provider handbook - Florida Health Care Plans

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PROVIDER HANDBOOK November, 2017

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PROVIDER HANDBOOK TABLE OF CONTENTS FHCP

Section 1 Corporate Profile FHCP Emergency Preparedness FHCP Provider Directory Information – Refer to Website Address Benefit Plans Model of Care Provider Education Tracking Sample FHCP Membership Cards TRIPLE OPTION (TO/POS) HMO Classic POINT OF SERVICE DEDUCTIBLE (HMO) STATE OF FLORIDA (HMO) STATE OF FLORIDA (HDHP) MEDVANTAGE NO RX (POS) MEDVANTAGE RX PLUS (POS) DEDUCTIBLE (POINT OF SERVICE) HMO (Halifax Health – HECN) MEDVANTAGE RX (MA-PD) MEDVANTAGE NO RX (MA-ONLY) DEDUCTIBLE HMO – A POINT OF SERVICE – A

FHCP

Section 2

Section 3 Administrative Staff Directory Department Responsibilities Case Management Enrollment Marketing Medical Claims Member Services Pharmaceutical Services Division Provider Services Quality Management / Performance Improvement Central Referrals

Role of HMO Network Physician Contract Determination and Appeals Credentialing of Providers for FHCP, Inc. Role of Primary Care Physician (PCP) Selection of Primary Care Physician Primary Care Physician Coverage FHCP Timely Access to Services Goals PCP Panel Management

Section 4

PCP Initial PCP Assignment Reassignment of PCP Provision of Health Care Services Policy & Procedure Provider Network Availability & Access Monitoring and Improvement Process Policy Request for PCP Change Form (Member initiated request/Provider initiated request/Provider status change) Medical Staff Bylaws, Rules & Regulations Policy Compliance Member’s Rights and Responsibilities Section 5 Member’s Rights and Responsibilities Policy Member Financial Responsibility Estimates Policy Medicare PART C Complaints/Grievances Policy Medicare PART C Organization Determinations and Appeals Policy Initial Determination and Reconsideration of Coverage of Non-Medicare BeneficiaryClaim New Member Transition Process Advance Directives Advanced Directives Policy Health Care Advance Directives Living Will Designation of Health Care Surrogate Uniform Donor Form State of Florida Do Not Resuscitate Order Admission Notification Hospital Admissions – Case Management Admission Notification Form Surgical & Special Procedure Form

Section 6

Claims Review and Processing Medicare Subscriber Claims Review and Processing Policy Non-Medicare Subscriber Claims Review and Processing Policy Qualified Medicare Beneficiaries (QMBs) Information Coordination of Benefits Policy

Section 7

Pharmacy /Affiliates FHCP Formulary Prescription Drug Benefits Pharmacy Services and Hours Medications Requiring Prior Authorizations Policy Prior Authorization Medication Form FHCP Contracting Pharmacies Enbrel Order Form Referral Form for Patients with HEP C Patient Agreement for Hepatitis C Treatment with Antivirals Remicade Order Form Synagis Referral Form Medical Appliances Formulary Policy General Part D Medication Transition Process Policy Medication Therapy Management Program (MTMP)

Section 8

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Pharmacist Review Request Risk and Quality Management Adverse Occurrence Reporting / Adverse Occurrence Reporting Form Quality Management / Performance Improvement Plan Policy Credentialing of Providers for Florida Health Care Plan, Inc. Policy

Section 9

Infection Control Infection Control Plan Policy Florida Dept. of Health/CDC Links Florida Dept. of Health Reportable Diseases/Conditions in Florida CDC STD Treatment Guidelines Chart Florida Dept. of Health Practitioner Disease Report Form Florida Dept. of Health/Animal Incident Report Form with Instructions

Section 10

Skilled Nursing Facilities (SNF) Skilled Nursing Facility Benefits Frequently Asked Questions and Answers

Section 11

Courier Services Courier Services Description Hours of Operation / Telephone / Fax

Section 12

Documents and Forms Department Procedure for Ordering Forms Forms Requisition

Section 13

Outpatient Laboratory Testing LabCorp Advantages Genetic Testing Locations LabCorp Requisition

Section 14

Preferred Fitness Program Preferred Fitness Medicare Members Gym List Refer to Website Address Preferred Fitness Members Gym List Refer to Website Address

Section 15

FHCP Forms Breast Cancer Screening and Mammography ECG Order Infusion Therapy Physician Orders Insurance Information Form Surgical & Special Procedures Form Prior Authorization Medication Form Admission Notification Form Radiology Requisition Radiology Dept. Appointment Form (Radiology) Bone Density Appointment Scheduling & Card Referral for Diabetes Self-Management Education Referral Form Referral to Minor Surgical Clinic (MSC)

Section 16

5 Rehabilitation Services Request Outpatient Rehabilitation Locations Screening Colonoscopy (East, Southeast & Flagler County Networks) Screening Colonoscopy (West Volusia Network) TMJ Screening Questionnaire Ultrasound Referral Form Order for Childhood Vaccines Order and Consent Form for Human Papillomavirus (HPV) Vaccine Precertification Form Electronic Data Interchange (EDI) AVAILITY

Section 17

Utilization Section 18 Utilization Management Affirmative Statement about Incentives Policy Medical Policies (Medical Coverage Guidelines) Medical and Clinical Guidelines Bariatric Surgery Policy New Technology & Organizational Determinations Policy Utilization Management Program Policy Pre-Service (Central Referrals) * Central Referral Department Guidelines for Processing Medical Referrals that Require Pre-authorization – Prospective Initial Organizational Determinations for Medicare Members Policy Concurrent Review (Case Management) * Concurrent Review for Non-Medicare Members Policy * Skilled Nursing Facility Utilization Policy * Discontinuation of Medicare Advantage Members’ Home Health Care and Skilled Nursing Facility Policy Medications Requiring Prior Authorizations Policy Prior Authorization Medication Form Retrospective Authorization Process Policy Post Service (Claims) * Medicare Subscriber Claims Review and Processing Policy * Non-Medicare Subscriber Claims Review & Processing Policy Appeal Process * Complaints/Grievances and Appeals (Large Group, Small Group & Individual Commercial Subscribers) Policy * Medicare PART C Organization Determinations & Appeals Policy

Referral Procedures Section 19 Central Referral Department Guidelines for Processing Medical Referrals that Require Pre-authorization – Prospective Initial Organizational Determinations for NonMedicare Members Central Referral Department Guidelines for Processing Medical Referrals that Require Pre-authorization – Prospective Initial Organizational Determinations for Medicare Members FHCP Referral Form

6 HMO Benefit Plans Referral (Pre-Service/Prior Authorization) Questions and Answers Provider Referral Guide – Volusia/Flagler Counties Refer to Website Address Provider Referral Guide – Seminole County Refer to Website Address Provider Referral Guide – Brevard County Refer to Website Address

Adult Preventative Medicine Recommendations Policy Section 20 Adult Preventative Medicine Recommendations Adult Preventative Health Log Recommended Adult Immunizations Schedule Wellness Screening Recommendations for Adults FHCP Disease Management Programs Case Management Coordination of Care Program Community Resource Coordination Referral Case Management Coordination of Care Referral Development of Clinical Review Criteria & Evaluation of New Technologies Policy Submission of Encounter Data Section 21 Guidelines for Completing CMS 1500 Forms Adolescent Well-Care Visits Routine GYN & Pap Smear for Patients Under 16 Years of Age Coding for Well Woman Assessment, Routine Physicals and Follow-up Office Visit for GYN Problem Requiring Repeat Pap Smear Program Management Department – Who to Contact Risk Adjustment Payments Medicare+Choice Physician Encounter Data Letter Medical Records and Privacy Policies Medical Record Policies Introduction Outside Primary Care Physician Orientation Requesting Records for Continuity of Care Medical Record Request Form Procedure for Dictating Medical Records Release of Information for Medical Records Confidentiality of Medical Records Clinical Records Access by Member Subpoenas for Records from Attorneys General Privacy Policy Individual Right to Notice of Privacy Practices Policy Uses and Disclosures of Protected Health Information Policy

Section 22

Radiology Department Facility Locations / Exams Performed Requesting Loan Films / Radiology Reports Radiology Requisition

Section 23

7 Ultrasound Department Facility Locations / Exams Performed Ultrasound Examinations Ultrasound Studies with CPT Codes and Preparations Ultrasound Referral Form

Section 24

After Hours Call Center Call Center Hours & Functions

Section 25

FHCP Holiday Calendar

Section 26

Grievances & Appeals Complaints, Appeals & Grievances Chart Contract Determinations and Appeals Policy Initial Determination and Reconsideration of Coverage of Medicare Beneficiary Claims Policy Initial Determination and Reconsideration of Coverage of Non-Medicare Beneficiary Claims Policy Medicare Subscriber Claims Review and Processing Policy Non-Medicare Subscriber Claims Review and Processing Policy Medical Staff Bylaws, Rules and Regulations Policy Participating Provider Payment Rate Disputes Policy Non-Par Provider Payment Rate Disputes Regarding Medicare New Member Transition Process Surgical Assistant Payment Policy

Section 27

Interpreter Services FHCP Interpreter Services Policy Interpreter Services Notice of Non-Discrimination

Section 28

Glossary of Terms

Section 29

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SECTION 1 FHCP Corporate Profile Emergency Preparedness

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Florida Health Care Plan, Inc. (FHCP) is proud to be a Health Care Provider in the State of Florida for 41 years serving Volusia, Flagler, Seminole and Brevard Counties.

FHCP is a community based corporation that exists to serve the health care needs of our members through the following Mission, Vision and Values statements. Our Mission is:

To provide Florida Health Care Plans' members with health care related services through dedicated employees and service partners who manage both the quality and the cost of health care.

Our Vision is:

To set the standard for managed health care in our community. We intend to be acknowledged as the leader by our members, employees, service partners and Governing Body.

Our Quality Policy is:

In our community, we manage both the quality and the cost of health care provided to the members of our health plan. We are committed to understanding the health care needs and meeting the requirements of our members, fellow employees and service partners. We will strive to do our jobs right the first time, every time.

CORPORATE PROFILE Florida Health Care Plan, Inc. (FHCP) is the oldest federally qualified HMO in Florida and the 2nd oldest federally qualified HMO in continuous existence in the United States. Florida Health Care Plan, Inc. (FHCP) was incorporated as a not-for-profit entity on June 2, 1971, commenced operations on July 1, 1974 and was federally qualified on August 21, 1976. Subsequently, on January 26, 1994, FHCP became a not-for-profit controlled affiliate of Halifax Community Health Center, a taxing district public hospital. In 1991, FHCP was selected as the first health care system for the Florida Healthy Kids Program. On January 1, 2009, FHCP was acquired by Florida Blue and made the transition from a not-for-profit to a for-profit entity. These transactions were approved by the Federal and State governments in accordance with all laws and regulations. FHCP's health care delivery system was unaffected by these changes in ownership. FHCP was also initially designated by the Agency for Health Care Administration as an Accountable Health Partnership in 1994, for the purpose of writing Small Group coverage in the State of Florida.

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FHCP provides health care services to almost 83,000 members in our service area of Volusia, Flagler, Seminole and Brevard Counties, Florida. The following table details FHCP's latest enrollment categorized by group type:

Group Type

Commercial

Total No. of Members Enrolled January 2017 35,781

Individual

32,700

Medicare

13,862

Total

82,343

Marketing activities that are directed to employer groups and their employees are conducted by FHCP in conjunction with Florida Blue. FHCP sales staff consists of salaried employees of FHCP who receive no commissions or bonuses in relation to the numbers of groups or employees who join FHCP. The sales staff are licensed health insurance agents and are regulated by the State of Florida. Florida Health Care Plan also works with brokers and consultants for commercial policies. FHCP also utilizes captive Florida Blue agents to Sell their Medicare and individual health plans. Members are enrolled in FHCP through the following group categories: Commercial/HMO Plans

This is FHCP's most common network for our HMO membership. Unless you specifically are an employee or dependent of the Daytona State College, Halifax Health, State of Florida, or VOTRAN, or are a Florida Healthy Kids Member, Medicare Member, Deductible Plans Member or have an additional rider, this would be the network for your benefit plan.

Daytona State College Plan

Daytona State College Employees and their eligible Dependents who have enrolled in FHCP.

Point of Service (POS)/ - Employer groups located in Volusia and Flagler Counties Triple Option Plan may enroll in conjunction with an HMO Plan for expanded and/or out-ofnetwork coverage. These plans allow members’ access to specialists without referral.

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High Deductible

Medicare Advantage

- Large and Small Employer Groups may choose a plan offering full medical benefits subject to a deductible and coinsurance. These plans are HSA and/or HRA compatible. -FHCP offers benefits to Medicare beneficiaries on individual basis.

Individual Plan

- FHCP offers health plans to provide comprehensive and long-term protection for individuals. These plans offer predictable costs through a combination of deductibles and co-pays.

Self-Funded

- FHCP offers Third Party Administration services to employer groups seeking a self-funded value proposition for health plan cost and quality management.

All FHCP members are encouraged to select a Primary Care Physician (PCP) from our network of providers who are responsible for coordinating the medical care of our members. As a staff model health plan, FHCP directly employs many of these providers on a full or part-time basis as primary care physicians. The remaining primary care physicians are contracted to provide primary care services to FHCP members in their private offices. Specialty care is provided through a combination of full and part-time FHCP employee providers along with contracted specialists throughout our service area. In addition, members are referred to subspecialty providers throughout the state as needed. FHCP members receive diagnostic, laboratory, and pharmacy services at facilities owned and operated by FHCP. These facilities are strategically located throughout our service area to limit our members' average travel time to thirty minutes or less for these services. Emergency, outpatient, and inpatient care is provided on a twenty-four hour basis through FHCP contracts with area hospitals. Our members are also served by various ancillary suppliers, extended care and rehabilitation centers located throughout our service area. Our Quality Management program focuses on areas such as provider credentialing and education; member and provider satisfaction; a review of member accessibility to and continuity of care; appropriateness of and effectiveness of procedures; and patient/family education. We continuously monitor these functions to assure quality care for our members. Our Outpatient Community Resource Program is designed to assist our members and their family through education and coordination to access local resources and services. FHCP is a strong advocate for our members. A member’s individual needs are reviewed to determine the appropriate programs and member eligibility. In addition to effective community resource referrals, the Outpatient Community Resource Program can help reduce a member’s out of pocket medical expenses by assisting members to apply for programs such as “Medicare Savings” and “Low Income Subsidy.”

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Every FHCP member admitted to a hospital or skilled nursing facility has a Registered Nurse in the FHCP Case Manager department who will collaborate with their physicians about their needed care. They monitor the member’s progress, and as they reach expected goals, assist them with transition to home, home health, skilled nursing or other acute care facility. This monitoring is known as concurrent utilization review. The goal is to help members navigate the complex health care system, obtain the care they need when they need it, and keep premiums low by using all services wisely. FHCP provides a year round 24 x 7 Nurse Advice line staffed by highly skilled registered nurses to assist our members with their health concerns in both English and Spanish. Through the call center triage module, nurses have access to the most trusted clinical information in the industry, including more than 400 symptom-based triage guidelines specifically written for adult, women’s, pediatric, and behavioral health topics. Besides providing triage care for current symptoms; the nurses can also help FHCP’s members better understand their diagnoses, prescribed medications and where and when to go for more help. The following is a sampling of the services provided by this 24/7 Nurse Advice Line: • Symptom assessment and triage • Urgent and non-urgent care advice • Program, physician and facility referrals • Drug and medication information • Recommendations or condition explanations • Health information Through symptom analysis, the Advice Line Registered Nurses relieve member stress by directing members to the right care, at the right facility, at the right time, saving everyone time and money. Too often, the emergency room is used for non-emergency reasons. Using the Nurse Advice Line to triage health issues for members has proven to get members the care they need and also to reduce unnecessary doctor and ER visits. In fact, more than 30% of the calls to our Nurse Advice Line are resolved with at-home treatment. Florida Health Care Plans provides an online health information portal that includes a variety of general health and wellness content. Included are: interactive tools, preventive care information, quizzes, a comprehensive library of diseases and conditions and the HealthMedia® Succeed™ health risk assessment (HRA). The Succeed HRA provides adult members a means of identifying their health risks, stage of change, motivation and barriers to self care. It evaluates health-related behaviors and health history around nutrition, weight, physical activity, stress, tobacco use, skin protection, injury prevention, alcohol use, and health screenings. Based on each individual’s evaluation, Succeed produces a 16-page individually tailored action plan around the participant’s top four health risks - just as a health coach would. The report that is generated identifies areas for improvement; offering selfcare modules to assist in taking charge of improving lifestyle and learning about disease and other health conditions. This plan also includes several interactive tools, videos, and recipes - as well as a complete medical library—so participants continually interact with the tailored plan—improving both participation and outcomes.

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Network providers are paid either by salary, capitation or a reduced fee-for-service basis. Claims are processed within mandated State and Federal time guidelines. As a Federal Type B Health Maintenance Organization, FHCP files required reports on an annual basis with the Health Care Financing Administration and the Florida Department of Financial Services. Florida Department of Financial Services data indicates that FHCP has consistently been one of the more financially secure Health Plans in the state.

FHCP has a fully implemented state-of-art Electronic Medical Record (EMR) Solution. All employed physicians, pharmacies and medical professionals have access to this system. Each member’s record is available to any provider involved in the members care and provides a “connected “network. The Electronic Medical Record not only provides safer, more efficient care to members, but has the capacity to save significant health care costs through the elimination of duplicated testing and costly polypharmacy events. The system is also designed to tract member unique features such as advance directives, health maintenance plan, allergies and drug interactions to enhance safety. FHCP’s EMR is also available in many key community locations such as emergency rooms, specialist’s offices & imaging departments to contribute to key safety initiatives such as medication reconciliation and avoidance of adverse drug reactions. FHCP offers a unique Extended Hours Care Centers solution to its members. Extended Hours Care Centers (EHCC) is a partnership between an employer and FHCP to align health benefits and healthcare services through integrated, innovative and affordable health plan designs. Using our proven patient-centered medical home model, FHCP integrates wellness with occupational health programs and couples robust medication therapy with patient education. Extended weekday and weekend office hours encourage appropriate utilization of health services; promote wellness and preventive care for members, while managing costs. Good health is all about good advice from trusted health professionals, easy accessible care, and great support. In the workplace, good health means many things, including better concentration, reduced absenteeism and longevity with an employer. Good health means employees and their families learn how to develop good habits and healthy lifestyles with the added benefit of having an employer and health plan partnership relationship to assist on this journey. Having contracts with all hospitals in Volusia and Flagler counties and select hospitals in Seminole and Brevard Counties, FHCP coordinates health care between all levels of care to expedite an employee’s return to health – and to their employer.

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FHCP Emergency Preparedness Please be advised that in the case of a disaster or declared State of Emergency by State or Federal Officials, FHCP preparedness shall involve the following actions by FHCP’s Contract Services Division: •

Network providers are issued a series bulletins (time permitting) prior to any hurricanes, pandemics or, after a disaster strikes via mass fax containing information relating to FHCP operations, pharmacy info, network adjustments, facility availability, etc. These bulletins are also issued to employed providers and our marketing department to assure consistency of information.



Information about FHCP compliance with State or Federal Directives related to a state of emergency are published on FHCP’s website. Such information includes emergency services hours and locations, coverage of non-participating provider claims, and other health and safety information.



A telephone tree is utilized, where possible, for emergency communication between department managers and their employees.



In cases where FHCP’s service locations or provider network are disrupted, overwhelmed, or if evacuations are ordered, members and providers are informed that FHCP relaxes requirements that HMO members use network providers for services. All claims for covered services during a specified State of Emergency period are covered at the HMO benefit level for all members.



FHCP Provider Services coordinates alternative site placement for displaced network Providers within FHCP facilities, where possible. Provider Services also helps secure alternative placement sites in health system facilities when needed.



FHCP’s Claims Manager coordinates prioritization of claims payments, identification of alternative worksites for displaced workers, etc. where possible.

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SECTION 2 FHCP PROVIDER DIRECTORY INFORMATION BENEFIT PLANS MODEL OF CARE PROVIDER EDUCATION TRACKING SAMPLE FHCP MEMBERSHIP CARDS

FHCP PROVIDER DIRECTORIES

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FHCP Provider Directories are available online at www.fhcp.com. Please follow the below steps to access the searchable directories or to print a pdf version of the latest edition. •

Go to WWW.FHCP.COM

Searchable Directories: •

Click on “Find a Doctor/Facility” located on the top left hand corner of the Screen.

This will bring you to the search function under “Provider Directory - Keeping You in the Loop”. Under the Search function, you can search for Provider Physicians/Specialists/Hospital or Facilities and Pharmacy. By following each of the steps, you can choose a Provider that is most convenient for you.

“Step 1: Are You an FHCP Member?” requires you to select whether or not you17 are a member of FHCP.

“Step 2: What Are You Searching For?” requires you to select the type of18 Provider you are searching for.

“Step 3: Find Your Membership Card” in the I’M A GUEST and click drop down19 box

“Step 4: General Search for Doctors in Your Area”. These functions allow you to search by elements such as Type of Physician, Specialty, Zip Code, County, Name, etc.

20 Print a pdf Version

Printable/pdf versions of the various FHCP “Provider Directories” are available under “Our Provider Networks” then at the lower left hand “printable Provider Directories”.

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FHCP PROVIDER DIRECTORY Refer to: http://www.fhcp.com/our-provider-networks/printable-provider-directories/

********* Should you have any questions about the participation status or availability of a physician or other provider, please contact FHCP’s Provider Services Department at 1 (800) 352- 9824. You may also request a printed directory by contacting FHCP’s Documents Department at (386) 615- 4055

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Florida Health Care Plans provides health care services to Members who live or work in our service area of Volusia, Flagler, Seminole and Brevard Counties. We offer a wide array of products to serve their needs including traditional HMO products, Point-of-Service with out-of-network benefits, Triple Option with expanded national network access as well as out-of-network benefits and High Deductible Health Plans. Groups with 2 or more employees are eligible to apply.

HMO Premium Plan • • • •

Low out-of-pocket costs Over 1,400 Providers and Contract Facilities in Volusia, Flagler, Seminole and Brevard Counties World wide coverage for Emergency and Urgent Care No paperwork or claim forms

Traditional HMO Plans focus on wellness and preventive care. We encourage members to seek medical treatment early, before potential health problems become severe. Simply choose to receive services from our growing network of over 1,400 Providers and Contract Facilities. With co-pays as low as $10 for Primary Care Visits and no charge for X-ray and laboratory services, you get superior coverage with low out of pocket costs. By paying a fixed monthly premium regardless of how much medical care you receive, you can easily control health care expenses. Florida Health Care Plans provides world wide coverage for Emergency and Urgent Care as well as Direct Access (no referral necessary) for Chiropractic, Dermatology, Optometry, Gynecology, Smoking Cessation and Weight Management Programs. With HMO coverage there are no deductibles or percentages, paperwork or claim forms. We keep it simple. All Florida Health Care Plans are available with Prescription Drug Coverage.

High Deductible Plans • • • •

Lower cost alternative for employee benefits Fixed co-pays for preventive care HSA and HRA qualified plans Tax advantages for employers and employees

High Deductible Plans offer maximum control over healthcare expenses at the lowest cost. By assuming a higher level of cost sharing and being directly involved in health care decision making, members can make careful and informed decisions about their medical spending. Being better informed about actual health care costs allows you to save money for health care expenses in future years, or in some plans for retirement. When combined with a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA), account balances can carry over from year to year providing tax advantages for employers and employees. High Deductible Plans are an excellent lower cost alternative for business owners offering employee health coverage.

Point of Service Plans • • • •

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Freedom of choice No referrals necessary Fixed co-pays for in-network services Add to HMO, Balance, or High Deductible plans

Point of Service coverage allows you to maximize your freedom of choice. With this rider, you can select from over 1,400 Providers and Contract Facilities for in-network services, taking advantage of fixed co-pay amounts for office visits, lower deductibles and less co-insurance. You may also decide to self-refer using a healthcare provider outside the FHCP Network, the choice is yours. Point of Service coverage can be added to any of our HMO, Balance, or High Deductible Plans.

Triple Option Plans • • •

Control your out-of-pocket expenses Fixed co-pays for in-network office visits Over 400,000 providers nationally at the Option 2 level

Triple Option coverage is designed to compliment Florida Health Care’s HMO Plans. With the Triple Option Rider, you have complete control of your out-of-pocket expenses for healthcare. The amount you pay is determined by your choice of provider. You may choose to receive care from any provider in Florida Health Care’s HMO Participating Provider Network (Option 1). You may also self-refer to any provider listed as a Florida Health Care Option 2 Provider which includes over 400,000 providers locally and nationally. At this level you will be responsible for co-pays or a deductible and co-insurance. Triple Option also gives you the freedom to receive care from a non-participating physician, facility, or hospital (Option 3).

Medicare

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Florida Health Care Plans, an MA Organization with a Medicare Contract, has been providing medical and prescription coverage to Medicare eligible beneficiaries since 1981. With the introduction of Medicare Part D in January 2006, FHCP offers various options for a Medicare beneficiary to enroll in. For more information on each of these options please see the information listed in our Medicare section for each of the following plan choices: •





FHCP’s Medvantage Plan — This plan was designed to offer all medical services that are covered by Original Medicare. In addition, FHCP also provides coverage for additional benefits. This plan does not offer the Medicare Part D prescription drug benefit. FHCP’s Medvantage Rx Plan — This plan provides all of the same medical benefits as the Medvantage program. In addition, the Medvantage Rx Plan offers the Medicare prescription drug benefit similar to the Medicare Part D Standard benefit. FHCP’s Medvantage Rx Plus Plan — This plan provides all of the same medical benefits as the Medvantage program. In addition, the Medvantage Rx Plus plan offers a Medicare prescription drug benefit which enhances the benefits of the Medicare Part D Standard benefit. Available in Brevard:





FHCP’s Premier Medvantage Plan --- This plan was designed to offer all medical services that are covered by Original medicare. In addition, FHCP offers the Medicare prescription drug benefit similar to the Medicare Part D Standard benefit FHCP’s Premier Plus Medvantage Plan – This plan provides all of the same medical benefits as the Premier program. In addition, the Medvantae RX Plus plan offers a Medicare prescription drug benefit which enhances the benefits of the Medicare Part D Standard benefit.

In order to provide Medicare—eligible beneficiaries with more choice, FHCP offers an Optional Supplemental Point of Service benefit. This Optional Supplemental POS benefit can only be added to the Medvantage, Medvantage Rx Plus and the Premier Plus Medvantage plans mentioned above for an additional monthly premium. The Optional Supplemental POS benefit allows a Medicare—eligible beneficiary to see any physician or utilize facilities that are not in FHCP’s network of providers without a referral. Please note that, when deciding to go to an out—of—network physician or facility, the POS benefit is LIMITED TO PROVIDERS THAT ARE CONTRACTED WITH MEDICARE ONLY. In addition, FHCP offers a Preferred Fitness Program for our Medicare members. The benefits of this program include unlimited visits to participating fitness clubs, an annual personal health analysis (optional), and an overall fitness evaluation. INDIVIDUAL HEALTH INSURANCE MARKETPLACE Florida Health Care Plans participates on the Health Insurance Exchange at www.healthcare.gov, offering individual and family coverage for all metal levels. Plan designs include HMO, Point of Service and Triple Option in addition to Catastrophic.

25 Model of Care Education Returned Provider Signed Evaluation Form Please fill out form, sign and fax to Florida Health Care Plans Clinical Services Department at: 386-615-4065. CMS requires that Florida Health Plans track that you received this self-study program. Evaluation: 1. Was this helpful in understand the general Model of Care Process? ___Yes

___ No

2. Are there other Model of Care items you’d like to see added? ___Yes

___No

3. Is there any additional training that you and your staff need related to FHCP Medvantage Dual Access Special Need Plan or the Model of Care? Provider Name (Print):______________________ Group/IPA Name (if applicable):____________________________ NPI: ___________________________ Provider ID: _____________________ Phone Number: _________________ Address: _______________________ City, State, Zip Code: _______________________ Provider Signature: ______________________________

For internal use only: Date Received: ______________ Annual Review Date: __________

Date: __________

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Embedded vs. Non-Embedded Deductible Overview: Many FHCP Benefit Plans contain a deductible. A deductible is the amount of money the member must pay for their medical expenses before FHCP will cover the costs of their medical care. All FHCP deductibles are met on an annual basis and the annual time frame is either based on the plan year or a calendar year. There are two different types of deductibles: embedded or non-embedded. Health Care Reform compliant plans have some benefits (i.e. preventative care) where the deductible does not have to first be satisfied before FHCP will pay the costs of the member’s visit. Embedded Deductible For Members covered by a family FHCP benefit plan with an embedded deductible, their plan contains two components, an individual deductible and a family deductible. Having two components to the deductible allows for each person in a family the opportunity to have FHCP cover their medical bills prior to the entire dollar amount of the family deductible being met. For these plans, the individual deductible is embedded in the family deductible. For example, if a subscriber has a wife and daughter as dependents on a family plan with a $3000 family embedded deductible, and the individual deductible is $1000, if the daughter incurs $1000 in medical bills, her deductible is met and FHCP will cover any subsequent medical bills for the daughter that year, even though the family deductible of $3000 has not yet been met. Non-embedded On the other hand, members with Plans that have a non-embedded family deductible do not have an individual deductible embedded in the family deductible. In this situation, before FHCP covers any member’s medical bills, the entire amount of the deductible must first be met. It can be met by one family member or a combination of family members however there are no benefits until expenses equaling the total deductible amount have been incurred. High Deductible Plans (HDHP) - HSA Compatible There are numerous FHCP benefit plans with deductibles, and each plan can have either an embedded or non-embedded deductible. High deductible health plan (HDHP) have a minimum annual deductible amount is required by the Internal Revenue Service (IRS). Members on a HDHP are allowed to open a tax free Health Savings Account (HSA), hence the IRS involvement in the plan design. These are called HSA compatible and have a HSA Plan Type or Resource Allocation Type (RAT) = 1 on the OOP screen. Plans where a RAT = 1 are always non-embedded.

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Sample FHCP Membership Cards

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SECTION 3 FHCP Administrative Staff Directory Department Responsibilities Case Management Case Management Coordination Central Referrals Enrollment Marketing Medical Claims Member Services Pharmaceutical Services Division Program Management Provider Services Quality Management / Performance Improvement

32 FLORIDA HEALTH CARE PLANS ADMINISTRATIVE STAFF DIRECTORY FUNCTION

PERSONNEL

LOCATION

PHONE / FAX

Admissions Notification & Certification of Inpatient Benefits

Admissions Coordinator

Holly Hill FHCP Case Management Dept.

386 / 676-7187 800 / 352-9824 Fax: 615-4058

FHCP Physicians Call Center FHCP Call Schedules

Supervisor

Halifax Health Medical Center

386 / 254-4242 Fax: 258-4858

Benefit Information: General / Member Co-Payments / Benefit Interpretation

Members call: Member Services

Holly Hill FHCP

386 / 615-4022 1-877-415-4022 Fax: 676-7149 386 / 615-4024

Physicians call: Program Management

Coordination of Benefits w/3rd Party Payers Analyst

Benefits Coordinator

Holly Hill FHCP

386 / 676-7123 Fax: 615-4017

Courier Services

Supervisor

Halifax Medical Center

386 / 254-4382 Beeper 831-4188

IS Department

FHCP Help Desk

Holly Hill FHCP

386 / 676-7100 Ext. 4090

FHCP President/CEO

Wendy Myers, M.D.

Holly Hill FHCP

386-676-7135 Fax: 386-676-7196

FHCP Chief Medical Officer

Joseph Zuckerman, M.D.

Holly Hill FHCP

386 / 615-4087 Fax: 386-615-4051

FHCP Vice President & Medical Director

David L. Williams, M.D. Daytona Beach FHCP

FHCP Utilization Mgmt. Physicians

Access through Case Management Utilization Review Department

386 / 238-3200 Ext: 3502 800 / 321-1227 386 / 676-7187 866 / 676-7187

33 ADMINISTRATIVE STAFF DIRECTORY- (Con’t.) FUNCTION

PERSONNEL

Credentialing

Credentialing & Administrative Specialist

LOCATION

PHONE / FAX

Holly Hill FHCP

386 / 676-7100 Ext. 7242 Fax: 481-5088

Infection Control

Department Manager

Holly Hill FHCP Port Orange Orange City

386 / 615-4065 386 /676-7159 800 / 352-9824

Medical Claims Status

Central Information

Holly Hill FHCP

386-615-5020 800 / 321-1227 Fax: 676-7191

Medical Records

Manager

Holly Hill FHCP

386 / 238-3287 386 / 238-3201 800 / 352-9824

Member Services

Manager

Holly Hill FHCP

386 / 615-4022 877 / 415-4022

Member Enrollment

Manager

Holly Hill FHCP

386 / 676-7176 800 / 352-9824 Fax: 676-7137

Practice Management

Administrator

Holly Hill FHCP

386 / 676-7189 or 386 / 676-7264 800 / 352-9824 Fax: 676-7148

Clinical Services

Administrator

Holly Hill FHCP

386 / 676-7113 800 / 352-9824 386 / 615-4065

Pharmacy

Administrator

Holly Hill FHCP

386 / 676-7173 800 / 352-9824

Physician Assignment

Members Services

Holly Hill FHCP

386 / 615-4022 800 / 352-9824

Provider Relations

Coordinator

Holly Hill FHCP

386 / 615-4001 800 / 352-9824

Provider Services

Contract Services Administrator

Holly Hill FHCP

386 / 615-4020 800 / 352-9824

34 ADMINISTRATIVE STAFF DIRECTORY- (Con’t.) FUNCTION

PERSONNEL

LOCATION

PHONE / FAX

Quality Management & Performance Improvement

Administrator

Holly Hill FHCP

386 / 676-7150 386 / 481-5088

Radiology Department

Manager

Daytona Beach FHCP

386 / 238-3200 Ext. 3353 800 / 321-1227

Referrals Department (Approvals, Pre-Auth. For Outpatient Testing)

Supervisor

Holly Hill FHCP

386 / 238-3230 800 / 321-1227 Fax: 238-3253

Risk & Patient Safety

Clinical Risk Manager

Holly Hill FHCP

386 / 615-5042 Fax: 481-5088

Revised 7/17

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FHCP DEPARTMENT RESPONSIBILITIES CASE MANAGEMENT: Provides continuum of care for FHCP members throughout the system. The UR Case Management Department’s focus includes Inpatient Hospital, Skilled Nursing Facility, and Home Health Care from admission through discharge. Clinical staff w i l l make authorization decisions based on medical necessity determined through use of evidenced based medicine. (i.e. MCG, Centers for Medicare and Medicaid Services, BCBSF Medical Policies), national standards, nationally recognized criteria, FHCP medical protocols and the Members benefit package. For Adverse Determinations made by the department, the member and the referring provider will be notified in writing. The denial letters will state the specific reason(s) for non-coverage, the process to obtain the review criteria and the appeal process for each party. CASE MANAGEMENT COMPLEX CARE PROGRAM: Program focus on helping members to navigate the health care system, functioning as a health coach, connecting members with community resources, and implementing measures to improve the quality of life and clinical outcomes. This program is voluntary and the member has the right to decline or discontinue participation.

CENTRAL REFERRAL DEPARTMENT: Oversees requests that require Prior Authorization of services as listed in the FHCP Provider Guidelines. The plan will make authorization decisions based on medical necessity determined by the clinical documentation submitted with the request. This in conjunction with the use of evidenced based medicine (i.e. MCG Guidelines, Centers for Medicare and Medicaid Services), national standards, nationally recognized criteria, FHCP medical protocols and the Members benefit package. On Adverse Determinations rendered by the department, the member and the referring provider will be notified in writing. D enial letters will state the specific reason(s) for non-coverage, the process to obtain the review criteria and the appeal process for each party. ENROLLMENT: Processes all completed employer group, Medicare Advantage, and Individual membership applications; provides new enrollees with applicable membership packets and cards, maintains employer group and subscriber files; completes all changes to membership status, updates system with demographic changes such as addresses and telephone numbers. MARKETING: Florida Health Care Plans (FHCP) Marketing has an in-house staff responsible for: sales and service of large and small commercial employer groups; individual product sales; Medicare sales; broker education and relations; public relations and advertising; product development; member communications; member group and broker satisfaction; account management; enrollment; and product regulatory compliance.

36 MEDICAL CLAIMS: Screens all received claims for accuracy of information; completes claim data-entry functions and processes claims for payment; answers questions about claim determinations and coordinates benefits with other payers (i.e. Workers Compensation, Auto, etc.) MEMBER SERVICES: Assists members with questions or concerns relating to FHCP services. Manages the Member complaint/grievance/appeal resolution process; and advises members of Plan benefits and services.

PHARMACEUTICAL SERVICES DIVISION: Responsible for the direct operation of the plan’s ambulatory Pharmacies and Pharmacy Formulary; and coordinates and administrates all affiliated pharmacy services as they relate to the Plan. PROGRAM MANAGEMENT: Supplies providers with benefit and eligibility information and clarification of FHCP coverage policy regarding all FHCP benefit plans. Is also responsible for the maintenance of benefit adjustment applications to support FHCP claims payment to providers along with the maintenance and set up of contracted provider fee schedules.

PROVIDER SERVICES: Orients and assists new and existing providers along with their staff in the administration of their FHCP contract, educates providers on FHCP policies and procedures; answers provider’s questions via on-site visits, telephone access and e-mail; maintains provider’s contract and assists with credentialing files; produces and distributes the Provider Handbook and Provider Newsletters; maintains Participating Provider Directories and online Provider Search, coordinates and monitors Provider panel assignments, coordinates Provider Surveys; facilitates Provider grievances and appeals, as well as, coordinates Provider appointments and reappointments to the FHCP Medical Staff. QUALITY MANAGEMENT/ PERFORMANCE IMPROVEMENT: Monitors and evaluates the health care services provided to FHCP’s members. The goal is to strive for continuous improvement in the areas of care, service, member satisfaction, and cost effectiveness. Areas covered: Quality Management, Performance Improvement, Accreditation, Risk Management/Patient Safety, Credentialing, Disease Management, and Clinical Reporting. Quality Management staff work with other departments to accomplish accreditation by meeting rigorous standards of the National Committee for Quality Assurance (NCQA). This includes HEDIS® quality measures (Healthcare Effectiveness Data and Information Set), CAHPS (Consumer Assessment of Healthcare Providers & Systems), patient experience surveys administered by CMS (Centers for Medicare & Medicaid Services), and Star quality measures (CMS).

Questions about any of these areas may be directed to the appropriate department as noted in the FHCP Staff Directory.

37

SECTION 4 Contract Determination and Appeals Credentialing of Providers for FHCP, Inc. Role of Primary Care Physician (PCP) Selection of Primary Care Physician Primary Care Physician Coverage FHCP Timely Access to Services Goals PCP Panel Management Provision of Health Care Services Policy Provider Network Availability & Access Monitoring and Improvement Process Policy Request for PCP Change Form (Member initiated request/Provider initiated request/ Provider status change) Medical Staff Bylaws, Rules & Regulations Policy Compliance

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82 ROLE OF PRIMARY CARE PHYSICIAN (PCP)

DEFINITION A Primary Care Physician (PPCP) provides or manages first contact, continuous and comprehensive health care services for a specific group of patients who have selected the physician as their principal health care provider. Primary Care Physicians (PCP’s) are usually generalist physicians, board eligible or board certified in family medicine, internal medicine or pediatrics. The PCP is the key medical person coordinating the patient’s health care and is responsible for, but not limited to, the following: *

A clinical focus on health promotion and disease prevention. The PCP will be knowledgeable and supportive of the organizational guidelines for preventative and disease oriented care.

*

Twenty-four (24) hours a day and 7 days a week on-call availability within a coverage group of other FHCP participating physicians.

*

Timely availability for ambulatory visits and calls at various levels of service (emergent, urgent, routine, symptomatic, and routine non-symptomatic) including health maintenance, as well as, symptom related care.

*

Involvement in all urgent and emergent clinical events.

*

Provide annual medical exams and other preventative health services as indicated.

*

Management and coordination of the use of ambulatory consultant services and diagnostic testing.

*

Support and involvement in all acute inpatient care.

*

Maintaining admitting privileges and active medical staff membership with the FHCP Medical Staff and at least one FHCP participating hospital unless otherwise covered by a Hospitalist admitting team per contract.

*

Support and involvement in Performance Improvement activities with a goal of improving the quality and reducing the cost of care.

*

Facilitating communication with the patient and FHCP.

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SELECTION OF PRIMARY CARE PHYSICIAN (PCP)

*

At enrollment, each HMO member is required to select a Primary Care Physician (PCP) from the list of FHCP participating providers. Each new enrollee is mailed a listing of available PCP’s. The member is instructed to call the Member Services Department and select a PCP before attempting to schedule an appointment. When members call Member Services, their selection is recorded and entered into the FHCP computer. FHCP encourages each new member to contact his/her PCP and to become established with the PCP’s practice.

*

Each PCP receives a monthly list of the members who have selected them as their PCP. Updates of member additions and deletions are provided throughout the month. Providers may also verify member PCP assignment through FHCP’s PAI website.

*

Members may appear on this eligibility list who are new to the physician and who have not yet established themselves as patients within the physician’s practice. Occasionally, members may require urgent or emergent care from their PCP prior to scheduling an initial appointment. The PCP is expected to accommodate the member’s request to be seen on an urgent basis, even if the member is not an established patient, and to care for the patient in the hospital if the PCP has admitting privileges.

*

If the PCP wants a member deleted from his/her panel, the Request for Primary Care Provider Change form must be completed with specific detail on the reason for the request, and forwarded to the Physician Assignment Office. The request will be reviewed by the Administer of Quality Management who will work with the physician to make an appropriate plan of care for the patient.

84 PRIMARY CARE PHYSICIAN COVERAGE •

Outpatient Coverage Provider shall provide outpatient coverage for all members assigned to the Provider Book twenty-four (24) hours per day, seven (7) days per week. In the event the Provider enters into agreement(s) with other physicians for purposes of sharing said responsibility, Provider agrees to have such physician(s) sign the FHCP “Covering Physician Agreement” as applicable.



Inpatient Services. FHCP Hospitalists shall provide hospital call coverage services and appropriately follow all FHCP members assigned to the Provider Book.



Hospital Call Coverage FHCP Hospitalists shall be responsible for covering primary care call with respect to those FHCP patients assigned to Provider’s panel, twenty-four (24) hours a day, seven (7) days per week, for the inpatient facilities herein designated for all FHCP members.



Use of FHCP Hospitalists Should Provider elect to discontinue use of Hospitalist call coverage, Provider shall notify FHCP in writing at least thirty (30) days prior to said change. Also, if Provider is being paid based on capitation FHCP’s capitation payment to Provider shall be adjusted as described in Capitation table

85 FHCP TIMELY ACCESS TO SERVICES GOALS • • • •

Emergency, to be seen immediately, as soon as possible Urgent Care or Treatment to be provided within 72 hours. Routine, symptomatic to be seen within two (2) weeks Routine, asymptomatic to be seen as medically appropriate

The following access definitions apply: Emergency Services and Care means medical screening, examination, and evaluation by a physician or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if an emergency medical condition exists, and if it does, the care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the emergency medical condition within the service capability of a hospital. Emergency A medical condition whereby the member reasonably believes that his/her health is in serious danger. Alternatively, defined as a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that the absence of immediate medical attention could reasonably be expected to result in any of the following: Serious jeopardy to the health of a patient, including a pregnant woman or a fetus. Serious impairment to bodily functions. Serious dysfunction of any bodily organ or part. Emergency Services and Care with respect to a pregnant woman: are those needed where: There is inadequate time to affect safe transfer to another hospital prior to delivery; That a transfer may pose a threat to the health and safety of the patient or fetus; or That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. Urgently needed services means any medical care or treatment that if not provided within 72 hours: (1) could seriously jeopardize the Member’s life or health or his or her ability to regain maximum function; or (2) in the opinion of a Physician with knowledge of the Member’s condition, would subject the Member to severe pain that cannot be adequately managed without the service(s) being rendered. Routine care is that level of care which can be delayed without anticipated deterioration in the patient's medical condition for a period of fourteen (14) calendar days. By utilization of the foregoing standards, FHCP does not intend to create standards of care different from those which are deemed acceptable within the FHCP service area. Rather, FHCP intends that network providers timely and appropriately respond to patient care needs, as they are presented, in accordance with standards of care existing within our service area.

86 PRIMARY CARE PHYSICIAN (PCP) Panel Management

*

Upon enrollment, each Member shall be provided with a current Directory and instructions as to how to select a PCP to coordinate their Health Care Services.

