provider connections newsletter - fall 2010

1199SEIU PROVIDER

ConnectionsYour Key to the

1199SEIUBenefit Funds

Fall 2010

Message from the

ExecutiveDirector

We know that in order for you to continue providing high-quality care to our members, you need accurate, up-to-dateinformation on our 1199SEIU Benefit Funds’ coverage andpolicies. In this issue of Provider Connections, we let you knowabout several important changes.

First, under the new healthcare reform law, we will extendcoverage of dependents to age 26 and eliminate lifetime andnewborn benefit maximums beginning January 1, 2011.We havealso made several updates to our prescription benefit programthat may require some changes in the way your 1199SEIUpatients access certain medications.And we have includedinformation about an exciting new service that we will soon beproviding to you – an online provider portal that will give youelectronic access to detailed eligibility and claims informationwhenever you need it.

As always, we value our ongoing relationship with you and hopeyou find the information in this newsletter helpful. If you haveany questions or concerns, we encourage you to speak to yourProvider Representative, or contact our Provider RelationsDepartment at (646) 473-7160.

Mitra Behroozi

Reminder:No Separate Facility Chargefor Office-Based Surgeries

If your 1199SEIU patient undergoes a surgical procedureat an office-based surgery center, the Benefit Funds willreimburse the practitioner at the full office-based rate butwill not pay a separate facility charge.Any facility chargesbilled on a CMS 15 or UB04 form will be denied. If youhave any questions about our reimbursement policies, pleasecontact our Provider Representatives at (646) 473-7160.

Remember:LabCorp and Quest Arethe Funds’ Preferred Labs

When you need to refer your 1199SEIU patients forany lab services, we want to remind you to be sure to useonly our preferred labs – LabCorp and Quest Diagnostics.Referring our members to the Funds’ preferred labshelps them get the quality care they’ve earned with nounnecessary out-of-pocket costs.Of course, for specializedlab tests, be sure to first contact the Funds at (646) 473-7160to determine if prior authorization is required.

Pre-AuthorizationNow Requiredfor Certain Oral and Spinal Surgeries

Beginning in 2011, our list of ambulatory surgicalprocedures that require pre-certification will be expandedto include certain oral surgeries and certain spinalsurgeries. If your 1199SEIU patient requires such aprocedure, you or the member must call CareAllies at(800) 227-9360 to receive pre-authorization. Pleasewatch for further announcements.

1199SEIU Benefit and Pension Funds330 West 42nd StreetNew york, NY 10036-6977

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COMING SOON:Personalized Patient,Coverage and ClaimsInformation at theClick of a Button

In just a few months, 1199SEIU providers will have accessto a new, online system that will provide the detailed,personalized information you need from the Funds.You willbe able to check your 1199SEIU patients’ eligibility andbenefit coverage, as well as claims status, remittancestatements and Explanations of Payment with the click ofa button.

This service will be provided through Navinet, a system thatmany of our 1199SEIU Benefit Funds’ providers already usefor other payers. If you already have a Navinet account, youwon’t need to make any changes at all.A single log-in willallow you to access information from all your contractedpayers, including the Funds.

Keep an eye out for more details!

Utilization Reviewfor Radiology Services

The Benefit Funds have contracted with a new vendor,Care to Care, to provide utilization review for our members’non-emergent, outpatient MRA,MRI, PET and CAT scansbeginning January 1, 2011. Care to Care will add an extralevel of review to ensure that our members receive thehighest quality and most appropriate radiology services.

If your 1199SEIU patients need any of these services,please continue to call (888) 910-1199 to request priorauthorization. MedFocus remains our preferred radiologyprovider network, so you can still refer our members to thesame imaging sites and providers.

ADDRESS SERVICE REQUESTED

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Health Reform Changes:Dependent Coverage Extended to Age 26;Maximums for Lifetime, Newborn and Biotech Drug CoverageEliminated as of January 1, 2011The recent passage of the Patient Protection and Affordable Care Act brings good news for 1199SEIUmembers. Effective January 1, 2011, coverage for dependents will be extended to age 26.

