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Y0067_PR_PhysTlkt_0514_IA 05/14/2014
Provider Toolkit
2014 – 2015
PFFS/PPO
Sample Letter from Physician to Patient .................................................................................................................4
HEDIS Quick Reference Guide ................................................................................................................................5
High Risk Medication Formulary Alternative List ....................................................................................................11
Preventive Checklist ............................................................................................................................................13
TABLE OF CONTENTS
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2014-15
Provider ToolkitDear Healthcare Provider:
We truly appreciate the care and support you provide to your patients who are Today’s Options® PFFS/PPO members. We know you are busy, which is why we have packaged some helpful forms and materials into this convenient Provider Toolkit. This kit contains updated versions of:
The Sample Letter from Physician to Patient For your convenience, we have included a pre-written sample letter that you can customize and send to your
Today’s Options PFFS/PPO patients who may be in need of medical services. To use this letter, save the file to your computer, type your updates into the editable fields, and print on your letterhead. It’s that easy.*
* Note: to remain compliant with Federal guidelines, the wording in the Sample Letter from Physician to Patient must remain
as written. When printing, please be sure to include the tracking number located on the bottom left corner of the page.
The HEDIS Quick Reference Guide Use this guide as a reference to code specific medical services. By coding properly, such as by using the appropriate
ICD-9 codes for a patient’s BMI index, you will help to reduce gaps through the claims system and reduce the potential for medical record requests.
The Chart of High Risk Medications (HRM) and Alternatives The Centers for Medicare & Medicaid Services (CMS) has determined that there are medications that may create a high
risk for the elderly. For your convenience, we have included this list along with alternative medications based on the CMS guidance.
The Preventive Checklist Form for Physician Offices This Checklist can be handed to your Today’s Options PFFS/PPO patients. It will remind them to ask you about their
needed medical services.
We hope you find this Provider Toolkit to be helpful. If you have any questions about how to use the items contained within this package, please contact Provider Relations at 1-855-810-9726.
Sincerely,
Erin PagePresident, Medicare Advantage
3Y0067_PR_TK_Lett_0514_IA 06/27/2014
I am writing to let you know that, according to our records, you are due for the following important medical services checked below: Annual physical exam Diabetes Screenings (may include the following): Eye Exam Blood Sugar Check (HbA1c) Screening for Kidney Disease (Nephropathy) Cholesterol Check (LDL) Blood Pressure Check Medication Review Body Mass Index (BMI) Bone Mineral Density Test (Test for Osteoporosis) Mammogram Colorectal Screening
Your health is very important to us, which is why we ask that you contact our office at to schedule an appointment at your earliest convenience. If you have had any of these services at another location, please let us know when and where they were completed.
We wish you good health.
Y0067_MBR_PQPP_MBRLetter_0514_IA 05/09/2014
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HEDIS Measure Goal Measure
Requirements Time Frame Age Range
*Recommended Service Codes Exclusions
High Risk Medications ( 65 years old) Formulary Alternative List
Plan Year 2014
INFORMATION FOR YOUR CONSIDERATION
Y0067_Rx_2014HRMAlterRefChartGenSTD_1013 IA 10/18/2013
HIGH RISK MEDICATION - FORMULARY ALTERNATIVE LISTPLAN YEAR 2014
Drug Class High-Risk Medications (Tier) Formulary Alternatives (Tier) Generic Standard
Antiarrhythmic Drug Digoxin (>0.125mg/day) (2)Higher doses associated with no additional benefit and may increase risk of toxicity
Antidepressants, TricyclicAmitriptyline (2), Clomipramine (3), Doxepin (2), Imipramine (2), Trimipramine (4)
Citalopram (1,3), Fluoxetine (2,3), Mirtazapine (2,3), Nortriptyline (2,4), Paroxetine (2,4), Sertraline (1,3), Trazodone (1), Budeprion (3), Bupropion (3), Venlafaxine (3), Pristiq (3), Viibryd (4)
Antihistamines, First Generation
Brompheniramine (OTC), Chlorpheniramine (OTC), Clemastine (OTC), Dexbrompheniramine (OTC), Dexchlorpheniramine (OTC), Diphenhydramine (OTC), Doxylamine (OTC), Triprolidine (OTC), Carbinoxamine (NF), Hydroxyzine (NF)
Astepro (nasal spray) (3), Azelastine (nasal spray) (3), Patanase (nasal spray) (3), Cetirizine Syrup (3), Levocetirizine (2)
Promethazine Tabs (NF) Ondansetron (3,4), alt for Promethazine for indication of nausea/vomiting
*Promethazine Tabs (NF), Phenadoz, Promethgan suppositories (1)
*Ondansetron (2) alt for Promethazine for indication of nausea/vomiting*
Please consider prescribing alternative therapy or discontinuing High Risk Medications for your patient(s) 65 years or older. The High Risk Medication (HRM) list is based upon the new American Geriatrics Society (AGS) recommendations and was first developed by the National Committee for Quality Assurance (NCQA) through its Healthcare Effectiveness Data and Information Set (HEDIS) and then adapted and endorsed by the Pharmacy Quality Alliance and by the National Quality Forum (NQF).