*

The Provider Access Specialist (PAS) shall maintain PCP Panel limits in the FHCP computer system and monitor appropriate assignment of Members to PCP’s based on contractual requirements.

*

The PAS shall advise appropriate FHCP personnel concerning the status of PCP panels as to those PCP’s accepting additional Members on their respective panels via a spreadsheet that is disseminated to the Member Services Department and the Provider Services Department.

87

PRIMARY CARE PHYSICIAN (PCP) Initial PCP Assignment •

Members shall be directed to call the Member Services Department for assistance in completing their initial PCP selection. A toll-free number shall be provided, along with FHCP’s TTY/TDD number for the hearing impaired. Members may also initially select their PCP in writing. Written initial assignment requests shall be processed by the PAS.



The Member’s verbal selection of PCP shall be recorded immediately by FHCP personnel in the FHCP Information System’s PCP Maintenance function. Written requests shall be entered within two (2) working days of receipt. The PCP’s FHCP provider number and date of assignment shall be entered into the PCP Maintenance screen, along with the initial selection change reason code, and the PCP’s network IPA.



Each new Member shall be sent a letter by the PAS from FHCP verifying their PCP assignment within two (2) working days of entry into the FHCP computer system.



Additions and deletions to each PCP’s panel shall be provided to the affected PCP’s office daily via FHCP’s online Provider Access Inquiry (PAI) system. In addition, electronic benefit and eligibility inquiries shall be provided via HIPAA compliant ANSI 270/271 transactions.



PCP shall be instructed to contact the PAS regarding any issues relating to the assignment of Members to their panel.



The PAS shall run a report of all Members, enrolled in FHCP benefit plans which require selection of a PCP, who have been enrolled in FHCP for (60) or more days who have not selected a PCP. These Members shall be assigned to a PCP geographically accessible to their home address. Letters shall be sent to these Members advising them of their assignment, along with the name, telephone number and location of their assigned PCP. Members will also be given information as to how to call FHCP and select a different PCP, if desired.

88 PRIMARY CARE PHYSICIAN (PCP) •

Reassignment of PCP at the request of the PCP A practitioner may request that a Member be deleted from his/her panel. Such action shall require Administrative review and approval prior to any action being taken by the practitioner and be based upon the FHCP’s Member’s Rights and Responsibilities , including but not limited to, the following: When a Member acts in a disruptive, unruly or abusive manner, or is uncooperative or noncompliant to the point where the provider’s ability to provide service is impaired; and When a Member refuses to accept a recommended treatment or procedure and Provider believes that no professionally acceptable alternative exists.



Change Requested by a FHCP staff PCP: FHCP staff shall be guided by FHCP Policy and Procedure # PC023.



Change Requested by a FHCP Network PCP: If the network PCP verbally requests that a Member be removed from his/her panel, the Request for PCP Change form shall be completed by the PCP. Written requests, signed by the practitioner, shall be submitted by the PCP to the Quality Management department for review. Upon approval by the Quality Management department, the completed request form shall be forwarded to the PAS. The PAS shall reflect the PCP’s panel Member change in the FHCP information system and generate a letter to the Member advising them of the change. Whenever possible, Members will be given at least thirty (30) days advance written notice of their PCP’s decision to remove them from their panel. Members will be provided with current information about other available PCP’s from whom they may select as their new PCP. Letters shall be sent via certified mail to Members with a return receipt requested. The PAS shall assure that each Member responds to the certified letter and selects a new PCP within the transition timeframe. Members who do not select a new PCP will be re-assigned by the PAS to a new PCP. Network PCP’s requesting the re-assignment shall be responsible for copying the Member’s medical record and forwarding them to the FHCP Medical Records department. FHCP shall be responsible for transferring said records to the Member’s new PCP.

89

PRIMARY CARE PHYSICIAN (PCP) •

Change Requested by a FHCP Member: If a Member chooses a PCP and letter wishes to change practitioners, the Member is permitted to do so at any time. The exceptions to this policy include: A Member who exhibits unacceptable behavior in the physician’s office or to the physician or his/her staff. This behavior must have prompted the creation of an Adverse Occurrence Report that is documented in Quantros (http://qxpert.quantros.com/FHCP/) for review by the FHCP Quality Management Division. A significant extenuating circumstance approved by the President/Chief Medical Offices and Chief Executive Officer. The Member may change their PCP via a telephone call to FHCP’s Member Services Department, via written request, or via one contact to FHCP’s internet based Member Portal application. The Member’s change request will be confirmed in writing by the PAS, or via automated response in the Member Portal application.

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PC032 Provider Network Availability & Access Monitoring and Improvement Process Attachment 1 – After-Hours PCP Access Survey

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FHCP After-Hours PCP Access Survey

Instructions:

1. Identify a statistically significant sample for the survey based upon total PCP practices that participate in FHCP’s HMO networks for Medicare, Commercial, and Exchange members. 2. Complete the Group Demographics cells, filling in the group name, telephone number (use the number published in the practitioner directory), practice location address and names of PCPs in the practice. One call covers all PCPs practicing at the practice location. 3. Complete the Survey Data Collection Information cells, filling in the date and time of data collection, the name of the staff person conducting the survey, and the survey type. Check the initial review survey type if this is the first time the practice was called. Check the recheck survey type if the call is to validate that the practice implemented corrective action after a first survey determined the after hours access process at that location did not meet FHCP standards. Note: calls must be made AFTER normal business hours, OR on weekends or holidays. Do not complete this survey during the business day. 4. The After Hours Access Survey Protocol is organized into 3 sections based on the type of after hours access the office location has: answering service, answering machine, or no response. Complete the ONE section used by the office to provide after hours access. The answering service and answering machine sections have two sub-sections: urgent requirement, and emergency requirement. Complete both subsections using the instructions below.  If speaking to an answering service, inform the service you are conducting a survey for Florida Health Care Plans, and have two questions for them. Ask them the questions noted in the urgent and emergent requirements rows, and select the response option within each sub-section that best matches their response. After the call is complete, use the scoring instructions to calculate the office’s score.  If the office uses an answering machine, listen to the message, and complete both the urgent and emergent sub-sections based on the message content. If necessary, make a second call to the office to obtain the information needed to score the message against the requirements. Use the scoring instructions to calculate the office’s score.  If the office does not have an after hours response mechanism, complete the no response section, choosing the option that best reflects the member’s experience when they call the office number after hours. Use the scoring instructions to calculate the office’s score. 5. Score the survey by completing the After Hours Access Survey Scoring section. 6. Follow-up with offices that passed and failed the survey, using the instructions at the bottom of page 2.

Page 1 of 3

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PC032 Provider Network Availability & Access Monitoring and Improvement Process Attachment 1 – After-Hours PCP Access Survey

Group Demographics Group Name:

Telephone number:

Practice location Street: address: City, State, Zip: Names of PCPs in practice:

Data collected on (date): Staff person conducting survey: Method Used Answering Service

Answering Machine

Survey Data Collection Information Time of data collection: Survey Type (check one:

After Hours Access Survey Protocol After Hours Access Options Scoring Instructions

Initial review Re-check Scoring

Urgent requirement: Ask service “What is your response when one of our members calls and reports they have an urgent matter they need to discuss with the doctor on call?” Offers to page doctor on call, Acceptable response, score as Pass he/she will call member back pass Offers to telephonically Acceptable response, score as Pass transfer member’s call directly to pass doctor on call Only offers to take a message Unacceptable response to urgent Fail so doctor can call member back requirement, score as fail next business day Emergency requirement: Ask service “What is your response if our member indicates that they feel the situation is too emergent to wait for a call-back from the on-call doctor?” Directs member to contact Choose one: Mandatory requirement. To 911 or go to nearest ER if he/she Pass pass, service must provide feels it is too emergent to wait emergency service information in for doctor to call them Fail response to emergency question. Score as Fail if service does not offer required information. Refuses to respond to survey Unacceptable response, score as Fail Fail Urgent requirement: Listen to the message, and select the response below which best reflects the instructions for how to deal with an urgent situation after hours. Provides instructions on how Acceptable response, score as Pass to page doctor if situation is pass. urgent Instructs member to go to ER Acceptable response, score as Pass or urgent care if situation cannot pass. wait until next business day

Page 2 of 3

PC032 Provider Network Availability & Access Monitoring and Improvement Process Attachment 1 – After-Hours PCP Access Survey

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FHCP After Hours Access Survey

Method Used Answering machine, continued.

No response

After Hours Access Survey Protocol After Hours Access Options Scoring Instructions

Scoring

Only provides instructions to Unacceptable response to urgent Fail leave a message which will be requirement, score as fail returned the next business day Emergency requirement: Listen to the message, and determine whether the message provides instructions for accessing after hours care in an emergent situation. Mark yes or no, based on message content. Does message provide Choose one: Mandatory requirement. To instructions to contact 911 or go pass, message must provide Pass to nearest ER if member feels information on accessing situation is emergent? Fail emergency services. Score as pass yes no if marked yes, score as fail if marked no. Check the description which best summarizes a member’s experience when calling the physician office phone number in the physician directory after hours: Phone rings repetitively, no Unacceptable response, score as Fail options to leave a message or fail receive instructions on how to access emergent/urgent care Receive a message that the Unacceptable response, score as Fail number is no longer in service. fail

After Hours Access Survey Scoring Score the survey by completing the section below. If either the answering service or answering machine section is completed, review the scores for the urgent and emergent requirements, and complete the 3 rows below. What is score on urgent requirement Pass Fail sub-section? What is score on emergent requirement Pass Fail sub-section? Overall score Check this option if BOTH Check this option if one or more failures urgent and emergent are noted above. requirements are marked Fail Pass above. Pass If the no response section is completed, site automatically fails. Check Fail the failure option to the right. Follow-up Instructions For offices that pass: Send a congratulatory letter informing them they meet FHCP’s after hour access standards. Thank them for their good service to members. For offices that fail: Issue a corrective action plan to any office that fails the after hours access survey. Send a copy of the survey instrument, and a cover letter requesting the office resolve the identified issue within 90 days. Re-audit the office within 90 days to confirm the issue has been corrected. Page 3 of 3

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Please complete all questions on this survey tool. Group Demographics Group Name:

Telephone number:

Practice location Street: address: City, State, Zip: Provide number of # of psychiatrists and nurse clinicians in practice practitioners with prescribing in each category authority:

# of all other licensed clinicians without prescribing authority:

Name of individual completing survey: Email address where survey received:

Data collected on (date):

Survey Data Collection Information Time of data collection:

Routine Appointment Access Appointment type: Prescriber initial visit A new patient calls and is requesting an appointment to see a clinician with prescribing authority because they need their medication renewed

Not applicable, we do not have any practitioners with prescribing authority at this practice location. Please go to next set of questions below. What is first available appointment date and time for this situation? What is the second available appointment date and time for this situation?

What is the third available appointment date and time for this situation?

Date:

Time:

Date:

Time:

Date:

Time:

129 Appointment type: Non-prescriber initial visit A new patient calls and is requesting an appointment to see a clinician without prescribing authority for a new patient visit

Not applicable, we do not have any clinicians without prescribing authority at this practice location. Please go to next set of questions below. What is first available appointment date and time for this situation? What is the second available appointment date and time for this situation? What is the third available appointment date and time for this situation?

Date:

Time:

Date:

Time:

Date:

Time:

Routine Follow-up Appointment Access Appointment type: Prescriber followup routine care An established patient calls and is requesting an appointment to see a clinician with prescribing authority for a follow-up visit for a non-urgent issue. Appointment type: Non-prescriber follow-up routine care An established patient calls and is requesting an appointment to see a clinician without prescribing authority for a follow-up visit for a non-urgent issue.

Not applicable, we do not have any clinicians with prescribing authority at this practice location. Please go to next set of questions below. What is first available appointment date Date: and time for this situation? What is the second available appointment Date: date and time for this situation? What is the third available appointment Date: date and time for this situation?

Not applicable, we do not have any clinicians without prescribing authority at this practice location. Please go to next set of questions below. What is first available appointment date and time for this situation? What is the second available appointment date and time for this situation? What is the third available appointment date and time for this situation?

Time: Time: Time:

Date:

Time:

Date:

Time:

Date:

Time:

130 Urgent Appointment Access Appointment type: Prescriber urgent visit A new patient calls and is requesting an appointment to see a prescriber for an urgent clinical issue. Appointment type: Non-prescriber urgent A new patient calls and is requesting an appointment to see a practitioner without prescribing authority for an urgent clinical issue.

Not applicable, we do not have any practitioners with prescribing authority at this practice location. Please go to next set of questions below. What is first available appointment date and time for this situation?

Not applicable, we do not have any PhD psychologists at this practice location. Please go to next set of questions below. What is first available appointment date and time for this situation?

Date:

Time:

Date:

Time:

Thank you for completing this questionnaire. Please return it to . All completed questionnaires are placed into a drawing for a . We will notify the winner by phone or email. Look for an update on the results of this survey and the winner in the next provider newsletter.

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Please complete all questions on this survey tool. Group Demographics Group Name: Practice location address: Provide number of clinicians in practice at this location Name of individual completing survey: Data collected on (date):

Telephone number: Street: City, State, Zip: # of :

# of :

# of :

Email address where survey received: Survey Data Collection Information Time of data collection:

Routine Appointment Access Appointment type: Initial visit A new patient calls and is requesting an appointment for a non-urgent issue.

Appointment type: Follow up visit An established patient calls and is requesting an appointment for a follow up visit for a non-urgent issue.

What is first available appointment date and time for this situation? What is the second available appointment date and time for this situation? What is the third available appointment date and time for this situation?

Date:

Time:

Date:

Time:

Date:

Time:

What is first available appointment date and time for this situation? What is the second available appointment date and time for this situation?

Date:

Time:

Date:

Time:

What is the third available appointment date and time for this situation?

Date:

Time:

132

Urgent Appointment Access Appointment type: Initial visit A new patient calls and is requesting an appointment for an urgent clinical issue. Appointment type: Follow-up visit An established patient calls and is requesting an appointment for an urgent clinical issue.

What is first available appointment date and time for this situation?

Date:

Time:

What is first available appointment date and time for this situation?

Date:

Time:

Thank you for completing this questionnaire. Please return it to . All completed questionnaires are placed into a drawing for a . We will notify the winner by phone or email. Look for an update on the results of this survey and the winner in the next provider newsletter.

133

Please complete all questions on this survey tool. Group Demographics Group Name:

Telephone number:

Practice location Street: address: City, State, Zip: Provide number of # of physicians: clinicians in practice at this location Name of individual completing survey: Data collected on (date):

# of physician assistants or nurse practitioners: Email address where survey received:

Survey Data Collection Information Time of data collection:

Routine Appointment Access Appointment type: Initial visit A new patient calls and is requesting an appointment for a non-urgent issue.

Appointment type: Follow up visit An established patient calls and is requesting an appointment for a follow up visit for a non-urgent issue.

What is first available appointment date and time for this situation? What is the second available appointment date and time for this situation? What is the third available appointment date and time for this situation?

Date:

Time:

Date:

Time:

Date:

Time:

What is first available appointment date and time for this situation? What is the second available appointment date and time for this situation?

Date:

Time:

Date:

Time:

What is the third available appointment date and time for this situation?

Date:

Time:

134 Florida Health Care Plans

Practitioner Availability Analysis

(From date) to (To date)

Introduction Because managed care plans require members to utilize a designated practitioner network, the organization must ensure there are adequate numbers and geographic distribution of primary care, behavioral health, and specialty care practitioners to meet member needs. Florida Health Care Plans (FHCP) monitors practitioner availability annually against its standards, and initiates actions as needed to improve practitioner availability. This report describes the monitoring methodology, results, analysis, and action.

Member Cultural Needs and Preferences FHCP analyzes data about member cultural, ethnic, racial and linguistic needs and preferences at least every other year to determine whether the current practitioner network is meeting these needs. Member cultural, ethnic, racial and linguistic needs and preferences are assessed through: • CAHPS survey results on respondent race and ethnicity • US census data on resident language preference and race distribution for the health plan’s service area • Data on member linguistic needs based on customer service language translation requests • Member expressed needs regarding practitioners who meet their ethnic, racial, cultural or linguistic needs through analysis of member complaints Trended CAHPS Data: Racial and Ethnic Composition of Respondents 20XX 20XX 20XX Total Number answering question # # # White % % % Black or African-American % % % Asian % % % Native Hawaiian or other Pacific % % % Islander American Indian or Alaska Native % % % Other % % % Proportion of respondents of Hispanic or Latino descent

135 The 201X census data for the service area shows racial composition to be (summarize racial composition data for the service area obtained from US Census web site here). (Discuss how the health plan’s racial data from CAHPS compares to the US census data. Is the health plan’s population more, or less diverse than the Census data? Is the health plan’s racial composition changing over the last three years, or staying the same?) The proportion of households in the service area that speak a language other than English was also obtained from US census data. Results indicate (summarize proportion that speak language other than English and give percentages of top languages other than English. Discuss whether the health plan believes its membership is similar to or different than the overall service area population and the rationale for that belief). Data on language translation requests in customer service for is below: (Summarize data about language translation requests in customer service, including at least top 5-10 languages, the number of requests for that language and the percent of total requests which were for that language. Compare language translation data to the US Census data. Discuss the similarities or differences between health plan language translation data and US Census data and reasons for that relationship.) In (year), there were (#) of member complaints about practitioner ability to meet member ethnic, racial, cultural or linguistic needs. Concerns voiced included (explain issues noted in member complaints. If no member complaints, need to state that in first sentence). (Summarize any other data the organization may have about member cultural needs and preferences here, such as survey results or results of any cultural diversity assessments, etc.) In sum, based on available data, we conclude that members have the following ethnic, racial, cultural or linguistic needs which must be met by network practitioners: • (Summarize needs here, i.e., practitioners that speak Spanish and Chinese) • (Place each need on a separate line, i.e., African American practitioners, especially in the southern part of the service area) The health plan examines available data about network practitioner’s ability to meet member’s ethnic, racial, cultural or linguistic needs. Today the health plan does not have reliable data on practitioner race, as this data point is an optional item on the practitioner credentialing application. (If the health plan has data on practitioner race, discuss it here.) However, the health plan does have reliable data on practitioners who speak languages other than English. The results of this analysis are below. (Insert a data table that reports the number and percent of total practitioners who speak each language in your database). Upon comparison of data on practitioners who speak languages other than English with the proportion of individuals in the service area who speak other languages, the (health

136 plan name) network (explain whether it meets or doesn’t meet member needs. If member needs are not met, discuss actions the health plan is implementing to close those gaps.)

Standards and Methodology – COMMERCIAL, MARKETPLACE and

MEDICARE

Practitioner availability monitoring is completed for primary care practitioners, high volume and high impact specialty care practitioners, and high volume behavioral health practitioner types. FHCP defines primary care practitioners as pediatricians, internal medicine practitioners, family practitioners and general practitioners. FHCP identifies High Volume Specialties through analysis of the number of number of visits by specialty. For 201X, FHCP identified High Volume Specialties for Commercial and Marketplace products as: Gynecology and Obstetrics. The High Volume Specialty for Medicare was Gynecology. High Impact Specialties are defined as Practitioners who treat conditions that have high mortality and morbidity rates and where such treatment requires significant resources. For 201X, FHCP identified High Impact Specialties for Commercial, Marketplace and Medicare as Medical and Radiation Oncology Practitoiners. FHCP identifies High Volume Behavioral Health Practitioner types for Commercial, Marketplace and Medicare through analysis of encounters/number of visits. For 201X, identified high volume behavioral health practitioner types were: Psychiatrists, Licensed Mental Health Counselors, and Licensed Clinical Social Workers. Table 1 lists the standards, measurement method, and measurement frequency for each practitioner type for whom availability is monitored. Monitoring takes place at the Commercial, Marketplace and Medicare product line. COMMERCIAL Table 1a: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency

137 COMMERCIAL Table 1a: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency Primary Care 1 Pediatrician for Ratio of PCPs per Annually Practitioners – every 2500 members members age birth to 18 years Pediatricians

Primary Care Practitioners – Internal Medicine

At least 75% of Pediatric PCP panels will be open to new members

Ratio of open PCP panels per total number of PCP panels

Annually

80% or more of Members age birth to 18 years will have a PCP office within 20 miles of member residence

GeoAccess

Annually

1 Internal Medicine PCP for every 2500 members age 18 years and older

Ratio of PCPs per members

Annually

At least 75% of Internal Medicine PCP panels will be open to new members

Ratio of open PCP panels per total number of PCP panels

Annually

85% or more of Members age 18 and older will have an Internal Medicine PCP office within 20 miles of member residence

GeoAccess

Annually

138 COMMERCIAL Table 1a: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency Primary Care 1 FP or GP PCP for Ratio of PCPs per Annually Practitioners – every 2500 members members ages 2 years and Family Practice / older General Practice

All Primary Care Practitioners

At least 75% of FP/GP PCP panels will be open to new members

Ratio of open PCP panels per total number of PCP panels

Annually

85% or more of Members ages 2 and older will have a FP or FP PCP office within 20 miles of member residence

GeoAccess

Annually

1 PCP for every 2500 Ratio of PCPs per members members

Annually

At least 75% of all PCP panels will be open to new members

Ratio of open PCP panels per total number of PCP panels

Annually

85% or more of Members will have a PCP office within 15 miles of member residence

GeoAccess

Annually

139 COMMERCIAL Table 1a: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency High volume specialty: #1 At least 90% will be Percent of open open to accepting Network new HMO members Practitioners per total par Practitioners of Annually Specialty 90% or more of Members will have an office within 20 miles of member residence High impact specialty: #1

High impact specialty: #2

GeoAccess

At least 95% will be Percent of open open to accepting Network new HMO members Practitioners per total par Practitioners of Specialty 90% or more of Members will have Specialty #1 Practitioner within 20 miles of member residence At least 95% will be open to accepting new HMO members

90% or more of Members will have a Specialty #2 Practitioner within 20 miles of member residence

Annually Annually

GeoAccess

Annually

Percent of open Network Practitioners per total par Practitioners of Specialty

Annually

GeoAccess

Annually

140 COMMERCIAL Table 1a: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency High volume behavioral health Percent of open prescribing At least 90% will be Network practitioner: open to accepting Practitioners per new HMO members total par Psychiatrist Practitioners of Annually (MD/DO) Specialty 90% or more of Members will have a Specialty office within 30 miles of member residence High volume behavioral health practitioner: Licensed Mental Health Counselor (LMHC)

GeoAccess

Annually

At least 90% will be Percent of open open to accepting Network new HMO members Practitioners per total par Practitioners of Specialty 90% or more of Members will have a LMHC office within 30 miles of member residence

Annually

GeoAccess Annually

141 COMMERCIAL Table 1a: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency High volume behavioral health At least 90% will be Percent of open practitioner: open to accepting Network Licensed Clinical new HMO members Practitioners per Annually Social Worker total par (LCSW) Practitioners of Specialty 90% or more of Members will have a LCSW office within 30 miles of member residence

GeoAccess Annually

MARKETPLACE Table 1b: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency Primary Care 1 Pediatrician for Ratio of PCPs per Annually Practitioners – every 2500 members members age birth to 18 years Pediatricians At least 75% of Pediatric PCP panels will be open to new members

Ratio of open PCP panels per total number of PCP panels

Annually

85% or more of Members will have a PCP office within 20 miles of member residence

GeoAccess

Annually

142 MARKETPLACE Table 1b: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency Primary Care 1 Internal Medicine Ratio of PCPs per Annually Practitioners – PCP for every 2500 members members age 18 Internal Medicine years and older

Primary Care Practitioners – Family Practice / General Practice

At least 75% of Internal Medicine PCP panels will be open to new members

Ratio of open PCP panels per total number of PCP panels

Annually

85% or more of Members age 18 and older will have an Internal Medicine PCP office within 20 miles of member residence

GeoAccess

Annually

1 FP or GP PCP for Ratio of PCPs per every 2500 members members ages 2 years and older

Annually

At least 75% of FP/GP PCP panels will be open to new members

Annually

85% or more of Members ages 2 and older will have a FP or FP PCP office within 20 miles of member residence

Ratio of open PCP panels per total number of PCP panels GeoAccess

Annually

143 MARKETPLACE Table 1b: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency All Primary Care 1 PCP for every 2500 Ratio of PCPs per Annually Practitioners members members

High volume specialty: #1

High impact specialty: #1

At least 75% of all PCP panels will be open to new members

Ratio of open PCP panels per total number of PCP panels

Annually

90% or more of Members will have a PCP office within 15 miles of member residence

GeoAccess

Annually

At least 90% will be Percent of open open to accepting Network new HMO members Practitioners per total par Practitioners of Specialty 90% or more of Members will have GeoAccess an office within 20 miles of member residence At least 95% will be Percent of open open to accepting Network new HMO members Practitioners per total par Practitioners of Specialty 90% or more of Members will have a Specialty #1 Practitioner within 20 miles of member residence

GeoAccess

Annually

Annually Annually

Annually

144 MARKETPLACE Table 1b: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency High impact At least 95% will be Percent of open Annually specialty: #2 open to accepting Network new HMO members Practitioners per total par Practitioners of Specialty 90% or more of Members will have a Specialty #2 Practitioner within 20 miles of member residence High volume behavioral health prescribing practitioner: Psychiatrist (MD/DO)

Percent of open At least 90% will be Network open to accepting Practitioners per new HMO members total par Practitioners of Specialty 90% or more of Members will have a Specialty office within 30 miles of member residence

High volume behavioral health practitioner: Licensed Mental Health Counselor (LMHC)

GeoAccess

Annually

GeoAccess

Annually

At least 90% will be Percent of open open to accepting Network new HMO members Practitioners per total par Practitioners of Specialty 90% or more of Members will have a LMHC office within 30 miles of member residence

Annually

Annually

GeoAccess Annually

145 MARKETPLACE Table 1b: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency High volume behavioral health At least 90% will be Percent of open practitioner: open to accepting Network Licensed Clinical new HMO members Practitioners per Annually Social Worker total par (LCSW) Practitioners of Specialty 90% or more of Members will have a LCSW office within 30 miles of member residence

GeoAccess Annually

MEDICARE Table 1c: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency Primary Care 1 Internal Medicine Ratio of PCPs per Annually Practitioners – PCP for every 2500 members members age 18 Internal Medicine years and older At least 75% of Internal Medicine PCP panels will be open to new members

Ratio of open PCP panels per total number of PCP panels

Annually

85% or more of Members age 18 and older will have an Internal Medicine PCP office within 20 miles of member residence

GeoAccess

Annually

146 MEDICARE Table 1c: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency Primary Care 1 FP or GP PCP for Ratio of PCPs per Annually Practitioners – every 2500 members members ages 2 years and Family Practice / older General Practice

All Primary Care Practitioners

High volume specialty: #1

At least 75% of FP/GP PCP panels will be open to new members

Ratio of open PCP panels per total number of PCP panels

Annually

85% or more of Members ages 2 and older will have a FP or FP PCP office within 20 miles of member residence

GeoAccess

Annually

1 PCP for every 2500 Ratio of PCPs per members members

Annually

At least 75% of All PCP panels will be open to new members

Ratio of open PCP panels per total number of PCP panels

Annually

90% or more of Members will have a PCP office within 15 miles of member residence

GeoAccess

Annually

90% or more of Members will have an office within 20 miles of member residence

GeoAccess Annually

147 MEDICARE Table 1c: Availability Standards and Measurement Methods by Practitioner Type Practitioner Type Standard Measurement Measurement Method Frequency High impact 90% or more of GeoAccess Annually specialty: #1 Members will have a Specialty #1 Practitioner within 20 miles of member residence High impact 90% or more of GeoAccess Annually specialty: #2 Members will have a Specialty #2 Practitioner within 20 miles of member residence

2.

CMS Standards for Medicare Network Practitioner Availability

For Medicare membership in Volusia, Flagler, Seminole and Brevard Counties, FHCP must annually demonstrate that it offers an adequate Network to provide access to Medicare covered services, as required by 42 CFR 422.122(a)(1). Standards for the number (quantity) and geographic distribution (time and distance) of Medicare Network Practitioners and Providers are set forth by CMS annually in the CMS Health Service Delivery (HSD) Reference file for each County within FHCP’s Medicare product service area. This Reference file sets forth the following: a.

Standards for Number of Practitioners and Providers. The CMS requirements for minimal number of practitioners and providers by county in the Medicare service area are detailed below for 20XX

148

Practitioner Specialty 20XX Primary Care Allergy and Immunology Cardiology Chiropractor Dermatology Endocrinology ENT/Otolaryngology Gastroenterology General Surgery Gynecology, OB/GYN Infectious Diseases Nephrology Neurology Neurosurgery Oncology - Medical, Surgical Oncology - Radiation Ophthalmology Orthopedic Surgery Physiatry, Rehabilitative Medicine Plastic Surgery Podiatry Psychiatry Pulmonology Rheumatology

CMS Practitioner Quantity Standard Volusia Medicare

Flagler Medicare

Seminole Medicare

Brevard Medicare

149

Practitioner Specialty 20XX

CMS Practitioner Quantity Standard Volusia Medicare

Flagler Medicare

Seminole Medicare

Brevard Medicare

Urology Vascular Surgery Cardiothoracic Surgery

Provider Type 20XX Acute Inpatient Hospital Beds Cardiac Surgery Program Cardiac Catheterization Services Critical Care Services/Intensive Care Outpatient Dialysis Surgical Services (Outpatient or ASC) Skilled Nursing Facilities Diagnostic Radiology Mammography Physical Therapy Occupational Therapy Speech Therapy Inpatient Psychiatric Facility Services Orthotics & Prosthetics Home Health Durable Medical Equipment Outpatient Infusion/Chemotherapy b.

CMS Facility Quantity Standard Volusia Flagler Seminole Brevard County County County County Medicare Medicare Medicare Medicare

CMS Standards for Geographic Access. The CMS requirements for travel time and distance to Practitioners and Providers by county in the Medicare service area as detailed below for 20XX. The standards require FHCP to demonstrate that ninety percent (90%) of Medicare Members (or more) have access to at least one Practitioner/Provider, for each specialty type, within CMS established time and distance requirements for the period being measured. CMS Practitioner Time & Distance Standards 20XX

Primary Care - (see Notes)

Time (Minutes) Distance (Miles)

Volusia

Flagler

Seminole

Brevard

150 CMS Practitioner Time & Distance Standards 20XX Allergy and Immunology Cardiology Chiropractor Dermatology Endocrinology ENT/Otolaryngology Gastroenterology General Surgery Gynecology, OB/GYN Infectious Diseases Nephrology Neurology Neurosurgery Oncology - Medical, Surgical Oncology - Radiation/ Radiation Oncology Ophthalmology Orthopedic Surgery Physiatry, Rehabilitative Medicine Plastic Surgery

Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles)

Volusia

Flagler

Seminole

Brevard

151 CMS Practitioner Time & Distance Standards 20XX Podiatry Psychiatry Pulmonology Rheumatology Urology Vascular Surgery Cardiothoracic Surgery

Cardiac Cath Services Critical Care/ICU Services Outpt Dialysis Surgical Services (Outpatient or ASC) Skilled Nursing Facilities Diagnostic Radiology Mammography Physical Therapy Occupational Therapy

Flagler

Seminole

Brevard

Volusia

Flagler

Seminole

Brevard

Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles)

CMS Practitioner Time & Distance Standards 20XX Time (Minutes) Acute Inpatient Hospital Distance (Miles) Cardiac Surgery Program

Volusia

Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes)

152

Speech Therapy Inpatient Psychiatric Facility Services Orthotics & Prosthetics Outpt. Infusion/ Chemotherapy

Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles) Time (Minutes) Distance (Miles)

Results COMMERCIAL Table 2: Measurement Results and Comparison to Performance Goal by Practitioner Type Practitioner Type Standard Results Goal Met? (Yes/No) Primary Care 1 Pediatrician for 1 Pediatrician / Practitioners – every 2500 members _______members age age birth to 18 years birth to 18 years Pediatricians At least 75% of Pediatric PCP panels will be open

___% of PCP panels that are open

85% or more of Members will have a PCP office within 20 miles of member residence

___% of members have at least 1 Pediatrician within 20 miles

153 COMMERCIAL Table 2: Measurement Results and Comparison to Performance Goal by Practitioner Type Practitioner Type Standard Results Goal Met? (Yes/No) Primary Care 1 Internal Medicine 1 Internal Medicine/ Practitioners – PCP for every 2500 _____members members age 18 Internal Medicine years and older

Primary Care Practitioners – Family Practice / General Practice

At least 75% of Internal Medicine PCP panels will be open to new members

___% of PCP panels that are open

85% or more of Members age 18 and older will have an Internal Medicine PCP office within 20 miles of member residence

____% or more of Members age 18 and older have an Internal Medicine PCP office within 20 miles of member residence

1 FP or GP PCP for 1 FP/GP/_____ every 2500 members members ages 2 years and older At least 75% of FP/GP PCP panels will be open to new members 85% or more of Members ages 2 and older will have a FP or FP PCP office within 20 miles of member residence

___% of PCP panels that are open _____% or more of Members ages 2 and older have a FP or FP PCP office within 20 miles of member residence

154 COMMERCIAL Table 2: Measurement Results and Comparison to Performance Goal by Practitioner Type Practitioner Type Standard Results Goal Met? (Yes/No) All Primary Care 1 PCP for every 2500 1 PCP /______ Practitioners members members

High volume specialty: #1

At least 75% of All PCP panels will be open to new members

___% of PCP panels that are open

90% or more of Members will have a PCP office within 15 miles of member residence

_____% of Members have a PCP office within 15 miles of member residence

At least 95% will be ____% are accepting open to accepting new HMO members new HMO members 90% or more of Members will have an office within 20 miles of member residence

High impact specialty: #1

____% of Members have an office within 20 miles of member residence

At least 95% will be ____% are accepting open to accepting new HMO members new HMO members 90% or more of Members will have a Specialty #1 Practitioner within 20 miles of member residence

____% of Members have a Specialty #1Practitioner within 20 miles of member residence

155 COMMERCIAL Table 2: Measurement Results and Comparison to Performance Goal by Practitioner Type Practitioner Type Standard Results Goal Met? (Yes/No) High impact At least 95% will be ____% are accepting specialty: #2 open to accepting new HMO members new HMO members

High volume behavioral health prescribing practitioner: Psychiatrist (MD/DO)

High volume behavioral health practitioner: Licensed Mental Health Counselor (LMHC)

90% or more of Members will have a Specialty #2 Practitioner within 20 miles of member residence At least 90% will be open to accepting new HMO members 90% or more of Members will have a Specialty office within 30 miles of member residence

_____% of Members have a Specialty #2 Practitioner within 20 miles of member residence ____% are accepting new HMO members ______% of Members have a Specialty office within 30 miles of member residence

____% are accepting At least 90% will be new HMO members open to accepting new HMO members ___% of Members 90% or more of have a LMHC office Members will have within 30 miles of a LMHC office member residence within 30 miles of member residence

156 COMMERCIAL Table 2: Measurement Results and Comparison to Performance Goal by Practitioner Type Practitioner Type Standard Results Goal Met? (Yes/No) High volume behavioral health At least 90% will be ____% are accepting practitioner: open to accepting new HMO members Licensed Clinical new HMO members Social Worker (LCSW) 90% or more of ___% of Members Members will have have a LCSW office a LCSW office within 30 miles of within 30 miles of member residence member residence

MARKETPLACE Table 2: Measurement Results and Comparison to Performance Goal by Practitioner Type Practitioner Type Standard Results Goal Met? (Yes/No)

157 MARKETPLACE Table 2: Measurement Results and Comparison to Performance Goal by Practitioner Type Practitioner Type Standard Results Goal Met? (Yes/No) Primary Care 1 Pediatrician for 1 Pediatrician / Practitioners – every 2500 members ______ members age age birth to 18 years birth to 18 years Pediatricians

Primary Care Practitioners – Internal Medicine

At least 75% of Pediatric PCP panels will be open

___% of PCP panels that are open

85% or more of Members will have a PCP office within 20 miles of member residence

_____% of Members have a PCP office within 20 miles of member residence

1 Internal Medicine PCP for every 2500 members age 18 years and older

1 Internal Medicine PCP / _______ members age 18 years and older

At least 75% of Internal Medicine PCP panels will be open 85% or more of Members age 18 and older will have an Internal Medicine PCP office within 20 miles of member residence

___% of PCP panels that are open

_____% of Members age 18 and older have an Internal Medicine PCP office within 20 miles of member residence

158 MARKETPLACE Table 2: Measurement Results and Comparison to Performance Goal by Practitioner Type Practitioner Type Standard Results Goal Met? (Yes/No) Primary Care 1 FP or GP PCP for 1 FP or GP PCP / Practitioners – every 2500 members _______members ages ages 2 years and 2 years and older Family Practice / older General Practice

All Primary Care Practitioners

High volume specialty: #1

At least 75% of FP/GP PCP panels will be open

___% of PCP panels that are open

85% or more of Members ages 2 and older will have a FP or FP PCP office within 20 miles of member residence

____% of Members ages 2 and older have a FP or FP PCP office within 20 miles of member residence

1 PCP for every 2500 1 PCP / _______ members members At least 75% of All PCP panels will be open

___% of PCP panels that are open

90% or more of Members will have a PCP office within 15 miles of member residence

______% of Members have a PCP office within 15 miles of member residence

At least 95% will be open to accepting ____% are accepting new HMO members new HMO members 90% or more of Members will have an office within 20 miles of member residence

____% of Members have an office within 20 miles of member residence

159 MARKETPLACE Table 2: Measurement Results and Comparison to Performance Goal by Practitioner Type Practitioner Type Standard Results Goal Met? (Yes/No) High impact At least 95% will be ____% are accepting specialty: #1 open to accepting new HMO members new HMO members

High impact specialty: #2

High volume behavioral health prescribing practitioner: Psychiatrist (MD/DO)

90% or more of Members will have a Specialty #1 Practitioner within 20 miles of member residence At least 95% will be open to accepting new HMO members

____% of Members have a Specialty #1 Practitioner within 30 miles of member residence

90% or more of Members will have a Specialty #2 Practitioner within 20 miles of member residence

_____% of Members have a Specialty #2 Practitioner within 30 miles of member residence

____% are accepting new HMO members

At least 90% will be open to accepting ____% are accepting new HMO members new HMO members 90% or more of Members will have a Specialty office within 30 miles of member residence

____% of Members have a Specialty office within 30 miles of member residence

160 MARKETPLACE Table 2: Measurement Results and Comparison to Performance Goal by Practitioner Type Practitioner Type Standard Results Goal Met? (Yes/No) High volume behavioral health At least 90% will be ____% are accepting practitioner: open to accepting new HMO members Licensed Mental new HMO members Health Counselor (LMHC) 90% or more of _____% of Members Members will have have a LMHC office a LMHC office within 30 miles of within 30 miles of member residence member residence High volume behavioral health practitioner: Licensed Clinical Social Worker (LCSW)

At least 90% will be ____% are accepting open to accepting new HMO members new HMO members 90% or more of Members will have a LCSW office within 30 miles of member residence

____% of Members have a LCSW office within 30 miles of member residence

MEDICARE Table 2: Measurement Results and Comparison to Performance Goal by Practitioner Type Practitioner Type Standard Results Goal Met? (Yes/No)

161 MEDICARE Table 2: Measurement Results and Comparison to Performance Goal by Practitioner Type Practitioner Type Standard Results Goal Met? (Yes/No) Primary Care 1 Internal Medicine 1 Internal Medicine Practitioners – PCP for every 2,500 PCP / ______ members age 18 members age 18 Internal Medicine years and older years and older At least 75% of Internal Medicine PCP panels will be open to new members 90% or more of Members age 18 and older will have an Internal Medicine PCP office within 20 miles of member residence Primary Care Practitioners – Family Practice / General Practice

___% of PCP panels that are open

_____% of Members age 18 and older have an Internal Medicine PCP office within 20 miles of member residence

1 FP or GP PCP for every 2,500 members ages 2 years and older

1 FP or GP PCP / _____ members ages 2 years and older

At least 75% of FP/GP PCP panels will be open to new members

___% of PCP panels that are open

90% or more of Members ages 2 and older will have a FP or FP PCP office within 20 miles of member residence

_____% of Members ages 2 and older have a FP or FP PCP office within 20 miles of member residence

162 MEDICARE Table 2: Measurement Results and Comparison to Performance Goal by Practitioner Type Practitioner Type Standard Results Goal Met? (Yes/No) All Primary Care 1 PCP for every 1 PCP / ______ Practitioners 2,500 members members At least 75% of All PCP panels will be open to new members

___% of PCP panels that are open

90% or more of Members will have a PCP office within 15 miles of member residence

____% of Members have a PCP office within 15 miles of member residence

High volume specialty: #1

. 90% or more of Members will have an Specialty #1 office within 20 miles of member residence

High impact specialty: #1

90% or more of Members will have a Specialty #1 Practitioner within 20 miles of member residence 90% or more of Members will have a Specialty #2 Practitioner within 20 miles of member residence

High impact specialty: #2

____% of Members have an office within 20 miles of member residence

____% of Members have a Specialty #1 Practitioner within 20 miles of member residence ____% of Members have a Specialty #2 Practitioner within 20 miles of member residence

Practitioner Availability Results in Comparison to CMS Standards:

163 Tables 3-7 below provide results for monitoring against the standards for adequate numbers and distance of practitioners and providers by county for the Medicare network. The Access Requirements columns show the proportion of members who met the time and distance geographic location standards. The Provider Requirements columns show whether the number of practitioners or providers met the minimum number standards for that county. Table 3 – Volusia County Medicare Network Availability Results Table 4 – Flagler County Medicare Network Availability Results Table 5 – Seminole County Medicare Network Availability Results Table 6 – Brevard County Medicare Network Availability Results Table 7 – PCP, Urgent Care and Emergency service Locations accessible via public transportation results Criteria. The CMS criteria referenced above may vary by “county type” to account for difference in patterns of care (Large Metro, Metro, Micro, Rural, CEAC). CMS categorized each county within FHCP’s service area as belonging to the Metro county type.

