New plan gives members ‘personal choice’ with lower out-of-pocket costs

Members who have enrolled in the innovative new product called Blue Cross^® Personal Choice PPO will have coverage beginning Oct. 1, 2016.

The product gives members the opportunity to lower their out-of-pocket costs when they coordinate their health care with their primary care doctor through our Organized Systems of Care program. It also offers access to the broader PPO network.

Here’s how it works:

• Members who select a primary care doctor who affiliates with a Level 1 OSC and who use other health care providers associated with that OSC receive high-quality, coordinated care at the lowest out-of-pocket cost.
• Members who have selected a primary care doctor in a Level 1 OSC but who seek services from other doctors and hospitals outside of that OSC will need a referral from their primary care doctor to stay at the Level 1 cost share.

E-referral process

An e-referral process has been developed to help manage your referrals electronically. If you currently use the e-referral system for your Blue Care Network patients, you already have access to the new Blue Cross Blue Shield of Michigan e-referral system. If e-referral is new to you, here’s what you do:

Request access to e-referral

• Go to the Sign Up or Change a User page at ereferrals.bcbsm.com.

Submit referrals

• Go to ereferrals.bcbsm.com and click on Login.
• Click on BCBSM e-referral.
• Choose Submit Referral from the Referrals/Authorization drop-down menu at the top.
• Fill in all required fields.
• Click Submit.

Training opportunities

We’re offering health care providers a wide range of training opportunities to learn about this new product. Here are two of them:

• Attend a one-hour webinar in September or October. If you haven’t already enrolled, click here to access the webinar invitation.
• Access an online training presentation by clicking here.

For more information

• Go to ereferrals.bcbsm.com, click on Blue Cross and then on Blue Cross Personal Choice PPO.
• Download an e-referral user guide.
• Check out the new flier on Blue Cross Personal Choice PPO.
• Visit PersonalChoicePPO.com.

If you have any additional questions after reviewing these resources, reach out to your provider consultant or other Blue Cross contact.

Drug copay coupons may increase costs for members

While it may seem as though copay coupons help to contain rising prices, they can actually lead to increased drug costs.

Copay coupons promote brand-name drugs instead of generic drugs, regardless of whether they reduce the higher copay amounts often required for the higher-cost brands. In fact, copay coupons are available for more than 400 branded drugs, with the majority for chronic conditions. Less expensive alternatives are available for many of these. Coupons are usually available only for the first fill of the medication.

How coupons work: Crestor vs. generic Lipitor

What our Pharmacy Services leaders have to say

Laurie Wesolowicz, director, Clinical Pharmacy Services:

Copay coupons weaken employers’ ability to use different copay amounts to lower drug costs. For our records, we can't tell if the copay was paid by the member or through a coupon. So the member’s actual copay may count against their deductible and out-of-pocket expenses even though most of it was covered by the coupon.

Copay coupons do little to help the poor and uninsured. The coupons actually cause their costs to increase because manufacturers must raise drug prices to cover the costs they spend on coupons, making necessary prescription drugs more expensive for them.

To control copay coupon’s long-term effects on the health care system, health care providers must help patients make high-value health care decisions. Copay coupons should only be used when absolutely necessary by those with a true financial burden, and they should never be used when a cheaper, equally effective and clinically appropriate alternative is available.

James Lang, vice president, Pharmacy Services:

Coupon copay programs have become a big problem for health plans and employer groups. At the moment, drug companies have coupon programs for more than 400 branded drugs, mostly to treat chronic conditions. The coupons encourage you to choose the higher-cost brands, rather than more affordable, but equally effective, options. This leaves employers, including Blue Cross, footing the difference. If current trends continue, copay coupons will increase drug costs at least $32 billion by 2021.

List features drugs not covered on the commercial Blue Cross drug list and preferred alternatives

To address the high cost of drugs and provide the best value for our members, Blue Cross Blue Shield of Michigan commercial plans will not cover select high-cost, FDA-approved drugs for which more cost-effective therapeutic alternatives are available. The drugs listed below are not covered on the commercial Blue Cross drug lists. In most cases, if a member fills a prescription for one of these drugs, he or she will pay the full retail price.

Providers should write a prescription for one of the preferred alternatives that Blue Cross covers. They have similar effectiveness, quality and safety but at a fraction of the cost. Our exclusions criteria are based on current medical information and have been approved by the Blue Cross Pharmacy and Therapeutics Committee. If medical necessity coverage is approved, quantity limits may apply.

