Blue Cross, BCN receive 4-star ratings from CMS

Blue Cross Blue Shield of Michigan and Blue Care Network both received 4-star ratings from the Centers for Medicare & Medicaid Services for 2020 for their Medicare Advantage health plans.

Together, these results mean that 100% of our members across the country are covered by four-star plans, making us one of an elite few that can make that claim.

The Medicare Star Rating System is a nationally recognized measurement program that provides an overall rating of a health plan’s quality and performance for the types of services each plan offers. It also measures a member’s experience with a plan. Measurement ranges from 1 star (lowest) to 5 stars (highest).

Attaining a 4-star rating is a moving target because the bar is set higher each year and it’s harder for health plans to hit it year after year.

“Our health care providers take Medicare star ratings very seriously,” Dr. Duane DiFranco, Blue Cross Blue Shield of Michigan’s vice president of Medicare star ratings and clinical performance, said in a recent column in Hospital and Physician Update. “They try hard to meet the Medicare star measures because they understand the key role these measures play in improving care outcomes for our Medicare population.”

Star Measure Tips
We post a series of tip sheets on web-DENIS to help providers meet key measures. We’re currently in the process of updating the tip sheets for 2020 and expect the new ones to be posted early in January.

Our 2019 tip sheets range from such topics as adult BMI assessment to statin use in persons with diabetes. You can access the series of 15 tip sheets from the Clinical Quality Corner section of BCBSM Newsletters and Resources or from the Clinical Quality Corner section of BCN Provider Publications and Resources. Our HEDIS Measure Tip Sheets are also posted there.

As a reminder, web-DENIS is a secure website so you’ll need to log in as a provider to access these tip sheets.

Tobacco Coaching program available to all PPO members, starting Jan. 1

Blue Cross Blue Shield of Michigan’s Tobacco Coaching program, powered by WebMD^®, will be available to all PPO members beginning Jan. 1, 2020. It’s previously only been available to PPO members of groups that purchased the program and to all Blue Care Network and Medicare Advantage members.

WebMD Health Services is an independent company supporting Blue Cross Blue Shield of Michigan and Blue Care Network by providing health and well-being services.

Tobacco Coaching is a 12-week, over-the-phone coaching program designed to help members quit using tobacco. It includes coaching on all types of tobacco products, including electronic cigarettes and vaping devices.

To be eligible for the program, Blue Cross members must:

• Be ready to set a quit date within the next 30 days
• Have used a tobacco product within the past seven days of their initial call to WebMD

Your patients who engage in the program will receive:

• Five calls from a specially trained health coach over a 12-week period
• Unlimited inbound calls to a health coach
• Blue Cross member account online resources
  

WebMD health coaches are available seven days a week, so it’s easy for your patients to schedule their coaching appointments at a time that’s convenient for them. Your patients can call 1-855-326-5102 beginning Jan. 1, 2020, to speak to a health coach and schedule their first coaching call.

Members who would like to quit using tobacco, but who aren’t ready to set a quit date in the next 30 days, will be referred to the Blue Cross^® Health & Well-Being online Digital Health Assistant Quit Tobacco program. Members can access Quit Tobacco by logging in to their bcbsm.com account.

About Federal Employee Program^® members
FEP members have their own smoking and tobacco cessation program. For more information, members can visit www.fepblue.org or contact Customer Service at 1-800-482-3600.

J0642 replaces J3490 and J3590 when billing levoleucovorin (khapzory)

The Centers for Medicare & Medicaid Services has established a permanent procedure code for specialty medical drug levoleucovorin (khapzory), effective Oct. 1, 2019.

All services from Jan. 1, 2019, through Sept. 30, 2019, will continue to be reported with codes J3490 and J3590. All services performed on and after Oct. 1, 2019, must be reported with J0642.

All services effective April 1, 2019, for facility billing will continue to be reported with code C9043.
The national drug codes are 68152-0112-01 and 68152-0114-01.

Outpatient Prospective Payment System

Injection

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.

We’re announcing 2020 updates for value-based reimbursement for specialists

Effective March 1, 2020, the Physician Group Incentive Program is:

• Introducing a new specialist value-based reimbursement opportunity through a pilot program
• Implementing a change to the specialist VBR methodology

New VBR opportunity
In 2020, PGIP is starting a pilot program to encourage specialists to adopt a team-based care approach, supported by care managers. We’ll facilitate this team-based care by using existing and upcoming Health Information Exchange capabilities in the PGIP physician organizations.

To be considered for this pilot, physician organizations must submit attestations on behalf of the participating specialists to PGIP by Jan. 10, 2020. PGIP physician organizations that meet program requirements will reach out to select specialists in their PO to assess interest and eligibility, and to obtain the necessary attestations.

In 2020, cardiologists, endocrinologists, nephrologists, oncologists and pulmonologists in PGIP can be included in this pilot.