Table 3 – Volusia County Medicare Practitioner Network Availability Results Spec Code S03 007 008 010 011 012 013 014 015 016 017 018 019 020 021 022 023 025 026 027 028 029

SpecDesc Primary Care Total Allergy and Immunology Cardiology Chiropractor Dermatology Endocrinology ENT/Otolaryngology Gastroenterology General Surgery Gynecology, OB/GYN Infectious Diseases Nephrology Neurology Neurosurgery Oncology - Medical, Surgical Oncology - Radiation Ophthalmology Orthopedic Surgery Physiatry, Rehabilitative Medicine Plastic Surgery Podiatry Psychiatry

Pct With Acce ss

Pct Without Access

Avg Dist

Avg Time

Met Access

Required Prvs

Servicing Prvs

Met Prvs

Met Overall

164 030 031 033 034 040 041 042 043 044 045 046 047 048 049 050 051 052 054 055 056 057

Pulmonology Rheumatology Urology Vascular Surgery Acute Inpatient Hospital Beds Cardiac Surgery Program Cardiac Catheterization Services Critical Care /Intensive Care Outpatient Dialysis Surgical Services (Outpt or ASC) Skilled Nursing Facilities Diagnostic Radiology Mammography Physical Therapy Occupational Therapy Speech Therapy Inpt. Psychiatric Facility Orthotics & Prosthetics Home Health Durable Medical Equipment Outpt. Infusion/Chemo

Table 4 – Flagler County Medicare Practitioner Network Availability Results Spec Code S03 007 008 010 011 012 013 014 015 016 017 018 019 020 021 022 023 025 026 027 028 029

SpecDesc Primary Care Allergy and Immunology Cardiology Chiropractor Dermatology Endocrinology ENT/Otolaryngology Gastroenterology General Surgery Gynecology, OB/GYN Infectious Diseases Nephrology Neurology Neurosurgery Oncology - Medical, Surgical Oncology – Radiation Ophthalmology Orthopedic Surgery Physiatry, Rehabilitative Med Plastic Surgery Podiatry Psychiatry

Pct With Access

Pct Without Access

Avg Dist

Avg Time

Met Access

Required Prvs

Servicing Prvs

Met Prvs

Met Overall

165 Table 4 – Flagler County Medicare Practitioner Network Availability Results Spec Code 030 031 033 034 040 041 042 043 044 045 046 047 048 049 050 051 052 054 055 056

SpecDesc Pulmonology Rheumatology Urology Vascular Surgery Acute Inpatient Hospital Beds Cardiac Surgery Program Cardiac Catheterization Services Critical Care /Intensive Care Outpatient Dialysis Surgical Services (Outpt or ASC) Skilled Nursing Facilities Diagnostic Radiology Mammography Physical Therapy Occupational Therapy Speech Therapy Inpt. Psychiatric Facility Orthotics & Prosthetics Home Health Durable Medical Equipment

Pct With Access

Pct Without Access

Avg Dist

Avg Time

Met Access

Required Prvs

Servicing Prvs

Met Prvs

Met Overall

Table 5 – Seminole County Medicare Practitioner Network Availability Results Spec Code S03 007 008 010 011 012 013 014 015 016 017 018 019

SpecDesc Primary Care Allergy and Immunology Cardiology Chiropractor Dermatology Endocrinology ENT/Otolaryngology Gastroenterology General Surgery Gynecology, OB/GYN Infectious Diseases Nephrology Neurology

Pct With Access

Pct Without Access

Avg Dist

Avg Time

Met Access

Required Prvs

Servicing Prvs

Met Prvs

Met Overall

166 Table 5 – Seminole County Medicare Practitioner Network Availability Results Spec Code 020 021 022 023 025 026 027 028 029 030 031 033 034 035 040 041 042 043 044 045 046 047 048 049 050 051 052 054 055 056 057

SpecDesc Neurosurgery Oncology - Medical, Surgical Oncology – Radiation Ophthalmology Orthopedic Surgery Physiatry, Rehabilitative Med Plastic Surgery Podiatry Psychiatry Pulmonology Rheumatology Urology Vascular Surgery Cardiothoracic Surgery Acute Inpatient Hospital Beds Cardiac Surgery Program Cardiac Catheterization Services Critical Care /Intensive Care Outpatient Dialysis Surgical Services (Outpt or ASC) Skilled Nursing Facilities Diagnostic Radiology Mammography Physical Therapy Occupational Therapy Speech Therapy Inpt. Psychiatric Facility Orthotics & Prosthetics Home Health Durable Medical Equipment Outpt. Infusion/Chemo

Pct With Access

Pct Without Access

Avg Dist

Avg Time

Met Access

Required Prvs

Servicing Prvs

Met Prvs

Met Overall

Table 6 – Brevard County Medicare Practitioner Network Availability Results Spec Code S03 007 008 010 011 012

Spec Desc Primary Care Allergy and Immunology Cardiology Chiropractor Dermatology Endocrinology

Pct With Access

Pct Without Access

Avg Dist

Avg Time

Met Access

Required Prvs

Servicing Prvs

Met Prvs

Met Overall

167 Table 6 – Brevard County Medicare Practitioner Network Availability Results Spec Code 013 014 015 016 017 018 019 020 021 022 023 025 026 027 028 029 030 031 033 034 040 041 042 043 044 045 046 047 048 049 050 051 052 054 055 056 057

Spec Desc ENT/Otolaryngology Gastroenterology General Surgery Gynecology, OB/GYN Infectious Diseases Nephrology Neurology Neurosurgery Oncology - Medical, Surgical Oncology – Radiation Ophthalmology Orthopedic Surgery Physiatry, Rehabilitative Med Plastic Surgery Podiatry Psychiatry Pulmonology Rheumatology Urology Vascular Surgery Acute Inpatient Hospital Beds Cardiac Surgery Program Cardiac Catheterization Services Critical Care /Intensive Care Outpatient Dialysis Surgical Services (Outpt or ASC) Skilled Nursing Facilities Diagnostic Radiology Mammography Physical Therapy Occupational Therapy Speech Therapy Inpt. Psychiatric Facility Orthotics & Prosthetics Home Health Durable Medical Equipment Outpt. Infusion/Chemo

Pct With Access

Pct Without Access

Avg Dist

Avg Time

Met Access

Required Prvs

Servicing Prvs

Results for PCP, Urgent Care and Emergency service Locations accessible via public transportation: Table 7 - MEDICARE Public Transportation Survey Practitioner Type Standard Results Goal Met? & County (Yes/No)

Met Prvs

Met Overall

168 Table 7 - MEDICARE Public Transportation Survey Practitioner Type Standard Results Goal Met? & County (Yes/No) Volusia County At least 70% of 80% of PCP Offices Yes PCP, Emergency PCP, and Department and Urgent Care Center 100% of Emergency, 100% of Emergency Yes Locations in and Departments relation to public transportation 90% of Urgent Care 100% of Urgent Yes Care Center Locations can be accessed by Public Transportation, where such transportation is available in the community Flagler County At least 70% of 100% of PCP PCP, Emergency Yes PCP, and Offices Department and Urgent Care Center 100% of Emergency, Locations in Yes and 100% of Emergency relation to public Departments transportation Flagler County does not offer general public transportation. However, public transportation specifically for access to medical services is available on a sliding scale basis.

90% of Urgent Care Locations can be accessed by Public Transportation, where such transportation is available in the community

100% of Urgent Care Center

Yes

169 Table 7 - MEDICARE Public Transportation Survey Practitioner Type Standard Results Goal Met? & County (Yes/No) Seminole County At least 70% of 85% of PCP Offices Yes PCP, Emergency PCP, and Department and Urgent Care Center 100% of Emergency, 100% of Emergency Yes Locations in and Departments relation to public transportation 90% of Urgent Care

Brevard County PCP, Emergency Department and Urgent Care Center Locations in relation to public transportation

Locations can be accessed by Public Transportation, where such transportation is available in the community At least 70% of PCP, and

95% of Urgent Care Yes Center

83% of PCP Offices

Yes

100% of Emergency, and

100% of Emergency Departments

Yes

90% of Urgent Care

90% of Urgent Care Yes Center

Locations can be accessed by Public Transportation, where such transportation is available in the community

170 Analysis Delete this box before finalizing the document

Instructions Write a narrative paragraph summarizing the quantitative analysis by: • Comparing results to the performance goal • Trending results over measurement periods • Summarizing the results of any drill down analysis performed A sample quantitative analysis appears below. Modify the sample to reflect your results. Geographic analysis at the plan level demonstrated that [all standards were met] for PCPs, high volume specialists, and high volume behavioral health practitioner types. Geographic analysis for the high impact specialty of medical and radiation oncology identified [gaps in the rural portions of the service area]. The ratio analysis also demonstrated that all adequate number standards were met except [psychiatry].

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Instructions

NET 3B requires identification and prioritization of opportunities to improve physical health availability and implementation of actions to improve performance. If your availability results indicate there are improvement opportunities, identify the root causes in the table below and prioritize which ones you will act on based on the potential positive impact for your members. Summarize the results of your barrier analysis to identify the root causes driving performance for any measure that did not meet the performance goal. Specify: • Participants in the barrier analysis. • Methods used to conduct the barrier analysis, i.e., brainstorming, process flow diagrams, fish bone diagrams, focus groups or interviews with members or practitioners, etc. • Opportunities identified as a result of barrier analysis. A sample barrier analysis summary appears below. Modify the sample to reflect your barriers and opportunities. Delete the sample text from the first two rows of the table and replace it with your organization’s information. [The lack of oncology services in rural areas is not a surprise to the health plan. One of the hospital systems in the service area is planning to initiate an outreach program to make oncology services available in the rural portion of the service area at least twice a month. The health plan also is exploring use of telemedicine services to increase availability of oncology services in the less populated portions of the service area.]

171

[The gap in child psychiatry is well known to the health plan, and is a national problem. There are inadequate numbers of child psychiatrists nationwide, FHCP contracts with all available child psychiatrists who are willing to accept managed care plans. In addition, our network contains numerous non-physician behavioral health practitioners to whom we refer members with less severe problems, reserving the scarcer child psychiatry resources for those members with the greatest need. If a member cannot obtain needed care in a timely manner, FHCP authorizes services to an out-of-network practitioner. In the last year, the health plan has only had to authorize services for an out-of-network child psychiatrist twice.] FHCP conducts analysis at the county level to identify potential opportunities to improve practitioner availability. County-level gaps are analyzed below. County Volusia

Flagler

Table 8 County Level Gap Analysis Practitioner Specialty Gap Analysis [Dermatologists] [Contract with all available dermatologists in county. Mostly rural county, available dermatologists in adjacent county at urban center. Members accustomed to going there to access care.] [Orthopedic Surgeons] [Rural county with only small hospital. Residents accustomed to traveling to Stone county to major medical center for major surgical procedures. No orthopedic surgeons practice in county].

Seminole Brevard

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Instructions Next, summarize the results of your barrier analysis to identify the root causes driving performance for any measure that did not meet the performance goal. Specify: • Participants in the barrier analysis. • Methods used to conduct the barrier analysis, i.e., brainstorming, process flow diagrams, fish bone diagrams, focus groups or interviews with members or practitioners, etc. • Opportunities identified as a result of barrier analysis. A sample barrier analysis summary appears below. Modify the sample to reflect your barriers and opportunities. Delete the sample text from the first two rows of the table and replace it with your organization’s information.

172 A group of internal staff completed the initial barrier analysis. Participants included two Provider Services Department staff responsible for practitioner availability monitoring, a QI Staff member, and two Community Liaisons. The group brainstormed the following potential barriers and opportunities for improvement: Table 9 Barrier Analysis Results Opportunity

Barrier [Lack of child psychiatrists willing to contract with managed care]



Consider raising fee schedule to make contracting more attractive • Continue to approach available child psychiatrists to ascertain willingness to contract [Child psychiatrist practice Streamline authorization process for already busy with non-managed high-volume network child care patients, can stay busy psychiatrists to make it easier to without dealing with managed treat managed care members care procedures]

Selected for Improvement? No Yes

Yes

Action Delete this box before finalizing the document

Instructions If your results did not meet the performance goal, NCQA expects organizations to initiate actions for improvement. Describe the actions implemented to reduce or remove the barriers to improvement. Use a table format similar to the one used in the QIA form, as illustrated below. • List the month and year the action was implemented in column 1. • Describe the action in column 2. Be specific, for example, recruited 3 new dermatologists in Grant county, rather than recruited new practitioners. • Copy the barrier the action addressed from column 1 in Table 9 to column 3 in Table 10.

Date Initiated

Table 10 Planned Actions Action Implemented

Barriers Addressed

173 Reporting Delete this table before finalizing the report

Instructions:

Use this next section to summarize reporting to QI committees. The intent of this section is to facilitate retrieval of information from QI committee minutes when needed, and reduce or eliminate the need to attach meeting minutes to the web-based Survey Tool. Sample text is included in row 1. Delete the sample text and insert information based on your organization’s committee reporting. This QI activity was reported to the following QI committees: Committee Name Contract Committee Customer Service Committee PI Council

Table 11 Committee Reporting Meeting Date Committee Actions or Recommendations Reviewed monitoring results, analysis, and proposed actions. Approved provider services contracting action plan.

174 Florida Health Care Plans

Practitioner Access Analysis

[From date] to [To date]

Introduction Consumers value timely access to medical care. Florida Health Care Plans (FHCP) monitors primary care appointment, primary care after-hours access, specialty care and behavioral health practitioner appointment accessibility annually against its standards, and initiates actions as needed to improve. This report describes access monitoring methodology, results, analysis, and action.

Section I: Primary Care Physician Appointment Access Standards and Methodology FHCP monitors primary care physician (PCP) appointment accessibility and after hours access to ensure members have access to primary care 24 hours a day, 7 days a week. Table 1 lists the primary care physician standards, measurement method, and measurement frequency for each aspect of performance that is monitored. Table 1: Standards and Measurement Methods by Access Measure Access Measure Standard and Measurement Measurement Performance Goal Method Frequency Primary care routine Results of members who CAHPS member Annually appointments report they always or satisfaction survey usually obtained urgent appointments as soon as they needed it (CAHPS question 6) meets 80% Quality Compass percentile Primary care urgent Results of members report CAHPS member Annually appointments they always or usually satisfaction survey obtained regular or routine care as soon as they needed it (CAHPS question 4) meets 80% Quality Compass percentile Primary care after 100% of PCP offices Calls to PCP offices Annually hours care surveyed have an afterafter hours (details hours access mechanism below) that meets health plan standards

175 Table 1: Standards and Measurement Methods by Access Measure Access Measure Standard and Measurement Measurement Performance Goal Method Frequency Access complaint Rate of member complaints Complaint analysis Annually analysis about physical health appointment access is less than 0.5 per 1000 members Member appeals Rate of member appeals Appeal analysis Annually related to access about physical health analysis access is less than 0.5 per 1000 members After Hours Access Measurement Methodology A universe of all Participating PCP group practice offices shall be used to identify a statistically valid sample of offices to identify those offices who have an After Hours access mechanism utilizing an answering service or recording. The sample size for the survey will include a statistically significant number of PCP practices based upon total PCP practices that participate in FHCP’s HMO networks for Medicare, Commercial, and Exchange members. Most PCP’s participate in all three networks, so where there is overlap that PCP group practice can count for each network’s results. FHCP staff will complete the Group Demographics cells, filling in the group name, telephone number (use the number published in the practitioner directory), practice location address and names of PCPs in the practice. One call covers all PCPs practicing at the practice location. Staff will complete the Survey Data Collection Information cells, filling in the date and time of data collection, the name of the staff person conducting the survey, and the survey type. Calls will be made AFTER normal business hours, OR on weekends or holidays only and not during the business day. The FHCP After-Hours Access Survey Protocol is organized into 3 sections based on the type of after hours access the office location has: answering service, answering machine, or no response. Also, the answering service and answering machine sections have two sub-categories: urgent requirement, and emergency requirement. Results from each surveyed Practice calculated to determine the office’s score in relation to the following criteria. a. Answering service response standard for urgent situations: The answering service will either offer to page the doctor on call, so that the doctor can call Member back; or offer to telephonically transfer Member’s call directly to the doctor on call. b. Answering service response standard for emergency situations: The answering service will direct the Member to contact 911 or go to nearest ER if he/she feels it is too emergent to wait for doctor to call them. c. Recorded response standard for urgent or emergency care: The PCP office telephone recording shall provide instructions on how to page the doctor if a situation is

176 urgent; or instructs the Member to call 911 for emergencies or go to the nearest ER or urgent care center if the situation cannot wait until the next business day.

Results Table 2: Measurement Results and Comparison to Performance Goal by Appointment Type and Product Line Access Measure Standard Results Goal Met? (Yes/No) th Primary care Results of members Medicare –___%, 50 routine percentile report they always or appointments usually obtained regular Commercial/Marketplace or routine care as soon – ___%, 50th percentile as they needed it meets ____% of the 50th Quality Compass percentile Primary care Results of members Medicare –___%, 50th urgent report they always or percentile appointments usually obtained urgent Commercial/Marketplace appointments as soon as – ___%, 50th percentile they needed it meets ____% of the 50th Quality Compass percentile Primary care after 100% of PCP offices ____% of Medicare hours care surveyed have an after Network PCP offices hours access mechanism surveyed that meets health plan ____% of standards Commercial/Marketplace Network PCP offices surveyed

Access complaint analysis

Rate of member complaints about physical health appointment access is less than 0.5 per 1000 members

have an after-hours access mechanism that meets Florida Health Care Plans standards Medicare member complaints = _____ per 1000 members Commercial Member complaints = _____ per 1000 members Marketplace member complaints = _____ per 1000 members

177 Table 2: Measurement Results and Comparison to Performance Goal by Appointment Type and Product Line Access Measure Standard Results Goal Met? (Yes/No) Member appeals Rate of member appeals Medicare member related to access about physical health appeals = _____ per 1000 analysis access is less than 0.5 members Commercial Member per 1000 members appeals = _____ per 1000 members Marketplace member s = _____ per 1000 members

Analysis Delete this box before finalizing the document

Instructions Write a narrative summary of the quantitative analysis which includes: • Comparing results to the performance goal • Trending results over measurement periods • Summarizing the results of any drill down analysis performed A sample quantitative analysis appears below. Modify the sample to reflect your results. [CAHPS survey results showed that routine appointment access did not meet the performance goal for commercial and Medicaid product lines, but did for the Marketplace product line. No product line met the performance goal of the 75th percentile for urgent appointments and both Medicaid and Commercial were at the 25th percentile. The volume of member complaints about access is very low and well within our performance goal threshold, and there were no member appeals related to access for any accredited product line. However, the CAHPS results demonstrate commercial and Medicaid members are not able to consistently obtain a routine appointment within a timeframe that meets their expectations and urgent appointment access did not meet expectations of the members in any product line. Barrier analysis on this topic is discussed later in this report.] [____% of PCP offices did not have an acceptable method of providing after hours access for members. The table below details the areas in which PCP offices did not meet health plan standards.] Criteria

Table 3 After Hours Access Detailed Results # & % Compliant Comments

178

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Instructions NET 3B requires identification and prioritization of opportunities to improve physical health access and implementation of actions to improve performance. If your PCP appointment and/or after hours access results indicate there are improvement opportunities, identify the root causes in the table below and prioritize which ones you will act on based on the potential positive impact for your members. Summarize the results of your barrier analysis to identify the root causes driving performance for any measure that did not meet the performance goal. Specify: • Participants in the barrier analysis. • Methods used to conduct the barrier analysis, i.e., brainstorming, process flow diagrams, fish bone diagrams, focus groups or interviews with members or practitioners, etc. • Opportunities identified as a result of barrier analysis. A sample barrier analysis summary appears below. Modify the sample to reflect your barriers and opportunities. Delete the sample text from the first two rows of the table and replace it with your organization’s information. A group of internal staff completed the initial barrier analysis. Participants included a QI analyst, and two provider relations representatives. The group brainstormed the following potential barriers and opportunities for improvement: Barrier

Table 4 Barrier Analysis Results Opportunity

Members expect to be able to obtain a routine appointment in less time that the doctor’s office offers one Some PCP offices are not aware their after hours access mechanism is not functioning

Establish incentive program for physician offices to move to open access scheduling Inform the office of the failure and request a corrective action plan

Selected for Improvement? Yes

Yes

179 Action Delete this box before finalizing the document

Instructions If your results did not meet the performance goal, NCQA expects organizations to initiate actions for improvement. Describe the actions implemented to reduce or remove the barriers to improvement. • List the month and year the action was implemented in column 1. • Describe the action in column 2. Be specific, for example, Communicated new incentive program design and requirements to all PCP offices via letter. • Copy the barrier the action addressed from column 1 in Table 4 to column 3 in Table 5. Table 5 Planned Actions Action Implemented

Date Initiated

Barriers Addressed

Reporting Delete this table before finalizing the report

Instructions: Use this next section to summarize reporting to QI committees. The intent of this section is to facilitate retrieval of information from QI committee minutes when needed, and reduce or eliminate the need to attach meeting minutes to the web-based Survey Tool. Sample text is included in row 1. Delete the sample text and insert information based on your organization’s committee reporting. Delete any rows not needed. This QI activity was reported to the following QI committees: Committee Name Customer Service Committee Quality Improvement Committee

Table 6 Committee Reporting Meeting Date Committee Actions or Recommendations Reviewed monitoring results, analysis, and proposed actions. Suggested action plan. Reviewed monitoring results, analysis, and proposed actions. Approved action plan.

180

Section II: Behavioral Health Appointment Access Florida Health Care Plans monitors behavioral health appointment access to determine whether members can receive timely appointments based on severity of illness. Table 7: Behavioral Health Standards and Measurement Methods by Appointment and Practitioner Type Access Measure Standard and Measurement Measurement Performance Goal Method Frequency Prescriber 95% will provide access to Appointment Annually behavioral health care for a non-lifeaccess survey non-life threatening threatening emergency emergency within 1 business day appointments Prescriber 85% of offices report a first Appointment Annually behavioral health available urgent access survey urgent appointment is open for a appointments patient within 48 hours of patient request Prescriber 80% of offices report a third Appointment Annually behavioral health available routine access survey new patient routine appointment is open for a appointments new patient within 10 business days of patient request Prescriber 80% of offices report a third Appointment Annually behavioral health available routine access survey established patient appointment is open for a routine follow-up established patient within appointments 14 days. Non-prescriber behavioral health non-life threatening emergency appointments Non-prescriber behavioral health urgent appointments

95% will provide access to care for a non-lifethreatening emergency within 1 business day

Appointment access survey

Annually

85% of offices report a first available urgent appointment is open for a patient within 48 hours of patient request

Appointment access survey

Annually

181 Table 7: Behavioral Health Standards and Measurement Methods by Appointment and Practitioner Type Access Measure Standard and Measurement Measurement Performance Goal Method Frequency Non-prescriber 80% of offices report a third Appointment Annually behavioral health available routine access survey new patient routine appointment is open for a appointments new patient within 10 business days of patient request Non-prescriber 80% of offices report a third Appointment Annually behavioral health available routine access survey established patient appointment is open for an routine follow-up established patient within appointments 14 days Complaints about behavioral health access Appeals about behavioral health access

Rate of member complaints about behavioral health appointment access is less than 0.5 per 1000 members Rate of member appeals about behavioral health access is less than 0.5 per 1000 members

Complaint analysis

Annually

Appeal analysis

Annually

Florida Health Care Plans measures behavioral health and medical specialty appointment access through a survey of practitioner offices. FHCP’s Provider Services Department surveys all applicable network (Medicare, Commercial & Marketplace) practitioner office locations surveys for self-reporting. Response to the survey is monitored, with repeat surveys sent to those practices that do not respond to the initial survey. Follow up to obtain completed surveys from non-responsive practices continues over a 6 week period with a response rate goal of sixty percent (60%). The survey questions are asked once for each office, and data is recorded for the open appointments, regardless of the practitioner who has open appointments. For routine appointments, data is gathered on first, second and third available appointments. Our routine appointment standard is based on the date of the third available appointment because it is the most sensitive method for detecting offices which have access issues since first and second available appointments often represent cancellations and while those open appointment slots frequently are available in a timely fashion, they often do not work for members. Urgent appointment data is gathered for the first available urgent appointment slot in the office.

182 Table 8 displays the survey response rate data. Table 8: Response Rate Data

Practitioner Type

# Office locations w/Practitioner type

#&% Office locations responding to survey

# Practitioners represented by offices responding to survey

# Practitioners of this type in the Network

% of Practitioner type results represent out of total contracted practitioners of that type

BH Prescribers BH NonPrescribers

Results Table 9: Behavioral Health Standards and Measurement Results by Appointment and Practitioner Type Access Measure Standard and Results Goal Met? Performance Goal (Yes/No) Prescriber 95% will provide access to ____% of offices behavioral health care for a non-lifereport a first available non-life threatening threatening emergency non-life-threatening emergency within 1 business day emergency appointments appointment within 1 business day Prescriber 85% of offices report a first ____% of offices behavioral health available urgent report a first available urgent appointment is open for a urgent appointment appointments patient within 48 hours of is open for a patient patient request within 48 hours of patient request Prescriber 80% of offices report a third ___% of offices report behavioral health available routine a third available new patient routine appointment is open for a routine appointment appointments new patient within 10 is open for a new business days of patient patient within 10 request business days of patient request

183 Table 9: Behavioral Health Standards and Measurement Results by Appointment and Practitioner Type Access Measure Standard and Results Goal Met? Performance Goal (Yes/No) Prescriber 80% of offices report a third ___% of offices report behavioral health available routine a third available established patient appointment is open for a routine appointment routine follow-up established patient within is open for a appointments 14 days of patient request established patient within 14 days of patient request Non-prescriber behavioral health non-life threatening emergency appointments Non-prescriber behavioral health urgent appointments Non-prescriber behavioral health new patient routine appointments

Non-prescriber behavioral health established patient routine follow-up appointments

Complaints about behavioral health access

95% will provide access to care for a non-lifethreatening emergency within 1 business day

____% of offices report a first available non-life-threatening emergency appointment within 1 business day 85% of offices report a first ___% of offices report available urgent a first available appointment is open for a urgent appointment patient within 48 hours of is open for a patient patient request within 48 hours of patient request 80% of offices report a third ___% of offices report available routine a third available appointment is open for a routine appointment new patient within 10 is open for a new business days of patient patient within 10 request business days of patient request 80% of offices report a third ___% of offices report available routine a third available appointment is open for an routine appointment established patient within is open for an 14 days of patient request established patient within 14 days of patient request Rate of member complaints about behavioral health appointment access is less than 0.5 per 1000 members

Member appeals Rate of member appeals related to behavioral about behavioral health

Rate of member complaints about behavioral health appointment access is less than ___ per 1000 members Rate of member appeals about

184 Table 9: Behavioral Health Standards and Measurement Results by Appointment and Practitioner Type Access Measure Standard and Results Goal Met? Performance Goal (Yes/No) health access access is less than 0.5 per behavioral health 1000 members access is less than ___ per 1000 members

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Instructions Write a narrative summary of the quantitative analysis which includes: • Comparing results to the performance goal • When multiple years of data is available, include it in the results table and trend results over measurement periods • Summarizing the results of any drill down analysis performed A sample quantitative analysis appears below. Modify the sample to reflect your results. [X% of BH prescriber offices met the standard for established patient routine appointment and established patient urgent appointment. The rate of BH prescriber offices with a third available new patient routine appointment fell below the goal by 30 percentage points. These findings are not surprising given that there are fewer BH prescribers available in the network and nation-wide shortage of psychiatrists. X% of BH non-prescriber offices met the standard for new patient and established patient follow-up routine appointment. The urgent appointment standard was not met in less than 10% of offices. There were only a few member complaints about behavioral health appointment access and no member appeals about behavioral health access. However, the appointment access survey results can help pinpoint which office locations do not meet the standards. That analysis is below. Table 10 below breaks out the number and percent of offices which met the standard for first, second and third available routine appointments for new and established patients. This data clearly demonstrates that it is much more challenging for a new patient to obtain a routine appointment within the standard than an established patient. ] Table 10: Analysis of Routine Appointment Access by First, Second and Third Available Appointment Date

185 Practitioner type

Offices with first

Offices with second

Offices with third

appt that met std

appt that met std

appt that met std

available routine

available routine

available routine

BH prescriber urgent appointment BH prescriber new patients routine BH prescriber established patient follow up appointment BH non-prescriber urgent BH non-prescriber new patient routine BH non-prescriber established patient follow-up appointment

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Instructions Now, discuss further which offices do not meet the appointment access standards. A sample analysis is below. Modify it based on your data. [The behavioral health appointment access data identified offices that could not provide a routine appointment for a new or established patient within the performance goal at the time the measurement was completed. As expected, behavioral health prescribers are far more likely to have appointment access issues than non-prescribers. Based on total number of survey respondents, XX prescriber offices did not have a first, second or third available new patient appointment within the performance goal. Data is more favorable for established patients, with XX offices not meeting goal. The list of prescriber offices not meeting goal is outlined below. [Discuss whether there is a pattern by geographic portions of the service area that do not meet goal, or if they are scattered across the service area. Comment on other key findings based on the data which can help you identify specific opportunities to improve behavioral health access.] Prescriber offices not meeting goal for routine new patient or established patients: • [List prescriber offices and locations here, placing each on a separate line with a new bullet point, or if the list is extensive, then place it in an appendix to the report] There are far more behavioral health non-prescribers than prescribers, so an office which cannot offer a first, second or third available routine appointment to a new patient within the performance goal numbered only XX and for established patients, the number

186 was XX. The list of non-prescriber offices not meeting goal is outlined below. [Discuss whether there is a pattern by geographic portions of the service area that do not meet goal, or if they are scattered across the service area. Comment on other key findings based on the data which can help you identify specific opportunities to improve behavioral health access.] Non-prescriber offices not meeting goal for routine new patient or established patients: • [List prescriber offices and locations here, placing each on a separate line with a new bullet point, or if the list is extensive, then place it in an appendix to the report]

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Instructions NET 3C requires identification and prioritization of opportunities to improve behavioral health access and implementation of actions to improve performance. If your behavioral health appointment access results indicate there are improvement opportunities, identify the root causes in the table below and prioritize which ones you will act on based on the potential positive impact for your members. Summarize the results of your barrier analysis to identify the root causes driving performance for any measure that did not meet the performance goal. Specify: • Participants in the barrier analysis. • Methods used to conduct the barrier analysis, i.e., brainstorming, process flow diagrams, fish bone diagrams, focus groups or interviews with members or practitioners, etc. • Opportunities identified as a result of barrier analysis. A sample barrier analysis summary appears below. Modify the sample to reflect your barriers and opportunities. Delete the sample text from the first row of the table and replace it with your organization’s information. A group of internal staff completed the initial barrier analysis. Participants included the behavioral health clinical director, a QI analyst, and two provider relations representatives. The group brainstormed the following potential barriers and opportunities for improvement: Barrier

Table 11 Barrier Analysis Results Opportunity

Limited number of behavioral health prescribers in the service area and network and their schedules tend to be full

Determine if there are any psychiatric nurse practitioners available for contracting

Selected for Improvement? Yes

187

Barrier

Table 11 Barrier Analysis Results Opportunity

Selected for Improvement?

Action Delete this box before finalizing the document

Instructions If your results did not meet the performance goal, NCQA expects organizations to initiate actions for improvement. Describe the actions implemented to reduce or remove the barriers to improvement by completing the table below. • List the month and year the action was implemented in column 1. • Describe the action in column 2. Be specific, for example, Do a web search for psychiatric nurse practitioners in the service area and if not in network, approach for contracting. • Copy the barrier the action addressed from column 1 in Table 11 to column 3 in Table 12. Table 12 Planned Actions Action Implemented

Date Initiated

Barriers Addressed

Reporting Delete this table before finalizing the report

Instructions: Use this next section to summarize reporting to QI committees. The intent of this section is to facilitate retrieval of information from QI committee minutes when needed, and reduce or eliminate the need to attach meeting minutes to the web-based Survey Tool. Sample text is included in row 1. Delete the sample text and insert information based on your organization’s committee reporting. Delete any rows not needed. This QI activity was reported to the following QI committees: Committee Name

Table 13 Committee Reporting Meeting Date Committee Actions or Recommendations

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Committee Name Customer Service Committee Quality Improvement Committee

Table 13 Committee Reporting Meeting Date Committee Actions or Recommendations Reviewed monitoring results, analysis, and proposed actions. Recommended action plan activities. Reviewed monitoring results, analysis, and proposed actions. Approved action plan.

189 Section III: Specialty Care Physician Appointment Access Standards and Methodology Florida Health Care Plans monitors OB/GYN, medical oncology and radiation oncology appointment accessibility to ensure members have access to high volume and high impact specialty medical care in a timely fashion. Table 14 lists the specialty care physician appointment access standards, measurement method, and measurement frequency for each aspect of performance that is monitored. Table 14: Standards and Measurement Methods by Access Measure Access Measure Standard and Measurement Measurement Performance Goal Method Frequency OB/GYN new 70% of offices report a third Office appointment Annually patient routine available routine access survey appointments appointment is open for a new patient within 14 days of patient request OB/GYN 80% of offices report a third Office appointment Annually established patient available routine access survey routine appointment is open for an appointment established patient within 14 days of patient request OB/GYN new 85% of offices report the Office appointment Annually patient urgent first available urgent access survey appointment appointment is open for a new patient within 48 hours of patient request OB/GYN 85% of offices report the Office appointment Annually established patient first available urgent access survey urgent appointment appointment is open for an established patient within 48 hours of patient request Medical Oncology new patient routine appointments Medical Oncology established patient routine appointment

70% of offices report a third available routine appointment is open for a new patient within 14 days of patient request 80% of offices report a third available routine appointment is open for an established patient within 14 days of patient request

Office appointment access survey

Annually

Office appointment access survey

Annually

190 Table 14: Standards and Measurement Methods by Access Measure Access Measure Standard and Measurement Measurement Performance Goal Method Frequency Medical Oncology 85% of offices report the Office appointment Annually new patient urgent first available urgent access survey appointment appointment is open for a new patient within 48 hours of patient request Medical Oncology 85% of offices report the Office appointment Annually established patient first available urgent access survey urgent appointment appointment is open for an established patient within 48 hours of patient request Radiation Oncology new patient routine appointments Radiation Oncology established patient routine appointment Radiation Oncology new patient urgent appointment Radiation Oncology established patient urgent appointment

Complaints

Appeals

70% of offices report a third available routine appointment is open for a new patient within 14 days of patient request 80% of offices report a third available routine appointment is open for an established patient within 14 days of patient request 85% of offices report the first available urgent appointment is open for a new patient within 48 hours of patient request 85% of offices report the first available urgent appointment is open for an established patient within 48 hours of patient request

Office appointment access survey

Annually

Office appointment access survey

Annually

Office appointment access survey

Annually

Office appointment access survey

Annually

Rate of member complaints about appointment access is less than 0.5 per 1000 members Rate of member appeals about physical health access is less than 0.5 per 1000 members

Complaint analysis

Annually

Appeal analysis

Annually

191 Table 14: Standards and Measurement Methods by Access Measure Access Measure Standard and Measurement Measurement Performance Goal Method Frequency CAHPS survey Annually Specialty care Results of members who appointment access report they always or usually obtained a specialist appointment as soon as they needed it (CAHPS question 25) meets 75th Quality Compass percentile Florida Health Care Plans measures high volume and high impact medical specialty appointment access through a survey of practitioner offices. FHCP’s Provider Services Department surveys all applicable network (Medicare, Commercial & Marketplace) practitioner office locations surveys for self-reporting. Response to the survey is monitored, with repeat surveys sent to those practices that do not respond to the initial survey. Follow up to obtain completed surveys from non-responsive practices continues over a 6 week period with a response rate goal of sixty percent (60%). The survey questions are asked once for each office, and data is recorded for the open appointments, regardless of the practitioner who has open appointments. For routine appointments, data is gathered on first, second and third available appointments. Our routine appointment standard is based on the date of the third available appointment because it is the most sensitive method for detecting offices which have access issues since first and second available appointments often represent cancellations and while those open appointment slots frequently are available in a timely fashion, they often do not work for members. Urgent appointment data is gathered for the first available urgent appointment slot in the office. Table 15: Response Rate Data

Practitioner Type

OB/GYN Medical Oncology Radiation Oncology

# Office locations w/Practitioner type

#&% Office locations responding to survey

# Practitioners represented by offices responding to survey

# Practitioners of this type in the Network

% of Practitioner type results represent out of total contracted practitioners of that type

192 Results Table 16: Measurement Results and Comparison to Performance Goal by Access Measure Access Measure Standard Results Goal Met? (Yes/No) OB/GYN new 70% of offices report a ___% of offices report a patient routine third available routine third available routine appointments appointment is open for a appointment is open new patient within 14 for a new patient days of patient request within 14 days of patient request OB/GYN 80% of offices report a ___% of offices report a established patient third available routine third available routine routine appointment is open for appointment is open appointment an established patient for an established within 14 days of patient patient within 14 days request of patient request OB/GYN new 85% of offices report the ___% of offices report patient urgent first available urgent the first available appointment appointment is open for a urgent appointment is new patient within 48 open for a new patient hours of patient request within 48 hours of patient request OB/GYN 85% of offices report the ___% of offices report established patient first available urgent the first available urgent appointment appointment is open for urgent appointment is an established patient open for an within 48 hours of patient established patient request within 48 hours of patient request Medical Oncology new patient routine appointments

70% of offices report a third available routine appointment is open for a new patient within 14 days of patient request

Medical Oncology established patient routine appointment

80% of offices report a third available routine appointment is open for an established patient within 14 days of patient request

___% of offices report a third available routine appointment is open for a new patient within 14 days of patient request ___% of offices report a third available routine appointment is open for an established patient within 14 days of patient request

193 Table 16: Measurement Results and Comparison to Performance Goal by Access Measure Access Measure Standard Results Goal Met? (Yes/No) Medical Oncology 85% of offices report the ___% of offices report new patient urgent first available urgent the first available appointment appointment is open for a urgent appointment is new patient within 48 open for a new patient hours of patient request within 48 hours of patient request Medical Oncology 85% of offices report the ___% of offices report established patient first available urgent the first available urgent appointment appointment is open for urgent appointment is an established patient open for an within 48 hours of patient established patient request within 48 hours of patient request Radiation Oncology new patient routine appointments

70% of offices report a third available routine appointment is open for a new patient within 14 days of patient request

Radiation Oncology established patient routine appointment

80% of offices report a third available routine appointment is open for an established patient within 14 days of patient request 85% of offices report the first available urgent appointment is open for a new patient within 48 hours of patient request

Radiation Oncology new patient urgent appointment

Radiation Oncology established patient urgent appointment

85% of offices report the first available urgent appointment is open for an established patient within 48 hours of patient request

___% of offices report a third available routine appointment is open for a new patient within 14 days of patient request ___% of offices report a third available routine appointment is open for an established patient within 14 days of patient request ___% of offices report the first available urgent appointment is open for a new patient within 48 hours of patient request ___% of offices report the first available urgent appointment is open for an established patient within 48 hours of patient request

194 Table 16: Measurement Results and Comparison to Performance Goal by Access Measure Access Measure Standard Results Goal Met? (Yes/No) Complaints Rate of member Rate of member complaints about complaints about appointment access is less appointment access is than 0.5 per 1000 less than ___ per 1000 members members Appeals Rate of member appeals Rate of member about physical health appeals about physical access is less than 0.5 per health access is less 1000 members than ___ per 1000 members Specialty Care Results of members who Results of members Appointment report they always or who report they Access usually obtained a always or usually specialist appointment as obtained a specialist soon as they needed it appointment as soon (CAHPS question 25) as they needed it th meets 75 Quality (CAHPS question 25) Compass percentile (meets/does not meet) 75th Quality Compass percentile

Analysis Delete this box before finalizing the document

Instructions Write a narrative summary of the quantitative analysis which includes: • Comparing results to the performance goal • When multiple years of data is available, include it in the results table and trend results over measurement periods • Summarizing the results of any drill down analysis performed A sample quantitative analysis appears below. Modify the sample to reflect your results and analysis. X% of OB/GYN offices met the standard for new and established patient routine appointment and established patient urgent appointment. The rate of OB/GYN offices with a new patient urgent appointment within X days of patient request fell below the goal by 15 percentage points.

195 X% of oncology offices met the standard for established patient routine appointment and established patient urgent appointment. The routine and urgent standards were not met for new patients. The volume of member complaints about specialty care access is very low and there were no member appeals related to specialty access during this measurement period. However, the CAHPS data on ability to obtain a specialist appointment when needed fell below the 75th percentile performance goal for commercial and Medicaid product lines. The Marketplace product line was just above the 75th percentile commercial product line rate and met goal. The CAHPS survey data indicate there is an opportunity to improve access to specialty care. Table 17 below breaks out the number and percent of offices which met the standard for first, second and third available routine appointments for new and established patients. This data clearly demonstrates that it is much more challenging for a new patient to obtain a routine appointment within the standard than an established patient. Table 17 Analysis of Routine Appointment Access by First, Second and Third Available Appointment Date Practitioner Offices with Offices with Offices type first available second available with third routine appt routine appt available routine that met std that met std appt that met std OB/GYN new patients OB/GYN established patients Medical Oncology new patients Medical Oncology established patients Radiation Oncology new patients Radiation Oncology established patients

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Delete this box before finalizing the document

Instructions NET 3B requires identification and prioritization of opportunities to improve physical health access and implementation of actions to improve performance. If your specialty care appointment access results or CAHPS data indicate there are improvement opportunities, identify the root causes in the table below and prioritize which ones you will act on based on the potential positive impact for your members. Summarize the results of your barrier analysis to identify the root causes driving performance for any measure that did not meet the performance goal. Specify: • Participants in the barrier analysis. • Methods used to conduct the barrier analysis, i.e., brainstorming, process flow diagrams, fish bone diagrams, focus groups or interviews with members or practitioners, etc. • Opportunities identified as a result of barrier analysis. A sample barrier analysis summary appears below. Modify the sample to reflect your barriers and opportunities. Delete the sample text from the first two rows of the table and replace it with your organization’s information. A group of internal staff completed the initial barrier analysis. Participants included a QI analyst, and two provider relations representatives. The group brainstormed the following potential barriers and opportunities for improvement: Barrier

Table 18 Barrier Analysis Results Opportunity

Physician offices schedule patients based on their perception of urgency of situation, and patient perception of urgency of situation may vary from that of physician office Limited number of oncologists available in service area to contract with, particularly in rural portion of service area, resulting in long appointment wait times

Encourage members to contact health plan and/or their primary care physician when they cannot obtain a timely appointment

Selected for Improvement? Yes

Explore alternative methods to increase access to oncology, including telemedicine

Yes

Confirm no additional oncologists in service area who could be added to network

Yes

197 Action Delete this box before finalizing the document

Instructions If your results did not meet the performance goal, NCQA requires organizations to initiate actions for improvement in NET 3B. Describe the actions implemented to reduce or remove the barriers to improvement. • List the month and year the action was implemented in column 1. • Describe the action in column 2. Be specific, for example, Communicated new incentive program design and requirements to all physician offices via letter. • Copy the barrier the action addressed from column 1 in Table 4 to column 3 in Table 19. Table 19 Planned Actions Action Implemented

Date Initiated

Barriers Addressed

Reporting Delete this table before finalizing the report

Instructions: Use this next section to summarize reporting to QI committees. The intent of this section is to facilitate retrieval of information from QI committee minutes when needed, and reduce or eliminate the need to attach meeting minutes to the web-based Survey Tool. Sample text is included in row 1. Delete the sample text and insert information based on your organization’s committee reporting. Delete extra rows from the table. This QI activity was reported to the following QI committees: Committee Name Customer Service Committee Quality Improvement Committee

Table 20 Committee Reporting Meeting Date Committee Actions or Recommendations Reviewed monitoring results, analysis, and proposed actions. Recommend action plan. Reviewed monitoring results, analysis, and proposed actions. Approved action plan.

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Urgent Appointment Access Appointment type: Initial visit A new patient calls and is requesting an appointment for an urgent clinical issue. Appointment type: Follow-up visit An established patient calls and is requesting an appointment for an urgent clinical issue.

What is first available appointment date and time for this situation?

Date:

Time:

What is first available appointment date and time for this situation?

Date:

Time:

Thank you for completing this questionnaire. Please return it to Florida Health Care Plans Provider Services Department P.O. Box 9910 Daytona Beach, FL 32120 or via email [email protected] All completed questionnaires are placed into a drawing for a . We will notify the winner by phone or email. Look for an update on the results of this survey and the winner in the next provider newsletter.

