adults are no longer required to qualify for special circumstances to receive these services.
Vision services. MassHealth covers medically necessary eyeglasses, eyeglass parts, eyeglass dispensing, certain contact lenses and other visual aids, including magnifying aids.
These services were already covered by MassHealth for members under the age of 21.

FCHP MassHealth covers the following services. Certain conditions and limitations may apply to services covered by FCHP as they may require prior approval.

Acute hospital inpatient administratively necessary days.
FCHP MassHealth Standard, FCHP MassHealth CommonHealth, FCHP MassHealth Basic and FCHP MassHealth Family Assistance cover all administratively necessary inpatient stays for members aged 21 years or older. (FCHP MassHealth benefits already covered these services for members under the age of 21.)
Certain 24-hour substance abuse treatment services.
FCHP MassHealth Standard, FCHP MassHealth CommonHealth, FCHP MassHealth Basic and FCHP MassHealth Family Assistance cover 24-hour post-medical detoxification substance abuse treatment services, defined as Level IIIB and Level IIIC by the Massachusetts Department of Public Health’s Bureau of Substance Abuse Services.
Chiropractor services.
FCHP MassHealth Standard, FCHP MassHealth CommonHealth, FCHP MassHealth Basic and FCHP MassHealth Family Assistance cover medically necessary services provided by a chiropractor for members aged 21 years or older. (FCHP MassHealth benefits already covered these services for members under the age of 21.)
Orthotics.
FCHP MassHealth Standard, FCHP MassHealth CommonHealth, FCHP MassHealth Basic and FCHP MassHealth Family Assistance cover medically necessary orthotic services. In addition to other changes, coverage for orthotic shoes is no longer restricted to members with severe diabetic foot disease.
Tobacco cessation services.
FCHP MassHealth Standard, FCHP MassHealth CommonHealth, FCHP MassHealth Basic and FCHP MassHealth Family Assistance cover tobacco cessation services for members of any age who smoke or use tobacco products, such as chewing tobacco. FCHP MassHealth members may receive group or individual counseling by requesting tobacco cessation counseling services from their doctor. These services are available through FCHP MassHealth physicians, community health centers and hospital outpatient departments (other than the emergency department). Also, members may request a prescription from their doctor for nicotine replacement medicine, including nicotine patches, gum and lozenges, and certain other medicines to help members in the process of quitting tobacco.
Transportation (out-of-state location).
FCHP MassHealth Standard and FCHP MassHealth CommonHealth members may receive nonemergency transportation by ambulance and other common carriers that generally are pre-arranged to transport a member to a service that is located outside a 50-mile radius of the Massachusetts border.
Wigs
FCHP MassHealth Standard, FCHP MassHealth CommonHealth, FCHP MassHealth Basic and FCHP MassHealth Family Assistance cover prosthetic wigs as prescribed by a physician related to a medical condition.

questions?
If your FCHP patients have any questions related to these changes, please ask them to contact the Fallon Community Health Plan Customer Service Department at 800-868-5200, Monday through Friday between 8 a.m. and 6 p.m. For more information on these benefits, providers may call our Customer Service Department or the MassHealth Customer Service Center at 800-868-5200.

the inside scoop on outside authorizations

by Steven Friedman, Ph.D., Clinical Manager, Outpatient Services, Beacon Health Strategies

At Beacon Health Strategies, we use a licensed and credentialed network of providers within a convenient geographic area to meet the behavioral health care needs of our FCHP members. We maintain clinical and quality oversight of this network to ensure the satisfaction of our referring providers and their patients.
Only in very particular circumstances do we approve out-of-network services. In these special instances, the nonparticipating provider must agree to a contract with Beacon in order for the request to be approved.

Requests for out-of-network services must be initiated by the FCHP member. A Beacon member services representative takes the information by phone, and then a Beacon behavioral health clinician reviews it. The main reasons for considering out-of-network requests are:

A linguistic or cultural specialty that is either not available in the FCHP network or not accessible to the member’s home or work
A full-time student attending college out of state
Confidentiality (i.e., when a member is known in a specific provider community and needs to see someone outside that community)
A specialty not currently available in the member’s geographic area
Compelling continuity of care (i.e., where a newly eligible member would be at psychiatric risk if a transfer of provider was to be initiated)

Our extensive provider network in most cases will meet the behavioral health needs of FCHP members. So, before making a referral to a nonparticipating provider (or suggesting a nonparticipating provider to a member), we ask that you contact a Beacon member services representative who will work with you to locate a FCHP network provider. For questions about out of network services, please call Beacon at 888-421-8861.

formulary updates

Fallon Community Health Plan has made several changes to its formularies, including changing prior authorization requirements and adding new medications. Please see the list of changes to our commercial plan and our Medicare Part D formularies below

commercial plan formulary

additions

Keflex (cephalexin) 750 mg caps	Tier 3
Seasonique^® (levonorgestrel/ethinyl estradiol)	Tier 2, Limit 1 pack, 3 copayments per pack

changes

Allegra^® (fexofenadine)	PA removed
Allegra-D^® (fexofenadine/pseudoephedrine)	PA removed
Cymbalta^® (duloxetine)	PA removed
Spiriva^® (tiotropium)	PA removed
iPlex^® (mecasermin)	Moratorium to Tier 3, PA required
Nexavar^® (sorafenib)	Moratorium to Tier 3, PA required
Revlimid^® (lenalidomide)	Moratorium to Tier 3, PA required
Sutent^® (sunitinib)	Moratorium to Tier 3, PA required
Vivaglobin^® (immune globulin, SC)	Moratorium to Tier 3, PA required
Zemplar^® (paricalcitol)	Moratorium to Tier 3, PA required

moratorium*

Dacogen^® (decitabine)
Elaprase^® (idursulfase)
Eraxis^® (anidulafungin)
Exubera^® (insulin, reg, inhalation)
Lucentis^® (ranibizumab)
Opana^® (oxymorphone, IR)
Opana ER^® (oxymorphone, ER)
Oracea^® (doxycycline)
Prezista^® (darunavir)
Sprycel^® (dasatinib)
Vivitrol^® (naltrexone IM extended release)
Zelapar^® (selegiline)
Zostavax^® (zoster vaccine SC)

* FCHP’s Moratorium Policy was enacted to ensure patient safety and to allow for adequate time for the development, review and approval of clinical criteria. When a new medication first becomes available, it will fall under this policy and be excluded from coverage. A process is in place that allows for the quick review of provider requests for noncovered pharmaceuticals.

medicare part d formulary