This list is not comprehensive. As part of this ongoing initiative, Blue Cross will continue to identify select high-cost drugs and will stop covering them when there are more cost-effective alternatives available for our commercial members.

Note: Michigan Education Special Services Association members are excluded from this program.

The list will be continuously updated and can be found online at the following locations:

• PPO drug lists for group members
• Clinical drug list
• Custom drug list
• Pharmacy Services
• 2016 drug lists

Drug list exclusions for Blue Cross commercial plans
The drugs shown below aren’t covered on the commercial Blue Cross Blue Shield of Michigan drug lists. In most cases, if you fill a prescription for one of these drugs, you’ll pay the full retail price.

Drug list exclusions at a glance
Click on each of the following excluded drugs for more information.:

Drug list exclusions with preferred alternatives
This list contains the class, subclass and preferred alternatives for the excluded drug. The trade names for the preferred alternatives are listed in parenthesis for reference.

Note: These exclusions apply to most Blue Cross commercial members; they don’t apply to Medicare Advantage plans.

CPT Category II and Z codes aid data collection, lessen administrative work for offices

What are CPT Category II and Z codes?
CPT Category II codes are tracking codes, while Z codes are diagnosis codes. Certain CPT II codes and Z codes facilitate data collection for HEDIS^® measures.** They can give you credit for quality care without the need for medical record review and can help you close gaps for HEDIS measures.

Here’s a closer look:

• CPT Category II codes describe components that are usually included in the evaluation and management process, such as A1c or blood pressure test results. They are billed in the procedure code field like CPT Category I codes are.
• Z codes are diagnosis codes. To illustrate how they might be used to facilitate data collection, submitting a claim with the appropriate ICD-10 diagnosis code to indicate a patient’s body mass index will alleviate the need to review the member’s medical record for BMI documentation.

Why should my practice use CPT Category II and Z codes?
The use of CPT Category II and Z codes on claims eases an office’s administrative burden. It does this by decreasing, while not completely eliminating, the need for medical record reviews to determine if certain HEDIS measures are met. Performance on certain HEDIS measures influences the level of reimbursement providers can receive through various incentive programs.

CPT Category II codes are adopted and reviewed by the Performance Measure Advisory Group, or PMAG. PMAG is made up of experts in performance measurement from organizations such as the American Medical Association, the National Committee for Quality Assurance, the Centers for Medicare & Medicaid Services and others.

For more information, download or print the following:

• CPT II quick guide for closing gaps for HEDIS measures
• HEDIS claim coding reference guide

**HEDIS^®, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance.

Reminder: Update your Provider Authorization form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before they can exchange protected health information electronically with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 remittance files, you must update your Provider Authorization form. Updating the form ensures that information is routed to the appropriate destination. You don’t need to update the Provider Authorization form if your submitter and trading partner IDs don’t change.

Keep these items in mind when changes occur. You should review your provider authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own national provider ID
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 files
• Selected a new destination for your 835 files

You must update your Provider Authorization form if you will send claims using a different submitter ID or route your 835s to a different unique receiver or trading partner ID. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

• Click on Quick Links.
• Click on Electronic Connectivity (EDI).
• Scroll down to EDI Agreements.
• Click on Update your Provider Authorization Form.

If you have questions about EDI enrollment, contact our help desk at 1-800-542-0945. For assistance with TPA and Provider Authorization forms, select the TPA option.

Use KX modifier for ground ambulance services over 25 miles

Blue Cross Blue Shield of Michigan pays an approved amount for ambulance services to transport a patient up to 25 miles by ground. If required, we'll pay for a greater distance if the nearest medical facility capable of treating the patient's condition exceeds 25 miles. In either case, a claim must meet the following conditions:

• The service is medically necessary because transport by any other means would endanger the patient’s health.
• The service must transport the patient to a hospital or transfer the patient from a hospital to another treatment location, such as another hospital, skilled nursing facility, medical clinic or the patient's home.

For dates of service starting on Sept. 1, 2016, for any ground mileage over 25 miles, providers need to:

• Include the KX modifier on the claim.
• Place the modifier on the mileage line of the claim.
• Maintain supporting documentation for the transportation.

Providers will only be required to submit documentation of ambulance service if we request it for a review.

Blue Cross physical therapy program expands

In partnership with eviCore healthcare, Blue Cross Blue Shield of Michigan is expanding its physical therapy use management program to include our Blue Cross Medicare Advantage PPO, Medicare Plus Blue^SM, in addition to Blue Cross commercial PPO.