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REQUEST FOR PCP CHANGE MEMBER NAME:

DOB:

HOME PHONE#:

MRN:

WORK PHONE#:

CURRENT PRIMARY CARE PROVIDER’S NAME: DESIRED PRIMARY CARE PROVIDER’S NAME:

1ST CHOICE: 2ND CHOICE:

PLEASE CHECK APPROPRIATE CHANGE REASON CODE BELOW: AA B C C1 C2 D E F G H I J K L M N

Initial Assignment Communication Issue (Unable to Understand) Communication Issue (Explanation of Medical Problem) Physician/Staff Failed to Call Pt after Patient Request Physician/Staff Failed to Call Pt with Test Results Lack of Confidence Inappropriate/Inadequate Care (Member’s Perception) Physician Attitude Physician Staff Attitude Waiting Time for Appointment Appointment Canceled/Rescheduled Excessively Want Same PCP as Other Family Member Prefer Main Health Care Facility PCP Too Far – Distance Problem Physician Terminated Contract with FHCP Other:

O P Q R S S1 T U V W X Y Z1 Z2

Prior FHCP Physician, now Recontracting with FHCP Physician Requested Change Change due to client’s age Client Deleted Member wants Female PCP Member wants Male PCP Member could/would not Give a Reason for Change Change from Default PCP after being active 60 days Updated Provider in Error New Member Reassigned PCP Requested Assignment to Panel Dental Change Only Returning Member to PCP & FHCP New Member who has PCP from prior insurance

COMMENTS:

HAVE YOU DISCUSSED THE ISSUE CHECKED ABOVE WITH MEMBER SERVICES:

REQUESTOR SIGNATURE

YES

NO

DATE

-------------------------------------------------------------------------------------------------------------------------------------------------------FOR OFFICE USE ONLY CHANGED TO PRIMARY CARE PHYSICIAN: CHANGE MADE BY: DATE CONFIRMATION OF CHANGE SENT TO MEMBER: 15-912/12-03

DATE:

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P.O. Box 9910, Daytona Beach, FL 32120, Phone: (386)676-7100, Toll Free: (800)352-9824 www.fhcp.com

Dear Healthcare Provider: The health care environment has become increasingly complex with hundreds of new and existing Federal and State regulations currently in effect and new technologies changing the way we conduct our business. In addition, numerous threats to our resources have been identified. To position ourselves to confront these issues effectively, FHCP has developed a program titled “Our Values in Action” that outlines these issues and sets forth a framework within which they can be addressed. Initially, FHCP created a program for its staff that included a Compliance Plan, Code of Conduct, and Anti-Fraud Plan. Every new and existing FHCP employee receives a copy of the handbook and training that outlines this program. It is a condition of employment at FHCP that all staff conducts themselves in a manner consistent with this program. Subsequently, FHCP seeks to encourage our contracted providers to develop and implement similar programs. Contained in this guide is information intended to assist all FHCP contracted healthcare providers with developing effective compliance programs that will reduce the likelihood of behavior inconsistent with the realities of today’s healthcare landscape. Compliance Plan guidance is outlined on the pages that follow. More recently, and in accordance with the Centers for Medicare & Medicaid Services (CMS), Medicare Advantage-Part D Plans must ensure that all of their contracted providers and their staff are appropriately trained regarding the prevention and detection of fraud, waste & abuse (FWA). To assist your organization in meeting this requirement, FHCP has created a Fraud, Waste, & Abuse and General Compliance training slideshow with an attestation of completion that can be found on our website at www.fhcp.com. You can also access the document directly by copying the following link into your browser: http://www.fhcp.com/providers/forms/forms/Fraud%20Waste%20Abuse%20Training.pdf Please note that contracted providers and related entities that have met the fraud, waste, and abuse certification requirement through enrollment into the Medicare program are deemed to have met the training and education requirements for fraud, waste, and abuse. FHCP requires that all of its providers conduct themselves and their practices in an ethical and lawful manner. We strongly encourage all of our contracted providers to develop programs appropriate for their settings that reduce the likelihood of inappropriate conduct. Please return completed attestations to: FHCP Government Relations and Compliance Unit. Sincerely,

Wendy Myers, M.D. President/Chief Executive Officer

216 Compliance Plan Guidance The U. S. Department of Health and Human Services’ Office of the Inspector General has developed Compliance Plan guidance for a number of different health care provider types. These guidelines can be accessed via the Internet at: http://oig.hhs.gov/compliance/compliance-guidance/index.asp In general each compliance plan should contain the following seven elements: Policies and Standards An organization must have established standards and procedures to be followed by its employees and other agents that are reasonably capable of reducing the prospect of inappropriate conduct. Oversight Responsibility Specific individual(s) within high-level personnel of the organization must have been assigned overall responsibility to oversee compliance with such standards and procedures. Training, Education & Communications The organization must have taken steps to effectively communicate its standards and procedures to all employees and other agents, i.e., by requiring participation in training plans or by disseminating publications that explain in a practical manner what is required. Effective Lines of Communication The organization must maintain an effective line of communication between employees and the individual responsible for overseeing compliance with applicable standards and policies. Enforcement & Discipline The organization must have in place standards that ensure the plan is consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense. Adequate discipline of individuals responsible for an offense is a necessary component of enforcement; however, the form of discipline that will be appropriate will be case specific. Auditing, Monitoring, and Reporting The organization must take reasonable steps to achieve compliance with its standards. Such steps should take the form of monitoring and auditing systems reasonably designed to detect inappropriate conduct by its employees and other agents, and by having in place and publicizing a reporting system whereby employees and other agents could report inappropriate conduct by others within the organization without fear of retribution. Response and Corrective Action The organization must have in place a mechanism by which the organization will respond to detected offenses and prevent further similar offenses - including any necessary modifications to its plan to prevent and detect violations of law.

217 Fraud, Waste, and Abuse (FWA) Training Guidance: FWA training programs should include: •

Laws and regulations related to MA and Part D fraud, waste and abuse (i.e., False Claims Act, Anti-Kickback statute, HIPAA, etc.).



Obligations of the first tier, downstream, and related entities (FDR’s) to have appropriate policies and procedures to address fraud, waste and abuse.



Process for reporting to the MAO or PDP sponsor suspected fraud, waste and abuse in first tier, downstream, and related entities.



Protections for employees of first tier, downstream, and related entities who report suspected fraud, waste and abuse.



Types of fraud, waste and abuse that can occur in first tier, downstream, and related entities.



Compliance program guidance, required elements, and descriptions.

Please access the General Compliance and Fraud, Waste, and Abuse (FWA) documents for contracted providers and staff for education and training on our website at www.fhcp.com. You can also access the document directly by pasting the following link into your browser: http://www.fhcp.com/providers/forms/forms/Fraud%20Waste%20Abuse%20Training.pdf

How to Report Violations: In the event that you identify or become aware of an activity that is not in accordance with applicable standards, whether committed by your organization or another, you are encouraged to report the act to: Government Relations and Compliance Unit Florida Health Care Plans 1340 Ridgewood Avenue Holly Hill, FL 32117 (386) 615-4080

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SECTION 5 MEMBER’S RIGHTS AND RESPONSIBILITIES Member’s Rights and Responsibilities Policy Member’s Financial Responsibility Estimates Policy Medicare PART C Complaints/Grievances Policy Medicare PART C Organizational Determination & Appeals Policy Initial Determination and Reconsideration of Coverage of NonMedicare Beneficiary Claims New Member Transition Process Advance Directives Advanced Directives Policy Health Care Advance Directives Living Will Designation of Health Care Surrogate

219 Uniform Donor Form State of Florida Do Not Resuscitate Order

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Florida Health Care Plans Member’s Rights

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You Have the Right: • To a reasonable response to your requests and need for treatment or service within FHCP’s capacity, and applicable laws and regulations. • To be informed about, consent to, or refuse recommended treatment. • To present grievances without compromise to future health care, if you feel these rights have not been provided. • To file an appeal. Contact FHCP’s Member Services Department at 1-877-615-4022 for information about the appeals process. • To be considered as an individual with personal values and belief systems, and to be treated with compassion, dignity, respect, reasonable protection from harm, and appropriate privacy. • To receive quality health care regardless of race, ethnicity, national origin, religion, sex, age, mental or physical disability, medical condition (including conditions arising out of acts of domestic violence), sexual orientation, sexual identity, claims experience, medical history, evidence of insurability, genetic information, or source of payment. • To be informed about your diagnoses, treatments, and prognoses. When concern for your health makes it inadvisable to give such information to you, such information will be made available to an individual designated by you or to a legally authorized representative. • To be assured of confidential treatment and disclosure of records and to be afforded an opportunity to approve or refuse the release of such information, except when release is required by law. • To be informed of what support services are available at no charge to you, including but not limited to, interpreter services in the language of your choice. • To refuse treatment to the extent permitted by law and be informed of the consequences of your refusal. When refusal of treatment by the member or the member’s legally authorized representative prevents the provision of appropriate care in accordance with ethical and professional standards, the relationship with the member may be terminated with reasonable notice.

FHCP MBR R&R(E) - (Rev. 7/2017)

• To participate in decisions involving your health care, including ethical issues and cultural and spiritual beliefs, unless concern for your health makes this participation detrimental to you. • To information about FHCP, its providers, practitioners and your member rights and responsibilities. • To participate in discussions involving medically necessary treatment options regardless of cost and/or benefit coverage. • To refuse to participate in experimental research. • To know the name of the physician coordinating your health care and to request a change of your primary care provider. • To make decisions concerning your medical care, including the right to accept or refuse medical treatment or surgical treatment and the right to formulate advance directives in accordance with the Federal Law titled “Patient Self-Determination Act” and the Florida Statute Chapter 765 “Health Care Advance Directives.” These rights shall also include the right to appoint a representative either by Power of Attorney or by designation of a Health Care Surrogate to make health care decisions for you and to provide informed consent if you are incapable of doing so. • To make recommendations regarding the organization’s member rights and responsibilities policy. • To bring any person of your choosing to the patient accessible areas of the healthcare facility or provider’s office to accompany you while receiving outpatient treatment or consulting with your health care provider, unless doing so would risk the safety or health of the patient, other patients, or staff of the facility or office or cannot be reasonably accommodated by the facility or provider.

Florida Health Care Plans Member’s Responsibilities

223

You Have the Responsibility: • To provide accurate and complete information about your present complaints, past illnesses, medications, and unexpected changes in your condition.

• To follow safety rules and posted signs.

• To understand, ask questions, and follow recommended treatment plan(s) to the best of your ability.

• To receive all of your health care through FHCP, with the exception of emergency care. (Members with a Point of Service or Triple Option Plan should review your “Summary of Benefits and Coverage” Sheet).

• To promptly respond to FHCP’s request for information regarding you and/or your dependents in relation to covered services.

• To understand that you are responsible for your actions and consequences, if you refuse treatment or do not follow provider’s instructions.

• To demonstrate respect and consideration towards medical personnel and other members.

• To report emergency treatment to FHCP at 1-877615-4022.

• To understand your health problems and to participate in developing mutually agreed upon goals to the best of your ability.

• To present your FHCP membership identification card each time you drop off and pick up a prescription.

• To know your medicines and take them according to the instructions provided. • To keep appointments reliably and arrive on time or notify the provider, 24 hours in advance, if you are unable to keep an appointment.

FHCP MBR R&R(E) - (Rev. 7/2017)

• To use the emergency room facilities only for medical emergencies and serious accidents. • To be financially responsible for any co-payments, co-insurance, and/or deductibles and to provide current information concerning your FHCP membership status to the provider.

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292 ADVANCE DIRECTIVES

Every competent adult has the right to make decisions concerning his or her own health, including the right to choose or refuse medical treatment.

When a person becomes unable to make decisions due to a physical or mental change, such as being in a coma or developing dementia (like Alzheimer’s disease), they are considered incapacitated. To make sure that an incapacitated person’s decisions about health care will still be respected, the Florida legislature enacted legislation pertaining to Health Care Advance Directives. The law recognizes the right of a competent adult to make an Advance Directive instructing his or her physician to provide, withhold, or withdraw life-prolonging procedures; to designate another individual to make treatment decisions, and/or to indicate the desire to make an anatomical donation after death.

By law hospitals, nursing homes, home health agencies, hospices, and health maintenance organizations (HMO’s) are required to provide their patients with written information concerning Health Care Advance Directives.

Health Care Advance Directives is a written or oral statement about how you want medical decisions made, should you not be able to make them yourself, and/or it can express your wish to make an anatomical donation after death. Some people make Advance Directives when they are diagnosed with a life-threatening illness. Others put their wishes into writing while they are healthy, often as part of their estate planning.

Florida Health Care Plan recognizes the importance of the ability of members to express their wishes about their health care and the right to choose or refuse medical treatment.

In order to make this information available to FHCP members, a FHCP Health Care Advance Directives booklet is given to all members. This booklet can be obtained through the Documents and Forms Department ion the FHCP Holly Hill facility.

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Health Care Advance Directives

The Patient’s Right to Decide

FHCP 2305 - 1/09 24-301/7-03P Rev. 1/09

Introduction

307

Every competent adult has the right to make decisions concerning his or her own health, including the right to choose or refuse medical treatment. When a person becomes unable to make decisions due to a physical or mental change, such as being in a coma or developing dementia (like Alzheimer’s disease), they are considered incapacitated. To make sure that an incapacitated person’s decisions about health care will still be respected, the Florida legislature enacted legislation pertaining to health care advance directives (Chapter 765, Florida Statutes). The law recognizes the right of a competent adult to make an advance directive instructing his or her physician to provide, withhold, or withdraw life-prolonging procedures; to designate another individual to make treatment decisions if the person becomes unable to make his or her own decisions; and/or to indicate the desire to make an anatomical donation after death. By law hospitals, nursing homes, home health agencies, hospices, and health maintenance organizations (HMOs) are required to provide their patients with written information, such as this pamphlet, concerning health care advance directives. The state rules that require this include 58A-2.0232, 59A-3.254, 59A- 4.106, 59A-8.0245, and 59A-12.013, Florida Administrative Code.

Questions About Health Care Advance Directives What is an Advance Directive? It is a written or oral statement about how you want medical decisions made should you not be able to make them yourself and/or it can express your wish to make an anatomical donation after death. Some people make advance directives when they are diagnosed with a life-threatening illness. Others put their wishes into writing while they are healthy, often as part of their estate planning. Three types of advance directives are: • • •

ALiving Will A Health Care Surrogate Designation An Anatomical Donation

You might choose to complete one, two, or all three of these forms. This pamphlet provides information to help you decide what will best serve your needs. What is a living will? It is a written or oral statement of the kind of medical care you want or do not want if you become unable to make your own decisions. It is called a living will because it takes effect while you are still living. You may wish to speak to your health care provider or attorney to be certain you have completed the living will in a way that your wishes will be understood. What is a health care surrogate designation? It is a document naming another person as your representative to make medical decisions for you if you are unable to make them yourself. You can include instructions about any treatment you want or do not want, similar to a living will. You can also designate an alternate surrogate. Which is best? Depending on your individual needs you may wish to complete any one or a combination of the three types of advance directives.

308 What is an anatomical donation? It is a document that indicates your wish to donate, at death, all or part of your body. This can be an organ and tissue donation to persons in need, or donation of your body for training of health care workers. You can indicate your choice to be an organ donor by designating it on your driver’s license or state identification card (at your nearest driver’s license office), signing a uniform donor form (seen elsewhere in this pamphlet), or expressing your wish in a living will. Am I required to have an advance directive under Florida law? No, there is no legal requirement to complete an advance directive. However, if you have not made an advance directive, decisions about your health care or an anatomical donation may be made for you by a court-appointed guardian, your wife or husband, your adult child, your parent, your adult sibling, an adult relative, or a close friend. The person making decisions for you may or may not be aware of your wishes. When you make an advance directive, and discuss it with the significant people in your life, it will better assure that your wishes will be carried out the way you want. Must an attorney prepare the advance directive? No, the procedures are simple and do not require an attorney, though you may choose to consult one. However, an advance directive, whether it is a written document or an oral statement, needs to be witnessed by two individuals. At least one of the witnesses cannot be a spouse or a blood relative. Where can I find advance directive forms? Florida law provides a sample of each of the following forms: a living will, a health care surrogate, and an anatomical donation. Elsewhere in this pamphlet we have included sample forms as well as resources where you can find more information and other types of advance directive forms. Can I change my mind after I write an advance directive? Yes, you may change or cancel an advance directive at any time. Any changes should be written, signed and dated. However, you can also change an advance directive by oral statement; physical destruction of the advance directive; or by writing a new advance directive. If your driver’s license or state identification card indicates you are an organ donor, but you no longer want this designation, contact the nearest driver’s license office to cancel the donor designation and a new license or card will be issued to you. What if I have filled out an advance directive in another state and need treatment in Florida? An advance directive completed in another state, as described in that state’s law, can be honored in Florida. What should I do with my advance directive if I choose to have one? • If you designate a health care surrogate and an alternate surrogate be sure to ask them if they agree to take this responsibility, discuss how you would like matters handled, and give them a copy of the document. • Make sure that your health care provider, attorney, and the significant persons in your life know that you have an advance directive and where it is located. You also may want to give them a copy. • Set up a file where you can keep a copy of your advance directive (and other important paperwork). Some people keep original papers in a bank safety deposit box. If you do, you may want to keep copies at your house or information concerning the location of your safety deposit box. • Keep a card or note in your purse or wallet that states that you have an advance directive and where it is located. • If you change your advance directive, make sure your health care provider, attorney and the significant persons in your life have the latest copy. If you have questions about your advance directive you may want to discuss these with your health care provider, attorney, or the significant persons in your life.

309 Additional Information Regarding Health Care Advance Directives Before making a decision about advance directives you might want to consider additional options and other sources of information, including the following: • As an alternative to a health care surrogate, or in addition to, you might want to designate a durable power of attorney. Through a written document you can name another person to act on your behalf. It is similar to a health care surrogate, but the person can be designated to perform a variety of activities (financial, legal, medical, etc.). You can consult an attorney for further information or read Chapter 709, Florida Statutes. If you choose someone as your durable power of attorney be sure to ask the person if he or she will agree to take this responsibility, discuss how you would like matters handled, and give the person a copy of the document. • If you are terminally ill (or if you have a loved one who is in a persistent vegetative state) you may want to consider having a pre-hospital Do Not Resuscitate Order (DNRO). A DNRO identifies people who do not wish to be resuscitated from respiratory or cardiac arrest. The pre-hospital DNRO is a specific yellow form available from the Florida Department of Health (DOH). Your attorney, health care provider, or an ambulance service may also have copies available for your use. You, or your legal representative, and your physician sign the DNRO form. More information is available on the DOH website, www.doh.state.fl.us or www.MyFlorida.com (type DNRO in these website search engines) or call (850) 245-4440. When you are admitted to a hospital the pre-hospital DNRO may be used during your hospital stay or the hospital may have its own form and procedure for documenting a Do Not Resuscitate Order. • If a person chooses to donate, after death, his or her body for medical training and research the donation will be coordinated by the Anatomical Board of the State of Florida. You, or your survivors, must arrange with a local funeral home, and pay, for a preliminary embalming and transportation of the body to theAnatomical Board located in Gainesville, Florida. After being used for medical education or research, the body will ordinarily be cremated. The cremains will be returned to the loved ones, if requested at the time of donation, or the Anatomical Board will spread the cremains over the Gulf of Mexico. For further information contact the Anatomical Board of the State of Florida at (800) 628-2594 or www.med.ufl.edu/anatbd. • If you would like to read more about organ and tissue donation to persons in need you can view the Agency for Health Care Administration’s website http://ahca.myflorida.com (Click on “Site Map” then scroll down to “Organ Donors”) or the federal government site www.organdonor.gov. If you have further questions you may want to talk with your health care provider. • Various organizations also make advance directive forms available. One such document is “Five Wishes” that includes a living will and a health care surrogate designation. “Five Wishes” gives you the opportunity to specify if you want tube feeding, assistance with breathing, pain medication, and other details that might bring you comfort such as what kind of music you might like to hear, among other things. You can find out more at: Aging with Dignity www.agingwithdignity.org (888) 594-7437

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Other resources include: American Association of Retired Persons (AARP) www.aarp.org (Type “advance directives” in the website’s search engine)

Your local hospital, nursing home, hospice, home health agency, and your attorney or health care provider may be able to assist you with forms or further information. Brochure: End of Life Issues www.FloridaHealthFinder.gov (888) 419-3456

311 Living Will Declaration made this day of , 20 I, , willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, if at any time I am mentally or physically incapacitated (initial) and I have a terminal condition (initial) and I have an end-stage condition (initial) and I am in a persistent vegetative state

or or

and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessarily to provide me with comfort care or to alleviate pain. I do , I do not desire that nutrition and hydration (food and water) be withheld or withdrawn when the application of such procecures would serve only to prolong artifically the process of dying. It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal. In the event I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration: Name: Address: Zip Code Phone:

I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration. Additional Instructions (optional):

(Signed)

(Witness)

(Witness)

(Address)

(Address)

(City, State, Zip)

(City, State, Zip)

(Phone)

(Phone) (At least one witness must not be a husband or wife or a blood relative of the principle.)

312 Definitions for terms on the Living Will form: “End-stage condition” means an irreversible condition that is caused by injury, disease, or illness which has resulted in progressively sever and permanent deterioration, and which, to a reasonable degree of medical probability, treatment of the condition would be ineffective. “Persistent vegetative state” menas a permanent and irreversible condition of unconsciousness in which there is: The absence of voluntary action or cognitive behavior of any kind and an inability to communicate or interact purposefully with the environment. “Terminal condition” menas a condition cause by injury, disease, or illness from which there is no reasonable medical probability of recovery and which, without treatment, can be expected to cause death. These definitions come from section 765.101 of the Florida Statues. The Statutes can be found in your local library or online at www.leg.state.fl.us.

313 Designation of Health Care Surrogate Name: (Last name)

(First Name)

(Middle Initial)

In the event that I have been determined to be incapacitated to provide informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate as my surrogate for health care decisions: Name: Address:

Zip Code:

Phone: If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate surrogate: Name: Address:

Zip Code:

Phone: I fully understand that this designation will permit my designee to make health care decisions and to provide, withhold, or withdraw consent on my behalf; to apply for public benefits to defray cost of health care; and to authorize my admission to or transfer from a health care facility. Additional instructions (optional):

I further affirm that this designation is not being made a condition of treatment or admission to a health care facility. I will notify and send a copy of this document to the following persons other than my surrogate, so they may know who my surrogate is. Name: Name: Signed:

Witnesses:

Date:

1. 2. (At least one witness must not be a husband or wife or a blood relative of the principle.)

314 Uniform Donor Form The undersigned hereby makes this anatomical gift, if medically acceptable, to take effect on death. The words and marks below indicate my desires: I give: (a)

any needed organs or parts

(b) only the following organs or parts for the purpose of transplantation, therapy, medical research, or education:

(c)

my body for anatomical study if needed. Limitations or special wishes, if any:

Signed by the donor and the following witnesses in the presence of each other:

Donor’s Signature

Date Signed

Donor’s Date of Birth

City and State

(Witness)

(Witness)

(Address)

(Address)

(City, State, Zip)

(City, State, Zip)

You can use this form to indicate your choice to be an organ donor. Or you can designate it on your driver’s license or a stte identification card (at your nearest driver’s license office.)

Health Care Advance Directives

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The card below may be used as a convenient method to inform others of your health care advance directives. Complete the card and cut it out. Place in your wallet or purse. You can always make copies and place another one on your refrigerator, in your car glove compartment, or other easy-to-find place.

Health Care Advance Directives I, the following Advance Directive(s):

have created

 LivingWill  Health Care Surrogate Designation  Anatomical Donation  Other (specify)

Contact: Name: Address:

Phone:

Signature: Date:

AHCA Revised 4/06

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SECTION 6 Hospital Admissions-Case Management Admission Notification Form Surgical & Special Procedure Form

318

Florida Health Care Plans Hospital Admissions-Case Management

To certify FHCP coverage of an admission and verify benefits for inpatient care, the FHCP Admission Coordinator (or covering staff) in the Case Management Department should be contacted. Phone: 386-676-7187 or 1-866-676-7187 Fax: 386-615-4058 or 386-676-7122 Case Management receives via fax, secure internet or secure email a daily census from local contracted facilities in which the Admission Coordinator works from to begin the authorization process. If the required information is not on the census received then the Admission Coordinator does not start authorization process until a face sheet from the facility is received. If a member is admitted Out-Of-Area, that facility calls Case Management Admissions Coordinator and the required information is obtained to begin the authorization process. See attached work sheet. Authorization request is then assigned to CM UR Nurse for review and determination per FHCP P&P CM001.

Admission Notification Hospital Identifier (# the hospital uses to identify pt) Type (Medical Record #, Account #, Patient ID #, etc.) Auth #: Date of Notification: Member Name: FHCP #: Date of Admit: Diagnosis Code: Diagnosis: Admitting Doctor: Admitting Hospital Code: Admitting Hospital: Physical Address: Main Hospital #: UR #: Caller's Name: Caller's Callback #: Obs or Full Inpatient?: If Obs, what is admit time? ER or Direct?: Transferred?: Requested clinicals faxed to FHCP at: 386-615-4058 Please check one of the following below: Attn: Med / Surg UR Case Manager Attn: Mental Health UR Case Manager

If Patient Already Discharged: Discharge Date D/C Time (if OBS) Disposition Additional Notes:

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FLORIDA HEALTH CARE PLANS SURGICAL & SPECIAL PROCEDURE FORM Phone: 386-238-3230 Fax: 386-238-3253 Section 1 (Please complete all areas) Date:

Auth #:

Patient Name:

Medical Record #:

S.S. #:

Address: Date of Birth:

Phone/Home:

In Case of Emergency Notify:

Work: Telephone:

Primary Care Physician:

Cell: Relationship:

Surgeon:

Diagnosis:

ICD-10 Code:

CPT Code: (Circle One)

Routine

Urgent

(Circle One)

Inpatient

Outpatient

* 23 Hour Observation

* Documentation is required to support 23 hr obs status

Facility: Comments – (Relating to actual surgery, if any): Surgical/Special Procedure:

Date of Procedure:

Time:

Pre-Op Joint Replacement Class:

Admission Date (if inpatient):

Attendance Date:

Section 2 (Available for your office use) Special Equipment / Drugs:

Anesthesia: (circle one)

General

MAC

Spinal

Regional Block

IV Sedation

Local

Section 3 (This section is for FHCP internal use only): This form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s PCP or the Referring Provider. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Approved / Disapproved

Date:

14-501 REV. 12-04-09 FHCP – 125 – Revised 07/13/12, 12/13/13 Reviewed 07-11-14, 10/1/15

By:

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SECTION 7 CLAIMS REVIEW AND PROCESSING Medicare Subscriber Claims Review and Processing Policy Non-Medicare Subscriber Claims Review and Processing Policy Qualified Medicare Beneficiaries (QMBs) Information Coordination of Benefits Policy VPay Payment Option

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342 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services

News Flash – REVISED product(s) from the Medicare Learning Network® (MLN)



“Medicare Physician Guide”, Guide, ICN 005933, Downloadable

MLN Matters® Number: SE1128 Revised

Related Change Request (CR) #: N/A

Related CR Release Date: N/A

Effective Date: N/A

Related CR Transmittal #: N/A

Implementation Date: N/A

Prohibition on Balance Billing Qualified Medicare Beneficiaries (QMBs) Note: This article was revised on August 28, 2012, to clarify the section of the Social Security Act that prohibits Medicare providers from balance billing QMBs for Medicare cost-sharing (page 2- bold).This article was previously updated on July 25, 2012, to reflect current Web addresses. All other content remains the same. Provider Types Affected All Medicare physicians, providers and suppliers who submit claims to Medicare for services and supplies provided to Qualified Medicare Beneficiaries (QMBs) are affected. This includes providers of services to enrollees of Medicare Advantage plans. What You Need to Know

STOP – Impact to You This Special Edition MLN Matters® Article provides guidance from the Centers for Medicare & Medicaid Services (CMS) to Medicare providers serving QMBs. All Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2010 American Medical Association.

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343 MLN Matters® Number: SE1128

Related Change Request Number: N/A

Medicare providers are reminded that they may not bill QMBs for Medicare cost-sharing. CAUTION – What You Need to Know All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs must be aware that they may not bill QMBs for Medicare cost-sharing. This includes deductible, coinsurance, and copayments, known as “balance billing.” Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997, prohibits Medicare providers from balance billing QMBs for Medicare cost-sharing. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions.

GO – What You Need to Do Refer to the Background and Additional Information Sections of this article for further details and resources about this guidance. Please ensure that you and your staffs are aware of the current balance billing law and policies regarding QMBs. Visit the State Medicaid Agency websites of the states in which you practice to learn how to submit claims if you are not currently submitting claims to a state. Background This article provides CMS guidance to Medicare providers to help them avoid inappropriately billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments. This is known as “balance billing.” Balance Billing of QMBs Is Prohibited by Federal Law

Under current law, Medicare providers cannot balance bill a QMB. Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997, prohibits Medicare providers from balance billing QMBs for Medicare cost-sharing. (Please note, this section of the Act is available at http://www.ssa.gov/OP_Home/ssact/title19/1902.htm on the Internet.) Specifically, the statute provides that the Medicare payment and any Medicaid payment are considered payment in full to the provider for services rendered to a QMB. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who balance bill QMB patients may be subject to sanctions based on Medicare provider requirements Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2010 American Medical Association.

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344 MLN Matters® Number: SE1128

Related Change Request Number: N/A

established in Sections 1902(n)(3)(C) and 1905(p)(3) of the Social Security Act. Medicare providers who violate these billing restrictions are violating their Medicare provider agreement. Please note that the statute referenced above supersedes Section 3490.14 of the “State Medicaid Manual,” which is no longer in effect, and therefore, may be causing confusion about QMB billing. QMBs and Benefits QMBs are persons who are entitled to Medicare Part A and are eligible for Medicare Part B; have incomes below 100 percent of the Federal Poverty Level; and have been determined to be eligible for QMB status by their State Medicaid Agency.



Medicaid pays the Medicare Part A and B premiums, deductibles, co-insurance and co-payments for QMBs.



At the State’s discretion, Medicaid may also pay Part C Medicare Advantage premiums for joining a Medicare Advantage plan that covers Medicare Part A and B benefits and Mandatory Supplemental Benefits.



Regardless of whether the State Medicaid Agency opts to pay the Part C premium, the QMB is not liable for any co-insurance or deductibles for Part C benefits.

Ways to Improve the Claims Process

Effective communications between you and State Medicaid Agencies can improve the claims process for all parties involved. Therefore, CMS suggests that you take the following four actions to improve communications with State Medicaid Agencies and better understand the billing process for services provided to QMB beneficiaries: 1. Determine if the State in which you operate has electronic crossover processes with the Medicare Coordination of Benefits Contractor (COBC) in place or if direct submission to the State Medicaid Agency is required or available. Nearly all States participate in the Medicare crossover process. It may just be that particular QMBs need to be added to the eligibility exchange between given States and Medicare. If a claim is automatically crossed over to another payer, such as Medicaid, it is customarily noted on the Medicare remittance advice. 2. Recognize that you must meet any state-imposed requirements and may need to complete the provider registration process to be entered into the State payment system. 3. Understand the specific requirements for provider registration for the State(s) in which you work. 4. Contact the State Medicaid Agency directly to determine the process you need to follow to begin submitting claims and receiving payment. Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2010 American Medical Association.

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345 MLN Matters® Number: SE1128

Related Change Request Number: N/A QMB Eligibility and Benefits

Dual Eligibility Qualified Medicare Beneficiary (QMB only)

Eligibility Criteria • •

QMB Plus





Income cannot exceed 100% of the Federal Poverty Level (FPL) Resources cannot exceed $6,600 for a single individual or $9,910 for an individual living with a spouse and no other dependents Meets all of the standards for QMB eligibility as described above, but also meets the financial criteria for full Medicaid coverage Individuals often qualify for full Medicaid benefits by meeting the Medically Needy standards, or through spending down excess income to the Medically Needy level.

Benefits • •

Entitled to Medicare Part A Eligible for Medicaid payment of Medicare Part B premiums, deductibles, co-insurance and co-pays (except for Part D)



Entitle to all benefits available to QMB, as well as all benefits available under the State Plan to a fully eligible Medicaid recipient

For more information about dual eligible categories and benefits, please visit http://www.medicare.gov/Publications/Pubs/pdf/10126.pdf on the Internet. Additional Information For more information about QMBs and other individuals who are dually eligible to receive Medicare and Medicaid benefits, please refer to the Medicare Learning Network® publication titled “Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles),” which is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/medicare_beneficiaries_dual_eligibles_at_a_glance.pdf on the CMS website.

For general Medicaid information, please visit the Medicaid web page at http://www.medicaid.gov/index.html on the CMS website. News Flash – Vaccinate Early to Protect Against the Flu. The Centers for Disease Control and Prevention (CDC) recommends a yearly flu vaccination as the first and most important step in protecting against flu viruses. Remind your patients that annual vaccination is recommended for optimal protection. Medicare pays for the flu vaccine and its administration for seniors and other Medicare beneficiaries with no co-pay or deductible. Take advantage of each office visit and start protecting your patients as soon as your 2011-2012 seasonal flu vaccine arrives. And, don’t forget to immunize yourself and your staff. Get the Flu Vaccination -- Not the Flu. Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of the influenza vaccine and its administration, as well as related educational resources for health care professionals and their staff, please visit http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/index.html on the Centers for Medicare & Medicaid Services (CMS) website. Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2010 American Medical Association.

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Patient Information Update Form

December 21, 2010

Please confirm the current information and make any necessary changes. Description Medical Record Number

Current

Change

Home: Work: Cell:

Home: Work: Cell:

Last Name First Name, MI Street Address City, State, Zip Date of Birth Home Phone Email Cell Phone Emergency Contact Name Emergency Contact Relationship Emergency Contact Phone

Primary Care Doctor Does this visit pertain to an auto accident?  Yes  No Does this visit pertain to an on the job injury?  Yes  No Insurance Information Insurance Company Name Insurance Company Address Type of Insurance

 Medical  Dental  Pharmacy Only  Medicare Supplement  Other

Policy Holder’s name and date of birth Policy Number and Group Number

Policy # Group #

Policy #

Group #

Effective Date Termination Date Relationship to Policy Holder Name(s) of covered dependents Additional Insurance Company Name Insurance Company Address Type of Insurance Policy Holder’s name and date of birth Policy Number and Group Number

 Medical  Dental  Pharmacy Only  Medicare Supplement  Other Policy #

Group #

Policy #

Group #

Effective Date Termination Date Relationship to Policy Holder Name(s) of covered dependents What is your preferred language? What is your Race? Do you have an Advance Directive on file with FHCP?

Do you need an interpreter? What is your Ethnicity? Yes No

Please sign to acknowledge information above is correct Patient Signature or Guardian Signature

Date

Yes

No

382

Florida Health Care Plans, Inc. Insurance Information Form

Notice to FHCP Patients Please notify your FHCP Physician when you are seeing him/her as a result of injuries sustained from any type of accident. If you have any questions regarding FHCP coverage of treatment for your injury, please contact Donna Pacifico at (386) 676-7123 or 1-800-352-9824. Mailing Address: P. O. Box 9671, Daytona Beach, 32120. Today’s Date: Check One:

Date of Accident/Injury: Workers Compensation

MRN: Auto Accident

Other (Fall)

ATTENTION: IF YOU CHECKED “Other” PLEASE CALL Donna Pacifico at (386) 676-7123. Name of Patient:

Social Security”:

Address:

Telephone # - (Home):

City:

(Work):

Your Auto Insurance Carrier Information Name of Your Insurance Co.:

Phone #:

Insurance Co. Address: Policy #:

Claim #:

State accident occurred:

Insured: Initial Emergency Treatment received at:

I authorize the above referenced Insurance Carrier to make payment of medical benefits directly to Florida Health Care Plan, Inc. for services rendered to me as a result of the above auto accident. Furthermore, I authorize the release of any medical or other information necessary to process this claim.

Date

Insured or Authorized Person’s Signature

Worker Compensation Insurance Information Please Provide FHCP with a Copy of the Notice of Injury Filed with Your Employer. Employer Name:

Telephone #:

Employer Address: Workers Compensation Carrier’s Name: Carrier’s Address: Carrier’s Telephone #: 32-302/3-02 RX

Adjuster’s Name:

383

384 Name: «First_Name» «Middle_Initial» «Last_Name»

7) Is the family member from the previous question currently employed? _____ Yes _____ No

8) How many employees does the family member’s employer have? _____ 1-99 employees

_____ 100 or more employees

9) Please supply the name and address of the family member’s employer. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

10) Please supply the name and address of the group health plan, i.e., the insurance company. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

H1035_FHCP A3294 – 2/2010

3

385

January 4, 2011 «FIRST_NAME» «LAST_NAME» «ADDRESS1» «ADDRESS2» «CITY», «STATE» «ZIP»

Dear «FIRST_NAME» «LAST_NAME»: The Centers for Medicare & Medicaid Services (CMS) has requested that we verify information about your Prescription Drug coverage. The information on the attached attestation has been given to us by CMS and/or you on your enrollment application. We need your help in determining if this information is correct and also ask that you complete any missing/new data. Please complete and return the attached attestation to us within the next 10 business days to the following address. We have enclosed a self-addressed postage-paid envelope for your convenience. Florida Health Care Plan, Inc PO Box 9910 Daytona Beach, FL 32120 If you have any questions, please contact our Enrollment Department at (800) 352-9824 extension 7176 or (386) 676-7176. The hearing impaired may call TRS Relay 711. Hours of operation are Monday through Friday, 8 a.m. to 5 p.m.

Sincerely,

Enrollment Department  

H1035_NR104 FYI 7/21/2010

«Type» D «File_Date»

386 FHCP Offers New Payment Option •

If you are already enrolled for electronic funds transfer through Florida Health Care Plans, there will be no changes for your payments and the following message will not apply.

Florida Health Care Plans has partnered with StoneEagle to offer an electronic claim payment option for providers using StoneEagle’s VPay process. This new service will be available to you shortly. VPay allows your office to receive payments electronically via the MasterCard network. This new service will provide a faster and more efficient way for you to receive payment. Providers accepting VPay will enjoy the following benefits:  Quick payments. VPay is delivered primarily via fax so you are receiving payments much quicker than checks.  Easy reconciliation. The VPayment and EOB are delivered together in a single document. Enter the card number in your terminal and post the EOB to your billing system and you are done!  No bank deposits. Your funds will be delivered electronically to your merchant account.  VPay eliminates the risk of fraud. StoneEagle guarantees the delivery of funds to your account, regardless of any fraudulent attempt to process a VCard. No more stolen, lost or whitewashed checks.  VPay’s Call Center is staffed with knowledgeable, well trained professionals that can assist with any questions you have about your VPayment. You do not have to enroll to use VPay. When you receive your VCard, just follow the directions provided on your remittance. The VPay process also includes an ACH/835 option. Please call the VPay Call Center at (888) 555-8426 to enroll for this service. We are excited to bring you this safe and efficient electronic method of claims payment. Please keep in mind that you can also check eligibility by registering with Availity at (800) AVAILITY (484-4548). You do not have to file your claims electronically in order to use this valuable service. This service is readily available to you. No more telephone calls! If you have any questions about this new service, please feel free to contact Steve Berberich, Director of Claims at Florida Health Care Plans. His email address is [email protected] and his telephone number is (386) 615-4085.

387

SECTION 8 PHARMACY / AFFILIATES FHCP Formulary Prescription Drugs Benefits Pharmacy Services and Hours FHCP Contracting Pharmacies Medications Requiring Prior Authorizations Policy FHCP Prior Authorization Medication Form Medical Appliances Formulary Policy General Part D Medication Transition Process Policy Medication Therapy Management Program (MTMP) Pharmacist Review Request: Medication Therapy Management

388

Commercial Drug Formulary (List of Covered Drugs)

Commercial Drug Formulary Last Updated: January 8, 2014

389 Formulary Tier Structure The amount you pay for each prescription is dependent on these factors: 1. The pharmacy you use to fill your prescription. 2. The type of drug you’re taking – generic or brand (preferred or non-preferred), formulary or non-formulary. Based on these factors, the drug is assigned a Tier Code as follows: • Tier 1 –Formulary Preferred Generic • Tier 2 –Formulary Non-Preferred Generic • Tier 3 –Formulary Preferred Brand • Tier 4 –Formulary Non-Preferred Brand • Tier 5 – Specialty Drugs • Tier 6 – Formulary Injectables DON'T SEE YOUR MEDICATION ON THE FHCP FORMULARY? FHCP can respond to all of your medication needs. Our Preferred Drug List, or Formulary, is broad and is composed of proven medications in every therapeutic drug class to assist our Members to better manage their health care. However, if you need a medication not on the FHCP Preferred Drug List, you can always obtain your medication from an FHCP Member Pharmacy at 85% of FHCP's already low price. Note: FHCP’s Formulary can also be found on our website at www.fhcp.com. If you are unable to find a certain drug within this booklet, please check out our website, as it is updated more frequently.

390

HOW TO SEARCH FOR A DRUG IN THE FLORIDA HEALTH CARE PLAN PREFERRED DRUG LIST (FORMULARY)

On the FHCP Website, click on the Members tab, click on “Formulary” http://www.fhcp.com/members/formulary/formulary.htm

Click on Commercial Formulary http://www.fhcp.com/members/plansAndBenefits/Commercial%20Formulary.pdf

When the PDF file comes up, press Control F. A pop-up search text box will appear at the top of the page. Type the drug name for which you are searching and click the right arrow in the pop-up search text box to begin the search. To close the pop-up search text box, click on the “x” in the pop-up search text box.

391 Florida Health Care Plan- FHCP Commercial Formulary Effective 1-8-13 (4:04.04) Antihistamine Drugs » First Generation Antihistamines » Ethanolamine Derivatives Product Name

Form

Strength

Pref

Coverage Details

Comment

CLEMASTINE FUMARATE

SYRP

0.67MG/5ML

T2

QL

syrup only, (TAVIST)

(4:04.12) Antihistamine Drugs » First Generation Antihistamines » Phenothiazine Derivatives Product Name

Form

Strength

Pref

Coverage Details

Comment

PHENADOZ

SUPP

25MG

T2

QL

(PHENERGAN)

PROMETHAZINE HCL

TABS

25MG

T2

(PHENERGAN)

PROMETHAZINE HCL

TABS

12.5MG

T2

(PHENERGAN)

PROMETHAZINE HCL

TABS

50MG

T2

(PHENERGAN)

PROMETHAZINE HCL

SUPP

12.5MG

T2

QL

(PHENERGAN)

PROMETHAZINE HCL

SUPP

25MG

T2

QL

(PHENERGAN)

PROMETHAZINE HCL PLAIN

SYRP

6.25MG/5ML

T2

QL

(PHENERGAN)

PROMETHAZINE VC PLAIN

SYRP

T2

QL

(PHENERGAN)

PROMETHEGAN

SUPP

5MG/5ML; 6.25MG/5ML 50MG

T2

QL

(PHENERGAN)

PROMETHEGAN

SUPP

25MG

T2

QL

(PHENERGAN)

PROMETHEGAN

SUPP

12.5MG

T2

QL

(PHENERGAN)

Coverage Details

Comment

(4:04.92) Antihistamine Drugs » First Generation Antihistamines » Derivatives, Miscellaneous Product Name

Form

Strength

Pref

CYPROHEPTADINE HCL

TABS

4MG

T2

CYPROHEPTADINE HCL

SYRP

2MG/5ML

T2

QL

(PERIACTIN)

Coverage Details

Comment

(PERIACTIN)

(4:08) Antihistamine Drugs » Second Generation Antihistamines Product Name

Form

Strength

Pref

LEVOCETIRIZINE DIHYDROCHLORIDE

TABS

5MG

T2

Product Name

Form

Strength

Pref

ALBENZA

TABS

200MG

T4

STROMECTOL

TABS

3MG

T4

QL

Coverage Details

(XYZAL)

(8:08) Anti-infective Agents » Anthelmintics Coverage Details

Comment

(8:12.02) Anti-infective Agents » Antibacterials » Aminoglycosides Product Name

Form

Strength

Pref

NEOMYCIN SULFATE

TABS

500MG

T2

TOBI

NEBU

300MG/5ML

T5

Comment

392

(8:12.06.04) Anti-infective Agents » Antibacterials » Cephalosporins » First Generation Cephalosporins Product Name

Form

Strength

Pref

Coverage Details

Comment

CEFADROXIL

SUSR

250MG/5ML

T2

QL

Susp Only (DURICEF)

CEFADROXIL

SUSR

500MG/5ML

T2

QL

Susp Only (DURICEF)

CEPHALEXIN

CAPS

250MG

T2

(KEFLEX)

CEPHALEXIN

CAPS

500MG

T2

(KEFLEX)

CEPHALEXIN

SUSR

125MG/5ML

T2

QL

(KEFLEX)

CEPHALEXIN

SUSR

250MG/5ML

T2

QL

(KEFLEX)

(8:12.06.08) Anti-infective Agents » Antibacterials » Cephalosporins » Second Generation Cephalosporins Product Name

Form

Strength

Pref

CEFACLOR

CAPS

250MG

T2

Coverage Details

Comment (CECLOR)

CEFACLOR

CAPS

500MG

T2

(CECLOR)

CEFPROZIL

TABS

250MG

T2

(CEFZIL)

CEFPROZIL

TABS

500MG

T2

(CEFZIL)

CEFPROZIL

SUSR

125MG/5ML

T2

QL

(CEFZIL)

CEFPROZIL

SUSR

250MG/5ML

T2

QL

(CEFZIL)

CEFUROXIME AXETIL

TABS

250MG

T2

tabs only, (CEFTIN)

CEFUROXIME AXETIL

TABS

500MG

T2

tabs only, (CEFTIN)

(8:12.06.12) Anti-infective Agents » Antibacterials » Cephalosporins » Third Generation Cephalosporins Product Name

Form

Strength

Pref

CEFDINIR

CAPS

300MG

T2

Coverage Details

Comment

CEFDINIR

SUSR

125MG/5ML

T2

QL

(OMNICEF)

CEFDINIR

SUSR

250MG/5ML

T2

QL

(OMNICEF)

SUPRAX

TABS

400MG

T4

SUPRAX

SUSR

100MG/5ML

T4

QL

Coverage Details

Comment

QL

(PEDIAZOLE)

(OMNICEF)

(8:12.12.04) Anti-infective Agents » Antibacterials » Macrolides » Erythromycins Product Name

Form

Strength

Pref

E.E.S. 400

TABS

400MG

T3

E.S.P.