As part of our ongoing effort to maintain a cost- and clinicallyeffective prescription drug program, the Funds are makingseveral updates to our prescription benefit program.

Dose Optimization Program

Effective November 2, 2010, we will add nine new drugclasses to our Dose Optimization Program, including those forrheumatoid arthritis, osteoporosis, Parkinson’s treatment andothers.This means that we will no longer cover prescriptionsfor two tablets or capsules of these drugs per day if they areavailable in a higher strength and may be prescribed once a day.

Of course, the Funds base these decisions on whether or notthe dose has the same therapeutic effect, based on FDA-approved prescribing and safety information, clinical guidelinesand uses that are considered reasonable, safe and effective.If you feel that twice-a-day dosing is necessary for your1199SEIU patients, you may contact Medco for a coveragereview at (800) 417-1764.

The Funds are currently in the process of enrolling eligibledependents and will be issuing new 1199SEIU HealthBenefits ID cards to these members and their childrenbefore the beginning of the new year.

We are also eliminating the maximum lifetimebenefit (currently $1 million for National BenefitFund members in the Member Choice program,or $500,000 for NBF members not in MemberChoice and for Greater NewYork Benefit Fundmembers). In addition, the $100,000 maximum onnewborn coverage will be removed, as will the

$100,000 maximum for biotechnology drugsfor medically necessary treatment.

If any of your 1199SEIU patients areaffected by these changes or havequestions about what the changes willmean to them, please refer them to ourMember Services Representativesat (646) 473-9200.

Prescription Benefit Updates:New Medications Added to Dose Optimizationand Specialty Care Pharmacy Programs

Fifteen Drugs Added toSpecialty Care Pharmacy

The Benefit Funds have added 15 drugs to our specialty carepharmacy,Accredo.The specialty care pharmacy is a reliable andsafe way for members to access medications that may requirespecial handling, such as refrigerated or injectable drugs.Members using these medications must have them deliveredthrough Accredo rather than pick them up at a pharmacy.

If your 1199SEIU patient requires one of these medications,you will need to call Accredo at (800) 987-4904 and providethe member’s 1199SEIU Member ID number.The Accredospecialty pharmacist will arrange for the medication to bedelivered directly to your patient.

The new specialty medications are:• Actemra• Ampyra• Botox• Dysport• Epoprostenol

for injection• Hizentra• Iprivask

A full list of specialty care drugs is available on our website atwww.1199SEIUBenefits.org.

Questions about OurPrescription Program?

You Can Get Answers 24/7 atwww.1199SEIUBenefits.org

The fastest, most convenient way to find details on ourprescription programs is right at your fingertips whenyou visit www.1199SEIUBenefits.org. You’ll find ourlatest Preferred Drug List, details of our plan design, ourparticipating pharmacies and all of the medicationsrequiring prior authorization or special handling. And whileour Provider Representatives are always happy to answeryour questions by phone from 9:00 am to 5:00 pm, Mondaythrough Friday, our website is available 24 hours a day,seven days a week. Log on today!

• Istodax• Myobloc• Prolia• Qutenza• Revatio for injection• Vpriv• Wilate• Xiaflex

Category

1) Selective AldosteroneBlockers

2) Anticonvulsants

3) Antinarcolepsy

4) Rheumatoid Arthritis

5) Osteoporosis

6) Parkinson Agents

7) Beta Blockers

8) Anti-viral (chronicHepatitis B infection)

9) Calcium ChannelBlockers

Affected Drugs

Inspra 25mg tablet,generic Eplerenone

Gabitril 2mg tablet

Provigil 100mg tablet

Arava 10mg tablet, genericLeflunomide

Fosamax 5mg tablet,generic Alendronate sodium

Azilect 0.5mg tablet

Coreg CR 10mg, 20mg,40mg capsule

Baraclude 0.5mg tablet

Cardizem CD 120mg, 180mg;Cardizem LA 120mg, 180mg(generic Diltiazem SR tablets);Cartia XT 120mg;Dilacor 120mg

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