The expansion is intended to improve patient care and manage utilization for the following Michigan provider types and services:

• Independent physical therapy
• Outpatient physical therapy
• Hospital outpatient physical therapy
• Occupational therapy

Speech and language pathology services will continue to be excluded. The program will provide category assignments based on risk adjusted visits per episode of care.

Category assignments
As previously announced in the June 2016 Record, beginning in September 2016, profile reports for category assignments will include physical therapy claims for Blue Cross Medicare Advantage PPO and Blue Cross commercial PPO plans.

• Category assignments are determined by 12 months of combined independent physical therapy and outpatient physical therapy claims data.
• Three category tiers — A, B or C — will continue being assigned to physical therapists.
• Independent occupational therapists will default to category B.
• Outpatient occupational therapists will default to the category of their facility.
• Hospital outpatient physical therapy will continue to be an independent categorization.

In late September or early October, eviCore will mail letters identifying your provider category based on your combined Medicare and commercial claims data. Physical therapists will continue to have the option to request a reconsideration of category status within 15 days from date of the category notification letter.

Preauthorization program
A preauthorization program is in development. Look for upcoming Record articles and web-DENIS messages for more detailed information about preauthorization requirements and seminars that will review all changes.

Blue Cross developing retail health center network

Blue Cross Blue Shield of Michigan is developing a retail health center network and creating a unique provider type for these centers. This network is effective Jan. 1, 2017.

What are retail health centers?
Retail health centers are health centers that treat uncomplicated, acute minor illnesses and injuries. They provide preventive health care services on a walk-in basis, offering convenient hours in a retail location.

Retail health center services are not meant to be a substitute for the ongoing, comprehensive health care services provided by a member’s primary care doctor.

Provider enrollment
If you’re interested in joining this network, enrollment information will be available in the Enrollment and Changes section of bcbsm.com./providers on Oct. 1. We’ll provide more details in the October Record and via web-DENIS.

You may need to sign a new agreement with us if you want to be designated as a retail health center but are currently contracted with us as another provider type.

Other information

• All participating retail health centers will be considered in-network for our PPO members.

• Contracted centers will be categorized as a “Retail Health Center” in the Find a Doctor search tool on bcbsm.com and on the Blue Cross and Blue Shield Association website at bcbs.com.

• Blue Care Network has been contracting with retail health centers since late 2014. There aren’t any changes planned for BCN at this time.

Additional information about the network will be communicated in future Record articles.

Update: Deadline extended for providers who prescribe drugs for Part D patients to enroll in Medicare

As you’ve read in The Record previously, Medicare will require nearly all providers (for example, dentists, physicians, psychiatrists, residents, nurse practitioners and physician assistants), including Medicare Advantage providers, who prescribe drugs for Part D patients to enroll in Medicare (or validly opt out, if appropriate).

The deadline for enrolling has been extended to Feb. 1, 2017. Beginning on that date, Medicare will enforce a requirement that Medicare Part D prescription drug benefit plans may not cover drugs prescribed by providers who aren’t enrolled in (or validly opted out of) Medicare, except in very limited circumstances.

Why is this important?

Unless you enroll (or validly opt out), Medicare Part D plans will be required to notify your Medicare patients that you aren’t able to prescribe covered Part D drugs. Note that if you opt out, you can’t receive reimbursement from traditional Medicare or a Medicare Advantage plan, either directly or indirectly (except for emergency and urgent care services).

Steps you need to take

To help your Medicare patients, please enroll in Medicare either fully to bill or for the limited purpose of prescribing Part D drugs as soon as possible. There are no fees to complete the process. You can enroll electronically or on paper as follows:

• Electronic process: Use the PECOS system by clicking here.** For limited enrollment, use the step-by-step instructions found here** and a video tutorial by clicking here.**

• Paper process: Complete the paper application for limited enrollment by clicking here** and submit it to the MAC in your geographic area. To locate your MAC, please refer to the MAC list at Part D Prescriber Enrollment - MAC List - Centers for Medicare & Medicaid Services.**

If you need help with enrolling in (or validly opting out of) Medicare, contact the MAC within your geographic area.

These new CMS rules will enable federal officials to better combat fraud and abuse in the Part D program through verification of providers’ credentials through the Medicare enrollment or opt-out process.

Questions? Need help?

Contact CMS at providerenrollment@cms.hhs.gov if you have questions about this information, you don’t prescribe drugs or if you believe that you aren’t eligible to enroll in Medicare (for example, you are a pharmacist).