Specialists participating in the pilot will be eligible to receive VBR (at 105% of the standard fee schedule) if they meet all the requirements of the pilot.

Updated psychologists VBR methodology
The methodology for determining the number of fully licensed psychologists eligible to be reimbursed in accordance with the VBR fee schedule is changing slightly next year. Effective March 1, 2020, four-fifths of the nominated, ranked psychologist practices in PGIP (versus two-thirds) will be eligible to receive VBR.

If you’re a member of PGIP and have questions, reach out to your PGIP physician organization.

Blue Cross, BCN to support providers who offer comprehensive opioid treatment

This article was updated on Dec. 9, 2019, to show that for Blue Cross and BCN members, applicable member cost-sharing amounts will apply.

Blue Cross Blue Shield of Michigan and Blue Care Network will implement the Centers for Medicare & Medicaid Services program that encourages providers to offer the comprehensive range of opioid treatment services that many patients need. You can view the CMS final rule on this program, which was published in the Federal Register.**

What this means
Starting Jan. 1, 2020, Blue Cross and BCN will use bundled rates to reimburse providers who offer certified opioid treatment programs, or OTPs. The bundled payment includes both drug and non-drug components and may allow for intensity add-on codes to be used when needed.

This will apply to services for our Medicare Advantage members (Medicare Plus Blue^SM PPO and BCN Advantage^SM) and our Blue Cross and BCN commercial members.

Once this change goes into effect, certified OTPs may qualify for bundled reimbursement.

Here’s some additional information you need to know.

What’s an OTP?
OTPs provide medication-assisted treatment along with counseling and other services for people diagnosed with an opioid use disorder. The treatment of opioid dependence with medications is governed by the Certification of Opioid Treatment Programs, 42 Code of Federal Regulations 8. This regulation created a system to accredit and certify opioid treatment programs.

SAMHSA’s Division of Pharmacologic Therapies is responsible for overseeing the certification of OTPs.

For information on how to obtain OTP certification, visit SAMHSA’s Certification of Opioid Treatment Programs** webpage.

About the CMS program
Section 2005 of the SUPPORT for Patients and Communities Act*** established a new Medicare Part B benefit for opioid use disorder, or OUD, treatment services. The OUD treatment services include medications for medication-assisted treatment furnished by opioid treatment programs.

To meet this statutory requirement, CMS has finalized the following:

• Definitions of OTP and OUD treatment services
• Enrollment policies for OTPs
• Methodology and estimated bundled payment rates for OTPs that vary by the medication used to treat OUD and service intensity, and by full and partial weeks
• Adjustments to the bundled payment rates for geography and annual updates
• Flexibility to deliver the counseling and therapy services described in the bundled payments via two-way interactive audio-video communication technology as clinically appropriate
• Zero beneficiary copayment for a time-limited duration

Blue Cross and BCN will implement this program beginning Jan. 1, 2020, as required by the SUPPORT for Patients and Communities Act. However, for Blue Cross and BCN members, applicable member cost-sharing amounts will apply.

What’s next?
Look for updates in future issues of The Record and BCN Provider News, as well as web-DENIS messages and news items on our ereferrals.bcsbm.com website.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
***SUPPORT stands for Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment.

Free waiver training to provide medication-assisted treatment offered by Mi-CCSI

The Michigan Center for Clinical Systems Improvement, known as Mi-CCSI, is hosting the American Society of Addiction Medicine Treatment of Opioid Use Disorder course at three locations in Michigan in 2020.

The training is provided by Mi-CCSI, the Michigan Opioid Collaborative and Blue Cross Blue Shield of Michigan. Blue Cross is a member of Mi-CCSI.

Each course will provide the required eight educational hours to obtain the medication-assisted treatment waiver to prescribe buprenorphine in an office setting for patients with opioid use disorder.

Following are details about the course offerings:

These courses fill up quickly, so we encourage you to register early. Also, for each course, the first 15 providers attending the full eight hours will be paid for the day as follows:

• Physicians (M.D.s and D.O.) — $500
• Advanced practice providers (nurse practitioners and physician assistants) — $250

Additional incentives
As announced at the September meeting of the Physician Group Incentive Program, Blue Cross will be offering incentives for Patient-Centered Medical Home practices that begin providing medication-assisted treatment. We’ll be providing details in the January issue of The Record and the January-February issue of Hospital and Physician Update.

Starting Jan. 1, we’ll change how we cover some drugs

Our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide our members with safe, high-quality prescription drug therapies. We continually review prescription drugs to provide the best value for our members, control costs and ensure members are using the right medication for the right condition.

Starting Jan. 1, 2020, we’ll change how we cover some brand-name and generic drugs. We’ll also set new quantity limits on certain drugs.

Note: Changes vary by drug list as specified below. For a complete list of 2020 covered drugs go to bcbsm.com/pharmacy. These changes apply to members with commercial pharmacy benefits (not Medicare D). They don’t apply to the Federal Employee Program^®.

