05/20/2020

Priority Health Update

Priority Health Managed Care Committee Member

Flora Varga, Cancer & Hematology Centers of West Michigan

Financial relief for members and employers in response to COVID-19

We're offering financial support to our members and employers facing challenges during the COVID-19 pandemic in the form of premium credits and waiving cost share in these ways:

• Medicare Advantage members will have no cost share for in-person and telehealth primary care services May 1, 2020 through Dec. 31, 2020.
• MyPriority Individual plan members will have a 15% premium credit for June and July 2020.
• Small group employers (2-50 employees) will have a 15% premium credit issued in June and July 2020.
• Large, fully funded employers will have the opportunity for premium credits in the fourth quarter, when the total amount of excess funds available can be determined.

Collecting copays from Medicare Advantage members

Because we’re waiving cost-sharing for all Medicare Advantage members for in-person and telehealth primary care services from May 1 – Dec. 31, 2020, primary care providers should not collect copays for these services from Medicare Advantage members. Even though providers won’t be collecting copays, they’ll still receive their full contracted fees.

Learn more and share information with your patients about our COVID-19 financial relief plan for members.

Medical policy updates

Below are links to updated or new policies. Remember, you can always find the latest updates to policies in the Pending/retired/updated medical policy list.

Prophylactic Cancer Risk Reduction Surgery - 91508

Effective May 14, 2020

Added family history as additional risk criteria when considering prophylactic simple mastectomy. This information was obtained from Comprehensive Cancer Network (NCCN) Guidelines for Genetic/Familial High-Risk Assessment: Breast and Ovarian. CLICK HERE

Prior authorization is no longer required for the following procedures:

• Prophylactic gastrectomy
• Prophylactic hysterectomy
• Prophylactic mastectomy
• Prophylactic oophorectomy
• Prophylactic salpingo-oophorectomy

Prior authorization is still required for prophylactic thyroidectomy.

Updated process for peer-to-peer reviews starts July 1

Starting July 1, you'll have one phone number to call if you want to schedule a peer-to-peer conversation with a medical director for inpatient and outpatient services to help you work with us quickly and easily. The phone number is 616.464.8432.

We've also expanded our hours of operations. You can contact us Monday—Friday, 8:30 a.m. - 4 p.m.  There's no change to the process for behavioral health services. Behavioral health providers should continue to call 616.464.8500.

What is a peer-to-peer review?
The purpose of peer-to-peer discussion is to exchange information regarding the medical necessity of a denied prior authorization request. The call does not take the place of documentation required to support authorization.

How do I request a peer-to-peer review?
You must schedule a peer-to-peer review within certain time frames, which vary depending on the authorization type.

Commercial formulary changes coming July 1, 2020

In July and January of each year, the Priority Health Pharmacy and Therapeutics committee makes changes to the commercial formulary to ensure our members have access to safe, effective, and affordable drugs.

So far in 2020, we’ve added 45 new drugs to the formulary. We’ve also made positive changes (reduced tier or removal of authorization requirement) on 11 drugs, which helps make them more affordable to our members.

On July 1, 2020, we’ll have 28 drug changes that either remove a drug from the formulary or increase the tier the drug is in. These changes impact approximately 3,420 unique members.

How we’re communicating to our members
Members who are impacted by any changes to the formulary receive a letter advising them of how their drug coverage will be changing and what steps they can take prior to July 1, 2020. The letters also include a list of alternative medications that may be options for them.

Learn more
Our May 21 Virtual Office Advisory webinar will cover these changes. Join us to ask questions and learn more. 

Biosimilars preferred over Herceptin, Avastin and Rituxan, effective July 1

Beginning July 1, 2020, we’ll be preferring lower cost biosimilar products over Herceptin^® (trastuzumab), Avastin^® (bevacizumab) and Rituxan^® (rituximab) when used for the treatment of cancer(s) for patients who are new to therapy. This change impacts all product lines, including commercial group, individual, Medicaid and Medicare.

Why we’re making this change
Our Pharmacy and Therapeutics Committee (comprised of network physicians) monitors the availability of new biosimilars, which have been proven to have no meaningful difference in safety, purity or effectiveness for our members and can help them save on out-of-pocket costs.

Preferred biosimilar products and billable codes
A list of preferred biosimilars and billable codes is included below.

Prior authorizations
Herceptin and Avastin do not currently require prior authorization. Therefore, their preferred biosimilars will not require prior authorization. Although Rituxan currently has a prior authorization requirement, we are removing the prior authorization for Rituxan biosimilars for individual, commercial group and Medicaid. At this time, we’re not removing prior authorization for Rituxan or Rituxan biosimilars for Medicare.

For patients currently on Herceptin, Avastin or Rituxan
This change will impact new starts only. Members currently receiving treatment using a non-preferred product will be able to continue their treatment.

Members receiving Avastin for the treatment of ocular disorders will not be required to use preferred biosimilars. Providers should be using a different code to indicate its use for treating ocular disorders. If a provider incorrectly bills for treatment of ocular disorders using the cancer code (J9035), the code will be denied.