Visit the CMS Part D Prescriber Enrolment website at Part D Prescriber Enrollment - MAC List - Centers for Medicare & Medicaid Services** for information about the new requirement, such as resources to check your application status or to sign up to receive email updates.

**Blue Cross Blue Shield of Michigan does not own or control this website.

Billing chart: Blues highlight medical, benefit policy changes

You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.

This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications & Resources.
• Click on Benefit Policy for a Code.
• Click on Topic.
• Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
• Enter the procedure code.
• Click on Finish.
• Click on Search.

Coding corner: Seizures vs. epilepsy

According to the Centers for Disease Control and Prevention, epilepsy affects more than 2 million adults in the U.S. A brain disorder, epilepsy is sometimes called a seizure disorder.

When a person has two or more seizures, they’re considered to have a seizure disorder. A seizure is a change in normal brain activity and is the main sign of epilepsy, but also can occur due to other medical problems. Symptoms vary according to the part of the brain that’s affected.

There can be multiple causes leading to a seizure. Conditions associated with seizures and epilepsy include:

• Developmental problems, such as cerebral palsy
• Head injuries
• Poisoning

If known, physician documentation must specify the reason for the seizure or convulsion, such as seizure disorder, traumatic brain injury, genetic disorders or epilepsy. If the cause is unknown or documentation is lacking, only the symptoms can be coded and could result in failure to correctly capture the patient’s condition. To accurately assign a code, the specific description of the epilepsy or recurrent seizure condition is necessary.

Supporting documentation related to treatment, such as anti-seizure medications, EEG tests and specific blood tests, also helps in accurately capturing and reporting the diagnosis.

Convulsions and seizures occur in certain types of epilepsy, but they can also be symptoms of other diseases, such as cerebrovascular accident, brain tumor, alcoholism and electrolyte imbalance. The code for epilepsy should not be assigned unless the physician specifically states epilepsy as the condition in the diagnostic statement.

The different types of seizures are grand mal, myoclonic, atonic, tonic, clonic and absence (petit mal). Accurate documentation of the seizure type is important in assigning the correct ICD-10 codes. The ICD-10 coding system has more codes to accommodate higher specificity in capturing diagnoses. Some examples are given in the table below.

Epilepsy and recurrent seizures require a fifth digit when coding in ICD-10 to indicate whether the patient’s condition is intractable or not. If a patient has intractable epilepsy, his or her condition is difficult to control using anticonvulsant medications, such as phenytoin or phenobarbital.

As with many other conditions, physician documentation is critical to accurately coding a diagnosis of seizure or epilepsy.

To access a flier on seizures and epilepsy, click here.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.

BlueCard^® connection: If an out-of-state plan rejected my claim as experimental, is my patient responsible for the charge?

Yes. You may bill the patient if both of the following apply:

• You receive a rejection on a BlueCard claim.
  
• The plan’s rejection advises you that the service or treatment reported on your claim is considered experimental or investigational and is the member’s liability.

The home plan where your patient is enrolled determines whether the service reported is a covered benefit, according to their member’s contracted benefits and the plan’s medical policy.

Blue Cross Blue Shield of Michigan’s medical policies, including those for experimental services, don’t apply to BlueCard claims.

Use of the Medical Policy and Pre-Cert/Pre-Auth Router can help you confirm the plan’s medical policy criteria. The router can also identify services that a home plan considers experimental or investigational. If a plan has a documented online medical policy, you can access the policy via our router.

You can access the Medical Policy and Pre-Cert/Pre-Auth Router by using any of these options:

• Logging in to web-DENIS and clicking on the BCBSM Provider Publications and Resources link.

• Clicking on a link in the medical records section of the online BlueCard chapter found in every online provider manual

• Going to bcbsm.com and following these steps:

• Click on Providers.
• Click on Quick Links.
• Click on Medical Policy and Pre-Cert/Pre-Auth Router.

On the router’s webpage, you can view a plan’s pre-service authorization requirements or its medical policies. To view the medical policies that a plan has available online, you’ll enter the member’s three-letter alpha-prefix and be routed to the plan’s webpage. The plan’s online policies include effective dates, clinical criteria for the service or treatment and the clinical information the plan used to determine their policy.

Consult the plan’s online policies before rendering a service or treatment to the patient. This BlueCard online tool also is an excellent resource to reference before requesting claim reconsideration on a billed and rejected claim.