Drugs on Preferred Drug List that will have a higher copayment
The brand-name drugs that will have a higher copayment are listed below, along with the covered preferred alternatives that have similar effectiveness, quality and safety. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available. 

Drugs on Preferred Drug List that won’t be covered
The brand-name and generic drugs that won’t be covered are listed below, along with the covered preferred alternatives that have similar effectiveness, quality and safety. Unless noted, both the brand name and available generic equivalents won’t be covered. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs on Clinical and Custom Drug Lists that will have a higher copayment
The brand-name drugs that will have a higher copayment are listed below along with the covered preferred alternatives that have similar effectiveness, quality and safety. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs on Clinical and Custom Drug Lists that won’t be covered
The brand-name and generic drugs that won’t be covered are listed below, along with the covered preferred alternatives that have similar effectiveness, quality and safety. Unless noted, both the brand name and available generic equivalents won’t be covered. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs on Custom Select Drug List that will have a higher copayment
The brand-name drugs that will have a higher copayment are listed below, along with the covered preferred alternatives that have similar effectiveness, quality and safety. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs on Custom Select Drug List that won’t be covered
The brand-name and generic drugs that won’t be covered are listed below along with the covered preferred alternatives that have similar effectiveness, quality and safety. Unless noted, both the brand name and available generic equivalents won’t be covered. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Quantity limits
The drugs below will have changes to the amount that can be filled. These changes apply to all drug lists.

New quantity limits, authorization requirement coming for ketoprofen for PPO, HMO commercial members

The following changes are coming for Blue Cross Blue Shield of Michigan and BCN HMO^SM commercial members:

• New courses of treatment involving ketoprofen 25 mg that begin on or after Dec. 1, 2019, require authorization. If you don’t obtain authorization, your patient may be responsible for the full cost of the drug.
• Effective March 1, 2020, ketoprofen 25 mg will be limited to four capsules per day or 120 capsules per 30 days. Requests to cover larger quantities will need to include documentation showing that the larger quantity is medically necessary.

Members who start taking ketoprofen prior to Dec. 1, 2019, can continue their treatment courses. However, as of March 1, 2020, you’ll need to secure authorization for these members to continue therapy.

Keep in mind that authorization isn’t a guarantee of payment. You can verify eligibility and benefits through web-DENIS.

We’ll notify affected members of these changes and encourage them to talk to their providers if they have concerns.

Note: These requirements don’t apply to Medicare Plus Blue^SM or BCN Advantage^SM members.

Certain infusion drugs won’t be covered in outpatient hospitals, starting in January

Beginning Jan. 1, 2020, Blue Cross Blue Shield of Michigan is adding two more medical drugs to the commercial site of care requirement. The following medical drugs will be subject to this requirement:

• Evenity^®  (HCPCS code J3111)
• Ultomiris^® (HCPCS code J1303)

Infusions for these drugs won’t be covered at hospital outpatient facilities without prior authorization for an approved location, starting Jan. 1.

These changes don’t apply to BCN Advantage^SM, Medicare Plus Blue^SM PPO or Federal Employee Program^® members. The authorization requirement only applies to groups currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.
An approved authorization will be payable for any of these professional locations:

• A doctor’s office or other health care provider’s office
• Ambulatory infusion center
• Your patient’s home, with treatment from a home infusion therapy provider

If health care providers don’t submit the appropriate prior approval requests and don’t receive approval for the outpatient hospital site of care, their patients will be responsible for the full cost of the medicine.  
Tell your patients to:

• Contact any of the infusion therapy providers listed on their member letter on the site of care program. We mailed a letter to members on Oct. 30, explaining the program requirements for these drugs. The infusion therapy providers will work with members to make the change easy.
• Log in to their member account at bcbsm.com and select Find a Doctor to locate therapy infusion providers.

For more information about hospital outpatient infusion therapy, read the following articles from earlier this year:

Certain infusion drugs won’t be covered in outpatient hospitals, starting Jan. 1

Certain infusion drugs won’t be covered in outpatient hospitals, starting April 1

We’re adding medical benefit specialty drugs to prior authorization and site of care programs for PPO members, starting Oct. 1

View The Record Archive for additional articles on this topic from 2018 and 2017.

Changes coming to specialty prior authorization drug list

We’re adding the following medications to the Medicare Plus Blue^SM and BCN Advantage^SM Part B specialty prior authorization drug list. These specialty medications are administered in outpatient sites of care, such as a physician’s office, an outpatient facility or a member’s home.