SUSR

T2

ERYTHROCIN STEARATE

TABS

200MG/5ML; 600MG/5ML 250MG

ERYTHROMYCIN

CPEP

250MG

T3

ERYTHROMYCIN ETHYLSUCCINATE

TABS

400MG

T3

(8:12.12.92) Anti-infective Agents » Antibacterials » Macrolides » Other Macrolides

T3

393 Product Name

Form

Strength

Pref

Coverage Details

Comment

AZITHROMYCIN

TABS

250MG

T2

(ZITHROMAX)

AZITHROMYCIN

TABS

600MG

T2

(ZITHROMAX)

AZITHROMYCIN

TABS

500MG

T2

(ZITHROMAX)

AZITHROMYCIN

SUSR

200MG/5ML

T2

QL

(ZITHROMAX)

AZITHROMYCIN

SUSR

100MG/5ML

T2

QL

(ZITHROMAX)

CLARITHROMYCIN

SUSR

125MG/5ML

T2

QL

(BIAXIN)

CLARITHROMYCIN

SUSR

250MG/5ML

T2

QL

(BIAXIN)

CLARITHROMYCIN

TABS

250MG

T2

not XL, (BIAXIN)

CLARITHROMYCIN

TABS

500MG

T2

not XL, (BIAXIN)

(8:12.16.04) Anti-infective Agents » Antibacterials » Penicillins » Natural Penicillins Product Name

Form

Strength

Pref

PENICILLIN V POTASSIUM

TABS

250MG

T2

Coverage Details

Comment (PEN VEE K)

PENICILLIN V POTASSIUM

TABS

500MG

T2

(PEN VEE K)

PENICILLIN V POTASSIUM

SOLR

125MG/5ML

T2

QL

(PEN VEE K)

PENICILLIN V POTASSIUM

SOLR

250MG/5ML

T2

QL

(PEN VEE K)

Coverage Details

Comment

(8:12.16.08) Anti-infective Agents » Antibacterials » Penicillins » Aminopenicillins Product Name

Form

Strength

Pref

AMOXICILLIN

TABS

875MG

T2

(AMOXIL)

AMOXICILLIN

CHEW

125MG

T2

(AMOXIL)

AMOXICILLIN

CHEW

250MG

T2

(AMOXIL)

AMOXICILLIN

CAPS

250MG

T2

(AMOXIL)

AMOXICILLIN

CAPS

500MG

T2

(AMOXIL)

AMOXICILLIN

SUSR

125MG/5ML

T2

QL

(AMOXIL)

AMOXICILLIN

SUSR

250MG/5ML

T2

QL

(AMOXIL)

AMOXICILLIN

SUSR

200MG/5ML

T2

QL

(AMOXIL)

AMOXICILLIN

SUSR

400MG/5ML

T2

QL

(AMOXIL)

AMOXICILLIN/CLAVULANATE POTASSIUM

CHEW

400MG; 57MG

T2

(AUGMENTIN)

AMOXICILLIN/CLAVULANATE POTASSIUM

TABS

500MG; 125MG

T2

(AUGMENTIN)

AMOXICILLIN/CLAVULANATE POTASSIUM

TABS

875MG; 125MG

T2

(AUGMENTIN)

AMOXICILLIN/CLAVULANATE POTASSIUM

CHEW

200MG; 28.5MG

T2

(AUGMENTIN)

AMOXICILLIN/CLAVULANATE POTASSIUM

TABS

250MG; 125MG

T2

AMOXICILLIN/CLAVULANATE POTASSIUM

SUSR

600MG/5ML; 42.9MG/5ML

T2

(AUGMENTIN) QL

(AUGMENTIN)

AMOXICILLIN/CLAVULANATE POTASSIUM

SUSR

T2

QL

(AUGMENTIN)

T2

QL

(AUGMENTIN)

T2

QL

(AUGMENTIN)

TB12

200MG/5ML; 28.5MG/5ML 400MG/5ML; 57MG/5ML 250MG/5ML; 62.5MG/5ML 1000MG; 62.5MG

AMOXICILLIN/CLAVULANATE POTASSIUM

SUSR

AMOXICILLIN/CLAVULANATE POTASSIUM

SUSR

AMOXICILLIN/CLAVULANATE POTASSIUM ER

T2

(AUGMENTIN XR)

AMPICILLIN

CAPS

250MG

T2

AMPICILLIN

CAPS

500MG

T2

AMPICILLIN

SUSR

125MG/5ML

T2

QL

AMPICILLIN

SUSR

250MG/5ML

T2

QL

(PRINCIPEN, OMNIPEN, POLYCILLIN) (PRINCIPEN, OMNIPEN, POLYCILLIN) (PRINCIPEN, OMNIPEN, POLYCILLIN) (PRINCIPEN, OMNIPEN, POLYCILLIN)

394

(8:12.16.12) Anti-infective Agents » Antibacterials » Penicillins » Penicillinase-resistant Penicillins Product Name

Form

Strength

Pref

DICLOXACILLIN SODIUM

CAPS

250MG

T2

Coverage Details

Comment (DYNAPEN/DYCILL)

DICLOXACILLIN SODIUM

CAPS

500MG

T2

(DYNAPEN/DYCILL)

(8:12.18) Anti-infective Agents » Antibacterials » Quinolones Product Name

Form

Strength

Pref

CIPROFLOXACIN HCL

TABS

500MG

T2

Coverage Details

Comment not Susp or XR, (CIPRO)

CIPROFLOXACIN HCL

TABS

250MG

T2

not Susp or XR, (CIPRO)

CIPROFLOXACIN HCL

TABS

750MG

T2

not Susp or XR, (CIPRO)

LEVOFLOXACIN

TABS

250MG

T2

(LEVAQUIN)

LEVOFLOXACIN

SOLN

25MG/ML

T2

(LEVAQUIN)

LEVOFLOXACIN

TABS

500MG

T2

(LEVAQUIN)

LEVOFLOXACIN

TABS

750MG

T2

(LEVAQUIN)

(8:12.20) Anti-infective Agents » Antibacterials » Sulfonamides Product Name

Form

Strength

Pref

SULFADIAZINE

TABS

500MG

T2

Coverage Details

Comment

SULFAMETHOXAZOLE/TRIMETHOPRIM

TABS

400MG; 80MG

T2

(BACTRIM , SEPTRA)

SULFAMETHOXAZOLE/TRIMETHOPRIM

SUSP

T2

(BACTRIM , SEPTRA)

SULFAMETHOXAZOLE/TRIMETHOPRIM DS

TABS

200MG/5ML; 40MG/5ML 800MG; 160MG

T2

(BACTRIM DS, SEPTRA DS)

SULFASALAZINE

TABS

500MG

T2

not EN, (AZULFIDINE)

SULFAZINE

TABS

500MG

T2

not EN, (AZULFIDINE)

Strength

Pref

(8:12.24) Anti-infective Agents » Antibacterials » Tetracyclines Product Name

Form

Coverage Details

Comment

DOXYCYCLINE HYCLATE

TABS

20MG

T2

(PERIOSTAT)

DOXYCYCLINE HYCLATE

CAPS

50MG

T2

(VIBRAMYCIN)

DOXYCYCLINE HYCLATE

CAPS

100MG

T2

(VIBRAMYCIN)

DOXYCYCLINE HYCLATE

TABS

100MG

T2

(VIBRATABS)

MINOCYCLINE HCL

CAPS

50MG

T2

(MINOCIN)

MINOCYCLINE HCL

CAPS

100MG

T2

(MINOCIN)

TETRACYCLINE HCL

CAPS

250MG

T2

(SUMYCIN)

TETRACYCLINE HCL

CAPS

500MG

T2

(SUMYCIN)

(8:12.28.20) Anti-infective Agents » Antibacterials » Antibacterials, Miscellaneous » Lincomycins Product Name

Form

Strength

Pref

CLINDAMYCIN HCL

CAPS

150MG

T2

Coverage Details

Comment 150mg only, (CLEOCIN)

CLINDAMYCIN PALMITATE HCL

SOLR

75MG/5ML

T2

(CLEOCIN)

(8:12.28.24) Anti-infective Agents » Antibacterials » Antibacterials, Miscellaneous » Oxazolidinones Product Name

Form

Strength

Pref

Coverage Details

ZYVOX

TABS

600MG

T3

PA

Comment

ZYVOX

SUSR

100MG/5ML

T3

PA

Product Name

Form

Strength

Pref

Coverage Details

TERBINAFINE HCL

TABS

250MG

T2

Product Name

Form

Strength

Pref

FLUCONAZOLE

TABS

100MG

T2

(DIFLUCAN)

FLUCONAZOLE

TABS

50MG

T2

(DIFLUCAN)

FLUCONAZOLE

TABS

200MG

T2

(DIFLUCAN)

FLUCONAZOLE

SUSR

10MG/ML

T2

QL

(DIFLUCAN)

FLUCONAZOLE

SUSR

40MG/ML

T2

QL

(DIFLUCAN)

FLUCONAZOLE

TABS

150MG

T2

QL

(DIFLUCAN)

ITRACONAZOLE

CAPS

100MG

T2

PA

(SPORONOX)

KETOCONAZOLE

TABS

200MG

T2

SPORANOX

SOLN

10MG/ML

T4

PA

Product Name

Form

Strength

Pref

Coverage Details

NYSTATIN

TABS

500000UNIT

T2

not PWD

NYSTATIN

SUSP

100000UNIT/ML

T2

not PWD

(8:14.04) Anti-infective Agents » Antifungals » Allylamines Comment (LAMISIL)

(8:14.08) Anti-infective Agents » Antifungals » Azoles Coverage Details

Comment

not shampoo, (NIZORAL)

(8:14.28) Anti-infective Agents » Antifungals » Polyenes Comment

395

396

(8:14.32) Anti-infective Agents » Antifungals » Pyrimidines Product Name

Form

Strength

Pref

FLUCYTOSINE

CAPS

250MG

T2

Coverage Details

Comment (ANCOBON)

FLUCYTOSINE

CAPS

500MG

T2

(ANCOBON)

(8:14.92) Anti-infective Agents » Antifungals » Antifungals, Miscellaneous Product Name

Form

Strength

Pref

GRISEOFULVIN MICROSIZE

SUSP

125MG/5ML

T2

Coverage Details

Comment (GRIFULVIN V SUSP)

(8:16.04) Anti-infective Agents » Antimycobacterials » Antituberculosis Agents Product Name

Form

Strength

Pref

ETHAMBUTOL HCL

TABS

400MG

T2

Coverage Details

Comment (MYAMBUTAL)

ETHAMBUTOL HCL

TABS

100MG

T2

(MYAMBUTAL)

ISONIAZID

TABS

100MG

T2

(LANIAZID)

ISONIAZID

TABS

300MG

T2

(LANIAZID)

MYCOBUTIN

CAPS

150MG

T3

PASER

PACK

4GM

T4

PRIFTIN

TABS

150MG

T4

PYRAZINAMIDE

TABS

500MG

T2

(RIFATER)

RIFAMPIN

CAPS

150MG

T2

(RIFADIN)

RIFAMPIN

CAPS

300MG

T2

(RIFADIN)

SEROMYCIN

CAPS

250MG

T4

TRECATOR

TABS

250MG

T4

(8:16.92) Anti-infective Agents » Antimycobacterials » Antimycobacterials, Miscellaneous Product Name

Form

Strength

Pref

Coverage Details

Comment

DAPSONE

TABS

100MG

T4

DAPSONE

TABS

25MG

T4

Product Name

Form

Strength

Pref

Coverage Details

Comment

RIMANTADINE HCL

TABS

100MG

T2

Product Name

Form

Strength

PEG-INTRON

KIT

150MCG/0.5ML

Pref

Coverage Details

Comment

T5

PA

PEG-INTRON

KIT

PEG-INTRON

KIT

80MCG/0.5ML

T5

PA

120MCG/0.5ML

T5

PA

PEG-INTRON

KIT

50MCG/0.5ML

T5

PA

(8:18.04) Anti-infective Agents » Antivirals » Adamantanes

(8:18.20) Anti-infective Agents » Antivirals » Interferons

397

PEG-INTRON REDIPEN

KIT

120MCG/0.5ML

T5

PA

PEG-INTRON REDIPEN

KIT

80MCG/0.5ML

T5

PA

PEG-INTRON REDIPEN

KIT

150MCG/0.5ML

T5

PA

PEGASYS

KIT

180MCG/0.5ML

T5

PA

PEGASYS

SOLN

180MCG/0.5ML

T5

PA

Coverage Details

Comment

Coverage Details

Comment

(8:18.28) Anti-infective Agents » Antivirals » Neuraminidase Inhibitors Product Name

Form

Strength

Pref

RELENZA DISKHALER

AEPB

5MG/BLISTER

T4

(8:18.32) Anti-infective Agents » Antivirals » Nucleosides and Nucleotides Product Name

Form

Strength

Pref

ACYCLOVIR

CAPS

200MG

T2

(ZOVIRAX)

ACYCLOVIR

TABS

400MG

T2

(ZOVIRAX)

ACYCLOVIR

TABS

800MG

T2

(ZOVIRAX)

ACYCLOVIR

SUSP

200MG/5ML

T2

(ZOVIRAX)

BARACLUDE

TABS

0.5MG

T3

BARACLUDE

TABS

1MG

T3

HEPSERA

TABS

10MG

T5

RIBAVIRIN

TABS

200MG

T6

RIBAVIRIN

CAPS

200MG

T6

TYZEKA

TABS

600MG

T4

VALACYCLOVIR HCL

TABS

1GM

T2

(VALTREX)

VALACYCLOVIR HCL

TABS

500MG

T2

(VALTREX)

VALCYTE

TABS

450MG

T3

VALCYTE

SOLR

50MG/ML

T3

PA

PA

(8:18.40) Anti-infective Agents » Antivirals » HCV Protease Inhibitors Product Name

Form

Strength

Pref

Coverage Details

VICTRELIS

CAPS

200MG

T5

PA

Comment

Coverage Details

Comment

Coverage Details

Comment

(8:30.04) Anti-infective Agents » Antiprotozoals » Amebicides Product Name

Form

Strength

Pref

PAROMOMYCIN SULFATE

CAPS

250MG

T3

(8:30.08) Anti-infective Agents » Antiprotozoals » Antimalarials Product Name

Form

Strength

Pref

ATOVAQUONE/PROGUANIL HCL

TABS

250MG; 100MG

T2

(MALARONE)

ATOVAQUONE/PROGUANIL HCL

TABS

62.5MG; 25MG

T2

(MALARONE)

CHLOROQUINE PHOSPHATE

TABS

500MG

T2

(ARALEN)

CHLOROQUINE PHOSPHATE

TABS

250MG

T2

(ARALEN)

DARAPRIM

TABS

25MG

T4

HYDROXYCHLOROQUINE SULFATE

TABS

200MG

T2

(PLAQUENIL)

MEFLOQUINE HCL

TABS

250MG

T2

(LARIAM)

(8:30.92) Anti-infective Agents » Antiprotozoals » Antiprotozoals, Miscellaneous Product Name

Form

Strength

Pref

ALINIA

TABS

500MG

T3

Coverage Details

Comment

MEPRON

SUSP

750MG/5ML

T3

METRONIDAZOLE

TABS

250MG

T2

(FLAGYL)

METRONIDAZOLE

TABS

500MG

T2

(FLAGYL)

Product Name

Form

Strength

Pref

NITROFURANTOIN MACROCRYSTALS

CAPS

50MG

T2

(MACRODANTIN)

NITROFURANTOIN MACROCRYSTALS

CAPS

100MG

T2

(MACRODANTIN)

NITROFURANTOIN MONOHYDRATE

CAPS

100MG

T2

(MACROBID)

TRIMETHOPRIM

TABS

100MG

T2

(TRIMPEX)

UROQID #2

TABS

500MG; 500MG

T3

(8:36) Anti-infective Agents » Urinary Anti-infectives Coverage Details

Comment

(12:04) Autonomic Drugs » Parasympathomimetic (Cholinergic) Agents Product Name

Form

Strength

Pref

BETHANECHOL CHLORIDE

TABS

25MG

T2

Coverage Details

Comment (URECHOLINE)

BETHANECHOL CHLORIDE

TABS

10MG

T2

(URECHOLINE)

BETHANECHOL CHLORIDE

TABS

50MG

T2

(URECHOLINE)

BETHANECHOL CHLORIDE

TABS

5MG

T2

(URECHOLINE)

DONEPEZIL HCL

TABS

5MG

T2

(ARICEPT)

DONEPEZIL HCL

TABS

10MG

T2

(ARICEPT)

DONEPEZIL HCL

TBDP

5MG

T2

(ARICEPT)

DONEPEZIL HCL

TBDP

10MG

T2

(ARICEPT)

GALANTAMINE HYDROBROMIDE

CP24

8MG

T2

(RAZADYNE ER)

GALANTAMINE HYDROBROMIDE

CP24

24MG

T2

(RAZADYNE ER)

GALANTAMINE HYDROBROMIDE

CP24

16MG

T2

(RAZADYNE ER)

GALANTAMINE HYDROBROMIDE

SOLN

4MG/ML

T2

(RAZADYNE)

GALANTAMINE HYDROBROMIDE

TABS

4MG

T2

(RAZADYNE)

398

GALANTAMINE HYDROBROMIDE

TABS

8MG

T2

(RAZADYNE)

GALANTAMINE HYDROBROMIDE

TABS

12MG

T2

(RAZADYNE)

GUANIDINE HCL

TABS

125MG

T4

MESTINON TIMESPAN

TBCR

180MG

T3

PILOCARPINE HYDROCHLORIDE

TABS

5MG

T2

(SALAGEN)

PYRIDOSTIGMINE BROMIDE

TABS

60MG

T2

(MESTINON)

(12:08.08) Autonomic Drugs » Anticholinergic Agents » Antimuscarinics/Antispasmodics Product Name

Form

Strength

Pref

Coverage Details

ATROVENT HFA

AERS

17MCG/ACT

T3

QL

Comment

CHLORDIAZEPOXIDE HCL/CLIDINIUM BROMIDE

CAPS

5MG; 2.5MG

T2

(LIBRAX)

DICYCLOMINE HCL

CAPS

10MG

T2

(BENTYL)

DICYCLOMINE HCL

TABS

20MG

T2

(BENTYL)

DICYCLOMINE HCL

SOLN

10MG/5ML

T2

(BENTYL)

GLYCOPYRROLATE

TABS

1MG

T2

(ROBINUL)

GLYCOPYRROLATE

TABS

2MG

T2

(ROBINUL)

HYOMAX-SL

SUBL

0.125MG

T2

(LEVSIN)

HYOSCYAMINE SULFATE

ELIX

0.125MG/5ML

T2

HYOSCYAMINE SULFATE

SOLN

0.125MG/ML

T2

HYOSCYAMINE SULFATE

TABS

0.125MG

T2

(LEVSIN)

HYOSCYAMINE SULFATE

SUBL

0.125MG

T2

(LEVSIN)

HYOSCYAMINE SULFATE ER

TB12

0.375MG

T2

(LEVBID)

HYOSCYAMINE SULFATE SR

TB12

0.375MG

T2

(LEVBID)

HYOSYNE

ELIX

0.125MG/5ML

T2

HYOSYNE

SOLN

0.125MG/ML

T2

QL

IPRATROPIUM BROMIDE

SOLN

0.03%

T2

QL

(ATROVENT NASAL)

IPRATROPIUM BROMIDE

SOLN

0.06%

T2

QL

(ATROVENT NASAL)

IPRATROPIUM BROMIDE

SOLN

0.02%

T2

QL

(ATROVENT NEB)

OSCIMIN SR

TB12

0.375MG

T2

(LEVBID)

PROPANTHELINE BROMIDE

TABS

15MG

T2

(PRO-BANTHINE)

SE-DONNA PB HYOS

ELIX

23%; 0.0194MG/5ML; 0.1037MG/5ML; 16.2MG/5ML; 0.0065MG/5ML

T2

QL

399

SPIRIVA HANDIHALER

CAPS

18MCG

T3

400

QL

(12:12.04) Autonomic Drugs » Sympathomimetic (Adrenergic) Agents » alpha-Adrenergic Agonists Product Name

Form

Strength

Pref

Coverage Details

Comment

MIDODRINE HCL

TABS

2.5MG

T2

(PRO-AMATINE)

MIDODRINE HCL

TABS

5MG

T2

(PRO-AMATINE)

MIDODRINE HCL

TABS

10MG

T2

(PRO-AMATINE)

(12:12.08.12) Autonomic Drugs » Sympathomimetic (Adrenergic) Agents » beta-Adrenergic Agonists » Selective beta-2-Adrenergic Agonists Product Name

Form

Strength

Pref

Coverage Details

ADVAIR DISKUS

AEPB

T4

QL

ADVAIR DISKUS

AEPB

T4

QL

ADVAIR DISKUS

AEPB

T4

QL

ADVAIR HFA

AERO

T4

QL

ADVAIR HFA

AERO

T4

QL

ADVAIR HFA

AERO

T4

QL

ALBUTEROL SULFATE

SYRP

100MCG/DOSE; 50MCG/DOSE 250MCG/DOSE; 50MCG/DOSE 500MCG/DOSE; 50MCG/DOSE 45MCG/ACT; 21MCG/ACT 115MCG/ACT; 21MCG/ACT 230MCG/ACT; 21MCG/ACT 2MG/5ML

Comment

T2

(VENTOLIN)

ALBUTEROL SULFATE

TABS

2MG

T2

(VENTOLIN)

ALBUTEROL SULFATE

TABS

4MG

T2

(VENTOLIN)

ALBUTEROL SULFATE

NEBU

0.083%

T2

QL

(VENTOLIN)

ALBUTEROL SULFATE

NEBU

0.5%

T2

QL

(VENTOLIN)

METAPROTERENOL SULFATE

TABS

10MG

T2

(ALUPENT)

METAPROTERENOL SULFATE

TABS

20MG

T2

(ALUPENT)

SEREVENT DISKUS

AEPB

50MCG/DOSE

T3

TERBUTALINE SULFATE

TABS

2.5MG

T2

TERBUTALINE SULFATE

TABS

5MG

T2

VENTOLIN HFA

AERS

108MCG/ACT

T3

QL (BRETHINE) (BRETHINE) QL

(12:12.12) Autonomic Drugs » Sympathomimetic (Adrenergic) Agents » alpha- and beta-Adrenergic Agonists Product Name

Form

Strength

Pref

Coverage Details

EPIPEN

DEVI

0.3MG/0.3ML

T3

QL

EPIPEN-JR

DEVI

0.15MG/0.3ML

T3

QL

Comment

(12:16.04.04) Autonomic Drugs » Sympatholytic (Adrenergic Blocking) Agents » alpha-Adrenergic Blocking Agents » Non-selective alpha-Adrenergic Blocking Agents Product Name

Form

Strength

Pref

Coverage Details

Comment

ERGOLOID MESYLATES

TABS

1MG

T2

(HYDERGINE)

401

(12:16.04.12) Autonomic Drugs » Sympatholytic (Adrenergic Blocking) Agents » alpha-Adrenergic Blocking Agents » Selective alpha-1-Adrenergic Blocking Agents Product Name

Form

Strength

Pref

ALFUZOSIN HCL ER

TB24

10MG

T2

Coverage Details

Comment (UROXATRAL)

TAMSULOSIN HCL

CAPS

0.4MG

T2

(FLOMAX)

(12:20.04) Autonomic Drugs » Skeletal Muscle Relaxants » Centrally Acting Skeletal Muscle Relaxants Product Name

Form

Strength

Pref

CARISOPRODOL

TABS

350MG

T2

Coverage Details

Comment

CYCLOBENZAPRINE HCL

TABS

10MG

T2

not cmpd or cod or 250mg (SOMA) not 5mg, (FLEXERIL)

METHOCARBAMOL

TABS

500MG

T2

(ROBAXIN)

METHOCARBAMOL

TABS

750MG

T2

(ROBAXIN)

TIZANIDINE HCL

TABS

2MG

T2

(ZANAFLEX)

TIZANIDINE HCL

TABS

4MG

T2

(ZANAFLEX)

(12:20.08) Autonomic Drugs » Skeletal Muscle Relaxants » Direct-acting Skeletal Muscle Relaxants Product Name

Form

Strength

Pref

DANTROLENE SODIUM

CAPS

50MG

T2

Coverage Details

Comment (DANTRIUM)

(12:20.12) Autonomic Drugs » Skeletal Muscle Relaxants » GABA-derivative Skeletal Muscle Relaxants Product Name

Form

Strength

Pref

BACLOFEN

TABS

10MG

T2

Coverage Details

Comment (LIORESAL)

BACLOFEN

TABS

20MG

T2

(LIORESAL)

(12:92) Autonomic Drugs » Autonomic Drugs, Miscellaneous Product Name

Form

Strength

Pref

Coverage Details

CHANTIX

TABS

0.5MG

T4

PA

CHANTIX CONTINUING MONTH PAK

TABS

1MG

T4

PA

NICOTROL INHALER

INHA

10MG

T3

PA; QL

Comment

(20:04.04) Blood Formation,Coagulation & Thrombosis » Antianemia Drugs » Iron Preparations Product Name

Form

Strength

Pref

FEROCON

CAPS

75MG; 15MCG; 110MG; 0.5MG; 240MG

T2

FEROTRINSIC

CAPS

75MG; 15MCG; 110MG; 0.5MG; 240MG

T2

Coverage Details

Comment

TL ICON

CAPS

75MG; 15MCG; 110MG; 0.5MG; 240MG

T2

TRICON

CAPS

75MG; 15MCG; 110MG; 0.5MG; 240MG

T2

402

(20:12.04.08) Blood Formation,Coagulation & Thrombosis » Antithrombotic Agents » Anticoagulants » Coumarin Derivatives Product Name

Form

Strength

Pref

JANTOVEN

TABS

1MG

T1

Coverage Details

Comment (COUMADIN)

JANTOVEN

TABS

3MG

T1

(COUMADIN)

JANTOVEN

TABS

4MG

T1

(COUMADIN)

JANTOVEN

TABS

5MG

T1

(COUMADIN)

WARFARIN SODIUM

TABS

1MG

T1

(COUMADIN)

WARFARIN SODIUM

TABS

2.5MG

T1

(COUMADIN)

WARFARIN SODIUM

TABS

5MG

T1

(COUMADIN)

WARFARIN SODIUM

TABS

7.5MG

T1

(COUMADIN)

WARFARIN SODIUM

TABS

10MG

T1

(COUMADIN)

WARFARIN SODIUM

TABS

2MG

T1

(COUMADIN)

WARFARIN SODIUM

TABS

4MG

T1

(COUMADIN)

WARFARIN SODIUM

TABS

3MG

T1

(COUMADIN)

WARFARIN SODIUM

TABS

6MG

T1

(COUMADIN)

(20:12.04.12) Blood Formation,Coagulation & Thrombosis » Antithrombotic Agents » Anticoagulants » Direct Thrombin Inhibitors Product Name

Form

Strength

Pref

Coverage Details

PRADAXA

CAPS

150MG

T4

PA

PRADAXA

CAPS

75MG

T4

PA

Comment

(20:12.04.14) Blood Formation,Coagulation & Thrombosis » Antithrombotic Agents » Anticoagulants » Direct Factor Xa Inhibitors Product Name

Form

Strength

Pref

Coverage Details

ELIQUIS

TABS

2.5MG

T3

PA

Comment

ELIQUIS

TABS

5MG

T3

PA

FONDAPARINUX SODIUM

SOLN

2.5MG/0.5ML

T6

PA

(ARIXTRA)

FONDAPARINUX SODIUM

SOLN

5MG/0.4ML

T6

PA

(ARIXTRA)

FONDAPARINUX SODIUM

SOLN

7.5MG/0.6ML

T6

PA

(ARIXTRA)

FONDAPARINUX SODIUM

SOLN

10MG/0.8ML

T6

PA

(ARIXTRA)

XARELTO

TABS

10MG

T3

PA

(20:12.04.16) Blood Formation,Coagulation & Thrombosis » Antithrombotic Agents » Anticoagulants » Heparins Product Name

Form

Strength

Pref

Coverage Details

Comment

ENOXAPARIN SODIUM

SOLN

30MG/0.3ML

T6

QL

(LOVENOX)

ENOXAPARIN SODIUM

SOLN

40MG/0.4ML

T6

QL

(LOVENOX)

ENOXAPARIN SODIUM

SOLN

60MG/0.6ML

T6

QL

(LOVENOX)

ENOXAPARIN SODIUM

SOLN

80MG/0.8ML

T6

QL

(LOVENOX)

ENOXAPARIN SODIUM

SOLN

100MG/ML

T6

QL

(LOVENOX)

ENOXAPARIN SODIUM

SOLN

120MG/0.8ML

T6

QL

(LOVENOX)

ENOXAPARIN SODIUM

SOLN

150MG/ML

T6

QL

(LOVENOX)

403

(20:12.14) Blood Formation,Coagulation & Thrombosis » Antithrombotic Agents » Platelet-reducing Agents Product Name

Form

Strength

Pref

ANAGRELIDE HYDROCHLORIDE

CAPS

1MG

T2

Coverage Details

Comment (AGRYLIN)

ANAGRELIDE HYDROCHLORIDE

CAPS

0.5MG

T2

(AGRYLIN)

(20:12.18) Blood Formation,Coagulation & Thrombosis » Antithrombotic Agents » Platelet-Aggregation Inhibitors Product Name

Form

Strength

Pref

AGGRENOX

CP12

25MG; 200MG

T3

Coverage Details

Comment

CILOSTAZOL

TABS

50MG

T2

(PLETAL)

CILOSTAZOL

TABS

100MG

T2

(PLETAL)

CLOPIDOGREL

TABS

75MG

T2

(PLAVIX)

TICLOPIDINE HCL

TABS

250MG

T2

for aspirin intolerant patients only, (TICLID)

(20:16) Blood Formation,Coagulation & Thrombosis » Hematopoietic Agents Product Name

Form

Strength

Pref

Coverage Details

ARANESP ALBUMIN FREE

SOLN

200MCG/ML

T5

PA

ARANESP ALBUMIN FREE

SOLN

300MCG/0.6ML

T5

PA

ARANESP ALBUMIN FREE

SOLN

40MCG/ML

T6

PA

ARANESP ALBUMIN FREE

SOLN

60MCG/ML

T6

PA

ARANESP ALBUMIN FREE

SOLN

100MCG/ML

T6

PA

ARANESP ALBUMIN FREE

SOLN

25MCG/0.42ML

T6

PA

NEULASTA

SOLN

6MG/0.6ML

T5

NEUMEGA

SOLR

5MG

T5

NEUPOGEN

SOLN

300MCG/ML

T5

NEUPOGEN

SOLN

480MCG/1.6ML

T5

PROCRIT

SOLN

2000UNIT/ML

T6

PA

PROCRIT

SOLN

3000UNIT/ML

T6

PA

PROCRIT

SOLN

4000UNIT/ML

T6

PA

Comment

PROCRIT

SOLN

10000UNIT/ML

T6

PA

PROCRIT

SOLN

20000UNIT/ML

T6

PA

PROCRIT

SOLN

40000UNIT/ML

T6

PA

PROMACTA

TABS

25MG

T5

PA

PROMACTA

TABS

50MG

T5

PA

PROMACTA

TABS

75MG

T5

PA

PROMACTA

TABS

12.5MG

T5

PA

Coverage Details

404

(20:24) Blood Formation,Coagulation & Thrombosis » Hemorrheologic Agents Product Name

Form

Strength

Pref

PENTOXIFYLLINE ER

TBCR

400MG

T2

Comment (TRENTAL)

(20:28.16) Blood Formation,Coagulation & Thrombosis » Antihemorrhagic Agents » Hemostatics Product Name

Form

Strength

Pref

AMINOCAPROIC ACID

SYRP

25%

T2

Coverage Details

Comment (AMICAR)

AMINOCAPROIC ACID

TABS

500MG

T2

(AMICAR)

AMINOCAPROIC ACID

TABS

1000MG

T2

(AMICAR)

(24:04.04.04) Cardiovascular Drugs » Cardiac Drugs » Antiarrhythmic Agents » Class Ia Antiarrhythmics Product Name

Form

Strength

Pref

DISOPYRAMIDE PHOSPHATE

CAPS

100MG

T2

Coverage Details

Comment (NORPACE)

DISOPYRAMIDE PHOSPHATE

CAPS

150MG

T2

(NORPACE)

NORPACE CR

CP12

100MG

T4

QUINIDINE GLUCONATE CR

TBCR

324MG

T2

QUINIDINE SULFATE

TABS

300MG

T2

QUINIDINE SULFATE

TABS

200MG

T2

QUINIDINE SULFATE ER

TBCR

300MG

T2

(QUINAGLUTE)

(24:04.04.08) Cardiovascular Drugs » Cardiac Drugs » Antiarrhythmic Agents » Class Ib Antiarrhythmics Product Name

Form

Strength

Pref

MEXILETINE HCL

CAPS

150MG

T2

Coverage Details

Comment (MEXITIL)

MEXILETINE HCL

CAPS

200MG

T2

(MEXITIL)

MEXILETINE HCL

CAPS

250MG

T2

(MEXITIL)

(24:04.04.12) Cardiovascular Drugs » Cardiac Drugs » Antiarrhythmic Agents » Class Ic Antiarrhythmics Product Name

Form

Strength

Pref

FLECAINIDE ACETATE

TABS

50MG

T2

Coverage Details

Comment (TAMBOCOR)

FLECAINIDE ACETATE

TABS

100MG

T2

(TAMBOCOR)

FLECAINIDE ACETATE

TABS

150MG

T2

(TAMBOCOR)

PROPAFENONE HCL

TABS

150MG

T2

not SR, (RYTHMOL)

PROPAFENONE HCL

TABS

300MG

T2

not SR, (RYTHMOL)

PROPAFENONE HCL

TABS

225MG

T2

not SR, (RYTHMOL)

(24:04.04.20) Cardiovascular Drugs » Cardiac Drugs » Antiarrhythmic Agents » Class III Antiarrhythmics Product Name

Form

Strength

Pref

AMIODARONE HCL

TABS

200MG

T2

TIKOSYN

CAPS

125MCG

T4

TIKOSYN

CAPS

250MCG

T4

TIKOSYN

CAPS

500MCG

T4

Coverage Details

Comment (CORDARONE)

(24:04.08) Cardiovascular Drugs » Cardiac Drugs » Cardiotonic Agents Product Name

Form

Strength

Pref

DIGOX

TABS

0.125MG

T1

Coverage Details

Comment (LANOXIN)

DIGOX

TABS

0.25MG

T1

(LANOXIN)

DIGOXIN

SOLN

0.05MG/ML

T1

(LANOXIN)

(24:04.92) Cardiovascular Drugs » Cardiac Drugs » Cardiac Drugs, Miscellaneous Product Name

Form

Strength

Pref

Coverage Details

RANEXA

TB12

500MG

T3

PA

RANEXA

TB12

1000MG

T3

PA

Comment

(24:06.04) Cardiovascular Drugs » Antilipemic Agents » Bile Acid Sequestrants Product Name

Form

Strength

Pref

Coverage Details

Comment

CHOLESTYRAMINE

POWD

4GM/DOSE

T2

QL

(QUESTRAN)

CHOLESTYRAMINE LIGHT

POWD

4GM/DOSE

T2

QL

(QUESTRAN LITE)

Coverage Details

Comment

Coverage Details

Comment

(24:06.05) Cardiovascular Drugs » Antilipemic Agents » Cholesterol Absorption Inhibitors Product Name

Form

Strength

Pref

ZETIA

TABS

10MG

T3

(24:06.06) Cardiovascular Drugs » Antilipemic Agents » Fibric Acid Derivatives Product Name

Form

Strength

Pref

FENOFIBRATE

TABS

145MG

T2

(TRICOR)

FENOFIBRATE

TABS

48MG

T2

(TRICOR)

FENOFIBRIC ACID DR

CPDR

45MG

T2

(TRILIPIX)

FENOFIBRIC ACID DR

CPDR

135MG

T2

(TRILIPIX)

GEMFIBROZIL

TABS

600MG

T2

(LOPID)

(24:06.08) Cardiovascular Drugs » Antilipemic Agents » HMG-CoA Reductase Inhibitors Product Name

Form

Strength

Pref

Coverage Details

Comment

405

ATORVASTATIN CALCIUM

TABS

10MG

T2

(LIPITOR)

ATORVASTATIN CALCIUM

TABS

20MG

T2

(LIPITOR)

ATORVASTATIN CALCIUM

TABS

40MG

T2

(LIPITOR)

ATORVASTATIN CALCIUM

TABS

80MG

T2

(LIPITOR)

CRESTOR

TABS

10MG

T3

CRESTOR

TABS

20MG

T3

CRESTOR

TABS

40MG

T3

CRESTOR

TABS

5MG

T3

LOVASTATIN

TABS

20MG

T1

(MEVACOR)

LOVASTATIN

TABS

40MG

T1

(MEVACOR)

LOVASTATIN

TABS

10MG

T1

(MEVACOR)

PRAVASTATIN SODIUM

TABS

10MG

T2

(PRAVACHOL)

PRAVASTATIN SODIUM

TABS

20MG

T2

(PRAVACHOL)

PRAVASTATIN SODIUM

TABS

40MG

T2

(PRAVACHOL)

PRAVASTATIN SODIUM

TABS

80MG

T2

(PRAVACHOL)

SIMVASTATIN

TABS

10MG

T2

(ZOCOR)

SIMVASTATIN

TABS

20MG

T2

(ZOCOR)

SIMVASTATIN

TABS

40MG

T2

(ZOCOR)

SIMVASTATIN

TABS

80MG

T2

(ZOCOR)

SIMVASTATIN

TABS

5MG

T2

(ZOCOR)

(24:06.92) Cardiovascular Drugs » Antilipemic Agents » Antilipemic Agents, Miscellaneous Product Name

Form

Strength

Pref

LOVAZA

CAPS

T3

NIACIN ER

TBCR

375MG; 465MG; 1GM 500MG

Coverage Details

Comment

T2

(NIASPAN)

NIACIN ER

TBCR

750MG

T2

(NIASPAN)

NIACIN ER

TBCR

1000MG

T2

(NIASPAN)

(24:08.16) Cardiovascular Drugs » Hypotensive Agents » Central Alpha-Agonists Product Name

Form

Strength

Pref

Coverage Details

Comment

CLONIDINE HCL

TABS

0.1MG

T1

(CATAPRES)

CLONIDINE HCL

TABS

0.2MG

T1

(CATAPRES)

CLONIDINE HCL

TABS

0.3MG

T2

(CATAPRES)

GUANFACINE HCL

TABS

1MG

T2

(TENEX)

GUANFACINE HCL

TABS

2MG

T2

(TENEX)

406

METHYLDOPA

TABS

250MG

T2

(ALDOMET)

METHYLDOPA

TABS

500MG

T2

(ALDOMET)

(24:08.20) Cardiovascular Drugs » Hypotensive Agents » Direct Vasodilators Product Name

Form

Strength

Pref

HYDRALAZINE HCL

TABS

10MG

T2

Coverage Details

Comment (APRESOLINE)

HYDRALAZINE HCL

TABS

25MG

T2

(APRESOLINE)

HYDRALAZINE HCL

TABS

50MG

T2

(APRESOLINE)

HYDRALAZINE HCL

TABS

100MG

T2

(APRESOLINE)

MINOXIDIL

TABS

2.5MG

T2

(LONITEN)

MINOXIDIL

TABS

10MG

T2

(LONITEN)

PROGLYCEM

SUSP

50MG/ML

T4

(24:08.32) Cardiovascular Drugs » Hypotensive Agents » Peripheral Adrenergic Inhibitors Product Name

Form

Strength

Pref

RESERPINE

TABS

0.1MG

T2

RESERPINE

TABS

0.25MG

T2

Coverage Details

Comment

Coverage Details

Comment

(24:12.08) Cardiovascular Drugs » Vasodilating Agents » Nitrates and Nitrites Product Name

Form

Strength

Pref

ISOSORBIDE DINITRATE

SUBL

2.5MG

T2

(ISORDIL)

ISOSORBIDE DINITRATE

TABS

5MG

T2

(ISORDIL)

ISOSORBIDE DINITRATE

TABS

10MG

T2

(ISORDIL)

ISOSORBIDE DINITRATE

TABS

20MG

T2

(ISORDIL)

ISOSORBIDE DINITRATE

TABS

30MG

T2

(ISORDIL)

ISOSORBIDE DINITRATE ER

TBCR

40MG

T2

(SORBITRATE)

ISOSORBIDE MONONITRATE ER

TB24

30MG

T2

(IMDUR)

ISOSORBIDE MONONITRATE ER

TB24

60MG

T2

(IMDUR)

ISOSORBIDE MONONITRATE ER

TB24

120MG

T2

(IMDUR)

NITRO-BID

OINT

2%

T2

NITRO-TIME

CPCR

6.5MG

T2

NITROGLYCERIN

PT24

0.4MG/HR

T2

(MINITRAN)

NITROGLYCERIN

PT24

0.6MG/HR

T2

(MINITRAN)

NITROGLYCERIN ER

CPCR

2.5MG

T2

NITROGLYCERIN ER

CPCR

6.5MG

T2

NITROGLYCERIN ER

CPCR

9MG

T2

QL

407

NITROGLYCERIN TRANSDERMAL

PT24

0.1MG/HR

T2

(MINITRAN)

NITROGLYCERIN TRANSDERMAL

PT24

0.2MG/HR

T2

(MINITRAN)

NITROGLYCERIN TRANSDERMAL

PT24

0.6MG/HR

T2

(MINITRAN)

NITROSTAT

SUBL

0.3MG

T3

NITROSTAT

SUBL

0.4MG

T3

NITROSTAT

SUBL

0.6MG

T3

(24:12.12) Cardiovascular Drugs » Vasodilating Agents » Phosphodiesterase Type 5 Inhibitors Product Name

Form

Strength

Pref

Coverage Details

Comment

SILDENAFIL CITRATE

TABS

20MG

T5

PA

(REVATIO)

Coverage Details

Comment

(24:12.92) Cardiovascular Drugs » Vasodilating Agents » Vasodilating Agents, Miscellaneous Product Name

Form

Strength

Pref

DIPYRIDAMOLE

TABS

25MG

T2

(PERSANTINE)

DIPYRIDAMOLE

TABS

50MG

T2

(PERSANTINE)

DIPYRIDAMOLE

TABS

75MG

T2

(PERSANTINE)

TRACLEER

TABS

62.5MG

T5

PA

TRACLEER

TABS

125MG

T5

PA

Coverage Details

(24:20) Cardiovascular Drugs » alpha-Adrenergic Blocking Agents Product Name

Form

Strength

Pref

DOXAZOSIN MESYLATE

TABS

1MG

T1

Comment not XL, (CARDURA)

DOXAZOSIN MESYLATE

TABS

2MG

T1

not XL, (CARDURA)

DOXAZOSIN MESYLATE

TABS

4MG

T1

not XL, (CARDURA)

DOXAZOSIN MESYLATE

TABS

8MG

T1

not XL, (CARDURA)

PRAZOSIN HCL

CAPS

1MG

T2

(MINIPRESS)

PRAZOSIN HCL

CAPS

2MG

T2

(MINIPRESS)

PRAZOSIN HCL

CAPS

5MG

T2

(MINIPRESS)

TERAZOSIN HCL

CAPS

10MG

T1

(HYTRIN)

TERAZOSIN HCL

CAPS

2MG

T1

(HYTRIN)

TERAZOSIN HCL

CAPS

5MG

T1

(HYTRIN)

TERAZOSIN HCL

CAPS

1MG

T1

(HYTRIN)

(24:24) Cardiovascular Drugs » beta-Adrenergic Blocking Agents Product Name

Form

Strength

Pref

Coverage Details

Comment

ACEBUTOLOL HCL

CAPS

200MG

T2

(SECTRAL)

ACEBUTOLOL HCL

CAPS

400MG

T2

(SECTRAL)

ATENOLOL

TABS

25MG

T1

(TENORMIN)

408

ATENOLOL

TABS

50MG

T1

(TENORMIN)

ATENOLOL

TABS

100MG

T1

(TENORMIN)

CARVEDILOL

TABS

3.125MG

T1

(COREG)

CARVEDILOL

TABS

6.25MG

T1

(COREG)

CARVEDILOL

TABS

12.5MG

T1

(COREG)

CARVEDILOL

TABS

25MG

T1

(COREG)

COREG CR

CP24

10MG

T3

COREG CR

CP24

20MG

T3

COREG CR

CP24

40MG

T3

COREG CR

CP24

80MG

T3

LABETALOL HCL

TABS

100MG

T2

(TRANDATE)

LABETALOL HCL

TABS

200MG

T2

(TRANDATE)

LABETALOL HCL

TABS

300MG

T2

(TRANDATE)

METOPROLOL TARTRATE

TABS

50MG

T1

not HCT, (LOPRESSOR)

METOPROLOL TARTRATE

TABS

100MG

T1

not HCT, (LOPRESSOR)

METOPROLOL TARTRATE

TABS

25MG

T1

not HCT, (LOPRESSOR)