For more information on the BlueCard program, including links and articles on online tools, reference the BlueCard chapter of the online provider manuals.

If you’re experiencing issues with the information provided in the BlueCard chapter of the online manual — or if you’d like more information on a particular topic — contact your provider consultant.

Want to suggest a topic to be covered in this series? Send an email to ProvComm@bcbsm.com and put “BlueCard series” in the subject line.

New plan gives members ‘personal choice’ with lower out-of-pocket costs

Members who have enrolled in the innovative new product called Blue Cross^® Personal Choice PPO will have coverage beginning Oct. 1, 2016.

The product gives members the opportunity to lower their out-of-pocket costs when they coordinate their health care with their primary care doctor through our Organized Systems of Care program. It also offers access to the broader PPO network.

Here’s how it works:

• Members who select a primary care doctor who affiliates with a Level 1 OSC and who use other health care providers associated with that OSC receive high-quality, coordinated care at the lowest out-of-pocket cost.
• Members who have selected a primary care doctor in a Level 1 OSC but who seek services from other doctors and hospitals outside of that OSC will need a referral from their primary care doctor to stay at the Level 1 cost share.

E-referral process

An e-referral process has been developed to help manage your referrals electronically. If you currently use the e-referral system for your Blue Care Network patients, you already have access to the new Blue Cross Blue Shield of Michigan e-referral system. If e-referral is new to you, here’s what you do:

Request access to e-referral

• Go to the Sign Up or Change a User page at ereferrals.bcbsm.com.

Submit referrals

• Go to ereferrals.bcbsm.com and click on Login.
• Click on BCBSM e-referral.
• Choose Submit Referral from the Referrals/Authorization drop-down menu at the top.
• Fill in all required fields.
• Click Submit.

Training opportunities

We’re offering health care providers a wide range of training opportunities to learn about this new product. Here are two of them:

• Attend a one-hour webinar in September or October. If you haven’t already enrolled, click here to access the webinar invitation.
• Access an online training presentation by clicking here.

For more information

• Go to ereferrals.bcbsm.com, click on Blue Cross and then on Blue Cross Personal Choice PPO.
• Download an e-referral user guide.
• Check out the new flier on Blue Cross Personal Choice PPO.
• Visit PersonalChoicePPO.com.

If you have any additional questions after reviewing these resources, reach out to your provider consultant or other Blue Cross contact.

Reminder: Update your Provider Authorization form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before they can exchange protected health information electronically with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 remittance files, you must update your Provider Authorization form. Updating the form ensures that information is routed to the appropriate destination. You don’t need to update the Provider Authorization form if your submitter and trading partner IDs don’t change.

Keep these items in mind when changes occur. You should review your provider authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own national provider ID
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 files
• Selected a new destination for your 835 files

You must update your Provider Authorization form if you will send claims using a different submitter ID or route your 835s to a different unique receiver or trading partner ID. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

• Click on Quick Links.
• Click on Electronic Connectivity (EDI).
• Scroll down to EDI Agreements.
• Click on Update your Provider Authorization Form.

If you have questions about EDI enrollment, contact our help desk at 1-800-542-0945. For assistance with TPA and Provider Authorization forms, select the TPA option.

Here’s how end-stage renal disease facilities can appeal audit findings

Non-hospital end-stage renal disease facilities that receive a Blue Cross Blue Shield of Michigan ESRD initial audit reporting letter have the option of accepting or appealing our audit findings.

Included with the reporting letter will be the Appeal Process Option – Non-Hospital form. You should complete the form and fax it to Blue Cross at 1-877-276-3920 within five days of receiving the letter.

How to appeal
If you don't agree with our audit findings, submit the following documentation to Blue Cross (address included in the letter) within 30 days of receiving the letter:

• An appeal letter or statement for each patient, including:
  
• The reason for the dispute — for example, we received incorrect payment or we disagree with the number of dialysis treatments denied
  
• The rationale to support your position
  
• A Request for Retrospective Review form
  
• This form is now included with the audit-reporting letter.
• Complete all fields to expedite the appeal process.

Documentation
The documentation necessary to submit an appeal for an ESRD appeal is as follows:

• Physician orders — A valid physician order for the audit period in question, indicating the frequency of dialysis treatments per week
• Dialysis or treatment logs — For each month of appealed services, regardless of the location where dialysis occurred, submit a dialysis or treatment log so we can verify that you performed the number of treatments billed to Blue Cross.
• Patient’s name and dates of service being appealed

Drug copay coupons may increase costs for members

While it may seem as though copay coupons help to contain rising prices, they can actually lead to increased drug costs.