Information contained in this document is for reference use only. We recognize that you, the prescriber, are best qualified to balance quality and cost-of-care considerations versus potential risk when selecting appropriate therapy for your patients. Our recommendations are provided as supplementary information for you to consider.
Information provided or made available through a Today’s Options® PFFS or Today’s Options® PPO Representative is not intended to replace the professional judgment of a licensed medical prescriber.
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Drug Class High-Risk Medications (Tier) Formulary Alternatives (Tier) Generic Standard
Anti-Infectives Nitrofurantoin (3) Sulfamethoxazole-Trimethoprim (1,2), Ciprofloxacin (1,4), Levofloxacin (3),
Antiparkinsonian Agents Benztropine (Oral) (2,4)Carbidopa-Levodopa (3,4), Pramipexole Dihydrochloride (3), Ropinirole HCL (3), Selegiline HCL (3), Azilect (3)
Antithrombiotics Ticlopidine (NF), Dipyridamole, oral short acting (NF) Clopidogrel (2), Aggrenox (4)
Barbiturates
Butalbital (containing prod) (NF) Replace with Non-Butalbital containing analgesics
Phenobarbital (2)
Carbamazepine (2,3,4), Divalproex (3), Gabapentin (2), Lamotrigine (2,3,4), Levetiracetam (3), Oxcarbazepine (3,4), Phenytoin (2,3), Primidone (3), Valproic acid (2,3)
Benzodiazepines: Long Acting
Amitriptyline-Chlordiazepoxide (NF), Chlordiazepoxide (NF), Chlordiazepoxide-Clidinium (NF), Diazepam (1,2), Flurazepam (NF)
Consult with physician
Cardiovascular: Central Alpha Agonists
Methyldopa (NF), Guafacine (NF), Guanabenz (NF), Reserpine (>0.1mg/day) (NF)
Thiazide Diuretics, Ace Inhibitors, Angiotensin Recptor Blockers, Long-Acting Dihydropyridine CCB (various)*
Endocrine AgentsArmour Thyroid (dessicated)(NF) Levothyroxine Sodium (1), Levoxyl (2),
Levothroid (1)
Megace ES (3), Megesterol (2,3) Nutritional Supplementation
Estrogen/Progestin (Single and/or Combination Products Oral/Patch)
Premarin (NF), Estropipate (NF), Prempro, Premphase (NF), Estradiol (2), Vivelle Dot (NF)
Consult with physician
Non-Benzodiazepine Hypnotics Lunesta (3), Zolpidem Tartrate (2), Zaleplon (3)
Avoid use >90 days; Non-Pharmacological Alternatives (Behavioral and/or Environmental Modifications)
Non-Cox-Selective NSAIDsIndomethacin (NF) Suggested for short-term use
Ketorolac (NF) Ibuprofen (1,3), Meloxicam (1,4), Naproxen (1,2), Celebrex (3)
Sulfonylureas, Long Acting Chlorpropamide (NF), Glyburide (3) Glipizide (1), Metformin (1)
Skeletal Muscle Relaxants
Carisoprodol (NF), Cyclobenzaprine (NF), Methocarbamol (NF), Metaxalone (NF), Chlorzoxazone (NF), Orphenadrine (NF)
Baclofen (2), Tizanidine (2)
*Alternatives consist of multiple therapeutic classes. See formulary for specific tier.
If you have any questions about this list, please contact Provider Relations at
Today’s Options® PFFS 1-866-568-8921 or Today’s Options® PPO 1-866-422-5009, Monday-Friday, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 711).
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Screenings/Test Treatment
Recomm
ended FrequencyDate Com
pletedNext Due Date
Appointment Scheduled
Doctor Contact Information
Cardiovascular ScreeningEvery 5 years
Date: ______ Time: ______
Colorectal Cancer Screening: Fecal Occult Blood Test
AnnuallyDate: ______ Tim
e: ______
Diabetes ScreeningAnnually
Date: ______ Time: ______
Breast Cancer ScreeningAnnually for w
omen
Date: ______ Time: ______
Glaucoma Screening
AnnuallyDate: ______ Tim
e: ______
Pap Test and Pelvic ExamEvery 1-2 years or as directed by your doctor
Date: ______ Time: ______
Prostate Cancer ScreeningAnnually for m
enDate: ______ Tim
e: ______
Flu ShotAnnually
Date: ______ Time: ______
Wellness Visit
AnnuallyDate: ______ Tim
e: ______
Bone Mass M
easurement
Every 2 yearsDate: ______ Tim
e: ______
Colorectal Cancer Screening: Barium
Enema
Every 2-4 yearsDate: ______ Tim
e: ______
Colorectal Cancer Screening: Flexible Sigm
oidoscopyEvery 4-10 years
Date: ______ Time: ______
Colorectal Cancer Screening: Colonoscopy
Every 2-10 yearsDate: ______ Tim
e: ______
Pneumococcal Shot
You may only need the Pneum
onia vaccine once in your lifetim
e. Call your doctor for m
ore information.
Date: ______ Time: ______