PROPRANOLOL HCL

TABS

10MG

T1

not LA, (INDERAL)

PROPRANOLOL HCL

TABS

20MG

T1

not LA, (INDERAL)

PROPRANOLOL HCL

TABS

80MG

T1

not LA, (INDERAL)

PROPRANOLOL HCL

TABS

40MG

T1

not LA, (INDERAL)

PROPRANOLOL HCL

TABS

60MG

T1

not LA, (INDERAL)

PROPRANOLOL HCL

SOLN

20MG/5ML

T2

(INDERAL)

PROPRANOLOL HCL

SOLN

40MG/5ML

T2

(INDERAL)

PROPRANOLOL/HYDROCHLOROTHIAZIDE

TABS

25MG; 80MG

T2

(INDERIDE)

PROPRANOLOL/HYDROCHLOROTHIAZIDE

TABS

25MG; 40MG

T2

(INDERIDE)

SOTALOL HCL

TABS

120MG

T2

(BETAPACE)

SOTALOL HCL

TABS

80MG

T2

(BETAPACE)

SOTALOL HCL

TABS

160MG

T2

(BETAPACE)

SOTALOL HCL

TABS

240MG

T2

(BETAPACE)

(24:28.08) Cardiovascular Drugs » Calcium-Channel Blocking Agents » Dihydropyridines Product Name

Form

Strength

Pref

AFEDITAB CR

TB24

30MG

T2

Coverage Details

Comment (ADALAT CC)

AFEDITAB CR

TB24

60MG

T2

(ADALAT CC)

409

AMLODIPINE BESYLATE

TABS

2.5MG

T2

(NORVASC)

AMLODIPINE BESYLATE

TABS

5MG

T2

(NORVASC)

AMLODIPINE BESYLATE

TABS

10MG

T2

(NORVASC)

NIFEDIAC CC

TB24

60MG

T2

(ADALAT CC)

NIFEDIAC CC

TB24

90MG

T2

(ADALAT CC)

NIFEDIAC CC

TB24

30MG

T2

(ADALAT CC)

NIFEDIPINE

CAPS

10MG

T2

not XL, (PROCARDIA)

NIFEDIPINE

CAPS

20MG

T2

not XL, (PROCARDIA)

NIFEDIPINE ER

TB24

90MG

T2

(ADALAT CC)

NIFEDIPINE ER

TB24

30MG

T2

(ADALAT CC)

NIFEDIPINE ER

TB24

60MG

T2

(ADALAT CC)

NIMODIPINE

CAPS

30MG

T4

(24:28.92) Cardiovascular Drugs » Calcium-Channel Blocking Agents » Calcium-Channel Blocking Agents, Misc Product Name

Form

Strength

Pref

DILTIAZEM CD

CP24

180MG

T2

Coverage Details

Comment not 360, (CARDIZEM CD)

DILTIAZEM CD

CP24

240MG

T2

not 360, (CARDIZEM CD)

DILTIAZEM CD

CP24

300MG

T2

not 360, (CARDIZEM CD)

DILTIAZEM CD

CP24

120MG

T2

not 360, (CARDIZEM CD)

DILTIAZEM HCL

TABS

30MG

T2

not SR, (CARDIZEM)

DILTIAZEM HCL

TABS

60MG

T2

not SR, (CARDIZEM)

DILTIAZEM HCL

TABS

90MG

T2

not SR, (CARDIZEM)

DILTIAZEM HCL

TABS

120MG

T2

not SR, (CARDIZEM)

DILTIAZEM HCL ER

CP24

240MG

T2

not 360, (CARDIZEM CD)

VERAPAMIL HCL

TABS

80MG

T2

(CALAN)

VERAPAMIL HCL

TABS

120MG

T2

(CALAN)

VERAPAMIL HCL

TABS

40MG

T2

(CALAN)

VERAPAMIL HCL ER

TBCR

240MG

T2

(CALAN-SR)

VERAPAMIL HCL ER

TBCR

120MG

T2

(CALAN-SR)

VERAPAMIL HCL ER

TBCR

180MG

T2

(CALAN-SR)

(24:32.04) Cardiovascular Drugs » Renin-Angiotensin-Aldosterone Sys Inhib » Angiotensin-Converting Enzyme Inhibitors Product Name

Form

Strength

Pref

Coverage Details

Comment

BENAZEPRIL HCL

TABS

40MG

T1

not HCT, (LOTENSIN)

BENAZEPRIL HCL

TABS

10MG

T1

not HCT, (LOTENSIN)

410

BENAZEPRIL HCL

TABS

5MG

T1

not HCT, (LOTENSIN)

BENAZEPRIL HCL

TABS

20MG

T1

not HCT, (LOTENSIN)

CAPTOPRIL

TABS

12.5MG

T1

(CAPOTEN)

CAPTOPRIL

TABS

50MG

T1

(CAPOTEN)

CAPTOPRIL

TABS

100MG

T1

(CAPOTEN)

CAPTOPRIL

TABS

25MG

T1

(CAPOTEN)

CAPTOPRIL/HYDROCHLOROTHIAZIDE

TABS

25MG; 15MG

T2

(CAPOZIDE)

CAPTOPRIL/HYDROCHLOROTHIAZIDE

TABS

50MG; 15MG

T2

(CAPOZIDE)

ENALAPRIL MALEATE

TABS

2.5MG

T1

(VASOTEC)

ENALAPRIL MALEATE

TABS

20MG

T1

(VASOTEC)

ENALAPRIL MALEATE

TABS

5MG

T1

(VASOTEC)

ENALAPRIL MALEATE

TABS

10MG

T1

(VASOTEC)

FOSINOPRIL SODIUM

TABS

10MG

T2

not HCT, (MONOPRIL)

FOSINOPRIL SODIUM

TABS

20MG

T2

not HCT, (MONOPRIL)

FOSINOPRIL SODIUM

TABS

40MG

T2

not HCT, (MONOPRIL)

LISINOPRIL

TABS

5MG

T1

(PRINIVIL)

LISINOPRIL

TABS

10MG

T1

(PRINIVIL)

LISINOPRIL

TABS

20MG

T1

(PRINIVIL)

LISINOPRIL

TABS

40MG

T1

(PRINIVIL)

LISINOPRIL

TABS

2.5MG

T1

(PRINIVIL)

LISINOPRIL

TABS

30MG

T2

(ZESTRIL)

RAMIPRIL

CAPS

1.25MG

T2

(ALTACE)

RAMIPRIL

CAPS

2.5MG

T2

(ALTACE)

RAMIPRIL

CAPS

5MG

T2

(ALTACE)

RAMIPRIL

CAPS

10MG

T2

(ALTACE)

(24:32.08) Cardiovascular Drugs » Renin-Angiotensin-Aldosterone Sys Inhib » Angiotensin II Receptor Antagonists Product Name

Form

Strength

Pref

Coverage Details

Comment

DIOVAN

TABS

80MG

T3

not HCT

DIOVAN

TABS

160MG

T3

not HCT

DIOVAN

TABS

320MG

T3

not HCT

DIOVAN

TABS

40MG

T3

not HCT

LOSARTAN POTASSIUM

TABS

25MG

T2

(COZAAR)

LOSARTAN POTASSIUM

TABS

50MG

T2

(COZAAR)

411

LOSARTAN POTASSIUM

TABS

100MG

T2

(COZAAR)

MICARDIS

TABS

20MG

T3

not HCT

MICARDIS

TABS

40MG

T3

not HCT

MICARDIS

TABS

80MG

T3

not HCT

(24:32.20) Cardiovascular Drugs » Renin-Angiotensin-Aldosterone Sys Inhib » Mineralocorticoid (Aldost) Recept Antag Product Name

Form

Strength

Pref

SPIRONOLACTONE

TABS

25MG

T2

Coverage Details

Comment (ALDACTONE)

SPIRONOLACTONE

TABS

50MG

T2

(ALDACTONE)

SPIRONOLACTONE/HYDROCHLOROTHIAZIDE

TABS

25MG; 25MG

T2

(ALDACTAZIDE)

(24:32.40) Cardiovascular Drugs » Renin-Angiotensin-Aldosterone Sys Inhib » Renin Inhibitors Product Name

Form

Strength

Pref

Coverage Details

TEKTURNA

TABS

150MG

T4

ST

TEKTURNA

TABS

300MG

T4

ST

Comment

(28:08.04.24) Central Nervous System Agents » Analgesics and Antipyretics » Nonsteroidal Anti-inflammatory Agents » Salicylates Product Name

Form

Strength

Pref

Coverage Details

Comment

BUTALBITAL COMPOUND

TABS

T2

(FIORINAL)

BUTALBITAL/ASPIRIN/CAFFEINE

TABS

T2

(FIORINAL)

SALSALATE

TABS

325MG; 50MG; 40MG 325MG; 50MG; 40MG 500MG

T2

(DISALCID)

SALSALATE

TABS

750MG

T2

(DISALCID)

(28:08.04.92) Central Nervous System Agents » Analgesics and Antipyretics » Nonsteroidal Anti-inflammatory Agents » Other Nonsteroidal Antiinflammatory Agents Product Name

Form

Strength

Pref

DICLOFENAC SODIUM DR

TBEC

50MG

T2

Coverage Details

Comment not XR, (VOLTAREN)

DICLOFENAC SODIUM DR

TBEC

75MG

T2

not XR, (VOLTAREN)

DICLOFENAC SODIUM DR

TBEC

25MG

T2

not XR, (VOLTAREN)

ETODOLAC

TABS

400MG

T2

(LODINE)

ETODOLAC

TABS

500MG

T2

(LODINE)

ETODOLAC

CAPS

200MG

T2

(LODINE)

ETODOLAC

CAPS

300MG

T2

(LODINE)

ETODOLAC ER

TB24

600MG

T2

(LODINE XL)

ETODOLAC ER

TB24

400MG

T2

(LODINE XL)

ETODOLAC ER

TB24

500MG

T2

(LODINE XL)

FENOPROFEN CALCIUM

TABS

600MG

T2

(NALFON)

412

IBUPROFEN

TABS

400MG

T1

(MOTRIN)

IBUPROFEN

TABS

600MG

T1

(MOTRIN)

IBUPROFEN

TABS

800MG

T1

(MOTRIN)

INDOMETHACIN

CAPS

25MG

T2

(INDOCIN)

INDOMETHACIN

CAPS

50MG

T2

(INDOCIN)

INDOMETHACIN ER

CPCR

75MG

T2

(INDOCIN-SR)

KETOPROFEN

CAPS

50MG

T2

KETOPROFEN

CAPS

75MG

T2

KETOROLAC TROMETHAMINE

TABS

10MG

T2

not 25mg or ER 200mg, (ORUDIS) not 25mg or ER 200mg, (ORUDIS) (TORADOL)

MECLOFENAMATE SODIUM

CAPS

50MG

T2

(MECLOMEN)

MECLOFENAMATE SODIUM

CAPS

100MG

T2

(MECLOMEN)

MELOXICAM

TABS

7.5MG

T1

(MOBIC)

MELOXICAM

TABS

15MG

T1

(MOBIC)

MELOXICAM

SUSP

7.5MG/5ML

T2

NABUMETONE

TABS

500MG

T2

(RELAFEN)

NABUMETONE

TABS

750MG

T2

(RELAFEN)

NAPROXEN

TABS

500MG

T1

(NAPROSYN)

NAPROXEN

TABS

375MG

T1

(NAPROSYN)

NAPROXEN

SUSP

125MG/5ML

T2

(NAPROSYN)

NAPROXEN

TABS

250MG

T2

(NAPROSYN)

NAPROXEN SODIUM

TABS

550MG

T2

(ANAPROX-DS)

OXAPROZIN

TABS

600MG

T2

(DAYPRO)

PIROXICAM

CAPS

10MG

T2

(FELDENE)

PIROXICAM

CAPS

20MG

T2

(FELDENE)

SULINDAC

TABS

200MG

T2

(CLINORIL)

SULINDAC

TABS

150MG

T2

(CLINORIL)

QL

QL

(MOBIC)

(28:08.08) Central Nervous System Agents » Analgesics and Antipyretics » Opiate Agonists Product Name

Form

Strength

Pref

Coverage Details

Comment

ACETAMINOPHEN/CODEINE

TABS

300MG; 15MG

T2

(TYLENOL W/CODEINE)

ACETAMINOPHEN/CODEINE

TABS

300MG; 60MG

T2

(TYLENOL W/CODEINE)

ACETAMINOPHEN/CODEINE

SOLN

T2

(TYLENOL W/CODEINE)

ACETAMINOPHEN/CODEINE #3

TABS

120MG/5ML; 12MG/5ML 300MG; 30MG

T2

(TYLENOL W/CODEINE)

413

ASCOMP/CODEINE

CAPS

BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE

CAPS

CODEINE SULFATE

414

T2

(FIORINAL W/CODEINE)

T2

(FIORINAL W/CODEINE)

TABS

325MG; 50MG; 40MG; 30MG 325MG; 50MG; 40MG; 30MG 15MG

CODEINE SULFATE

TABS

30MG

T2

DILAUDID

LIQD

1MG/ML

T3

FENTANYL

PT72

12MCG/HR

T2

PA

(DURAGESIC)

FENTANYL

PT72

75MCG/HR

T2

PA

(DURAGESIC)

FENTANYL

PT72

100MCG/HR

T2

PA

(DURAGESIC)

FENTANYL

PT72

25MCG/HR

T2

PA

(DURAGESIC)

FENTANYL

PT72

50MCG/HR

T2

PA

(DURAGESIC)

HYDROCODONE/ACETAMINOPHEN

TABS

325MG; 5MG

T2

(NORCO)

HYDROCODONE/ACETAMINOPHEN

TABS

325MG; 7.5MG

T2

(NORCO)

HYDROCODONE/ACETAMINOPHEN

TABS

325MG; 10MG

T2

(NORCO)

HYDROCODONE/ACETAMINOPHEN

TABS

660MG; 10MG

T2

old formulation, (VICODIN HP)

HYDROCODONE/ACETAMINOPHEN

TABS

500MG; 5MG

T2

old formulation, (VICODIN)

HYDROCODONE/ACETAMINOPHEN

TABS

750MG; 7.5MG

T2

old formulation, (VICODIN-ES)

HYDROMORPHONE HCL

TABS

4MG

T2

(DILAUDID)

HYDROMORPHONE HCL

TABS

8MG

T2

(DILAUDID)

HYDROMORPHONE HCL

TABS

2MG

T2

(DILAUDID)

MEPERIDINE HCL

TABS

100MG

T2

(DEMEROL)

MEPERIDINE HCL

TABS

50MG

T2

(DEMEROL)

MEPERITAB

TABS

50MG

T2

(DEMEROL)

MEPERITAB

TABS

100MG

T2

(DEMEROL)

METHADONE HCL

SOLN

5MG/5ML

T2

(DOLOPHINE)

METHADONE HCL

TABS

5MG

T2

(DOLOPHINE)

METHADONE HCL

TABS

10MG

T2

(DOLOPHINE)

METHADOSE

TABS

10MG

T2

(DOLOPHINE)

MORPHINE SULFATE

TABS

15MG

T2

(MSIR)

MORPHINE SULFATE

TABS

30MG

T2

(MSIR)

MORPHINE SULFATE

SOLN

10MG/5ML

T2

(ROXANOL)

MORPHINE SULFATE

SOLN

20MG/5ML

T2

(ROXANOL)

MORPHINE SULFATE

SOLN

20MG/ML

T2

(ROXANOL)

T2

MORPHINE SULFATE

SOLN

100MG/5ML

T2

(ROXANOL)

MORPHINE SULFATE ER

TBCR

15MG

T2

(MS CONTIN)

MORPHINE SULFATE ER

TBCR

30MG

T2

(MS CONTIN)

MORPHINE SULFATE ER

TBCR

60MG

T2

(MS CONTIN)

MORPHINE SULFATE ER

TBCR

100MG

T2

(MS CONTIN)

MORPHINE SULFATE ER

TBCR

200MG

T2

(MS CONTIN)

OXYCODONE/ACETAMINOPHEN

TABS

325MG; 5MG

T2

(PERCOCET)

OXYCODONE/ACETAMINOPHEN

CAPS

500MG; 5MG

T2

(TYLOX)

ROXICET

SOLN

T2

ROXICET

TABS

325MG/5ML; 5MG/5ML 325MG; 5MG

T2

(PERCOCET)

TRAMADOL HCL

TABS

50MG

T2

(ULTRAM)

(28:08.12) Central Nervous System Agents » Analgesics and Antipyretics » Opiate Partial Agonists Product Name

Form

Strength

Pref

Coverage Details

Comment

BUPRENORPHINE HCL

SUBL

2MG

T2

PA

(SUBUTEX)

BUPRENORPHINE HCL

SUBL

8MG

T2

PA

(SUBUTEX)

BUPRENORPHINE HCL/NALOXONE HCL

SUBL

8MG; 2MG

T2

PA

(SUBOXONE)

BUPRENORPHINE HCL/NALOXONE HCL

SUBL

2MG; 0.5MG

T2

PA

(SUBOXONE)

SUBOXONE

FILM

2MG; 0.5MG

T4

PA

SUBOXONE

FILM

4MG; 1MG

T4

PA

SUBOXONE

FILM

8MG; 2MG

T4

PA

SUBOXONE

FILM

12MG; 3MG

T4

PA

(28:08.92) Central Nervous System Agents » Analgesics and Antipyretics » Analgesics and Antipyretics, Misc Product Name

Form

Strength

Pref

BUTALBITAL/ACETAMINOPHEN/CAFFEINE

TABS

325MG; 50MG; 40MG

T2

Coverage Details

Comment (FIORICET)

(28:10) Central Nervous System Agents » Opiate Antagonists Product Name

Form

Strength

Pref

NALTREXONE HCL

TABS

50MG

T2

Coverage Details

Comment (REVIA)

(28:12.04) Central Nervous System Agents » Anticonvulsants » Barbiturates Product Name

Form

Strength

Pref

PRIMIDONE

TABS

250MG

T2

Coverage Details

Comment (MYSOLINE)

PRIMIDONE

TABS

50MG

T2

(MYSOLINE)

(28:12.08) Central Nervous System Agents » Anticonvulsants » Benzodiazepines Product Name

Form

Strength

Pref

Coverage Details

Comment

415

CLONAZEPAM

TABS

0.5MG

T2

(KLONOPIN)

CLONAZEPAM

TABS

1MG

T2

(KLONOPIN)

CLONAZEPAM

TABS

2MG

T2

(KLONOPIN)

CLONAZEPAM ODT

TBDP

0.125MG

T2

(KLONOPIN)

CLONAZEPAM ODT

TBDP

0.25MG

T2

(KLONOPIN)

CLONAZEPAM ODT

TBDP

0.5MG

T2

(KLONOPIN)

ONFI

TABS

5MG

T4

PA

ONFI

TABS

10MG

T4

PA

ONFI

TABS

20MG

T4

PA

Coverage Details

(28:12.12) Central Nervous System Agents » Anticonvulsants » Hydantoins Product Name

Form

Strength

Pref

DILANTIN

CAPS

30MG

T3

Comment

PEGANONE

TABS

250MG

T4

PHENYTOIN

SUSP

125MG/5ML

T2

(DILANTIN)

PHENYTOIN INFATABS

CHEW

50MG

T2

(DILANTIN)

PHENYTOIN SODIUM EXTENDED

CAPS

100MG

T2

(DILANTIN)

(28:12.20) Central Nervous System Agents » Anticonvulsants » Succinimides Product Name

Form

Strength

Pref

CELONTIN

CAPS

300MG

T4

Coverage Details

Comment

ETHOSUXIMIDE

SOLN

250MG/5ML

T2

(ZARONTIN)

ETHOSUXIMIDE

CAPS

250MG

T2

(ZARONTIN)

(28:12.92) Central Nervous System Agents » Anticonvulsants » Anticonvulsants, Miscellaneous Product Name

Form

Strength

Pref

Coverage Details

BANZEL

TABS

400MG

T4

PA

Comment

BANZEL

SUSP

40MG/ML

T4

PA

CARBAMAZEPINE

TABS

200MG

T2

not XR (TEGRETOL)

CARBAMAZEPINE

CHEW

100MG

T2

not XR (TEGRETOL)

CARBAMAZEPINE

SUSP

100MG/5ML

T2

not XR (TEGRETOL)

DIVALPROEX SODIUM

CPSP

125MG

T2

(DEPAKOTE SPRINKLES)

DIVALPROEX SODIUM DR

TBEC

125MG

T2

(DEPAKOTE)

DIVALPROEX SODIUM DR

TBEC

250MG

T2

(DEPAKOTE)

DIVALPROEX SODIUM DR

TBEC

500MG

T2

(DEPAKOTE)

DIVALPROEX SODIUM ER

TB24

250MG

T2

(DEPAKOTE ER)

416

417

DIVALPROEX SODIUM ER

TB24

500MG

T2

(DEPAKOTE ER)

FELBAMATE

SUSP

600MG/5ML

T2

(FELBATOL)

FELBAMATE

TABS

400MG

T2

(FELBATOL)

FELBAMATE

TABS

600MG

T2

(FELBATOL)

GABAPENTIN

TABS

600MG

T2

(NEURONTIN)

GABAPENTIN

CAPS

100MG

T2

(NEURONTIN)

GABAPENTIN

TABS

800MG

T2

(NEURONTIN)

GABAPENTIN

CAPS

300MG

T2

(NEURONTIN)

GABAPENTIN

CAPS

400MG

T2

(NEURONTIN)

GABAPENTIN

SOLN

250MG/5ML

T2

(NEURONTIN)

GABITRIL

TABS

16MG

T4

LAMOTRIGINE

TABS

25MG

T2

not XR or ODT, (LAMICTAL)

LAMOTRIGINE

CHEW

25MG

T2

not XR or ODT, (LAMICTAL)

LAMOTRIGINE

TABS

100MG

T2

not XR or ODT, (LAMICTAL)

LAMOTRIGINE

TABS

150MG

T2

not XR or ODT, (LAMICTAL)

LAMOTRIGINE

TABS

200MG

T2

not XR or ODT, (LAMICTAL)

LAMOTRIGINE

CHEW

5MG

T2

not XR or ODT, (LAMICTAL)

LEVETIRACETAM

SOLN

100MG/ML

T2

(KEPPRA)

LEVETIRACETAM

TABS

500MG

T2

(KEPPRA)

LEVETIRACETAM

TABS

750MG

T2

(KEPPRA)

LEVETIRACETAM

TABS

250MG

T2

(KEPPRA)

LEVETIRACETAM

TABS

1000MG

T2

(KEPPRA)

LEVETIRACETAM ER

TB24

750MG

T2

(KEPPRA ER)

LEVETIRACETAM ER

TB24

500MG

T2

LYRICA

SOLN

20MG/ML

T4

PA

LYRICA

CAPS

25MG

T4

PA; QL

LYRICA

CAPS

50MG

T4

PA; QL

LYRICA

CAPS

75MG

T4

PA; QL

LYRICA

CAPS

100MG

T4

PA; QL

LYRICA

CAPS

150MG

T4

PA; QL

LYRICA

CAPS

200MG

T4

PA; QL

LYRICA

CAPS

300MG

T4

PA; QL

LYRICA

CAPS

225MG

T4

PA; QL

(KEPPRA ER)

OXCARBAZEPINE

TABS

150MG

T2

(TRILEPTAL)

OXCARBAZEPINE

TABS

300MG

T2

(TRILEPTAL)

OXCARBAZEPINE

TABS

600MG

T2

(TRILEPTAL)

OXCARBAZEPINE

SUSP

60MG/ML

T2

(TRILEPTAL)

POTIGA

TABS

50MG

T4

POTIGA

TABS

200MG

T4

POTIGA

TABS

300MG

T4

POTIGA

TABS

400MG

T4

SABRIL

TABS

500MG

T4

PA

SABRIL

PACK

500MG

T4

PA

TIAGABINE HYDROCHLORIDE

TABS

2MG

T2

(GABITRIL)

TIAGABINE HYDROCHLORIDE

TABS

4MG

T2

(GABITRIL)

TOPIRAMATE

CPSP

15MG

T2

(TOPAMAX)

TOPIRAMATE

CPSP

25MG

T2

(TOPAMAX)

TOPIRAMATE

TABS

200MG

T2

(TOPAMAX)

TOPIRAMATE

TABS

25MG

T2

(TOPAMAX)

TOPIRAMATE

TABS

50MG

T2

(TOPAMAX)

TOPIRAMATE

TABS

100MG

T2

(TOPAMAX)

VALPROIC ACID

SYRP

250MG/5ML

T2

(DEPAKENE)

VALPROIC ACID

CAPS

250MG

T2

(DEPAKENE)

VIMPAT

TABS

50MG

T4

PA

VIMPAT

TABS

100MG

T4

PA

VIMPAT

TABS

150MG

T4

PA

VIMPAT

TABS

200MG

T4

PA

VIMPAT

SOLN

10MG/ML

T4

PA

ZONISAMIDE

CAPS

25MG

T2

(ZONEGRAN)

ZONISAMIDE

CAPS

50MG

T2

(ZONEGRAN)

ZONISAMIDE

CAPS

100MG

T2

(ZONEGRAN)

(28:16.04.12) Central Nervous System Agents » Psychotherapeutic Agents » Antidepressants » Monoamine Oxidase Inhibitors Product Name

Form

Strength

Pref

MARPLAN

TABS

10MG

T4

Coverage Details

Comment

PHENELZINE SULFATE

TABS

15MG

T2

(NARDIL)

TRANYLCYPROMINE SULFATE

TABS

10MG

T2

(PARNATE)

418

419 (28:16.04.16) Central Nervous System Agents » Psychotherapeutic Agents » Antidepressants » Selective Serotonin- and Norepinephrine-reuptake Inhibitors Product Name

Form

Strength

Pref

Coverage Details

Comment

DESVENLAFAXINE ER

TB24

50MG

T2

DESVENLAFAXINE ER

TB24

100MG

T2

DULOXETINE HCL

CPEP

20MG

T2

(CYMBALTA)

DULOXETINE HCL

CPEP

30MG

T2

(CYMBALTA)

DULOXETINE HCL

CPEP

60MG

T2

(CYMBALTA)

PRISTIQ

TB24

50MG

T3

PRISTIQ

TB24

100MG

T3

VENLAFAXINE HCL

TABS

75MG

T2

(EFFEXOR)

VENLAFAXINE HCL

TABS

100MG

T2

(EFFEXOR)

VENLAFAXINE HCL

TABS

25MG

T2

(EFFEXOR)

VENLAFAXINE HCL

TABS

37.5MG

T2

(EFFEXOR)

VENLAFAXINE HCL

TABS

50MG

T2

(EFFEXOR)

VENLAFAXINE HCL ER

CP24

37.5MG

T2

(EFFEXOR)

VENLAFAXINE HCL ER

CP24

75MG

T2

(EFFEXOR)

VENLAFAXINE HCL ER

CP24

150MG

T2

(EFFEXOR)

(28:16.04.20) Central Nervous System Agents » Psychotherapeutic Agents » Antidepressants » Selective Serotonin-reuptake Inhibitors Product Name

Form

Strength

Pref

CITALOPRAM HYDROBROMIDE

SOLN

10MG/5ML

T1

Coverage Details

Comment (CELEXA)

CITALOPRAM HYDROBROMIDE

TABS

10MG

T1

(CELEXA)

CITALOPRAM HYDROBROMIDE

TABS

20MG

T1

(CELEXA)

CITALOPRAM HYDROBROMIDE

TABS

40MG

T1

(CELEXA)

ESCITALOPRAM OXALATE

TABS

5MG

T2

(LEXAPRO)

ESCITALOPRAM OXALATE

TABS

10MG

T2

(LEXAPRO)

ESCITALOPRAM OXALATE

TABS

20MG

T2

(LEXAPRO)

ESCITALOPRAM OXALATE

SOLN

5MG/5ML

T2

(LEXAPRO)

FLUOXETINE HCL

CAPS

10MG

T1

not 40mg, (PROZAC)

FLUOXETINE HCL

CAPS

20MG

T1

not 40mg, (PROZAC)

FLUOXETINE HCL

SOLN

20MG/5ML

T2

(PROZAC)

FLUVOXAMINE MALEATE

TABS

25MG

T2

not CR, (LUVOX)

FLUVOXAMINE MALEATE

TABS

50MG

T2

not CR, (LUVOX)

FLUVOXAMINE MALEATE

TABS

100MG

T2

not CR, (LUVOX)

PAROXETINE HCL

TABS

10MG

T2

(PAXIL)

PAROXETINE HCL

TABS

20MG

T2

(PAXIL)

PAROXETINE HCL

TABS

30MG

T2

(PAXIL)

PAROXETINE HCL

TABS

40MG

T2

(PAXIL)

PAROXETINE HCL ER

TB24

12.5MG

T2

(PAXIL CR)

PAROXETINE HCL ER

TB24

25MG

T2

(PAXIL CR)

PAROXETINE HCL ER

TB24

37.5MG

T2

(PAXIL CR)

PAXIL

SUSP

10MG/5ML

T4

SERTRALINE HCL

CONC

20MG/ML

T2

(ZOLOFT)

SERTRALINE HCL

TABS

25MG

T2

not 50mg, (ZOLOFT)

SERTRALINE HCL

TABS

100MG

T2

not 50mg, (ZOLOFT)

420

(28:16.04.24) Central Nervous System Agents » Psychotherapeutic Agents » Antidepressants » Serotonin Modulators Product Name

Form

Strength

Pref

NEFAZODONE HCL

TABS

100MG

T2

Coverage Details

Comment (SERZONE)

NEFAZODONE HCL

TABS

200MG

T2

(SERZONE)

NEFAZODONE HCL

TABS

250MG

T2

(SERZONE)

NEFAZODONE HCL

TABS

150MG

T2

(SERZONE)

NEFAZODONE HCL

TABS

50MG

T2

(SERZONE)

TRAZODONE HCL

TABS

100MG

T1

not 300mg, (DESYREL)

TRAZODONE HCL

TABS

50MG

T1

not 300mg, (DESYREL)

TRAZODONE HCL

TABS

150MG

T2

not 300mg, (DESYREL)

VIIBRYD

KIT

VIIBRYD

TABS

10MG

T4

VIIBRYD

TABS

20MG

T4

VIIBRYD

TABS

40MG

T4

T4

(28:16.04.28) Central Nervous System Agents » Psychotherapeutic Agents » Antidepressants » Tricyclics and Other Norepinephrine-reuptake Inhibitors Product Name

Form

Strength

Pref

AMITRIPTYLINE HCL

TABS

10MG

T1

Coverage Details

Comment (ELAVIL)

AMITRIPTYLINE HCL

TABS

25MG

T1

(ELAVIL)

AMITRIPTYLINE HCL

TABS

50MG

T1

(ELAVIL)

AMITRIPTYLINE HCL

TABS

75MG

T1

(ELAVIL)

AMITRIPTYLINE HCL

TABS

100MG

T1

(ELAVIL)

AMITRIPTYLINE HCL

TABS

150MG

T2

(ELAVIL)

AMOXAPINE

TABS

25MG

T2

(ASENDIN)

AMOXAPINE

TABS

50MG

T2

(ASENDIN)

AMOXAPINE

TABS

100MG

T2

(ASENDIN)

AMOXAPINE

TABS

150MG

T2

(ASENDIN)

CLOMIPRAMINE HCL

CAPS

75MG

T2

(ANAFRANIL)

CLOMIPRAMINE HCL

CAPS

25MG

T2

(ANAFRANIL)

CLOMIPRAMINE HCL

CAPS

50MG

T2

(ANAFRANIL)

DESIPRAMINE HCL

TABS

10MG

T2

(NORPRAMIN)

DESIPRAMINE HCL

TABS

25MG

T2

(NORPRAMIN)

DESIPRAMINE HCL

TABS

50MG

T2

(NORPRAMIN)

DESIPRAMINE HCL

TABS

75MG

T2

(NORPRAMIN)

DESIPRAMINE HCL

TABS

100MG

T2

(NORPRAMIN)

DESIPRAMINE HCL

TABS

150MG

T2

(NORPRAMIN)

DOXEPIN HCL

CAPS

10MG

T1

(SINEQUAN)

DOXEPIN HCL

CAPS

25MG

T1

(SINEQUAN)

DOXEPIN HCL

CAPS

50MG

T1

(SINEQUAN)

DOXEPIN HCL

CONC

10MG/ML

T2

(SINEQUAN)

DOXEPIN HCL

CAPS

75MG

T2

(SINEQUAN)

DOXEPIN HCL

CAPS

100MG

T2

(SINEQUAN)

DOXEPIN HCL

CAPS

150MG

T2

(SINEQUAN)

IMIPRAMINE HCL

TABS

10MG

T2

not PM, (TOFRANIL)

IMIPRAMINE HCL

TABS

25MG

T2

not PM, (TOFRANIL)

IMIPRAMINE HCL

TABS

50MG

T2

not PM, (TOFRANIL)

MAPROTILINE HCL

TABS

25MG

T2

(LUDIOMIL)

MAPROTILINE HCL

TABS

50MG

T2

(LUDIOMIL)

MAPROTILINE HCL

TABS

75MG

T2

(LUDIOMIL)

NORTRIPTYLINE HCL

CAPS

10MG

T1

(PAMELOR)

NORTRIPTYLINE HCL

CAPS

25MG

T1

(PAMELOR)

NORTRIPTYLINE HCL

CAPS

50MG

T2

(PAMELOR)

NORTRIPTYLINE HCL

CAPS

75MG

T2

(PAMELOR)

NORTRIPTYLINE HCL

SOLN

10MG/5ML

T2

(PAMELOR)

PERPHENAZINE/AMITRIPTYLINE

TABS

10MG; 4MG

T2

(TRIAVIL/ETRAFON)

PERPHENAZINE/AMITRIPTYLINE

TABS

50MG; 4MG

T2

(TRIAVIL/ETRAFON)

421

PERPHENAZINE/AMITRIPTYLINE

TABS

10MG; 2MG

T2

(TRIAVIL/ETRAFON)

PERPHENAZINE/AMITRIPTYLINE

TABS

25MG; 2MG

T2

(TRIAVIL/ETRAFON)

PERPHENAZINE/AMITRIPTYLINE

TABS

25MG; 4MG

T2

(TRIAVIL/ETRAFON)

PROTRIPTYLINE HCL

TABS

5MG

T2

(VIVACTIL)

PROTRIPTYLINE HCL

TABS

10MG

T2

(VIVACTIL)

TRIMIPRAMINE MALEATE

CAPS

25MG

T2

(SURMONTIL)

TRIMIPRAMINE MALEATE

CAPS

50MG

T2

(SURMONTIL)

TRIMIPRAMINE MALEATE

CAPS

100MG

T2

(SURMONTIL)

422

(28:16.04.92) Central Nervous System Agents » Psychotherapeutic Agents » Antidepressants » Miscellaneous Antidepressants Product Name

Form

Strength

Pref

BUDEPRION SR

TB12

100MG

T2

Coverage Details

Comment not 200mg (WELLBUTRIN SR)

BUDEPRION SR

TB12

150MG

T2

not 200mg (WELLBUTRIN SR)

BUPROBAN

TB12

150MG

T2

(ZYBAN)

BUPROPION HCL

TABS

75MG

T2

(WELLBUTRIN)

BUPROPION HCL

TABS

100MG

T2

(WELLBUTRIN)

BUPROPION HCL ER

TB12

100MG

T2

not 200mg (WELLBUTRIN SR)

BUPROPION HCL SR

TB12

150MG

T2

(ZYBAN)

BUPROPION HCL SR

TB12

100MG

T2

not 200mg (WELLBUTRIN SR)

BUPROPION HCL SR

TB12

150MG

T2

not 200mg (WELLBUTRIN SR)

BUPROPION HCL XL

TB24

150MG

T2

(WELLBUTRIN XL)

BUPROPION HCL XL

TB24

300MG

T2

(WELLBUTRIN XL)

MIRTAZAPINE

TABS

15MG

T2

(REMERON)

MIRTAZAPINE

TABS

30MG

T2

(REMERON)

MIRTAZAPINE

TABS

45MG

T2

(REMERON)

MIRTAZAPINE

TABS

7.5MG

T2

(REMERON)

MIRTAZAPINE

TBDP

15MG

T2

(REMERON)

MIRTAZAPINE ODT

TBDP

30MG

T2

(REMERON)

MIRTAZAPINE ODT

TBDP

45MG

T2

(REMERON)

(28:16.08.04) Central Nervous System Agents » Psychotherapeutic Agents » Antipsychotics » Atypical Antipsychotics Product Name

Form

Strength

Pref

Coverage Details

ABILIFY

TABS

2MG

T4

PA

ABILIFY

TABS

5MG

T4

PA

ABILIFY

TABS

10MG

T4

PA

Comment

423

ABILIFY

TABS

15MG

T4

PA

ABILIFY

TABS

20MG

T4

PA

ABILIFY

TABS

30MG

T4

PA

ABILIFY

SOLN

1MG/ML

T4

PA

ABILIFY DISCMELT

TBDP

10MG

T4

PA

ABILIFY DISCMELT

TBDP

15MG

T4

PA

CLOZAPINE

TABS

25MG

T2

CLOZAPINE

TABS

100MG

T2

FANAPT

TABS

1MG

T4

PA

FANAPT

TABS

2MG

T4

PA

FANAPT

TABS

4MG

T4

PA

FANAPT

TABS

6MG

T4

PA

FANAPT

TABS

8MG

T4

PA

FANAPT

TABS

10MG

T4

PA

FANAPT

TABS

12MG

T4

PA

INVEGA

TB24

3MG

T3

INVEGA

TB24

6MG

T3

INVEGA

TB24

9MG

T3

LATUDA

TABS

20MG

T4

PA

LATUDA

TABS

40MG

T4

PA

LATUDA

TABS

60MG

T4

PA

LATUDA

TABS

80MG

T4

PA

LATUDA

TABS

120MG

T4

PA

OLANZAPINE

TABS

2.5MG

T2

PA

(ZYPREXA)

OLANZAPINE

TABS

5MG

T2

PA

(ZYPREXA)

OLANZAPINE

TABS

7.5MG

T2

PA

(ZYPREXA)

OLANZAPINE

TABS

10MG

T2

PA

(ZYPREXA)

OLANZAPINE

TABS

15MG

T2

PA

(ZYPREXA)

OLANZAPINE

TABS

20MG

T2

PA

(ZYPREXA)

OLANZAPINE ODT

TBDP

5MG

T2

PA

OLANZAPINE ODT

TBDP

10MG

T2

PA

(ZYPREXA ODT)

OLANZAPINE ODT

TBDP

15MG

T2

PA

(ZYPREXA ODT)

QUETIAPINE FUMARATE

TABS

25MG

T2

(CLOZARIL) (CLOZARIL)

(SEROQUEL)

QUETIAPINE FUMARATE

TABS

100MG

T2

(SEROQUEL)

QUETIAPINE FUMARATE

TABS

200MG

T2

(SEROQUEL)

QUETIAPINE FUMARATE

TABS

300MG

T2

(SEROQUEL)

QUETIAPINE FUMARATE

TABS

50MG

T2

(SEROQUEL)

QUETIAPINE FUMARATE

TABS

400MG

T2

(SEROQUEL)

RISPERIDONE

TABS

0.25MG

T2

(RISPERDAL)

RISPERIDONE

TABS

0.5MG

T2

(RISPERDAL)

RISPERIDONE

TABS

1MG

T2

(RISPERDAL)

RISPERIDONE

TABS

2MG

T2

(RISPERDAL)

RISPERIDONE

TABS

4MG

T2

(RISPERDAL)

RISPERIDONE

TABS

3MG

T2

(RISPERDAL)

RISPERIDONE

SOLN

1MG/ML

T2

(RISPERDAL)

RISPERIDONE M-TAB

TBDP

0.5MG

T2

(RISPERDAL-M)

RISPERIDONE M-TAB

TBDP

1MG

T2

(RISPERDAL-M)

RISPERIDONE M-TAB

TBDP

2MG

T2

(RISPERDAL-M)

SAPHRIS

SUBL

10MG

T4

PA

SAPHRIS

SUBL

5MG

T4

PA

SEROQUEL XR

TB24

50MG

T4

PA

SEROQUEL XR

TB24

150MG

T4

PA

SEROQUEL XR

TB24

200MG

T4

PA

SEROQUEL XR

TB24

300MG

T4

PA

SEROQUEL XR

TB24

400MG

T4

PA

ZIPRASIDONE HCL

CAPS

20MG

T2

PA

(GEODON)

ZIPRASIDONE HCL

CAPS

40MG

T2

PA

(GEODON)

ZIPRASIDONE HCL

CAPS

60MG

T2

PA

(GEODON)

ZIPRASIDONE HCL

CAPS

80MG

T2

PA

(GEODON)

(28:16.08.08) Central Nervous System Agents » Psychotherapeutic Agents » Antipsychotics » Butyrophenones Product Name

Form

Strength

Pref

HALOPERIDOL

CONC

2MG/ML

T2

Coverage Details

Comment (HALDOL)

HALOPERIDOL

TABS

2MG

T2

(HALDOL)

HALOPERIDOL

TABS

1MG

T2

(HALDOL)

HALOPERIDOL

TABS

5MG

T2

(HALDOL)

HALOPERIDOL

TABS

0.5MG

T2

(HALDOL)

424

HALOPERIDOL

TABS

10MG

T2

(HALDOL)

HALOPERIDOL

TABS

20MG

T2

(HALDOL)

425

(28:16.08.24) Central Nervous System Agents » Psychotherapeutic Agents » Antipsychotics » Phenothiazines Product Name

Form

Strength

Pref

CHLORPROMAZINE HCL

TABS

25MG

T2

Coverage Details

(THORAZINE)

CHLORPROMAZINE HCL

TABS

50MG

T2

(THORAZINE)

CHLORPROMAZINE HCL

TABS

10MG

T2

(THORAZINE)

CHLORPROMAZINE HCL

TABS

100MG

T2

(THORAZINE)

CHLORPROMAZINE HCL

TABS

200MG

T2

(THORAZINE)

COMPRO

SUPP

25MG

T2

FLUPHENAZINE HCL

ELIX

2.5MG/5ML

T2

(PROLIXIN)

FLUPHENAZINE HCL

TABS

1MG

T2

(PROLIXIN)

FLUPHENAZINE HCL

TABS

2.5MG

T2

(PROLIXIN)

FLUPHENAZINE HCL

TABS

5MG

T2

(PROLIXIN)

FLUPHENAZINE HCL

TABS

10MG

T2

(PROLIXIN)

FLUPHENAZINE HCL

CONC

5MG/ML

T3

(PROLIXIN)

PERPHENAZINE

TABS

2MG

T2

(TRILAFON)

PERPHENAZINE

TABS

8MG

T2

(TRILAFON)

PERPHENAZINE

TABS

16MG

T2

(TRILAFON)

PROCHLORPERAZINE

SUPP

25MG

T2

PROCHLORPERAZINE MALEATE

TABS

5MG

T2

(COMPAZINE)

PROCHLORPERAZINE MALEATE

TABS

10MG

T2

(COMPAZINE)

THIORIDAZINE HCL

TABS

10MG

T2

(MELLARIL)

THIORIDAZINE HCL

TABS

25MG

T2

(MELLARIL)

THIORIDAZINE HCL

TABS

50MG

T2

(MELLARIL)

THIORIDAZINE HCL

TABS

100MG

T2

(MELLARIL)

TRIFLUOPERAZINE HCL

TABS

1MG

T2

(STELAZINE)

TRIFLUOPERAZINE HCL

TABS

2MG

T2

(STELAZINE)

TRIFLUOPERAZINE HCL

TABS

5MG

T2

(STELAZINE)

TRIFLUOPERAZINE HCL

TABS

10MG

T2

(STELAZINE)

QL

QL

Comment

(COMPAZINE SUPPOSITORIES)

(COMPAZINE SUPPOSITORIES)

(28:16.08.32) Central Nervous System Agents » Psychotherapeutic Agents » Antipsychotics » Thioxanthenes Product Name

Form

Strength

Pref

THIOTHIXENE

CAPS

1MG

T2

Coverage Details

Comment (NAVANE)

THIOTHIXENE

CAPS

2MG

T2

(NAVANE)

THIOTHIXENE

CAPS

5MG

T2

(NAVANE)

THIOTHIXENE

CAPS

10MG

T2

(NAVANE)

(28:16.08.92) Central Nervous System Agents » Psychotherapeutic Agents » Antipsychotics » Miscellaneous Antipsychotics Product Name

Form

Strength

Pref

LOXAPINE SUCCINATE

CAPS

5MG

T2

Coverage Details

Comment (LOXITANE)

