Florida Blue is expanding the portfolio of utilization management (UM) programs to include non-emergent cardiology services.
Florida Blue is introducing a cardiology services UM program to improve the quality of care members receive and control rising health care costs.
· Providers should submit a request for preapproval (also called a pre-service review) before a member has certain cardiology services on or after July 9, 2018.
· The request will be evaluated for the medical necessity of the procedure. If a preapproval is not requested prior to the service being rendered, then a post service medical necessity review will be performed.
· If the services do not meet medical necessity criteria, the services may be denied in accordance with the member’s contract. This means that some PPO members may be responsible for the cost of the service if they elect to have it performed. To help prevent this from happening, Florida Blue is continuing to:
- Conduct outreach to providers to educate them about the requirement for preapproval, the benefits of preapproval and the consequences that their patient may experience if they don’t get preapproval.
- Review member claims and appeals on a case-by-case basis to ensure members had the adequate information available to them when they made the decision to have treatment. Every effort will be made to remove any financial burden from members who were following their in-network providers’ instructions and were not aware of medical necessity determinations that might leave them with responsibility for the cost of the service.
- As with our existing UM programs, the member has the ability to appeal by submitting a Health Plan Grievance & Appeal Form (Non-HMO). This form is available on the Member Forms page on floridablue.com/members.
Florida Blue is working with AIM Specialty Health (AIM). AIM will receive and process the pre-service reviews for the following procedures in non-emergent situations:
· Diagnostic Coronary Angiography
· Percutaneous Coronary Intervention (PCI)
· Arterial Ultrasound
The Centers for Medicare and Medicaid Services (CMS) is issuing new Medicare cards beginning this month. The new cards aim to reduce the risk of fraud and identity theft. Florida Blue has conducted extensive outreach efforts aimed at members, providers and vendors to prepare them for the change. We’ve also updated our systems to accommodate the new cards
Members' social security numbers have been replaced with a unique Medicare number. The gender and signature fields have also been removed.
The new card won’t change Florida Blue coverage or benefits. More detailed information will be provided by Medicare when members receive their cards in the mail.
Cards are being mailed through April 2019 by CMS—not Florida Blue. Not everyone will receive their cards at the same time, so there’s no cause for concern if friends’, neighbors’ or even a spouses’ cards arrive at different times. Florida Medicare members should be on the lookout for their cards after June 2018.
Encourage impacted family and friends to make sure their mailing address is current with the Social Security Administration. Updates can be submitted online at ssa.gov/myaccount or by phone at 1-800-772-1213.
For more information or to check to see when your card will arrive, visit medicare.gov/newcard
Alliance Rx Walgreens Prime
PrimeMail is now known as Alliance Rx Walgreens Prime, a new company created by Prime Therapeutics and Walgreens. This means that members who are currently receiving mail order medications from PrimeMail will now begin receiving their home delivery from Alliance Rx Walgreens Prime. Members currently receiving mail order will be notified of the name change. In addition, Florida Blue collaterals and forms that reference PrimeMail will be updated to reference the new name and will be provided as soon as available.
In this September, we provided information about the upcoming rebranding of PrimeMail to Alliance Rx Walgreens Prime effective March 31. Additionally, the term mail order will be replaced with home delivery. There will be no change to the service provided, and there is nothing members need to do differently in order to have their prescriptions sent to them.
New Coverage Requirements for Short-Acting Opioids
Effective October 1, Florida Blue updated its Responsible Rx Utilization Management programs to include short-acting opioid medications, such as oxycodone, hydrocodone and others.
As part of Florida Blue’s commitment to address the opioid crisis in the United States and in Florida, we introduced prior authorization and supply limits for use of short-acting opioids. These changes have been made to help ensure the appropriate use of opioid pain medication for members suffering from chronic pain. This also is designed to protect both members and their families from the risk of opioid abuse, misuse and diversion, while providing continued access to opioid medications when appropriate.
The new Responsible Rx guidelines are in addition to the recent changes that Florida Blue made to coverage of OxyContin (below update dated Sept 21).
New Supply Limit and Prior Authorization Changes:
Effective October 1, 2017, Florida Blue now requires a seven day limit for short-acting (immediate release) opioids for new prescriptions.
- Use of short-acting opioids beyond the seven-day limit will require prior authorization.
- The 7-day limit only affects new opioid users. Members on a stable, ongoing, short-acting opioid treatment plan are not impacted.
- Prior authorization criteria allows for extended use (beyond seven days) of short-acting opioids in the following situations:
- Chronic cancer pain*
- Hospice care*
- Chronic non-cancer pain*
Recently Prime Therapeutics LLC (Prime) a pharmacy benefit manager (PBM) and Walgreens have formed a
combined central specialty pharmacy and mail services company, as part of a strategic alliance first announced
by the companies last August
We are actively working to unite mail services and central specialty operations.
As part of that effort we will be upgrading our pharmacy systems. While this is happening, rest assured that you
will continue to receive the same care and support you expect from Prime Therapeutics Specialty Pharmacy
(Prime Specialty Pharmacy).
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