For dates of service on or after Feb. 3, 2020, the following medications will require authorization:

• Beovu^® (J3490/C9399)
• Zolgensma^® (J3590)
• Skyrizi™ (J3590)
• Spravato™ (J3490)
• Hemlibra^® (J7170)
• Cuvitru™ (J1555)
• Panzyga^® (J1599)
• Ventavis^® (Q4074)

How to bill
For Medicare Plus Blue and BCN Advantage, we require authorization for these medications for the following sites of care when you bill them as a professional service or as an outpatient facility service and they’re billed electronically through an 837P transaction or on a professional CMS-1500 claim form:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)
• Home (place of service code 12)

We also require authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Reminder
You must obtain authorization prior to administering these medications. Use the NovoLogix^® online tool to quickly submit your authorization requests. It offers real-time status checks and immediate approvals for certain medications. Also:

• For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the “Medical Drug PA” box when you completed the Provider Secured Access Application form, you already have access to NovoLogix. If you didn’t check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List.

The authorization requirements for these drugs will be reflected on the drug list on Jan. 1, 2020.

Commercial PPO members will need authorization for Eylea and Lucentis

Blue Cross Blue Shield of Michigan members who begin receiving the following therapies on or after Jan. 1, 2020, will require prior authorization:

• Eylea (aflibercept, HCPCS code J0178)
• Lucentis (ranibizumab, HCPCS code J2778)

This requirement applies only to groups that currently participate in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

To help ensure continuity of care, members who start therapy before Jan. 1 won’t need authorization to continue therapy.

Note: Authorization for these drugs is currently required for BCN HMOSM (commercial), BCN Advantage^SM and Medicare Plus Blue^SM PPO members.

This requirement doesn’t apply to Blue Cross’ PPO members covered under the Federal Employee Program^® Service Benefit Plan.

As a reminder, authorization isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for their patients.

List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Requirements for drugs covered under the medical benefit – BCN HMO and Blue Cross PPO document located in the Medical Benefit Drugs – Pharmacy section of the ereferrals.bcbsm.com website.

The authorization requirement for Eylea and Lucentis will be reflected in the requirements list on Jan. 1, 2020.

Hepatitis B vaccines will be covered for MPSERS members with Blue Preferred, starting in January

Our Blue Preferred^® PPO plan will begin covering hepatitis B vaccines for Michigan Public School Employees’ Retirement System group members, starting in January 2020. The influenza vaccine is already covered.

There’s no cost to the member for either of these vaccines. You can identify MPSERS members by the prefix MSR on their Blue Cross Blue Shield of Michigan membership ID cards.

Note: MPSERS members don’t have coverage for vaccines and other services at retail health clinics, such as CVS MinuteClinic or Walgreens Healthcare Clinic.

GM ConnectedCare: Ascension Genesys plan option effective in January

Effective Jan. 1, 2020, General Motors will offer a new medical plan option, named ConnectedCare: Ascension Genesys, for salaried employees and eligible dependents in select ZIP codes in the Flint area.

This GM plan, administered by Blue Cross Blue Shield of Michigan, includes medical, surgical and hearing services. As reported in the biling chart, the plan is not affiliated with BCN Advantage^SM ConnectedCare.

Members’ ID cards will indicate they are with General Motors and in an Ascension Genesys custom plan. The group number is 83640.

The plan option features two benefit levels:

• Level I includes Ascension Genesys providers and other ConnectedCare-affiliated providers.
• Level 2 includes all other providers.

As always, you can check web-DENIS for information about benefits and eligibility for your patients.

We’ll include behavioral health practitioners in our PPO retrospective review process, as of February 2020

Beginning February 2020, our PPO network management team will begin reviewing the practitioner retrospective practice profiles of behavioral health professionals. The network management team routinely monitors PPO network practitioners to evaluate practice patterns and ensure PPO utilization standards are met.

All providers contractually agree to provide PPO members with efficient, cost-effective care that meets current utilization standards. The network management team will evaluate practitioners against established demographic and utilization criteria, comparing the practitioner’s utilization history to that of their Michigan peers.

Blue Cross Blue Shield of Michigan will monitor utilization patterns with the understanding that the unique aspects of a practitioner’s individual practice may affect his or her ability to perform within the averages established by a practitioner’s peers.

A more detailed look at what’s involved with this process will be included in the January 2020 issue of The Record.

What are the guidelines for annual exams?

Some health care providers have asked us: How many physical exams do Blue Cross Blue Shield of Michigan or Blue Care Network members qualify for each year? The answer depends on what type of plan a member has.

• For members who have BCN coverage, there are no limits on how many times a member can schedule a physical, sometimes called a health maintenance exam.
• Members with Blue Cross Blue Shield of Michigan commercial coverage typically qualify for one physical per year under the terms of the Affordable Care Act, but some members may qualify for more, depending on their age, sex and the type of plan they have. Also, keep in mind that government guidelines for commercial coverage don’t apply to members who are part of the Federal Employee Program®, Michigan Public School Employees' Retirement System, the UAW Retiree Medical Benefits Trust or other retiree or self-funded groups that don’t follow government rules.
• Members with Medicare Advantage plans qualify for annual wellness visits. We’ll have more details on “Welcome to Medicare visits” in the January Record.