LOXAPINE SUCCINATE

CAPS

10MG

T2

(LOXITANE)

LOXAPINE SUCCINATE

CAPS

25MG

T2

(LOXITANE)

LOXAPINE SUCCINATE

CAPS

50MG

T2

(LOXITANE)

ORAP

TABS

1MG

T4

ORAP

TABS

2MG

T4

(28:20.04) Central Nervous System Agents » Anorexigenic Agents and Respiratory and CNS Stimulants » Amphetamines Product Name

Form

Strength

Pref

Coverage Details

Comment

AMPHETAMINE/DEXTROAMPHETAMINE

CP24

T2

QL

(ADDERALL XR)

AMPHETAMINE/DEXTROAMPHETAMINE

CP24

2.5MG; 2.5MG; 2.5MG; 2.5MG 3.75MG; 3.75MG; 3.75MG; 3.75MG

T2

QL

(ADDERALL XR)

AMPHETAMINE/DEXTROAMPHETAMINE

CP24

T2

QL

(ADDERALL XR)

AMPHETAMINE/DEXTROAMPHETAMINE

CP24

5MG; 5MG; 5MG; 5MG 6.25MG; 6.25MG; 6.25MG; 6.25MG

T2

QL

(ADDERALL XR)

AMPHETAMINE/DEXTROAMPHETAMINE

CP24

T2

QL

(ADDERALL XR)

DEXTROAMPHETAMINE SULFATE

TABS

7.5MG; 7.5MG; 7.5MG; 7.5MG 5MG

T2

(DEXTROSTAT)

DEXTROAMPHETAMINE SULFATE

TABS

10MG

T2

(DEXTROSTAT)

DEXTROAMPHETAMINE SULFATE ER

CP24

10MG

T2

(DEXEDRINE CR)

DEXTROAMPHETAMINE SULFATE ER

CP24

15MG

T2

(DEXEDRINE CR)

DEXTROAMPHETAMINE SULFATE ER

CP24

5MG

T2

(DEXEDRINE CR)

VYVANSE

CAPS

20MG

T3

QL

VYVANSE

CAPS

30MG

T3

QL

VYVANSE

CAPS

40MG

T3

QL

VYVANSE

CAPS

50MG

T3

QL

VYVANSE

CAPS

60MG

T3

QL

VYVANSE

CAPS

70MG

T3

QL

426

(28:20.32) Central Nervous System Agents » Anorexigenic Agents and Respiratory and CNS Stimulants » Respiratory and CNS Stimulants Product Name

Form

Strength

Pref

METADATE ER

TBCR

20MG

T2

Coverage Details

Comment (RITALIN SR)

METHYLPHENIDATE HCL

TABS

5MG

T2

(RITALIN)

METHYLPHENIDATE HCL

TABS

10MG

T2

(RITALIN)

METHYLPHENIDATE HCL

TABS

20MG

T2

(RITALIN)

METHYLPHENIDATE HCL CD

CPCR

50MG

T2

QL

(METADATE CD)

METHYLPHENIDATE HCL CD

CPCR

60MG

T2

QL

(METADATE CD)

METHYLPHENIDATE HCL CD

CPCR

10MG

T2

QL

(METADATE CD)

METHYLPHENIDATE HCL CD

CPCR

20MG

T2

QL

(METADATE CD)

METHYLPHENIDATE HCL CD

CPCR

30MG

T2

QL

(METADATE CD)

METHYLPHENIDATE HCL CD

CPCR

40MG

T2

QL

(METADATE CD)

METHYLPHENIDATE HCL ER

TBCR

18MG

T2

QL

(CONCERTA)

METHYLPHENIDATE HCL ER

TBCR

27MG

T2

QL

(CONCERTA)

METHYLPHENIDATE HCL ER

TBCR

36MG

T2

QL

(CONCERTA)

METHYLPHENIDATE HCL ER

TBCR

54MG

T2

QL

(CONCERTA)

METHYLPHENIDATE HCL ER

TBCR

20MG

T2

(RITALIN SR)

METHYLPHENIDATE HCL SR

TBCR

20MG

T2

(RITALIN SR)

METHYLPHENIDATE HYDROCHLORIDE

SOLN

10MG/5ML

T2

(METHYLIN)

(28:20.80) Central Nervous System Agents » Anorexigenic Agents and Respiratory and CNS Stimulants » Wakefulness-promoting Agents Product Name

Form

Strength

Pref

Coverage Details

Comment

MODAFINIL

TABS

100MG

T2

PA; QL

(PROVIGIL)

MODAFINIL

TABS

200MG

T2

PA; QL

(PROVIGIL)

Coverage Details

Comment

(28:24.04) Central Nervous System Agents » Anxiolytics, Sedatives, and Hypnotics » Barbiturates Product Name

Form

Strength

Pref

PHENOBARBITAL

ELIX

20MG/5ML

T2

PHENOBARBITAL

TABS

16.2MG

T2

PHENOBARBITAL

TABS

32.4MG

T2

PHENOBARBITAL

TABS

64.8MG

T2

PHENOBARBITAL

TABS

97.2MG

T2

PHENOBARBITAL

SOLN

20MG/5ML

T2

(28:24.08) Central Nervous System Agents » Anxiolytics, Sedatives, and Hypnotics » Benzodiazepines Product Name

Form

Strength

Pref

ALPRAZOLAM

TABS

2MG

T2

Coverage Details

Comment not XR, (XANAX)

427

ALPRAZOLAM

TABS

0.5MG

T2

not XR, (XANAX)

ALPRAZOLAM

TABS

1MG

T2

not XR, (XANAX)

ALPRAZOLAM

TABS

0.25MG

T2

not XR, (XANAX)

CHLORDIAZEPOXIDE HCL

CAPS

10MG

T2

(LIBRIUM)

CHLORDIAZEPOXIDE HCL

CAPS

5MG

T2

(LIBRIUM)

CHLORDIAZEPOXIDE HCL

CAPS

25MG

T2

(LIBRIUM)

CLORAZEPATE DIPOTASSIUM

TABS

3.75MG

T2

(TRANXENE)

CLORAZEPATE DIPOTASSIUM

TABS

7.5MG

T2

(TRANXENE)

CLORAZEPATE DIPOTASSIUM

TABS

15MG

T2

(TRANXENE)

DIAZEPAM

GEL

2.5MG

T2

PA; QL

(DIASTAT)

DIAZEPAM

GEL

10MG

T2

PA; QL

(DIASTAT)

DIAZEPAM

GEL

20MG

T2

PA; QL

(DIASTAT)

DIAZEPAM

SOLN

1MG/ML

T2

(VALIUM)

DIAZEPAM

TABS

2MG

T2

(VALIUM)

DIAZEPAM

TABS

5MG

T2

(VALIUM)

DIAZEPAM

TABS

10MG

T2

(VALIUM)

FLURAZEPAM HCL

CAPS

15MG

T2

(DALMANE)

FLURAZEPAM HCL

CAPS

30MG

T2

(DALMANE)

LORAZEPAM

TABS

2MG

T2

(ATIVAN)

LORAZEPAM

TABS

0.5MG

T2

(ATIVAN)

LORAZEPAM

TABS

1MG

T2

(ATIVAN)

TEMAZEPAM

CAPS

30MG

T2

not 7.5mg, (RESTORIL)

TEMAZEPAM

CAPS

15MG

T2

not 7.5mg, (RESTORIL)

(28:24.92) Central Nervous System Agents » Anxiolytics, Sedatives, and Hypnotics » Anxiolytics, Sedatives, & Hypnotics Misc Product Name

Form

Strength

Pref

BUSPIRONE HCL

TABS

5MG

T2

Coverage Details

Comment (BUSPAR)

BUSPIRONE HCL

TABS

10MG

T2

(BUSPAR)

BUSPIRONE HCL

TABS

15MG

T2

(BUSPAR)

BUSPIRONE HCL

TABS

30MG

T2

(BUSPAR)

HYDROXYZINE HCL

TABS

10MG

T2

(ATARAX)

HYDROXYZINE HCL

TABS

25MG

T2

(ATARAX)

HYDROXYZINE HCL

TABS

50MG

T2

(ATARAX)

HYDROXYZINE HCL

SYRP

10MG/5ML

T2

(ATARAX)

428

HYDROXYZINE HCL

SOLN

10MG/5ML

T2

(ATARAX)

HYDROXYZINE PAMOATE

CAPS

25MG

T2

(VISTARIL)

HYDROXYZINE PAMOATE

CAPS

50MG

T2

(VISTARIL)

HYDROXYZINE PAMOATE

CAPS

100MG

T2

(VISTARIL)

MEPROBAMATE

TABS

400MG

T2

(EQUANIL)

MEPROBAMATE

TABS

200MG

T2

(EQUANIL)

SOMNOTE

CAPS

500MG

T2

ZALEPLON

CAPS

5MG

T2

(SONATA)

ZALEPLON

CAPS

10MG

T2

(SONATA)

ZOLPIDEM TARTRATE

TABS

5MG

T2

(AMBIEN)

ZOLPIDEM TARTRATE

TABS

10MG

T2

(AMBIEN)

Product Name

Form

Strength

Pref

LITHIUM CARBONATE

CAPS

300MG

T1

(ESKALITH)

LITHIUM CARBONATE

CAPS

150MG

T2

(ESKALITH)

LITHIUM CARBONATE ER

TBCR

450MG

T2

(ESKALITH-CR)

LITHIUM CARBONATE ER

TBCR

300MG

T2

(LITHOBID)

LITHIUM CITRATE

SOLN

8MEQ/5ML

T2

(28:28) Central Nervous System Agents » Antimanic Agents Coverage Details

Comment

(28:32.28) Central Nervous System Agents » Antimigraine Agents » Selective Serotonin Agonists Product Name

Form

Strength

Pref

Coverage Details

Comment

RIZATRIPTAN BENZOATE

TABS

5MG

T2

QL

(MAXALT)

RIZATRIPTAN BENZOATE

TABS

10MG

T2

QL

(MAXALT)

SUMATRIPTAN

SOLN

20MG/ACT

T2

QL

(IMITREX)

SUMATRIPTAN

SOLN

5MG/ACT

T2

QL

(IMITREX)

SUMATRIPTAN SUCCINATE

SOLN

4MG/0.5ML

T2

QL

(IMITREX)

SUMATRIPTAN SUCCINATE

SOLN

6MG/0.5ML

T2

QL

(IMITREX)

SUMATRIPTAN SUCCINATE

TABS

50MG

T2

QL

(IMITREX)

SUMATRIPTAN SUCCINATE

TABS

25MG

T2

QL

(IMITREX)

SUMATRIPTAN SUCCINATE

TABS

100MG

T2

QL

(IMITREX)

(28:32.92) Central Nervous System Agents » Antimigraine Agents » Antimigraine Agents, Miscellaneous Product Name

Form

Strength

Pref

ISOMETHEPTENE/DICHLORALPHENAZONE/ACETAMINOPHEN

CAPS

T2

MIGERGOT

SUPP

325MG; 100MG; 0; 65MG 100MG; 2MG

T2

Coverage Details

Comment (MIDRIN)

QL

(CAFERGOT)

429

430

(28:36.04) Central Nervous System Agents » Antiparkinsonian Agents » Adamantanes Product Name

Form

Strength

Pref

AMANTADINE HCL

CAPS

100MG

T2

Coverage Details

Comment (SYMMETREL)

AMANTADINE HCL

TABS

100MG

T2

(SYMMETREL)

AMANTADINE HCL

SYRP

50MG/5ML

T2

(SYMMETREL)

(28:36.08) Central Nervous System Agents » Antiparkinsonian Agents » Anticholinergic Agents Product Name

Form

Strength

Pref

Coverage Details

Comment

BENZTROPINE MESYLATE

TABS

0.5MG

T2

(COGENTIN)

BENZTROPINE MESYLATE

TABS

1MG

T2

(COGENTIN)

BENZTROPINE MESYLATE

TABS

2MG

T2

(COGENTIN)

TRIHEXYPHENIDYL HCL

ELIX

0.4MG/ML

T2

(ARTANE)

TRIHEXYPHENIDYL HCL

TABS

5MG

T2

(ARTANE)

TRIHEXYPHENIDYL HCL

TABS

2MG

T2

(ARTANE)

(28:36.12) Central Nervous System Agents » Antiparkinsonian Agents » COMT Inhibitors Product Name

Form

Strength

Pref

ENTACAPONE

TABS

200MG

T2

Coverage Details

Comment (COMTAN)

(28:36.16) Central Nervous System Agents » Antiparkinsonian Agents » Dopamine Precursors Product Name

Form

Strength

Pref

CARBIDOPA/LEVODOPA

TABS

10MG; 100MG

T2

Coverage Details

Comment (SINEMET)

CARBIDOPA/LEVODOPA

TABS

25MG; 100MG

T2

(SINEMET)

CARBIDOPA/LEVODOPA

TABS

25MG; 250MG

T2

(SINEMET)

CARBIDOPA/LEVODOPA ER

TBCR

50MG; 200MG

T2

(SINEMET CR)

CARBIDOPA/LEVODOPA ER

TBCR

25MG; 100MG

T2

(SINEMET CR)

(28:36.20.04) Central Nervous System Agents » Antiparkinsonian Agents » Dopamine Receptor Agonists » Ergot-derivative Dopamine Receptor Agonists Product Name

Form

Strength

Pref

Coverage Details

Comment

BROMOCRIPTINE MESYLATE

TABS

2.5MG

T2

(PARLODEL)

BROMOCRIPTINE MESYLATE

CAPS

5MG

T2

(PARLODEL)

CABERGOLINE

TABS

0.5MG

T2

(DOSTINEX)

(28:36.20.08) Central Nervous System Agents » Antiparkinsonian Agents » Dopamine Receptor Agonists » Nonergot-derivative Dopamine Receptor Agonists Product Name

Form

Strength

Pref

PRAMIPEXOLE DIHYDROCHLORIDE

TABS

0.25MG

T2

Coverage Details

Comment (MIRAPEX)

PRAMIPEXOLE DIHYDROCHLORIDE

TABS

0.5MG

T2

(MIRAPEX)

PRAMIPEXOLE DIHYDROCHLORIDE

TABS

1MG

T2

(MIRAPEX)

PRAMIPEXOLE DIHYDROCHLORIDE

TABS

1.5MG

T2

(MIRAPEX)

PRAMIPEXOLE DIHYDROCHLORIDE

TABS

0.125MG

T2

(MIRAPEX)

PRAMIPEXOLE DIHYDROCHLORIDE

TABS

0.75MG

T2

(MIRAPEX)

ROPINIROLE ER

TB24

6MG

T2

(REQUIP-XL)

ROPINIROLE ER

TB24

2MG

T2

(REQUIP-XL)

ROPINIROLE ER

TB24

4MG

T2

(REQUIP-XL)

ROPINIROLE ER

TB24

8MG

T2

(REQUIP-XL)

ROPINIROLE ER

TB24

12MG

T2

(REQUIP-XL)

ROPINIROLE HCL

TABS

0.25MG

T2

(REQUIP)

ROPINIROLE HCL

TABS

1MG

T2

(REQUIP)

ROPINIROLE HCL

TABS

5MG

T2

(REQUIP)

ROPINIROLE HCL

TABS

0.5MG

T2

(REQUIP)

ROPINIROLE HCL

TABS

2MG

T2

(REQUIP)

ROPINIROLE HCL

TABS

3MG

T2

(REQUIP)

ROPINIROLE HCL

TABS

4MG

T2

(REQUIP)

(28:36.32) Central Nervous System Agents » Antiparkinsonian Agents » Monoamine Oxidase B Inhibitors Product Name

Form

Strength

Pref

Coverage Details

EMSAM

PT24

6MG/24HR

T4

PA; QL

Comment

EMSAM

PT24

9MG/24HR

T4

PA; QL

SELEGILINE HCL

TABS

5MG

T2

(ELDEPRYL)

SELEGILINE HCL

CAPS

5MG

T2

(ELDEPRYL)

(28:40) Central Nervous System Agents » Fibromyalgia Agents Product Name

Form

Strength

Pref

Coverage Details

SAVELLA

TABS

100MG

T4

PA

SAVELLA

TABS

12.5MG

T4

PA

SAVELLA

TABS

25MG

T4

PA

SAVELLA

TABS

50MG

T4

PA

SAVELLA TITRATION PACK

MISC

T4

PA; QL

Coverage Details

Comment

(28:92) Central Nervous System Agents » Central Nervous System Agents, Misc Product Name

Form

Strength

Pref

ACAMPROSATE CALCIUM DR

TBEC

333MG

T2

INTUNIV

TB24

1MG

T4

Comment (CAMPRAL)

PA

431

432

INTUNIV

TB24

2MG

T4

PA

INTUNIV

TB24

3MG

T4

PA

INTUNIV

TB24

4MG

T4

PA

NAMENDA

SOLN

10MG/5ML

T3

NAMENDA

TABS

5MG

T3

not XR

NAMENDA

TABS

10MG

T3

not XR

NAMENDA TITRATION PAK

TABS

RILUTEK

TABS

50MG

T3

STRATTERA

CAPS

10MG

T3

STRATTERA

CAPS

25MG

T3

STRATTERA

CAPS

40MG

T3

STRATTERA

CAPS

18MG

T3

STRATTERA

CAPS

60MG

T3

STRATTERA

CAPS

80MG

T3

STRATTERA

CAPS

100MG

T3

XENAZINE

TABS

25MG

T5

XYREM

SOLN

500MG/ML

T4

Product Name

Form

Strength

Pref

BAYER BREEZE 2 TEST DISC

DISK

T2

(TEST STRIPS)

BAYER CONTOUR BLOOD GLUCOSE TEST STRIPS

STRP

T2

(TEST STRIPS)

BAYER CONTOUR NEXT BLOOD GLUCOSE TEST

STRP

T2

(TEST STRIPS)

T3 PA

PA

(36:26) Diagnostic Agents » Diabetes Mellitus Coverage Details

Comment

(40:08) Electrolytic, Caloric, and Water Balance » Alkalinizing Agents Product Name

Form

Strength

Pref

CYTRA-K

SOLN

T2

POTASSIUM CITRATE

TBCR

334MG/5ML; 1100MG/5ML 540MG

Coverage Details

Comment

T2

(UROCIT-K)

POTASSIUM CITRATE

TBCR

1080MG

T2

(UROCIT-K)

(40:10) Electrolytic, Caloric, and Water Balance » Ammonia Detoxicants Product Name

Form

Strength

Pref

Coverage Details

BUPHENYL

TABS

500MG

T4

PA

Comment

ENULOSE

SOLN

10GM/15ML

T2

QL

limit 1pt/31days, (CEPHULAC)

GENERLAC

SOLN

10GM/15ML

T2

QL

limit 1pt/31days, (CEPHULAC)

LACTULOSE

SOLN

10GM/15ML

433

T2

QL

limit 1pt/31days, (CEPHULAC)

Coverage Details

Comment

(40:12) Electrolytic, Caloric, and Water Balance » Replacement Preparations Product Name

Form

Strength

Pref

CALCIUM ACETATE

CAPS

667MG

T2

(PHOSLO)

K-EFFERVESCENT

TBEF

25MEQ

T2

(K-LYTE)

K-PHOS

TABS

500MG

T4

K-VESCENT

TBEF

25MEQ

T2

KLOR-CON

PACK

20MEQ

T2

KLOR-CON 10

TBCR

10MEQ

T2

(K-TAB)

KLOR-CON 8

TBCR

8MEQ

T2

(SLOW-K)

KLOR-CON/EF

TBEF

25MEQ

T2

(K-LYTE)

PHOSPHA 250 NEUTRAL

TABS

T2

POTASSIUM CHLORIDE

LIQD

155MG; 852MG; 130MG 10%

POTASSIUM CHLORIDE

LIQD

20%

T2

POTASSIUM CHLORIDE

SOLN

10%

T2

POTASSIUM CHLORIDE CR

TBCR

10MEQ

T2

(K-TAB)

POTASSIUM CHLORIDE SR

TBCR

8MEQ

T2

(SLOW-K)

(K-LYTE)

T2

(40:18.18) Electrolytic, Caloric, and Water Balance » Ion-removing Agents » Potassium-removing Agents Product Name

Form

KIONEX

POWD

SPS

SUSP

Strength 15GM/60ML

Pref

Coverage Details

Comment

T2

(KAYEXELATE)

T2

(KAYEXALATE)

(40:18.19) Electrolytic, Caloric, and Water Balance » Ion-removing Agents » Phosphate-removing Agents Product Name

Form

Strength

Pref

Coverage Details

FOSRENOL

CHEW

500MG

T4

PA

FOSRENOL

CHEW

750MG

T4

PA

FOSRENOL

CHEW

1000MG

T4

PA

Coverage Details

Comment

(40:28.08) Electrolytic, Caloric, and Water Balance » Diuretics » Loop Diuretics Product Name

Form

Strength

Pref

BUMETANIDE

TABS

0.5MG

T1

Comment (BUMEX)

BUMETANIDE

TABS

1MG

T1

(BUMEX)

BUMETANIDE

TABS

2MG

T2

(BUMEX)

EDECRIN

TABS

25MG

T3

sulfa allergic pts

FUROSEMIDE

TABS

20MG

T1

(LASIX)

FUROSEMIDE

TABS

40MG

T1

(LASIX)

FUROSEMIDE

TABS

80MG

T1

(LASIX)

FUROSEMIDE

SOLN

10MG/ML

T2

(LASIX)

FUROSEMIDE

SOLN

8MG/ML

T2

(LASIX)

(40:28.16) Electrolytic, Caloric, and Water Balance » Diuretics » Potassium-sparing Diuretics Product Name

Form

Strength

Pref

AMILORIDE HCL

TABS

5MG

T2

Coverage Details

Comment (MIDAMOR)

AMILORIDE/HYDROCHLOROTHIAZIDE

TABS

5MG; 50MG

T2

(MODURETIC)

TRIAMTERENE/HYDROCHLOROTHIAZIDE

CAPS

25MG; 37.5MG

T1

(DYAZIDE)

TRIAMTERENE/HYDROCHLOROTHIAZIDE

TABS

25MG; 37.5MG

T1

(MAXZIDE)

TRIAMTERENE/HYDROCHLOROTHIAZIDE

TABS

50MG; 75MG

T1

(MAXZIDE)

(40:28.20) Electrolytic, Caloric, and Water Balance » Diuretics » Thiazide Diuretics Product Name

Form

Strength

Pref

CHLOROTHIAZIDE

TABS

250MG

T2

Coverage Details

Comment (DIURIL)

CHLOROTHIAZIDE

TABS

500MG

T2

(DIURIL)

DIURIL

SUSP

250MG/5ML

T4

HYDROCHLOROTHIAZIDE

TABS

25MG

T1

(HYDRODIURIL)

HYDROCHLOROTHIAZIDE

TABS

50MG

T1

(HYDRODIURIL)

METHYCLOTHIAZIDE

TABS

5MG

T2

(ENDURON)

(40:28.24) Electrolytic, Caloric, and Water Balance » Diuretics » Thiazide-like Diuretics Product Name

Form

Strength

Pref

CHLORTHALIDONE

TABS

50MG

T1

Coverage Details

Comment (HYGROTON)

CHLORTHALIDONE

TABS

25MG

T1

(HYGROTON)

METOLAZONE

TABS

2.5MG

T2

(ZAROXOLYN)

METOLAZONE

TABS

10MG

T2

(ZAROXOLYN)

METOLAZONE

TABS

5MG

T2

(ZAROXOLYN)

(40:40) Electrolytic, Caloric, and Water Balance » Uricosuric Agents Product Name

Form

Strength

Pref

PROBENECID

TABS

500MG

T2

Coverage Details

Comment (BENEMID)

PROBENECID/COLCHICINE

TABS

0.5MG; 500MG

T2

(COLBENEMID)

Product Name

Form

Strength

Pref

BENZONATATE

CAPS

100MG

T2

(TESSALON PERLES)

BENZONATATE

CAPS

200MG

T2

(TESSALON PERLES)

(48:08) Respiratory Tract Agents » Antitussives Coverage Details

Comment

434

CHERATUSSIN AC

SYRP

10MG/5ML; 100MG/5ML 10MG/5ML; 100MG/5ML; 30MG/5ML

T2

QL

(ROBITUSSIN AC)

CHERATUSSIN DAC

SOLN

T2

QL

(ROBITUSSIN DAC)

GUAIFENESIN DAC

SOLN

10MG/5ML; 100MG/5ML; 30MG/5ML

T2

QL

(ROBITUSSIN DAC)

GUAIFENESIN/CODEINE

SOLN

T2

QL

(ROBITUSSIN AC)

HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE

SYRP

10MG/5ML; 100MG/5ML 1.5MG/5ML; 5MG/5ML

T2

QL

(HYCODAN)

HYDROMET

SYRP

T2

QL

(HYCODAN)

MYTUSSIN DAC

SOLN

1.5MG/5ML; 5MG/5ML 10MG/5ML; 100MG/5ML; 30MG/5ML

T2

QL

(ROBITUSSIN DAC)

PROMETHAZINE VC/CODEINE

SYRP

10MG/5ML; 5MG/5ML; 6.25MG/5ML

T2

QL

(PHENERGAN)

PROMETHAZINE-DM

SYRP

T2

QL

(PHENERGAN)

PROMETHAZINE/CODEINE

SYRP

15MG/5ML; 6.25MG/5ML 10MG/5ML; 6.25MG/5ML

T2

QL

(PHENERGAN)

Coverage Details

Comment

(48:10.24) Respiratory Tract Agents » Anti-inflammatory Agents » Leukotriene Modifiers Product Name

Form

Strength

Pref

MONTELUKAST SODIUM

CHEW

4MG

T2

(SINGULAIR)

MONTELUKAST SODIUM

CHEW

5MG

T2

(SINGULAIR)

MONTELUKAST SODIUM

TABS

10MG

T2

(SINGULAIR)

MONTELUKAST SODIUM

PACK

4MG

T2

(SINGULAIR)

ZAFIRLUKAST

TABS

10MG

T2

(ACCOLATE)

ZAFIRLUKAST

TABS

20MG

T2

(ACCOLATE)

ZYFLO CR

TB12

600MG

T4

(48:10.32) Respiratory Tract Agents » Anti-inflammatory Agents » Mast-cell Stabilizers Product Name

Form

Strength

Pref

CROMOLYN SODIUM

CONC

100MG/5ML

T2

Coverage Details

Comment (GASTROCROM)

CROMOLYN SODIUM

NEBU

20MG/2ML

T2

(INTAL NEB)

Product Name

Form

Strength

Pref

Coverage Details

PULMOZYME

SOLN

1MG/ML

T6

PA; QL

(48:24) Respiratory Tract Agents » Mucolytic Agents Comment

435

436

(48:92) Respiratory Tract Agents » Respiratory Tract Agents, Miscellaneous Product Name

Form

Strength

Pref

Coverage Details

XOLAIR

SOLR

150MG

T5

PA

Comment

(52:02) Eye, Ear, Nose & Throat Preparations » Antiallergic Agents Product Name

Form

Strength

Pref

Coverage Details

ALOMIDE

SOLN

0.1%

T3

QL

Comment

AZELASTINE HCL

SOLN

137MCG/SPRAY

T2

QL

(ASTELIN)

CROMOLYN SODIUM

SOLN

4%

T2

QL

(CROLOM)

PATANASE

SOLN

0.6%

T3

QL

(52:04.04) Eye, Ear, Nose & Throat Preparations » Anti-infectives » Antibacterials Product Name

Form

Strength

Pref

Coverage Details

Comment

AK-POLY-BAC

OINT

T2

QL

BACITRACIN

OINT

500UNIT/GM; 10000UNIT/GM 500UNIT/GM

T2

QL

BACITRACIN/POLYMYXIN B

OINT

T2

QL

CILOXAN

OINT

500UNIT/GM; 10000UNIT/GM 0.3%

T3

QL

CIPROFLOXACIN HCL

SOLN

0.3%

T2

QL

(CILOXAN)

ERYTHROMYCIN

OINT

5MG/GM

T2

QL

(ILOTYCIN)

GENTAK

OINT

0.3%

T2

QL

(GARAMYCIN)

GENTAMICIN SULFATE

SOLN

0.3%

T2

QL

(GARAMYCIN)

LEVOFLOXACIN

SOLN

0.5%

T2

QL

(LEVAQUIN)

MOXEZA

SOLN

0.5%

T3

QL

NEO-POLYCIN

OINT

400UNIT/GM; 3.5MG/GM; 10000UNIT/GM

T2

QL

(NEOSPORIN OPHTH OINT)

NEOMYCIN/BACITRACIN/POLYMYXIN

OINT

400UNIT/GM; 5MG/GM; 10000UNIT/GM

T2

QL

(NEOSPORIN OPHTH OINT)

NEOMYCIN/POLYMYXIN/GRAMICIDIN

SOLN

0.025MG/ML; 1.75MG/ML; 10000UNIT/ML

T2

QL

(NEOSPORIN OPHTH SOLN)

OFLOXACIN

SOLN

0.3%

T2

QL

(FLOXIN)

OFLOXACIN

SOLN

0.3%

T2

QL

(OCUFLOX)

POLYCIN

OINT

T2

QL

POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE

SOLN

T2

QL

(POLYTRIM)

SODIUM SULFACETAMIDE

SOLN

500UNIT/GM; 10000UNIT/GM 10000UNIT/ML; 0.1% 10%

T2

QL

(BLEPH-10)

(POLYSPORIN OPHTHALMIC)

SULFACETAMIDE SODIUM

OINT

10%

T2

QL

(BLEPH-10)

SULFACETAMIDE SODIUM

SOLN

10%

T2

QL

(BLEPH-10)

TOBRAMYCIN SULFATE

SOLN

0.3%

T2

QL

(TOBREX)

TOBREX

OINT

0.3%

T3

QL

TRIMETHOPRIM SULFATE/POLYMYXIN B SULFATE

SOLN

T2

QL

VIGAMOX

SOLN

10000UNIT/ML; 0.1% 0.5%

T3

QL

(POLYTRIM)

(52:04.16) Eye, Ear, Nose & Throat Preparations » Anti-infectives » Antifungals Product Name

Form

Strength

Pref

Coverage Details

NATACYN

SUSP

5%

T3

QL

Comment

(52:04.20) Eye, Ear, Nose & Throat Preparations » Anti-infectives » Antivirals Product Name

Form

Strength

Pref

Coverage Details

Comment

TRIFLURIDINE

SOLN

1%

T2

QL

(VIROPTIC)

ZIRGAN

GEL

0.15%

T4

QL

(52:04.92) Eye, Ear, Nose & Throat Preparations » Anti-infectives » EENT Anti-infectives, Miscellaneous Product Name

Form

Strength

Pref

Coverage Details

Comment

CHLORHEXIDINE GLUCONATE

SOLN

0.12%

T2

QL

(PERIDEX)

Comment

(52:08.08) Eye, Ear, Nose & Throat Preparations » Anti-inflammatory Agents » Corticosteroids Product Name

Form

Strength

Pref

Coverage Details

ALREX

SUSP

0.2%

T4

QL

BLEPHAMIDE

SUSP

0.2%; 10%

T3

QL

BLEPHAMIDE S.O.P.

OINT

0.2%; 10%

T3

QL

CIPRODEX

SUSP

0.3%; 0.1%

T3

QL

DEXAMETHASONE SODIUM PHOSPHATE

SOLN

0.1%

T2

QL

(DECADRON OPHTH)

FLUNISOLIDE

SOLN

0.025%

T2

QL

(NASALIDE)

FLUOCINOLONE ACETONIDE

OIL

0.01%

T2

QL

(DERMOTIC)

FLUOROMETHOLONE

SUSP

0.1%

T2

QL

(FML)

FLUTICASONE PROPIONATE

SUSP

50MCG/ACT

T2

QL

(FLONASE)

FML

OINT

0.1%

T3

QL

FML FORTE

SUSP

0.25%

T3

QL

LOTEMAX

SUSP

0.5%

T4

QL

LOTEMAX

OINT

0.5%

T4

QL

LOTEMAX

GEL

0.5%

T4

QL

437

NEO-POLYCIN HC

OINT

400UNIT/GM; 1%; 3.5MG/GM; 10000UNIT/GM

T2

QL

(CORTISPORIN)

NEOMYCIN/POLYMYXIN/BACITRACIN/HYDROCORTISONE

OINT

400UNIT/GM; 1%; 0.5%; 10000UNIT/GM

T2

QL

(CORTISPORIN)

NEOMYCIN/POLYMYXIN/DEXAMETHASONE

OINT

0.1%; 3.5MG/GM; 10000UNIT/GM

T2

QL

(MAXITROL)

NEOMYCIN/POLYMYXIN/DEXAMETHASONE

SUSP

0.1%; 3.5MG/ML; 10000UNIT/ML

T2

QL

(MAXITROL)

NEOMYCIN/POLYMYXIN/HC

SOLN

T2

QL

(CORTISPORIN)

NEOMYCIN/POLYMYXIN/HYDROCORTISONE

SUSP

T2

QL

(CORTISPORIN)

PRED MILD

SUSP

1%; 3.5MG/ML; 10000UNIT/ML 1%; 3.5MG/ML; 10000UNIT/ML 0.12%

T3

QL

PRED-G

SUSP

0.3%; 1%

T3

QL

PRED-G S.O.P.

OINT

0.3%; 0.6%

T3

QL

PREDNISOLONE ACETATE

SUSP

1%

T2

QL

(PRED-FORTE)

PREDNISOLONE SODIUM PHOSPHATE

SOLN

1%

T2

QL

(INFLAMASE FORTE)

SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE TOBRADEX

SOLN

0.23%; 10%

T2

QL

(VASOCIDIN)

OINT

0.1%; 0.3%

T3

QL

TOBRAMYCIN/DEXAMETHASONE

SUSP

0.1%; 0.3%

T2

QL

(TOBRADEX)

TRIAMCINOLONE ACETONIDE

INHA

55MCG/ACT

T2

QL

(NASACORT)

(52:08.20) Eye, Ear, Nose & Throat Preparations » Anti-inflammatory Agents » Nonsteroidal Anti-inflammatory Agents Product Name

Form

Strength

Pref

Coverage Details

Comment

DICLOFENAC SODIUM

SOLN

0.1%

T2

QL

not XR, (VOLTAREN)

FLURBIPROFEN SODIUM

SOLN

0.03%

T2

QL

(OCUFEN)

ILEVRO

SUSP

0.3%

T3

QL

KETOROLAC TROMETHAMINE

SOLN

0.4%

T2

QL

(ACULAR LS)

KETOROLAC TROMETHAMINE

SOLN

0.5%

T2

QL

(ACULAR)

NEVANAC

SUSP

0.1%

T3

QL

(52:08.92) Eye, Ear, Nose & Throat Preparations » Anti-inflammatory Agents » EENT Anti-inflammatory Agents, Misc Product Name

Form

Strength

Pref

Coverage Details

RESTASIS

EMUL

0.05%

T3

QL

Strength

Pref

Coverage Details

Comment

(52:16) Eye, Ear, Nose & Throat Preparations » Local Anesthetics Product Name

Form

Comment

438

ANTIPYRINE/BENZOCAINE

SOLN

5.4%; 1.4%

T2

QL

(AURALGAN)

LIDOCAINE VISCOUS

SOLN

2%

T2

QL

(XYLOCAINE)

PROPARACAINE HCL

SOLN

0.5%

T2

QL

(ALCAINE)

Product Name

Form

Strength

Pref

Coverage Details

Comment

ATROPINE SULFATE

SOLN

1%

T2

QL

ATROPINE SULFATE

OINT

1%

T2

QL

CYCLOGYL

SOLN

0.5%

T3

QL

CYCLOPENTOLATE HCL

SOLN

1%

T2

QL

ISOPTO HOMATROPINE

SOLN

2%

T3

QL

ISOPTO HOMATROPINE

SOLN

5%

T3

QL

TROPICAMIDE

SOLN

0.5%

T2

QL

TROPICAMIDE

SOLN

1%

T2

QL

(52:24) Eye, Ear, Nose & Throat Preparations » Mydriatics

(52:40.04) Eye, Ear, Nose & Throat Preparations » Antiglaucoma Agents » alpha-Adrenergic Agonists Product Name

Form

Strength

Pref

Coverage Details

Comment

BRIMONIDINE TARTRATE

SOLN

0.2%

T2

QL

not P, (ALPHAGAN)

(52:40.08) Eye, Ear, Nose & Throat Preparations » Antiglaucoma Agents » beta-Adrenergic Blocking Agents Product Name

Form

Strength

Pref

Coverage Details

Comment

BETAXOLOL HCL

SOLN

0.5%

T2

QL

(KERLONE)

BETOPTIC-S

SUSP

0.25%

T3

QL

CARTEOLOL HCL

SOLN

1%

T2

QL

(OCUPRESS)

LEVOBUNOLOL HCL

SOLN

0.5%

T1

QL

(BETAGAN)

LEVOBUNOLOL HCL

SOLN

0.25%

T2

QL

(BETAGAN)

TIMOLOL MALEATE

SOLN

0.25%

T1

QL

not XE, (TIMOPTIC)

TIMOLOL MALEATE

SOLN

0.5%

T1

QL

not XE, (TIMOPTIC)

(52:40.12) Eye, Ear, Nose & Throat Preparations » Antiglaucoma Agents » Carbonic Anhydrase Inhibitors Product Name

Form

Strength

Pref

ACETAZOLAMIDE

TABS

250MG

T2

(DIAMOX)

ACETAZOLAMIDE

TABS

125MG

T2

(DIAMOX)

ACETAZOLAMIDE ER

CP12

500MG

T2

(DIAMOX CR)

DORZOLAMIDE HCL

SOLN

2%

T2

QL

(TRUSOPT)

DORZOLAMIDE HCL/TIMOLOL MALEATE

SOLN

T2

QL

(COSOPT)

METHAZOLAMIDE

TABS

22.3MG/ML; 6.8MG/ML 50MG

T2

Coverage Details

Comment

(NEPTAZANE)

439

METHAZOLAMIDE

TABS

25MG

T2

(NEPTAZANE)

(52:40.20) Eye, Ear, Nose & Throat Preparations » Antiglaucoma Agents » Miotics Product Name

Form

Strength

Pref

Coverage Details

ISOPTO CARBACHOL

SOLN

1.5%

T3

QL

ISOPTO CARBACHOL

SOLN

3%

T3

QL

PHOSPHOLINE IODIDE

SOLR

0.125%

T3

PILOCARPINE HCL

SOLN

1%

T2

QL

PILOCARPINE HCL

SOLN

2%

T2

QL

PILOCARPINE HCL

SOLN

4%

T2

QL

PILOPINE HS

GEL

4%

T3

QL

Comment

(52:40.28) Eye, Ear, Nose & Throat Preparations » Antiglaucoma Agents » Prostaglandin Analogs Product Name

Form

Strength

Pref

Coverage Details

Comment

LATANOPROST

SOLN

0.005%

T2

QL

(XALATAN)

TRAVATAN Z

SOLN

0.004%

T3

QL

(52:92) Eye, Ear, Nose & Throat Preparations » EENT Drugs, Miscellaneous Product Name

Form

Strength

Pref

Coverage Details

Comment

ACETIC ACID

SOLN

2%

T2

QL

(VOSOL)

ACETIC ACID/ALUMINUM ACETATE

SOLN

T2

QL

(DOMBORO OTIC)

APRACLONIDINE

SOLN

0.5%

T2

QL

(IOPIDINE)

Product Name

Form

Strength

Pref

Coverage Details

Comment

DIPHENOXYLATE/ATROPINE

LIQD

T2

(LOMOTIL)

DIPHENOXYLATE/ATROPINE

TABS

0.025MG/5ML; 2.5MG/5ML 0.025MG; 2.5MG

T2

(LOMOTIL)

LOPERAMIDE HCL

CAPS

2MG

T2

(IMODIUM)

Product Name

Form

Strength

Pref

Coverage Details

PEG-3350

SOLR

236GM; 2.97GM; 6.74GM; 5.86GM; 22.74GM

T2

QL

Product Name

Form

Strength

Pref

Coverage Details

URSODIOL

CAPS

300MG

T2

2%

(56:08) Gastrointestinal Drugs » Antidiarrhea Agents

(56:12) Gastrointestinal Drugs » Cathartics and Laxatives Comment

(56:14) Gastrointestinal Drugs » Cholelitholytic Agents

(56:16) Gastrointestinal Drugs » Digestants

Comment (ACTIGALL)

440

441 Product Name

Form

Strength

Pref

CREON

CPEP

15000UNIT; 3000UNIT; 9500UNIT

T3

CREON

CPEP

30000UNIT; 6000UNIT; 19000UNIT

T3

CREON

CPEP

60000UNIT; 12000UNIT; 38000UNIT

T3

CREON

CPEP

120000UNIT; 24000UNIT; 76000UNIT

T3

PANCREAZE

CPEP

43750UNIT; 10500UNIT; 25000UNIT

T3

PANCREAZE

CPEP

70000UNIT; 16800UNIT; 40000UNIT

T3

PANCREAZE

CPEP

61000UNIT; 21000UNIT; 37000UNIT

T3

ZENPEP

CPEP

27000UNIT; 5000UNIT; 17000UNIT

T4

ZENPEP

CPEP

55000UNIT; 10000UNIT; 34000UNIT

T4

ZENPEP

CPEP

82000UNIT; 15000UNIT; 51000UNIT

T4

ZENPEP

CPEP

109000UNIT; 20000UNIT; 68000UNIT

T4

ZENPEP

CPEP

136000UNIT; 25000UNIT; 85000UNIT

T4

Coverage Details

Comment

Coverage Details

Comment

(56:22.08) Gastrointestinal Drugs » Antiemetics » Antihistamines Product Name

Form

Strength

Pref

TRIMETHOBENZAMIDE HCL

CAPS

300MG

T2

(TIGAN)

(56:22.20) Gastrointestinal Drugs » Antiemetics » 5-HT3 Receptor Antagonists Product Name

Form

Strength

Pref

Coverage Details

Comment

ONDANSETRON HCL

TABS

4MG

T2

QL

(ZOFRAN)

ONDANSETRON HCL

TABS

8MG

T2

QL

(ZOFRAN)

ONDANSETRON HCL

SOLN

4MG/5ML

T2

QL

(ZOFRAN)

ONDANSETRON ODT

TBDP

4MG

T2

QL

(ZOFRAN)

ONDANSETRON ODT

TBDP

8MG

T2

QL

(ZOFRAN)

(56:22.92) Gastrointestinal Drugs » Antiemetics » Antiemetics, Miscellaneous Product Name

Form

Strength

Pref

Coverage Details

Comment

DRONABINOL

CAPS

2.5MG

T2

PA; QL

(MARINOL)

DRONABINOL

CAPS

5MG

T2

PA; QL

(MARINOL)

DRONABINOL

CAPS

10MG

T2

PA; QL

(MARINOL)

EMEND

CAPS

80MG

T6

PA

EMEND

CAPS

40MG

T6

PA

EMEND

CAPS

T6

PA

(56:28.12) Gastrointestinal Drugs » Antiulcer Agents and Acid Suppressants » Histamine H2-Antagonists Product Name

Form

Strength

Pref

CIMETIDINE

TABS

300MG

T2

Coverage Details

Comment (TAGAMET)

CIMETIDINE

TABS

400MG

T2

(TAGAMET)

CIMETIDINE

TABS

800MG

T2

(TAGAMET)

CIMETIDINE HCL

SOLN

300MG/5ML

T2

(TAGAMET)

RANITIDINE HCL

TABS

300MG

T1

(ZANTAC)

RANITIDINE HCL

TABS

150MG

T1

(ZANTAC)

RANITIDINE HCL

SYRP

75MG/5ML

T2

(ZANTAC)

RANITIDINE HCL

SYRP

15MG/ML

T2

(ZANTAC)

(56:28.28) Gastrointestinal Drugs » Antiulcer Agents and Acid Suppressants » Prostaglandins Product Name

Form

Strength

Pref

MISOPROSTOL

TABS

100MCG

T2

Coverage Details

Comment (CYTOTEC)

MISOPROSTOL

TABS

200MCG

T2

(CYTOTEC)

(56:28.32) Gastrointestinal Drugs » Antiulcer Agents and Acid Suppressants » Protectants Product Name

Form

Strength

Pref

CARAFATE

SUSP

1GM/10ML

T3

SUCRALFATE

TABS

1GM

T2

Coverage Details

Comment (CARAFATE)

(56:28.36) Gastrointestinal Drugs » Antiulcer Agents and Acid Suppressants » Proton-pump Inhibitors Product Name