Copay coupons promote brand-name drugs instead of generic drugs, regardless of whether they reduce the higher copay amounts often required for the higher-cost brands. In fact, copay coupons are available for more than 400 branded drugs, with the majority for chronic conditions. Less expensive alternatives are available for many of these. Coupons are usually available only for the first fill of the medication.

How coupons work: Crestor vs. generic Lipitor

What our Pharmacy Services leaders have to say

Laurie Wesolowicz, director, Clinical Pharmacy Services:

Copay coupons weaken employers’ ability to use different copay amounts to lower drug costs. For our records, we can't tell if the copay was paid by the member or through a coupon. So the member’s actual copay may count against their deductible and out-of-pocket expenses even though most of it was covered by the coupon.

Copay coupons do little to help the poor and uninsured. The coupons actually cause their costs to increase because manufacturers must raise drug prices to cover the costs they spend on coupons, making necessary prescription drugs more expensive for them.

To control copay coupon’s long-term effects on the health care system, health care providers must help patients make high-value health care decisions. Copay coupons should only be used when absolutely necessary by those with a true financial burden, and they should never be used when a cheaper, equally effective and clinically appropriate alternative is available.

James Lang, vice president, Pharmacy Services:

Coupon copay programs have become a big problem for health plans and employer groups. At the moment, drug companies have coupon programs for more than 400 branded drugs, mostly to treat chronic conditions. The coupons encourage you to choose the higher-cost brands, rather than more affordable, but equally effective, options. This leaves employers, including Blue Cross, footing the difference. If current trends continue, copay coupons will increase drug costs at least $32 billion by 2021.

List features drugs not covered on the commercial Blue Cross drug list and preferred alternatives

To address the high cost of drugs and provide the best value for our members, Blue Cross Blue Shield of Michigan commercial plans will not cover select high-cost, FDA-approved drugs for which more cost-effective therapeutic alternatives are available. The drugs listed below are not covered on the commercial Blue Cross drug lists. In most cases, if a member fills a prescription for one of these drugs, he or she will pay the full retail price.

Providers should write a prescription for one of the preferred alternatives that Blue Cross covers. They have similar effectiveness, quality and safety but at a fraction of the cost. Our exclusions criteria are based on current medical information and have been approved by the Blue Cross Pharmacy and Therapeutics Committee. If medical necessity coverage is approved, quantity limits may apply.

This list is not comprehensive. As part of this ongoing initiative, Blue Cross will continue to identify select high-cost drugs and will stop covering them when there are more cost-effective alternatives available for our commercial members.

Note: Michigan Education Special Services Association members are excluded from this program.

The list will be continuously updated and can be found online at the following locations:

• PPO drug lists for group members
• Clinical drug list
• Custom drug list
• Pharmacy Services
• 2016 drug lists

Drug list exclusions for Blue Cross commercial plans
The drugs shown below aren’t covered on the commercial Blue Cross Blue Shield of Michigan drug lists. In most cases, if you fill a prescription for one of these drugs, you’ll pay the full retail price.

Drug list exclusions at a glance
Click on each of the following excluded drugs for more information.:

Drug list exclusions with preferred alternatives
This list contains the class, subclass and preferred alternatives for the excluded drug. The trade names for the preferred alternatives are listed in parenthesis for reference.

Note: These exclusions apply to most Blue Cross commercial members; they don’t apply to Medicare Advantage plans.

Reminder: Blue Cross members can get select vaccines under pharmacy benefit at participating pharmacies starting Oct. 1

Starting Oct. 1, 2016, Blue Cross Blue Shield of Michigan commercial (non-Medicare) members will have select vaccine coverage for $0 copay under their pharmacy benefits plan. This will allow select vaccines to be given at Blue Cross participating pharmacies and billed through the pharmacy claims processing system. This program will cover the same vaccines listed in the Vaccine Affiliation Program.

Below is a list of frequently asked questions.

Can Blue Cross members’ vaccines be processed under both their pharmacy benefits and medical plans?

Yes, but submit only one bill to one plan per claim. Both plans require a qualified administrator at a Blue Cross participating pharmacy or medical office to give the vaccine.

• Qualified pharmacists giving the vaccine can bill the member’s pharmacy benefits plan or medical plan when the pharmacy participates in the medical Vaccine Affiliation Program.