Because of these variations in coverage, it’s always best to check benefits and eligibility for your patients on web-DENIS.

Finding benefit information on web-DENIS
To find information on web-DENIS about how many physical exams are covered per calendar year for a specific member, you can follow these steps:

• From the homepage of web-DENIS, click Subscriber Info., then Eligibility/Coverage/COB. Type in the member’s contract number and click Enter.
• Select the member, and in the Detailed Benefits column, click MED (for medical benefits).

If you entered a Michigan-based contract number, you’ll be routed to the Explainer tool. Here’s what to do next:

• Click Topic.
• Under Unique Identifier, select HCPCS Code and type in the appropriate physical exam code (for example, *99395). Click Finish and then Search.
• Click the Benefit Package Report tab, then Coverage Limitations to determine requirements for that contract.

If you entered a national contract number, you’ll be routed to a NASCO benefits page. Here’s what to do next:

• Select your provider type (usually General Practice or OB-GYN for preventive care) and click GO.
• Scroll down to PHYSICAL EXAM to view any limitations.

Adult Body Mass Index Assessment identifies health risk in adults

When documenting height and weight in a patient’s medical record, remember to calculate and document the patient’s body mass index. BMI is considered the most efficient and effective method for assessing excess body fat.

Careful monitoring of BMI will help health care providers identify adults who are at increased risk of developing diseases associated with obesity.

A Medicare star rating measure that’s also a HEDIS^® measure — Adult Body Mass Index Assessment — assesses adults ages 18 to 74 who had their BMI documented during an outpatient visit in the past two years. Calculation of BMI is often overlooked by providers when documenting claims. This missing data results in providers not meeting the criteria for this measure.

View the Adult Body Mass Index Assessment tip sheet on web-DENIS for a list of ICD-10 codes that can be used on claims when coding BMI. The tip sheet also includes tips on helping patients reach and maintain a healthier weight. As a reminder, since web-DENIS is a secure website, you’ll need to log in as a provider to access the tip sheet.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

Tips to manage acute low back pain in adults

According to the Michigan Quality Improvement Consortium, 90% of low back pain episodes resolve within six weeks, regardless of treatment. Typically, imaging isn’t required within the first six weeks, unless certain red flags are present. Red flags include, but aren’t limited to:

• Cauda equina syndrome
• Cancer
• Infection
• Spinal fracture
• Loss of bladder control or bowel control

Without red flags, a conservative approach is preferred. These approaches include:

• Instructing the patient to stay active as tolerated by pain
• Avoiding bed rest
• Doing back exercises and stretches
• Injury prevention
• Using over-the-counter pain relievers

MQIC published Management of Acute Low Back Pain in Adults** as a guideline for providers. The guideline recommends focusing on patient reassurance, detailed history and physical exam, therapy, referrals and medication strategies.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Tools to help educate your pregnant patients

Everyone expects pregnancy to bring an expanding waistline. But some women are surprised when other body changes occur, such as:

• Body aches
• Fatigue
• Heartburn
• Morning sickness

All these changes make it important for women to see their doctor for prenatal care not only for the baby, but for themselves.

The U.S. Department of Health and Human Services’ website on women’s health** offers information on body changes and pregnancy-related discomfort to help educate women on what to expect and how to manage symptoms. The site addresses such symptoms as body aches, breast changes, dizziness, hemorrhoids and nasal problems. 

The number of prenatal tests that women are expected to get can also be confusing and overwhelming. Expectant mothers may wonder what kind of prenatal tests need to be done and why. Share this flyer, listing common prenatal tests, with your patients. For more information about pregnancy care and tests that you can share with your patients, click here.** 

Programs for FEP members
The Blue Cross and Blue Shield Federal Employee Program^® offers the Pregnancy Care Incentive Program to pregnant members enrolled in the Standard or Basic Option plan. The program is designed to encourage pregnant women to receive prenatal care in the first trimester and throughout their pregnancy. The program also provides education to help pregnant members make better choices to keep themselves and their babies healthy.

FEP members who would like more information on the Pregnancy Care Incentive Program, and other incentive programs FEP offers, can visit www.fepblue.org or contact Customer Service at 1-800-482-3600.

Resources for other members
Blue Cross offers the Pregnancy Assistant program through Blue Cross Health & Well-Being, powered by WebMD^®. It provides information and activities for women who are pregnant, planning to become pregnant or those who supporting someone who’s pregnant. See this flyer for more information.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Blue Cross, BCN to support providers who offer comprehensive opioid treatment

Blue Cross Blue Shield of Michigan and Blue Care Network will implement the Centers for Medicare & Medicaid Services program that encourages providers to offer the comprehensive range of opioid treatment services that many patients need. You can view the CMS final rule on this program, which was published in the Federal Register.**

What this means
Starting Jan. 1, 2020, Blue Cross and BCN will use bundled rates to reimburse providers who offer certified opioid treatment programs, or OTPs. The bundled payment includes both drug and non-drug components and may allow for intensity add-on codes to be used when needed.

