Connection supplemental articles and policies - March 2010

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Connection - March 2010 (pdf, 208 KB)

Supplemental articles



Payment policies

The following policy is new – effective May 1, 2010:

  • Limited Services Clinics Payment Policy

The following policies have been reviewed. Changes, effective May 1, 2010, are indicated on the policies and summarized in the print version of Connection:

 

Script Alert


Formulary updates

Fallon Community Health Plan often makes changes to its formularies, including changing prior authorization requirements and adding new medications. Below are the latest changes to our commercial plan formulary.

Commercial plan formulary

Additions  
Aczone (dapsone gel) Tier 3, PA required
Adcirca (tadalafil) Tier 3, PA required
Bepreve (bepotastine) Tier 3
Dritho-Crème (anthralin) Tier 3
Edluar (zolpidem, SL) Tier 3, PA required
Effient (prasugrel) Tier 3, PA required
Fibricor (fenofibric acid) Tier 3
Kapidex (dexlansoprazole) Tier 3, QLL 30 per 30 days
Multaq (dronedarone) Tier 3, PA required
Nucynta (tapentadol) Tier 3, PA required
Prevacid-24 OTC $5 copay for up to 42 units
Prilosec OTC $5 copay for up to 42 units
Promacta (eltrombopag) Tier 3, PA required
Renvela Powder (sevelamer) Tier 2
Sabril (vigabatrin) Tier 3, PA required
Samsca (tolvaptan) Tier 3, PA required
Saphris (asenapine) Tier 3, PA required
   
Changes  
Apriso (mesalamine) PA removed
Lexapro (antidepressant) Moved to Tier 3
Prevacid (lansoprazole) Rx Removed from formulary
Prilosec (omeprazole) Rx Removed from formulary
Protonix (pantoprazole) Removed from formulary
Rhinocort (steroid nasal spray) Moved to Tier 3
Zegerid (omeprazole, NaBicarb) Removed from formulary
   
New to Market Policy*  
BenzeFoam (benzoyl peroxide 5.3%)
Fanapt (iloperidone)
Intuniv (guanfacine 24 hr)
Metozolv (metoclopramide ODT)
Pacnex (BPO cleanser 4.25%)
Stelara (ustekinumab)
Sumaxin (sulfacetamide/sulfur wash)
Terbinex Kit (terbinafine/Hydroxyprop chitosan)
Valturna (aliskiren/valsartan)

* FCHP’s New to Market 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 non-covered pharmaceuticals.

 

Coding corner


2010 CPT/HCPCS codes that require preauthorization

As mentioned in the January Connection, all new 2010 codes require preauthorization until a final review is performed by Fallon Community Health Plan. We’ve now reviewed the 2010 CPT/HCPCS Codes, and some of them will continue to require preauthorization. These codes (see below) have been added to the list of procedures that require preauthorization and are effective immediately.

CODE

DESCRIPTION

37761 Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg

43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)
63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed
63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed
63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed
63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed
74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material
74262 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed
74263 Computed tomographic (CT) colonography, screening, including image postprocessing 
75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium
75572 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)
75573 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed)
75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
78452 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
78453 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
78454 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
89398 Unlisted reproductive medicine laboratory procedure
90644 Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza B vaccine, tetanus toxoid conjugate (Hib-MenCY-TT), 4-dose schedule, when administered to children 2-15 months of age, for intramuscular use
93750 Interrogation of ventricular assist device (VAD), in person, with physician analysis of device parameters (eg, drivelines, alarms, power surges), review of device function (eg, flow and volume status, septum status, recovery), with programming, if performed, and report
95905 Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report
C9254 Injection, lacosamide, 1 mg
E0433 Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge
E1036 Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs
G0420 Face-to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour
G0421 Face-to-face educational services related to the care of chronic kidney disease; group, per session, per one hour
G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session
G0424 Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day
G0425 Initial inpatient telehealth consultation, typically 30 minutes communicating with the patient via telehealth
G0426 Initial inpatient telehealth consultation, typically 50 minutes communicating with the patient via telehealth
G0427 Initial inpatient telehealth consultation, typically 70 minutes or more communicating with the patient via telehealth
G0430 Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure
G0431 Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class
J0586 Injection, abobotulinumtoxina, 5 units
J0598 Injection, C1 esterase inhibitor (human), 10 units
J0718 Injection, certolizumab pegol, 1 mg
J2562 Injection, plerixafor, 1 mg
J2793 Injection, rilonacept, 1 mg
J2796 Injection, romiplostim, 10 micrograms
J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg
L2861 Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each
L3891 Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each
L5973 Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source
L8031 Breast prosthesis, silicone or equal, with integral adhesive
L8627 Cochlear implant, external speech processor, component, replacement
L8628 Cochlear implant, external controller component, replacement
L8629 Transmitting coil and cable, integrated, for use with cochlear implant device, replacement
L8692 Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment
Q0138 Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use)
Q0139 Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD on dialysis)
Q4074 Iloprost, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, up to 20 micrograms