• Participating medical offices giving the vaccine should bill the member’s medical plan.

Note: All medical and pharmacy claims are subject to monitoring.

Who can receive vaccinations at participating retail pharmacies using their prescription drug plan?

Most Blue Cross commercial (non-Medicare) members with prescription drug coverage are eligible. The vaccine will be covered with no cost share to members if their benefits meet the coverage criteria. Note: Not all members are eligible so you’ll need to check the members’ benefits.

• Check to make sure the vaccine is payable under the member’s medical plan or pharmacy benefits
• Check the age requirements for the vaccine. If a member doesn’t meet the age requirement the claim won’t be covered.

Sample Blue Cross membership cards with the pharmacy benefits plan:

MOS Rx Grp: BCBSMRX1	NASCO Rx Grp: BCBSMAN

What is the message for rejected pharmacy claims?

The message for rejected pharmacy claims is 70 for Product-Service Not Covered if there’s no age requirement.

If the age requirement isn’t met, the message is 60 for Product-Service Not Covered for patient age.

What vaccines can be processed under the Blue Cross pharmacy benefits plan?
Listed below are the vaccines and age requirements covered under the pharmacy benefits plan.

Note: Members’ coverage for vaccines may vary, so check their benefits to make sure which vaccines are covered.

Can a member get a vaccine before Oct. 1, 2016?

Yes, if the member has vaccine coverage under his or her medical benefits.

How should pharmacy vaccines be billed for Blue Cross commercial (non-Medicare) members?

The vaccines are billed like any other pharmacy claim:

• Bill the metric quantity administered (for example, bill 0.5 ml; don’t bill quantity of 1).
• Follow state regulations when administering vaccines.
• Use the National Council for Prescription Drug Programs format to submit the vaccines.

Vaccines must be prescribed by a licensed prescriber or doctor to be covered. Standing physician orders are also acceptable. Pharmacies should refer to Schedule B of the Restated and Amended Preferred Rx Participation Agreement and Traditional Rx Participation Agreement we sent you.

All standard claims should include the following:

Does this new process pertain to Blue Care Network or Medicare Part D members?

No. These members can continue to receive vaccines as they do today.  The BCN and Medicare Part D programs are not changed as a result of this new program designed for Blue Cross commercial members with pharmacy coverage.

What should the pharmacy do if it has Blue Cross vaccine billing issues?

If you have any questions or billing issues, call the Express Scripts^® Pharmacy Technical Help Desk at 1-800-922-1557.

All GM employees receive continuous glucose monitor benefit

Effective Jan. 1, 2016, continuous glucose monitors became a benefit for all General Motors’ hourly employees. The following information applies to all GM members, including GM salaried members who already have this benefit.

The following guidelines must be met for the continuous glucose monitor to be considered for reimbursement for these members:

• Patients with recurrent unexplained severe hypoglycemia
• Pregnant women with insulin-requiring diabetes complicated by recurrent hypoglycemia, which has not been resolved by following best practices
• Patients who have recurrent unexplained severe hypoglycemia and who do not already have an adequately functioning insulin pump may be considered for glucose sensors and transmitters associated with an integrated insulin pump.
• The patient must complete a comprehensive diabetes education program. Care management participation is required for continuous glucose monitor claims to be paid.

The relevant procedure codes are A9276, A9277 and A9278.

When claims are submitted for these procedure codes, the following supporting documentation must be on file or claims will be rejected:

• Prescription for equipment and supplies with a duration of need specified on the prescription
• Blood sugar logs with two to three months of information
• Treatment notes, including evidence of recurrent hypoglycemic unawareness
• History of the medical condition and documents to support medical necessity, including lab results

GM follows the standard Blue Cross Blue Shield of Michigan processing processing guidelines for this benefit.

Note: Patients must meet the criteria for both the continuous subcutaneous insulin infusion pump as well as for the continuous glucose monitor.

Here’s what you need to know about eligibility requirements for pneumatic compression devices

Effective Jan. 1, 2017, patients will be required to participate in conservative therapy (e.g., use of an appropriate compression bandage system or compression garment and regular exercise) before they can be considered for a pneumatic compression device. This requirement applies to procedure codes E0650, E0651 and E0652, and depends on the patient’s condition.

If the patient shows improvement, the patient will continue with conservative therapy. For a detailed list of the conservative therapy required by the Centers for Medicare & Medicaid Services, click here.