This will apply to services for our Medicare Advantage members (Medicare Plus Blue^SM PPO and BCN Advantage^SM) and our Blue Cross and BCN commercial members.

Once this change goes into effect, certified OTPs may qualify for bundled reimbursement.

Here’s some additional information you need to know.

What’s an OTP?
OTPs provide medication-assisted treatment along with counseling and other services for people diagnosed with an opioid use disorder. The treatment of opioid dependence with medications is governed by the Certification of Opioid Treatment Programs, 42 Code of Federal Regulations 8. This regulation created a system to accredit and certify opioid treatment programs.

SAMHSA’s Division of Pharmacologic Therapies is responsible for overseeing the certification of OTPs.

For information on how to obtain OTP certification, visit SAMHSA’s Certification of Opioid Treatment Programs** webpage.

About the CMS program
Section 2005 of the SUPPORT for Patients and Communities Act*** established a new Medicare Part B benefit for opioid use disorder, or OUD, treatment services. The OUD treatment services include medications for medication-assisted treatment furnished by opioid treatment programs.

To meet this statutory requirement, CMS has finalized the following:

• Definitions of OTP and OUD treatment services
• Enrollment policies for OTPs
• Methodology and estimated bundled payment rates for OTPs that vary by the medication used to treat OUD and service intensity, and by full and partial weeks
• Adjustments to the bundled payment rates for geography and annual updates
• Flexibility to deliver the counseling and therapy services described in the bundled payments via two-way interactive audio-video communication technology as clinically appropriate
• Zero beneficiary copayment for a time-limited duration

Blue Cross and BCN will implement this program beginning Jan. 1, 2020, as required by the SUPPORT for Patients and Communities Act.

What’s next?
Look for updates in future issues of The Record and BCN Provider News, as well as web-DENIS messages and news items on our ereferrals.bcsbm.com website.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
***SUPPORT stands for Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment.

Starting Jan. 1, we’ll change how we cover some drugs

Our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide our members with safe, high-quality prescription drug therapies. We continually review prescription drugs to provide the best value for our members, control costs and ensure members are using the right medication for the right condition.

Starting Jan. 1, 2020, we’ll change how we cover some brand-name and generic drugs. We’ll also set new quantity limits on certain drugs.

Note: Changes vary by drug list as specified below. For a complete list of 2020 covered drugs go to bcbsm.com/pharmacy. These changes apply to members with commercial pharmacy benefits (not Medicare D). They don’t apply to the Federal Employee Program^®.

Drugs on Preferred Drug List that will have a higher copayment
The brand-name drugs that will have a higher copayment are listed below, along with the covered preferred alternatives that have similar effectiveness, quality and safety. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available. 

Drugs on Preferred Drug List that won’t be covered
The brand-name and generic drugs that won’t be covered are listed below, along with the covered preferred alternatives that have similar effectiveness, quality and safety. Unless noted, both the brand name and available generic equivalents won’t be covered. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs on Clinical and Custom Drug Lists that will have a higher copayment
The brand-name drugs that will have a higher copayment are listed below along with the covered preferred alternatives that have similar effectiveness, quality and safety. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs on Clinical and Custom Drug Lists that won’t be covered
The brand-name and generic drugs that won’t be covered are listed below, along with the covered preferred alternatives that have similar effectiveness, quality and safety. Unless noted, both the brand name and available generic equivalents won’t be covered. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs on Custom Select Drug List that will have a higher copayment
The brand-name drugs that will have a higher copayment are listed below, along with the covered preferred alternatives that have similar effectiveness, quality and safety. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs on Custom Select Drug List that won’t be covered
The brand-name and generic drugs that won’t be covered are listed below along with the covered preferred alternatives that have similar effectiveness, quality and safety. Unless noted, both the brand name and available generic equivalents won’t be covered. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Quantity limits
The drugs below will have changes to the amount that can be filled. These changes apply to all drug lists.

Certain infusion drugs won’t be covered in outpatient hospitals, starting in January

Beginning Jan. 1, 2020, Blue Cross Blue Shield of Michigan is adding two more medical drugs to the commercial site of care requirement. The following medical drugs will be subject to this requirement:

• Evenity^®  (HCPCS code J3111)
• Ultomiris^® (HCPCS code J1303)

Infusions for these drugs won’t be covered at hospital outpatient facilities without prior authorization for an approved location, starting Jan. 1.

These changes don’t apply to BCN Advantage^SM, Medicare Plus Blue^SM PPO or Federal Employee Program^® members. The authorization requirement only applies to groups currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.
An approved authorization will be payable for any of these professional locations:

• A doctor’s office or other health care provider’s office
• Ambulatory infusion center
• Your patient’s home, with treatment from a home infusion therapy provider

If health care providers don’t submit the appropriate prior approval requests and don’t receive approval for the outpatient hospital site of care, their patients will be responsible for the full cost of the medicine.  
Tell your patients to:

• Contact any of the infusion therapy providers listed on their member letter on the site of care program. We mailed a letter to members on Oct. 30, explaining the program requirements for these drugs. The infusion therapy providers will work with members to make the change easy.
• Log in to their member account at bcbsm.com and select Find a Doctor to locate therapy infusion providers.

For more information about hospital outpatient infusion therapy, read the following articles from earlier this year:

Certain infusion drugs won’t be covered in outpatient hospitals, starting Jan. 1

Certain infusion drugs won’t be covered in outpatient hospitals, starting April 1

We’re adding medical benefit specialty drugs to prior authorization and site of care programs for PPO members, starting Oct. 1

View The Record Archive for additional articles on this topic from 2018 and 2017.

Changes coming to specialty prior authorization drug list

We’re adding the following medications to the Medicare Plus Blue^SM and BCN Advantage^SM Part B specialty prior authorization drug list. These specialty medications are administered in outpatient sites of care, such as a physician’s office, an outpatient facility or a member’s home.

For dates of service on or after Feb. 3, 2020, the following medications will require authorization:

• Beovu^® (J3490/C9399)
• Zolgensma^® (J3590)
• Skyrizi™ (J3590)
• Spravato™ (J3490)
• Hemlibra^® (J7170)
• Cuvitru™ (J1555)
• Panzyga^® (J1599)
• Ventavis^® (Q4074)

How to bill
For Medicare Plus Blue and BCN Advantage, we require authorization for these medications for the following sites of care when you bill them as a professional service or as an outpatient facility service and they’re billed electronically through an 837P transaction or on a professional CMS-1500 claim form:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)
• Home (place of service code 12)

We also require authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Reminder
You must obtain authorization prior to administering these medications. Use the NovoLogix^® online tool to quickly submit your authorization requests. It offers real-time status checks and immediate approvals for certain medications. Also:

• For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the “Medical Drug PA” box when you completed the Provider Secured Access Application form, you already have access to NovoLogix. If you didn’t check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List.

The authorization requirements for these drugs will be reflected on the drug list on Jan. 1, 2020.

Commercial PPO members will need authorization for Eylea and Lucentis

Blue Cross Blue Shield of Michigan members who begin receiving the following therapies on or after Jan. 1, 2020, will require prior authorization:

• Eylea (aflibercept, HCPCS code J0718)
• Lucentis (ranibizumab, HCPCS code J2778)

This requirement applies only to groups that currently participate in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

To help ensure continuity of care, members who start therapy before Jan. 1 won’t need authorization to continue therapy.

Note: Authorization for these drugs is currently required for BCN HMOSM (commercial), BCN Advantage^SM and Medicare Plus Blue^SM PPO members.

This requirement doesn’t apply to Blue Cross’ PPO members covered under the Federal Employee Program^® Service Benefit Plan.

As a reminder, authorization isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for their patients.

List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Requirements for drugs covered under the medical benefit – BCN HMO and Blue Cross PPO document located in the Medical Benefit Drugs – Pharmacy section of the ereferrals.bcbsm.com website.

The authorization requirement for Eylea and Lucentis will be reflected in the requirements list on Jan. 1, 2020.

GM ConnectedCare: Ascension Genesys plan option effective in January

Effective Jan. 1, 2020, General Motors will offer a new medical plan option, named ConnectedCare: Ascension Genesys, for salaried employees and eligible dependents in select ZIP codes in the Flint area.

This GM plan, administered by Blue Cross Blue Shield of Michigan, includes medical, surgical and hearing services. As reported in the biling chart, the plan is not affiliated with BCN Advantage^SM ConnectedCare.

Members’ ID cards will indicate they are with General Motors and in an Ascension Genesys custom plan. The group number is 83640.

The plan option features two benefit levels:

• Level I includes Ascension Genesys providers and other ConnectedCare-affiliated providers.
• Level 2 includes all other providers.

As always, you can check web-DENIS for information about benefits and eligibility for your patients.

Starting Jan. 1, we’ll change how we cover some drugs

Our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide our members with safe, high-quality prescription drug therapies. We continually review prescription drugs to provide the best value for our members, control costs and ensure members are using the right medication for the right condition.

Starting Jan. 1, 2020, we’ll change how we cover some brand-name and generic drugs. We’ll also set new quantity limits on certain drugs.

Note: Changes vary by drug list as specified below. For a complete list of 2020 covered drugs go to bcbsm.com/pharmacy. These changes apply to members with commercial pharmacy benefits (not Medicare D). They don’t apply to the Federal Employee Program^®.

Drugs on Preferred Drug List that will have a higher copayment
The brand-name drugs that will have a higher copayment are listed below, along with the covered preferred alternatives that have similar effectiveness, quality and safety. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available. 