If the patient no longer shows improvement with additional conservative therapy, then he or she will be eligible for a pneumatic compression device. A completed Certificate of Medical Necessity, which has been signed and dated by the treating physician, must be kept on file by the provider and made available upon request.

Providers may use one of the following Certificate of Medical Necessity forms for pneumatic compression pumps:

• CMS-846
• DME 04.04B

Or providers may use their own form if it includes all the same information as the forms listed above. Providers can keep the form in the parient file or attach it electronically to the claim.

Blue Cross physical therapy program expands

In partnership with eviCore healthcare, Blue Cross Blue Shield of Michigan is expanding its physical therapy use management program to include our Blue Cross Medicare Advantage PPO, Medicare Plus Blue^SM, in addition to Blue Cross commercial PPO.

The expansion is intended to improve patient care and manage utilization for the following Michigan provider types and services:

• Independent physical therapy
• Outpatient physical therapy
• Hospital outpatient physical therapy
• Occupational therapy

Speech and language pathology services will continue to be excluded. The program will provide category assignments based on risk adjusted visits per episode of care.

Category assignments
As previously announced in the June 2016 Record, beginning in September 2016, profile reports for category assignments will include physical therapy claims for Blue Cross Medicare Advantage PPO and Blue Cross commercial PPO plans.

• Category assignments are determined by 12 months of combined independent physical therapy and outpatient physical therapy claims data.
• Three category tiers — A, B or C — will continue being assigned to physical therapists.
• Independent occupational therapists will default to category B.
• Outpatient occupational therapists will default to the category of their facility.
• Hospital outpatient physical therapy will continue to be an independent categorization.

In late September or early October, eviCore will mail letters identifying your provider category based on your combined Medicare and commercial claims data. Physical therapists will continue to have the option to request a reconsideration of category status within 15 days from date of the category notification letter.

Preauthorization program
A preauthorization program is in development. Look for upcoming Record articles and web-DENIS messages for more detailed information about preauthorization requirements and seminars that will review all changes.

Reminder: Medicare Plus Blue^SM PPO prior authorization program expansion and training webinar

As you read in the August Record, Blue Cross Blue Shield of Michigan will expand its prior authorization program later this year to include three additional services for our Medicare Plus Blue^SM PPO members who reside in Michigan and use Michigan providers.

The expansion is intended to eliminate the unnecessary use of certain procedures to improve patient care and manage health care costs. Following are the three additional types of services, the purpose of prior authorization for these services and the effective dates.

Starting Sept. 1, 2016:

• Inpatient and outpatient lumbar spinal fusion surgery — Manage the utilization of spinal fusion surgeries to ensure clinical appropriateness
• Outpatient interventional pain management — Manage the use of outpatient interventional pain procedures, including epidural injections, facet block and radiofrequency ablations, to help eliminate inappropriate delivery of such procedures

Starting Nov. 1, 2016:

• Outpatient radiation oncology — Manage the use of radiation therapy inclusive of modalities, dosing, coding and treatment goals, while reducing expenditures and the patient’s exposure to radiation therapy

For interventional pain management and lumbar spinal fusion surgery dates of service starting Sept. 1, prior authorization requests may be submitted on eviCore’s website**or by phone at 1-877-917-2583 (BLUE). The recommended and quickest way to obtain authorizations is online. If a prior authorization isn’t obtained for the above services, claims will be denied and providers will be responsible for the costs.

You can request a prior authorization online and locate the clinical worksheets and CPT code list for the mentioned services one of the following ways:

• At the eviCore implementation website**
• At the Blue Cross website. Go to bcbsm.com, click on Provider Secured Services, then log in to web-DENIS to find the authorization information.

The clinical worksheets will give you the information you need to request a prior authorization. The eviCore implementation site also includes Frequently Asked Questions, a Quick Reference Guide, national guidelines and information on webinars.

Training webinars
We published the full training webinar schedule for interventional pain management and lumbar spinal fusion surgery in a web-DENIS message posted Aug. 4. The remaining September webinars are listed below, as well as the times and dates for the outpatient radiation oncology webinars:

You can sign up for webinars at medsolutions.webex.com**

• Click on the Training Center tab at the top of the page.
• Click on the Upcoming tab, then find the date and time of the session you want to attend.
• Click on Register and enter the registration information.

Note: The webinar times listed on the website are Central time; the times listed above are Eastern time.

We’ll continue to provide more details about these changes in future issues of The Record and in web-DENIS broadcast messages.

**Blue Cross Blue Shield of Michigan does not own or control this website.