Drugs on Preferred Drug List that won’t be covered
The brand-name and generic drugs that won’t be covered are listed below, along with the covered preferred alternatives that have similar effectiveness, quality and safety. Unless noted, both the brand name and available generic equivalents won’t be covered. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs on Clinical and Custom Drug Lists that will have a higher copayment
The brand-name drugs that will have a higher copayment are listed below along with the covered preferred alternatives that have similar effectiveness, quality and safety. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs on Clinical and Custom Drug Lists that won’t be covered
The brand-name and generic drugs that won’t be covered are listed below, along with the covered preferred alternatives that have similar effectiveness, quality and safety. Unless noted, both the brand name and available generic equivalents won’t be covered. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs on Custom Select Drug List that will have a higher copayment
The brand-name drugs that will have a higher copayment are listed below, along with the covered preferred alternatives that have similar effectiveness, quality and safety. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs on Custom Select Drug List that won’t be covered
The brand-name and generic drugs that won’t be covered are listed below along with the covered preferred alternatives that have similar effectiveness, quality and safety. Unless noted, both the brand name and available generic equivalents won’t be covered. The brand names of select covered alternatives are provided for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Quantity limits
The drugs below will have changes to the amount that can be filled. These changes apply to all drug lists.

New quantity limits, authorization requirement coming for ketoprofen for PPO, HMO commercial members

The following changes are coming for Blue Cross Blue Shield of Michigan and BCN HMO^SM commercial members:

• New courses of treatment involving ketoprofen 25 mg that begin on or after Dec. 1, 2019, require authorization. If you don’t obtain authorization, your patient may be responsible for the full cost of the drug.
• Effective March 1, 2020, ketoprofen 25 mg will be limited to four capsules per day or 120 capsules per 30 days. Requests to cover larger quantities will need to include documentation showing that the larger quantity is medically necessary.

Members who start taking ketoprofen prior to Dec. 1, 2019, can continue their treatment courses. However, as of March 1, 2020, you’ll need to secure authorization for these members to continue therapy.

Keep in mind that authorization isn’t a guarantee of payment. You can verify eligibility and benefits through web-DENIS.

We’ll notify affected members of these changes and encourage them to talk to their providers if they have concerns.

Note: These requirements don’t apply to Medicare Plus Blue^SM or BCN Advantage^SM members.

Changes coming to specialty prior authorization drug list

We’re adding the following medications to the Medicare Plus Blue^SM and BCN Advantage^SM Part B specialty prior authorization drug list. These specialty medications are administered in outpatient sites of care, such as a physician’s office, an outpatient facility or a member’s home.

For dates of service on or after Feb. 3, 2020, the following medications will require authorization:

• Beovu^® (J3490/C9399)
• Zolgensma^® (J3590)
• Skyrizi™ (J3590)
• Spravato™ (J3490)
• Hemlibra^® (J7170)
• Cuvitru™ (J1555)
• Panzyga^® (J1599)
• Ventavis^® (Q4074)

How to bill
For Medicare Plus Blue and BCN Advantage, we require authorization for these medications for the following sites of care when you bill them as a professional service or as an outpatient facility service and they’re billed electronically through an 837P transaction or on a professional CMS-1500 claim form:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)
• Home (place of service code 12)

We also require authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Reminder
You must obtain authorization prior to administering these medications. Use the NovoLogix^® online tool to quickly submit your authorization requests. It offers real-time status checks and immediate approvals for certain medications. Also:

• For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the “Medical Drug PA” box when you completed the Provider Secured Access Application form, you already have access to NovoLogix. If you didn’t check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List.

The authorization requirements for these drugs will be reflected on the drug list on Jan. 1, 2020.

Commercial PPO members will need authorization for Eylea and Lucentis

Blue Cross Blue Shield of Michigan members who begin receiving the following therapies on or after Jan. 1, 2020, will require prior authorization:

• Eylea (aflibercept, HCPCS code J0718)
• Lucentis (ranibizumab, HCPCS code J2778)

This requirement applies only to groups that currently participate in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

To help ensure continuity of care, members who start therapy before Jan. 1 won’t need authorization to continue therapy.

Note: Authorization for these drugs is currently required for BCN HMOSM (commercial), BCN Advantage^SM and Medicare Plus Blue^SM PPO members.

This requirement doesn’t apply to Blue Cross’ PPO members covered under the Federal Employee Program^® Service Benefit Plan.

As a reminder, authorization isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for their patients.

List of requirements
For a list of requirements related to drugs covered under the medical benefit, see the Requirements for drugs covered under the medical benefit – BCN HMO and Blue Cross PPO document located in the Medical Benefit Drugs – Pharmacy section of the ereferrals.bcbsm.com website.

The authorization requirement for Eylea and Lucentis will be reflected in the requirements list on Jan. 1, 2020.