Form

Strength

Pref

LANSOPRAZOLE

CPDR

15MG

T2

Coverage Details

Comment not Solutab,(PREVACID)

LANSOPRAZOLE

CPDR

30MG

T2

not Solutab,(PREVACID)

OMEPRAZOLE

CPDR

10MG

T2

(PRILOSEC)

OMEPRAZOLE

CPDR

20MG

T2

(PRILOSEC)

442

PANTOPRAZOLE SODIUM

TBEC

20MG

T2

(PROTONIX)

PANTOPRAZOLE SODIUM

TBEC

40MG

T2

(PROTONIX)

PROTONIX

PACK

40MG

T3

Product Name

Form

Strength

Pref

METOCLOPRAMIDE HCL

TABS

10MG

T1

(REGLAN)

METOCLOPRAMIDE HCL

TABS

5MG

T2

(REGLAN)

METOCLOPRAMIDE HCL

SOLN

5MG/5ML

T2

(REGLAN)

Product Name

Form

Strength

Pref

ASACOL

TBEC

400MG

T3

ASACOL HD

TBEC

800MG

T3

BALSALAZIDE DISODIUM

CAPS

750MG

T2

CANASA

SUPP

1000MG

T3

DIPENTUM

CAPS

250MG

T4

LOTRONEX

TABS

0.5MG

T3

PA

LOTRONEX

TABS

1MG

T3

PA

MESALAMINE

ENEM

4GM

T2

QL

(ROWASA)

Product Name

Form

Strength

Pref

Coverage Details

Comment

AMITIZA

CAPS

8MCG

T4

PA

AMITIZA

CAPS

24MCG

T4

PA

LINZESS

CAPS

145MCG

T4

PA

LINZESS

CAPS

290MCG

T4

PA

Product Name

Form

Strength

Pref

Coverage Details

CHEMET

CAPS

100MG

T3

CUPRIMINE

CAPS

250MG

T3

EXJADE

TBSO

125MG

T6

PA

EXJADE

TBSO

250MG

T6

PA

EXJADE

TBSO

500MG

T6

PA

Product Name

Form

Strength

Pref

Coverage Details

ASMANEX 120 METERED DOSES

AEPB

220MCG/INH

T3

QL

(56:32) Gastrointestinal Drugs » Prokinetic Agents Coverage Details

Comment

(56:36) Gastrointestinal Drugs » Anti-inflammatory Agents Coverage Details

Comment

(COLAZAL) QL

(56:92) Gastrointestinal Drugs » GI Drugs, Miscellaneous

(64:00) Heavy Metal Antagonists Comment

(68:04) Hormones and Synthetic Substitutes » Adrenals Comment

443

444

ASMANEX 30 METERED DOSES

AEPB

220MCG/INH

T3

QL

ASMANEX 30 METERED DOSES

AEPB

110MCG/INH

T3

QL

ASMANEX 60 METERED DOSES

AEPB

220MCG/INH

T3

QL

BUDESONIDE

CP24

3MG

T2

PA

(ENTOCORT EC)

BUDESONIDE

SUSP

0.25MG/2ML

T2

PA; QL

(PULMICORT RESPULES)

BUDESONIDE

SUSP

0.5MG/2ML

T2

PA; QL

(PULMICORT RESPULES)

CORTISONE ACETATE

TABS

25MG

T2

(CORTONE)

DEXAMETHASONE

SOLN

0.5MG/5ML

T2

(DECADRON)

DEXAMETHASONE

TABS

0.5MG

T2

(DECADRON)

DEXAMETHASONE

TABS

0.75MG

T2

(DECADRON)

DEXAMETHASONE

TABS

1MG

T2

(DECADRON)

DEXAMETHASONE

TABS

1.5MG

T2

(DECADRON)

DEXAMETHASONE

TABS

4MG

T2

(DECADRON)

DEXAMETHASONE

TABS

6MG

T2

(DECADRON)

DEXAMETHASONE

ELIX

0.5MG/5ML

T2

(DECADRON)

DEXAMETHASONE INTENSOL

CONC

1MG/ML

T2

QL

DULERA

AERO

T4

QL

DULERA

AERO

T4

QL

ENTOCORT EC

CP24

5MCG/ACT; 200MCG/ACT 5MCG/ACT; 100MCG/ACT 3MG

T4

PA

FLOVENT DISKUS

AEPB

50MCG/BLIST

T3

QL

FLOVENT DISKUS

AEPB

250MCG/BLIST

T3

QL

FLOVENT DISKUS

AEPB

100MCG/BLIST

T3

QL

FLOVENT HFA

AERO

44MCG/ACT

T3

QL

FLOVENT HFA

AERO

110MCG/ACT

T3

QL

FLOVENT HFA

AERO

220MCG/ACT

T3

QL

FLUDROCORTISONE ACETATE

TABS

0.1MG

T2

(FLORINEF)

HYDROCORTISONE

TABS

20MG

T2

(CORTEF)

HYDROCORTISONE

TABS

5MG

T2

(CORTEF)

HYDROCORTISONE

TABS

10MG

T2

(CORTEF)

METHYLPREDNISOLONE

TABS

4MG

T2

(MEDROL)

METHYLPREDNISOLONE

TABS

16MG

T2

(MEDROL)

METHYLPREDNISOLONE DOSE PACK

TABS

4MG

T2

(MEDROL)

(DECADRON)

(ENTOCORT EC)

PREDNISOLONE

SOLN

15MG/5ML

T2

(PRELONE)

PREDNISOLONE SODIUM PHOSPHATE

SOLN

5MG/5ML

T2

(ORAPRED)

PREDNISONE

TABS

10MG

T2

(DELTASONE)

PREDNISONE

TABS

20MG

T2

(DELTASONE)

PREDNISONE

TABS

50MG

T2

(DELTASONE)

PREDNISONE

SOLN

5MG/5ML

T2

(DELTASONE)

PREDNISONE

TABS

5MG

T2

(DELTASONE)

PREDNISONE

TABS

1MG

T2

(DELTASONE)

PREDNISONE

TABS

2.5MG

T2

(DELTASONE)

PULMICORT

SUSP

1MG/2ML

T3

PA; QL

QVAR

AERS

40MCG/ACT

T4

QL

QVAR

AERS

80MCG/ACT

T4

QL

SYMBICORT

AERO

T4

QL

SYMBICORT

AERO

160MCG/ACT; 4.5MCG/ACT 80MCG/ACT; 4.5MCG/ACT

T4

QL

445

(68:08) Hormones and Synthetic Substitutes » Androgens Product Name

Form

Strength

Pref

Coverage Details

ANADROL-50

TABS

50MG

T4

PA

Comment

ANDROGEL

GEL

50MG/5GM

T4

QL

ANDROGEL

GEL

40.5MG/2.5GM

T4

QL

ANDROXY

TABS

10MG

T2

(HALOTESTIN)

DANAZOL

CAPS

100MG

T2

(DANOCRINE)

DANAZOL

CAPS

200MG

T2

(DANOCRINE)

DANAZOL

CAPS

50MG

T2

(DANOCRINE)

OXANDRIN

TABS

2.5MG

T3

PA

(OXANDRIN)

OXANDROLONE

TABS

2.5MG

T2

PA

(OXANDRIN)

TESTIM

GEL

1%

T4

QL

Coverage Details

(68:12) Hormones and Synthetic Substitutes » Contraceptives Product Name

Form

Strength

Pref

APRI

TABS

0.15MG; 30MCG

T2

Comment (DESOGEN)

AVIANE

TABS

20MCG; 0.1MG

T2

(ALESSE)

CAMILA

TABS

0.35MG

T2

(MICRONOR)

CRYSELLE-28

TABS

30MCG; 0.3MG

T2

(LO-OVRAL)

CYCLAFEM 1/35

TABS

35MCG; 1MG

T2

not 7/7/7, (ORTHO NOVUM)

ENPRESSE-28

TABS

ERRIN

TABS

GIANVI

446

T2

(TRIPHASIL)

0.35MG

T2

(MICRONOR)

TABS

3MG; 0.02MG

T2

(YAZ)

GILDESS FE 1.5/30

TABS

T2

(LOESTRIN-FE)

GILDESS FE 1/20

TABS

30MCG; 75MG; 1.5MG 20MCG; 75MG; 1MG

T2

(LOESTRIN-FE)

JOLIVETTE

TABS

0.35MG

T2

(MICRONOR)

JUNEL FE 1.5/30

TABS

T2

(LOESTRIN-FE)

JUNEL FE 1/20

TABS

30MCG; 75MG; 1.5MG 20MCG; 75MG; 1MG

T2

(LOESTRIN-FE)

KELNOR 1/35

TABS

35MCG; 1MG

T2

(DEMULEN)

LEVORA 0.15/30-28

TABS

30MCG; 0.15MG

T2

(NORDETTE)

LOW-OGESTREL

TABS

30MCG; 0.3MG

T2

(LO-OVRAL)

LUTERA

TABS

20MCG; 0.1MG

T2

(ALESSE)

MICROGESTIN FE

TABS

20MCG; 75MG; 1MG

T2

(LOESTRIN-FE)

MICROGESTIN FE 1.5/30

TABS

T2

(LOESTRIN-FE)

MONONESSA

TABS

30MCG; 75MG; 1.5MG 35MCG; 0.25MG

T2

not LO, (ORTHO CYCLEN)

MYZILRA

TABS

T2

(TRIPHASIL)

NECON 0.5/35-28

TABS

35MCG; 0.5MG

T2

not 7/7/7, (ORTHO NOVUM)

NECON 1/35

TABS

35MCG; 1MG

T2

not 7/7/7, (ORTHO NOVUM)

NECON 1/50-28

TABS

50MCG; 1MG

T2

not 7/7/7, (ORTHO NOVUM)

NECON 10/11-28

TABS

35MCG

T2

not 7/7/7, (ORTHO NOVUM)

NORA-BE

TABS

0.35MG

T2

(MICRONOR)

NORETHINDRONE

TABS

0.35MG

T2

(MICRONOR)

NORTREL 0.5/35 (28)

TABS

35MCG; 0.5MG

T2

not 7/7/7, (ORTHO NOVUM)

NORTREL 1/35

TABS

35MCG; 1MG

T2

not 7/7/7, (ORTHO NOVUM)

OGESTREL

TABS

50MCG; 0.5MG

T2

(OVRAL)

ORSYTHIA

TABS

20MCG; 0.1MG

T2

(ALESSE)

PORTIA-28

TABS

0.03MG; 0.15MG

T2

(NORDETTE)

PREVIFEM

TABS

35MCG; 0.25MG

T2

not LO, (ORTHO CYCLEN)

RECLIPSEN

TABS

0.15MG; 30MCG

T2

(DESOGEN)

SOLIA

TABS

0.15MG; 30MCG

T2

(DESOGEN)

447

SPRINTEC 28

TABS

35MCG; 0.25MG

T2

not LO, (ORTHO CYCLEN)

SRONYX

TABS

20MCG; 0.1MG

T2

(ALESSE)

TRI-SPRINTEC

TABS

T2

not LO, (ORTHO TRICYCLEN)

TRIVORA-28

TABS

T2

(TRIPHASIL)

ZOVIA 1/35E

TABS

35MCG; 1MG

T2

(DEMULEN)

ZOVIA 1/50E

TABS

50MCG; 1MG

T2

(DEMULEN)

(68:16.04) Hormones and Synthetic Substitutes » Estrogens and Antiestrogens » Estrogens Product Name

Form

Strength

Pref

EEMT

TABS

1.25MG; 2.5MG

T2

Coverage Details

Comment (ESTRATEST)

ESTERIFIED ESTROGENS/METHYLTESTOSTERONE

TABS

1.25MG; 2.5MG

T2

(ESTRATEST)

ESTERIFIED ESTROGENS/METHYLTESTOSTERONE HS

TABS

0.625MG; 1.25MG

T2

(ESTRATEST HS)

ESTRACE

CREA

0.1MG/GM

T4

ESTRADIOL

TABS

0.5MG

T1

(ESTRACE)

ESTRADIOL

TABS

1MG

T1

(ESTRACE)

ESTRADIOL

TABS

2MG

T1

(ESTRACE)

ESTRADIOL

PTWK

0.025MG/24HR

T2

not PRO, (CLIMARA)

ESTRADIOL

PTWK

0.05MG/24HR

T2

not PRO, (CLIMARA)

ESTRADIOL

PTWK

0.075MG/24HR

T2

not PRO, (CLIMARA)

ESTRADIOL

PTWK

0.1MG/24HR

T2

not PRO, (CLIMARA)

ESTRADIOL

PTWK

37.5MCG/24HR

T2

not PRO, (CLIMARA)

ESTRADIOL

PTWK

0.06MG/24HR

T2

not PRO, (CLIMARA)

ESTROPIPATE

TABS

0.75MG

T2

(OGEN)

ESTROPIPATE

TABS

1.5MG

T2

(OGEN)

ESTROPIPATE

TABS

3MG

T2

(OGEN)

MENEST

TABS

0.3MG

T4

PA

MENEST

TABS

0.625MG

T4

PA

MENEST

TABS

1.25MG

T4

PA

MENEST

TABS

2.5MG

T4

PA

PREMARIN

TABS

0.3MG

T3

PREMARIN

TABS

0.45MG

T3

PREMARIN

TABS

0.625MG

T3

PREMARIN

TABS

0.9MG

T3

QL

PREMARIN

TABS

1.25MG

T3

PREMARIN

CREA

0.625MG/GM

T3

PREMPHASE

TABS

0.625MG; 5MG

T3

PREMPRO

TABS

0.625MG; 5MG

T3

PREMPRO

TABS

0.3MG; 1.5MG

T3

PREMPRO

TABS

0.45MG; 1.5MG

T3

PREMPRO

TABS

0.625MG; 2.5MG

T3

448 QL

(68:16.12) Hormones and Synthetic Substitutes » Estrogens and Antiestrogens » Estrogen Agonist-Antagonists Product Name

Form

Strength

Pref

EVISTA

TABS

60MG

T3

Coverage Details

Comment

Comment

(68:18) Hormones and Synthetic Substitutes » Gonadotropins Product Name

Form

Strength

Pref

Coverage Details

SYNAREL

SOLN

2MG/ML

T4

PA; QL

(68:20.02) Hormones and Synthetic Substitutes » Antidiabetic Agents » Alpha-Glucosidase Inhibitors Product Name

Form

Strength

Pref

Coverage Details

Comment

ACARBOSE

TABS

50MG

T2

(PRECOSE)

ACARBOSE

TABS

25MG

T2

(PRECOSE)

ACARBOSE

TABS

100MG

T2

(PRECOSE)

(68:20.03) Hormones and Synthetic Substitutes » Antidiabetic Agents » Amylinomimetics Product Name

Form

Strength

Pref

Coverage Details

SYMLINPEN 120

SOLN

2700MCG/2.7ML

T3

PA

SYMLINPEN 60

SOLN

1500MCG/1.5ML

T3

PA

Coverage Details

Comment

(68:20.04) Hormones and Synthetic Substitutes » Antidiabetic Agents » Biguanides Product Name

Form

Strength

Pref

METFORMIN HCL

TABS

500MG

T1

Comment (GLUCOPHAGE)

METFORMIN HCL

TABS

1000MG

T1

(GLUCOPHAGE)

METFORMIN HCL

TABS

850MG

T1

(GLUCOPHAGE)

METFORMIN HCL ER

TB24

500MG

T2

(GLUCOPHAGE)

METFORMIN HCL ER

TB24

750MG

T2

(GLUCOPHAGE)

(68:20.05) Hormones and Synthetic Substitutes » Antidiabetic Agents » Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Product Name

Form

Strength

Pref

Coverage Details

JANUVIA

TABS

50MG

T4

PA; QL

JANUVIA

TABS

25MG

T4

PA; QL

Comment

JANUVIA

TABS

100MG

T4

PA; QL

ONGLYZA

TABS

2.5MG

T4

PA; QL

ONGLYZA

TABS

5MG

T4

PA; QL

TRADJENTA

TABS

5MG

T3

ST

449

(68:20.06) Hormones and Synthetic Substitutes » Antidiabetic Agents » Incretin Mimetics Product Name

Form

Strength

Pref

Coverage Details

BYDUREON

SUSR

2MG

T4

PA; QL

BYETTA

SOLN

5MCG/0.02ML

T3

PA; QL

BYETTA

SOLN

10MCG/0.04ML

T3

PA; QL

Comment

(68:20.08) Hormones and Synthetic Substitutes » Antidiabetic Agents » Insulins Product Name

Form

Strength

Pref

Coverage Details

HUMULIN R U-500 (CONCENTRATED)

SOLN

500UNIT/ML

T3

QL

Comment

LANTUS

SOLN

100UNIT/ML

T4

QL

no Pens

LEVEMIR

SOLN

100UNIT/ML

T3

QL

no Pens

NOVOLIN 70/30

SUSP

T3

QL

no Pens

NOVOLIN N

SUSP

30UNIT/ML; 70UNIT/ML 100UNIT/ML

T3

QL

no Pens

NOVOLIN R

SOLN

100UNIT/ML

T3

QL

no Pens

NOVOLOG

SOLN

100UNIT/ML

T3

QL

no Pens

NOVOLOG MIX 70/30

SUSP

30UNIT/ML; 70UNIT/ML

T3

QL

no Pens

Coverage Details

Comment

(68:20.16) Hormones and Synthetic Substitutes » Antidiabetic Agents » Meglitinides Product Name

Form

Strength

Pref

NATEGLINIDE

TABS

60MG

T2

(STARLIX)

NATEGLINIDE

TABS

120MG

T2

(STARLIX)

(68:20.20) Hormones and Synthetic Substitutes » Antidiabetic Agents » Sulfonylureas Product Name

Form

Strength

Pref

CHLORPROPAMIDE

TABS

100MG

T2

Coverage Details

Comment (DIABENESE)

CHLORPROPAMIDE

TABS

250MG

T2

(DIABENESE)

GLIMEPIRIDE

TABS

1MG

T1

(AMARYL)

GLIMEPIRIDE

TABS

2MG

T1

(AMARYL)

GLIMEPIRIDE

TABS

4MG

T1

(AMARYL)

GLIPIZIDE

TABS

5MG

T1

(GLUCOTROL)

GLIPIZIDE

TABS

10MG

T1

(GLUCOTROL)

GLYBURIDE

TABS

2.5MG

T1

(DIABETA)

GLYBURIDE

TABS

5MG

T1

(DIABETA)

GLYBURIDE

TABS

1.25MG

T2

(DIABETA)

GLYBURIDE MICRONIZED

TABS

3MG

T2

(MICRONASE)

TOLAZAMIDE

TABS

250MG

T2

(TOLINASE)

TOLAZAMIDE

TABS

500MG

T2

(TOLINASE)

TOLBUTAMIDE

TABS

500MG

T2

(TOLINASE)

(68:20.28) Hormones and Synthetic Substitutes » Antidiabetic Agents » Thiazolidinediones Product Name

Form

Strength

Pref

Coverage Details

Comment

PIOGLITAZONE HCL

TABS

45MG

T2

ST

(ACTOS)

PIOGLITAZONE HCL

TABS

30MG

T2

ST

(ACTOS)

PIOGLITAZONE HCL

TABS

15MG

T2

ST

(ACTOS)

(68:22.12) Hormones and Synthetic Substitutes » Antihypoglycemic Agents » Glycogenolytic Agents Product Name

Form

Strength

Pref

Coverage Details

GLUCAGON EMERGENCY KIT

KIT

1MG

T3

QL

Comment

Product Name

Form

Strength

Pref

Coverage Details

Comment

CALCITONIN-SALMON

SOLN

200UNIT/ACT

T2

QL

(MIACALCIN)

FORTEO

SOLN

600MCG/2.4ML

T5

PA

Product Name

Form

Strength

Pref

Coverage Details

DESMOPRESSIN ACETATE

TABS

0.1MG

T2

(DDAVP)

DESMOPRESSIN ACETATE

TABS

0.2MG

T2

(DDAVP)

DESMOPRESSIN ACETATE

SOLN

0.01%

T2

(68:24) Hormones and Synthetic Substitutes » Parathyroid

(68:28) Hormones and Synthetic Substitutes » Pituitary

QL

Comment

(DDAVP)

(68:30.04) Hormones and Synthetic Substitutes » Somatotropin Agonists and Antagonists » Somatotropin Agonists Product Name

Form

Strength

Pref

Coverage Details

OMNITROPE

SOLN

5MG/1.5ML

T6

PA

OMNITROPE

SOLN

10MG/1.5ML

T6

PA

OMNITROPE

SOLR

5.8MG

T6

PA

Comment

(68:30.08) Hormones and Synthetic Substitutes » Somatotropin Agonists and Antagonists » Somatotropin Antagonists Product Name

Form

Strength

Pref

Coverage Details

SOMAVERT

SOLR

10MG

T5

PA

Product Name

Form

Strength

Pref

Coverage Details

MEDROXYPROGESTERONE ACETATE

TABS

10MG

T1

Comment

(68:32) Hormones and Synthetic Substitutes » Progestins Comment (PROVERA)

450

MEDROXYPROGESTERONE ACETATE

TABS

5MG

T1

(PROVERA)

MEDROXYPROGESTERONE ACETATE

TABS

2.5MG

T1

(PROVERA)

NORETHINDRONE ACETATE

TABS

5MG

T2

(AYGESTIN)

451

(68:36.04) Hormones and Synthetic Substitutes » Thyroid and Antithyroid Agents » Thyroid Agents Product Name

Form

Strength

Pref

LEVOTHYROXINE SODIUM

TABS

25MCG

T1

Coverage Details

Comment

LEVOTHYROXINE SODIUM

TABS

50MCG

T1

LEVOTHYROXINE SODIUM

TABS

75MCG

T1

LEVOTHYROXINE SODIUM

TABS

88MCG

T1

LEVOTHYROXINE SODIUM

TABS

100MCG

T1

LEVOTHYROXINE SODIUM

TABS

112MCG

T1

LEVOTHYROXINE SODIUM

TABS

125MCG

T1

LEVOTHYROXINE SODIUM

TABS

150MCG

T1

LEVOTHYROXINE SODIUM

TABS

175MCG

T1

LEVOTHYROXINE SODIUM

TABS

200MCG

T1

LEVOTHYROXINE SODIUM

TABS

300MCG

T1

LEVOTHYROXINE SODIUM

TABS

137MCG

T1

LIOTHYRONINE SODIUM

TABS

5MCG

T2

(SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID (CYTOMEL)

LIOTHYRONINE SODIUM

TABS

25MCG

T2

(CYTOMEL)

LIOTHYRONINE SODIUM

TABS

50MCG

T2

(CYTOMEL)

(68:36.08) Hormones and Synthetic Substitutes » Thyroid and Antithyroid Agents » Antithyroid Agents Product Name

Form

Strength

Pref

METHIMAZOLE

TABS

5MG

T2

Coverage Details

Comment (TAPAZOLE)

METHIMAZOLE

TABS

10MG

T2

(TAPAZOLE)

PROPYLTHIOURACIL

TABS

50MG

T2

(PTU)

Product Name

Form

Strength

Pref

METHYLERGONOVINE MALEATE

TABS

0.2MG

T2

(76:00) Oxytocics

(84:04.04) Skin and Mucous Membrane Preparations » Anti-infectives » Antibacterials

Coverage Details

Comment (METHERGINE)

452 Product Name

Form

Strength

Pref

Coverage Details

Comment

CLINDAMYCIN PHOSPHATE

CREA

2%

T2

QL

Vaginal only (CLEOCIN)

ERYTHROMYCIN

SOLN

2%

T2

QL

(A/T/S)

GENTAMICIN SULFATE

OINT

0.1%

T2

QL

(GARAMYCIN)

GENTAMICIN SULFATE

CREA

0.1%

T2

QL

(GARAMYCIN)

METRONIDAZOLE

GEL

1%

T2

QL

METRONIDAZOLE

CREA

0.75%

T2

QL

(METROCREAM)

METRONIDAZOLE

GEL

0.75%

T2

QL

(METROGEL)

METRONIDAZOLE

LOTN

0.75%

T2

QL

(METROLOTION)

METRONIDAZOLE VAGINAL

GEL

0.75%

T2

QL

(METROGEL)

MUPIROCIN

OINT

2%

T2

QL

(BACTROBAN)

MUPIROCIN

CREA

2%

T2

QL

(BACTROBAN)

VANDAZOLE

GEL

0.75%

T2

QL

(METROGEL)

VITAZOL

CREA

0.75%

T2

QL

(METROCREAM)

(84:04.06) Skin and Mucous Membrane Preparations » Anti-infectives » Antivirals Product Name

Form

Strength

Pref

Coverage Details

Comment

ACYCLOVIR

OINT

5%

T2

QL

not crm

DENAVIR

CREA

1%

T4

QL

(84:04.08.08) Skin and Mucous Membrane Preparations » Anti-infectives » Antifungals » Azoles Product Name

Form

Strength

Pref

Coverage Details

Comment

CLOTRIMAZOLE

LOZG

10MG

T2

QL

(MYCELEX TROCHES)

CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE

CREA

0.05%; 1%

T2

QL

(LOTRISONE)

CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE

LOTN

0.05%; 1%

T2

QL

(LOTRISONE)

CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE

CREA

0.05%; 1%

T2

QL

(LOTRISONE)

ECONAZOLE NITRATE

CREA

1%

T2

QL

(SPECTAZOLE)

KETOCONAZOLE

CREA

2%

T2

QL

not shampoo, (NIZORAL)

OXISTAT

LOTN

1%

T3

QL

OXISTAT

CREA

1%

T3

QL

TERCONAZOLE

CREA

0.4%

T2

QL

(TERAZOL)

TERCONAZOLE

CREA

0.8%

T2

QL

(TERAZOL)

TERCONAZOLE

SUPP

80MG

T2

QL

(TERAZOL)

ZAZOLE

CREA

0.4%

T2

QL

(TERAZOL)

453

(84:04.08.20) Skin and Mucous Membrane Preparations » Anti-infectives » Antifungals » Hydroxypyridones Product Name

Form

Strength

Pref

Coverage Details

Comment

CICLOPIROX

GEL

0.77%

T2

QL

not Shampoo, (LOPROX)

CICLOPIROX

SUSP

0.77%

T2

QL

not Shampoo, (LOPROX)

CICLOPIROX NAIL LACQUER

SOLN

8%

T2

QL

(PENLAC)

CICLOPIROX OLAMINE

CREA

0.77%

T2

QL

not Shampoo, (LOPROX)

(84:04.08.28) Skin and Mucous Membrane Preparations » Anti-infectives » Antifungals » Polyenes Product Name

Form

Strength

Pref

Coverage Details

Comment

NYSTATIN

OINT

100000UNIT/GM

T2

QL

not PWD

NYSTATIN

CREA

100000UNIT/GM

T2

QL

not PWD

(84:04.12) Skin and Mucous Membrane Preparations » Anti-infectives » Scabicides and Pediculicides Product Name

Form

Strength

Pref

Coverage Details

Comment

MALATHION

LOTN

0.5%

T2

QL

(OVIDE)

PERMETHRIN

CREA

5%

T2

QL

(ELIMITE)

(84:04.92) Skin and Mucous Membrane Preparations » Anti-infectives » Local Anti-infectives, Miscellaneous Product Name

Form

Strength

Pref

Coverage Details

Comment

SELENIUM SULFIDE

LOTN

2.5%

T2

QL

(SELSUN)

SSD

CREA

1%

T2

QL

(SILVADENE)

(84:06) Skin and Mucous Membrane Preparations » Anti-inflammatory Agents Product Name

Form

Strength

Pref

Coverage Details

Comment

ANUCORT-HC

SUPP

25MG

T2

QL

(ANUSOL HC)

BETAMETHASONE DIPROPIONATE

CREA

0.05%

T2

QL

(DIPROSONE)

BETAMETHASONE DIPROPIONATE

OINT

0.05%

T2

QL

(DIPROSONE)

BETAMETHASONE DIPROPIONATE

LOTN

0.05%

T2

QL

(DIPROSONE)

BETAMETHASONE VALERATE

OINT

0.1%

T2

QL

(VALISONE)

BETAMETHASONE VALERATE

CREA

0.1%

T2

QL

(VALISONE)

BETAMETHASONE VALERATE

LOTN

0.1%

T2

QL

(VALISONE)

CLOBETASOL PROPIONATE

OINT

0.05%

T2

QL

(TEMOVATE)

CLOBETASOL PROPIONATE

SOLN

0.05%

T2

QL

(TEMOVATE)

CLOBETASOL PROPIONATE

GEL

0.05%

T2

QL

(TEMOVATE)

CLOBETASOL PROPIONATE

CREA

0.05%

T2

QL

(TEMOVATE)

CLOBETASOL PROPIONATE

LOTN

0.05%

T2

QL

(TEMOVATE)

CLOBETASOL PROPIONATE EMOLLIENT

CREA

0.05%

T2

QL

(TEMOVATE)

COLOCORT

ENEM

100MG/60ML

T2

QL

(CORTENEMA)

CORDRAN TAPE

TAPE

4MCG/SQCM

T3

QL

CORDRAN TAPE

TAPE

4MCG/SQCM

T3

QL

CORTISPORIN

OINT

400UNIT/GM; 1%; 0.5%; 5000UNIT/GM

T3

QL

CORTISPORIN

CREA

T3

QL

DESONIDE

LOTN

0.5%; 0.5%; 10000UNIT/GM 0.05%

T2

QL

(TRIDESILON)

DESONIDE

CREA

0.05%

T2

QL

(TRIDESILON)

DESONIDE

OINT

0.05%

T2

QL

(TRIDESILON)

DESOXIMETASONE

CREA

0.25%

T2

QL

not spray, (TOPICORT)

DESOXIMETASONE

GEL

0.05%

T2

QL

not spray, (TOPICORT)

DESOXIMETASONE

OINT

0.25%

T2

QL

not spray, (TOPICORT)

DESOXIMETASONE

CREA

0.05%

T2

QL

not spray, (TOPICORT)

DESOXIMETASONE

OINT

0.05%

T2

QL

not spray, (TOPICORT)

DIFLORASONE DIACETATE

OINT

0.05%

T2

QL

(MAXIFLOR)

DIFLORASONE DIACETATE

CREA

0.05%

T2

QL

(MAXIFLOR)

FLUOCINOLONE ACETONIDE

CREA

0.01%

T2

QL

(SYNALAR)

FLUOCINOLONE ACETONIDE

SOLN

0.01%

T2

QL

(SYNALAR)

FLUOCINOLONE ACETONIDE

CREA

0.025%

T2

QL

(SYNALAR)

FLUOCINOLONE ACETONIDE

OINT

0.025%

T2

QL

(SYNALAR)

FLUOCINONIDE

CREA

0.05%

T2

QL

(LIDEX)

FLUOCINONIDE

OINT

0.05%

T2

QL

(LIDEX)

FLUOCINONIDE

GEL

0.05%

T2

QL

(LIDEX)

FLUOCINONIDE

SOLN

0.05%

T2

QL

(LIDEX)

FLUOCINONIDE-E

CREA

0.05%

T2

QL

(LIDEX-E)

FLUTICASONE PROPIONATE

LOTN

0.05%

T2

QL

(CUTIVATE)

FLUTICASONE PROPIONATE

OINT

0.005%

T2

QL

(CUTIVATE)

FLUTICASONE PROPIONATE

CREA

0.05%

T2

QL

(CUTIVATE)

HYDROCORTISONE

ENEM

100MG/60ML

T2

QL

(CORTENEMA)

HYDROCORTISONE

CREA

2.5%

T2

QL

(HYTONE)

HYDROCORTISONE

OINT

2.5%

T2

QL

(HYTONE)

HYDROCORTISONE

LOTN

2.5%

T2

QL

(HYTONE)

HYDROCORTISONE ACETATE

SUPP

25MG

T2

QL

(ANUSOL HC)

454

HYDROCORTISONE BUTYRATE

CREA

0.1%

T2

QL

(LOCOID)

HYDROCORTISONE BUTYRATE

SOLN

0.1%

T2

QL

(LOCOID)

HYDROCORTISONE BUTYRATE

OINT

0.1%

T2

QL

(LOCOID)

MOMETASONE FUROATE

SOLN

0.1%

T2

QL

(ELOCON)

MOMETASONE FUROATE

CREA

0.1%

T2

QL

(ELOCON)

MOMETASONE FUROATE

OINT

0.1%

T2

QL

(ELOCON)

NYSTATIN/TRIAMCINOLONE

CREA

T2

QL

not PWD, (MYCOLOG)

NYSTATIN/TRIAMCINOLONE

OINT

T2

QL

not PWD, (MYCOLOG)

PROCTOZONE-HC

CREA

100000UNIT/GM; 1MG/GM 100000UNIT/GM; 0.1% 2.5%

T2

QL

(ANUSOL HC)

TRIAMCINOLONE ACETONIDE

CREA

0.5%

T2

QL

(ARISTOCORT)

TRIAMCINOLONE ACETONIDE

CREA

0.025%

T2

QL

(ARISTOCORT)

TRIAMCINOLONE ACETONIDE

CREA

0.1%

T2

QL

(ARISTOCORT)

TRIAMCINOLONE ACETONIDE

OINT

0.025%

T2

QL

(ARISTOCORT)

TRIAMCINOLONE ACETONIDE

OINT

0.1%

T2

QL

(ARISTOCORT)

TRIAMCINOLONE ACETONIDE

LOTN

0.025%

T2

QL

(ARISTOCORT)

TRIAMCINOLONE ACETONIDE

LOTN

0.1%

T2

QL

(ARISTOCORT)

TRIAMCINOLONE ACETONIDE

OINT

0.5%

T2

QL

(ARISTOCORT)

TRIAMCINOLONE ACETONIDE

PSTE

0.1%

T2

QL

(KENALOG ORABASE)

TRIAMCINOLONE IN ORABASE

PSTE

0.1%

T2

QL

(KENALOG ORABASE)

(84:08) Skin and Mucous Membrane Preparations » Antipruritics and Local Anesthetics Product Name

Form

Strength

Pref

Coverage Details

Comment

LIDOCAINE

PTCH

5%

T2

PA

(LIDODERM)

LIDOCAINE

OINT

5%

T2

QL

oint only, (XYLOCAINE)

LIDOCAINE/PRILOCAINE

CREA

2.5%; 2.5%

T2

QL

(EMLA)

PHENAZOPYRIDINE HCL

TABS

200MG

T2

PRUDOXIN

CREA

5%

T2

QL

not 100mg, (PYRIDIUM)

(84:16) Skin and Mucous Membrane Preparations » Cell Stimulants and Proliferants Product Name

Form

Strength

Pref

Coverage Details

Comment

TRETINOIN

CREA

0.1%

T2

PA; QL

(RETIN-A)

TRETINOIN

CREA

0.05%

T2

PA; QL

(RETIN-A)

TRETINOIN

CREA

0.025%

T2

PA; QL

(RETIN-A)

TRETINOIN

GEL

0.025%

T2

PA; QL

(RETIN-A)

TRETINOIN

GEL

0.01%

T2

PA; QL

(RETIN-A)

455

456

(84:28) Skin and Mucous Membrane Preparations » Keratolytic Agents Product Name

Form

Strength

Pref

Coverage Details

X-VIATE

LOTN

40%

T2

QL

X-VIATE

CREA

40%

T2

QL

Comment

(84:50.06) Skin and Mucous Membrane Preparations » Depigmenting and Pigmenting Agents » Pigmenting Agents Product Name

Form

Strength

Pref

Coverage Details

OXSORALEN

LOTN

1%

T3

QL

OXSORALEN ULTRA

CAPS

10MG

T3

Comment

(84:92) Skin and Mucous Membrane Preparations » Skin and Mucous Membrane Agents, Misc Product Name

Form

Strength

Pref

Coverage Details

Comment

ACITRETIN

CAPS

10MG

T5

PA

(SORIATANE)

ACITRETIN

CAPS

25MG

T5

PA

(SORIATANE)

ACITRETIN

CAPS

17.5MG

T5

PA

(SORIATANE)

CALCIPOTRIENE

SOLN

0.005%

T2

QL

(DOVONEX)

CALCIPOTRIENE

CREA

0.005%

T2

QL

(DOVONEX)

CALCIPOTRIENE

OINT

0.005%

T2

QL

(DOVONEX)

ELIDEL

CREA

1%

T4

QL

FLUOROURACIL

SOLN

2%

T2

QL

(EFUDEX)

FLUOROURACIL

SOLN

5%

T2

QL

(EFUDEX)

FLUOROURACIL

CREA

5%

T2

QL

(EFUDEX)

IMIQUIMOD

CREA

5%

T2

QL

(ALDARA)

PANRETIN

GEL

0.1%

T3

PODOFILOX

SOLN

0.5%

T2

QL

(CONDYLOX)

SANTYL

OINT

250UNIT/GM

T4

QL

SOLARAZE

GEL

3%

T3

PA; QL

TARGRETIN

GEL

1%

T5

QL

TAZORAC

GEL

0.1%

T4

PA; QL

TAZORAC

CREA

0.05%

T4

PA; QL

TAZORAC

CREA

0.1%

T4

PA; QL

VASOLEX

OINT

788MG/GM; 87MG/GM; 90UNIT/GM

T2

QL

(86:12.04) Smooth Muscle Relaxants » Genitourinary Smooth Muscle Relaxants » Antimuscarinics Product Name

Form

Strength

Pref

FLAVOXATE HCL

TABS

100MG

T2

Coverage Details

Comment (URISPAS)

OXYBUTYNIN CHLORIDE

SYRP

5MG/5ML

T2

(DITROPAN)

OXYBUTYNIN CHLORIDE

TABS

5MG

T2

(DITROPAN)

TOVIAZ

TB24

4MG

T3

TOVIAZ

TB24

8MG

T3

(86:16) Smooth Muscle Relaxants » Respiratory Smooth Muscle Relaxants Product Name

Form

Strength

Pref

THEOPHYLLINE CR

TB12

200MG

T2

Coverage Details

Comment (THEO-DUR)

THEOPHYLLINE CR

TB12

100MG

T2

(THEO-DUR)

THEOPHYLLINE ER

TB12

450MG

T2

(THEO-DUR)

THEOPHYLLINE ER

TB12

300MG

T2

(THEO-DUR)

Product Name

Form

Strength

Pref

FOLIC ACID

TABS

1MG

T2

Product Name

Form

Strength

Pref

CALCITRIOL

CAPS

0.25MCG

T2

(ROCALTROL)

CALCITRIOL

SOLN

1MCG/ML

T2

(ROCALTROL)

CALCITRIOL

CAPS

0.5MCG

T2

(ROCALTROL)

VITAMIN D

CAPS

50000UNIT

T2

ZEMPLAR

CAPS

2MCG

T4

PA

ZEMPLAR

CAPS

1MCG

T4

PA

Product Name

Form

Strength

Pref

Coverage Details

Comment

MEPHYTON

TABS

5MG

T3

Product Name

Form

Strength

Pref

Coverage Details

Comment

MULTI-VIT/FLUORIDE

SOLN

35MG/ML; 400UNIT/ML; 2MCG/ML; 8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.25MG/ML; 0.5MG/ML; 5UNIT/ML; 1500UNIT/ML

T2

QL

(88:08) Vitamins » Vitamin B Complex Coverage Details

Comment

Coverage Details

Comment

(88:16) Vitamins » Vitamin D

(88:24) Vitamins » Vitamin K Activity

(88:28) Vitamins » Multivitamin Preparations

457

458

MULTI-VIT/FLUORIDE

SOLN

35MG/ML; 400UNIT/ML; 2MCG/ML; 8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.5MG/ML; 0.5MG/ML; 5UNIT/ML; 1500UNIT/ML

T2

QL

MULTI-VIT/IRON/FLUORIDE

SOLN

35MG/ML; 400UNIT/ML; 10MG/ML; 8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.25MG/ML; 0.5MG/ML; 5UNIT/ML; 1500UNIT/ML

T2

QL

PRENATAL PLUS

TABS

120MG; 0; 200MG; 400UNIT; 2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG; 22MG; 4000UNIT; 25MG

T2

TRI-VIT/FLUORIDE

SOLN

35MG/ML; 400UNIT/ML; 0.25MG/ML; 1500UNIT/ML

T2

QL

(TRI-VI-FLOR)

TRI-VIT/FLUORIDE

SOLN

35MG/ML; 400UNIT/ML; 0.5MG/ML; 1500UNIT/ML

T2

QL

(TRI-VI-FLOR)

TRI-VIT/FLUORIDE/IRON

SOLN

35MG/ML; 0.25MG/ML; 10MG/ML; 1500UNIT/ML; 400UNIT/ML

T2

QL

(TRI-VI-FLOR W/IRON)

(STUARTNATAL PLUS)

TRINATE

TABS

120MG; 3000UNIT; 200MG; 400UNIT; 2MG; 12MCG; 28MG; 1MG; 25MG; 20MG; 25MG; 4MG; 1.8MG; 22MG; 25MG

T2

(STUARTNATAL PLUS-3)

(92:04) Miscellaneous Therapeutic Agents » Alcohol Deterrents Product Name

Form

Strength

Pref

DISULFIRAM

TABS

250MG

T2

Coverage Details

Comment (ANTABUSE)

DISULFIRAM

TABS

500MG

T2

(ANTABUSE)

(92:08) Miscellaneous Therapeutic Agents » 5-alpha-Reductase Inhibitors Product Name

Form

Strength

Pref

AVODART

CAPS

0.5MG

T3

Coverage Details

Comment

FINASTERIDE

TABS

5MG

T2

Product Name

Form

Strength

Pref

ACETYLCYSTEINE

SOLN

10%

T2

(MUCOMYST)

ACETYLCYSTEINE

SOLN

20%

T2

(MUCOMYST)

LEUCOVORIN CALCIUM

TABS

5MG

T2

(WELLCOVORIN)

LEUCOVORIN CALCIUM

TABS

10MG

T2

(WELLCOVORIN)

LEUCOVORIN CALCIUM

TABS

15MG

T2

(WELLCOVORIN)

(PROSCAR)

(92:12) Miscellaneous Therapeutic Agents » Antidotes Coverage Details

Comment

(92:16) Miscellaneous Therapeutic Agents » Antigout Agents Product Name

Form

Strength

Pref

ALLOPURINOL

TABS

100MG

T1

Coverage Details

Comment (ZYLOPRIM)

ALLOPURINOL

TABS

300MG

T1

(ZYLOPRIM)

COLCRYS

TABS

0.6MG

T4

QL

(92:20) Miscellaneous Therapeutic Agents » Immunomodulatory Agents Product Name

Form

Strength

Pref

Coverage Details

ACTIMMUNE

SOLN

2000000UNIT/0.5ML

T5

PA

AVONEX

KIT

30MCG/VIAL

T5

AVONEX

KIT

30MCG/0.5ML

T5

AVONEX PEN

KIT

30MCG/0.5ML

T5

BETASERON

KIT

0.3MG

T5

Comment

459

460

COPAXONE

KIT

20MG/ML

T5

REBIF

SOLN

22MCG/0.5ML

T5

REBIF

SOLN

44MCG/0.5ML

T5

REBIF TITRATION PACK

SOLN

THALOMID

CAPS

50MG

T3

PA

THALOMID

CAPS

100MG

T3

PA

THALOMID

CAPS

150MG

T3

PA

THALOMID

CAPS

200MG

T3

PA

T5

(92:24) Miscellaneous Therapeutic Agents » Bone Resorption Inhibitors Product Name

Form

Strength

Pref

Coverage Details

Comment

ALENDRONATE SODIUM

TABS

70MG

T1

QL

(FOSAMAX)

ALENDRONATE SODIUM

TABS

5MG

T2

(FOSAMAX)

ALENDRONATE SODIUM

TABS

10MG

T2

(FOSAMAX)

ALENDRONATE SODIUM

TABS

35MG

T2

QL

(FOSAMAX)

(92:28) Miscellaneous Therapeutic Agents » Cariostatic Agents Product Name

Form

Strength

Pref

Coverage Details

Comment

SF

GEL

1.1%

T2

QL

(PREVIDENT)

SODIUM FLUORIDE

CHEW

0.25MG

T2

(LURIDE)

SODIUM FLUORIDE

CHEW

0.5MG

T2

(LURIDE)

SODIUM FLUORIDE

CHEW

1MG

T2

(LURIDE)

SODIUM FLUORIDE

SOLN

0.5MG/ML

T2

QL

(LURIDE)

Comment

(92:36) Miscellaneous Therapeutic Agents » Disease-modifying Antirheumatic Agents Product Name

Form

Strength

Pref

Coverage Details

ENBREL

KIT

25MG

T5

PA

ENBREL

SOLN

50MG/ML

T5

PA

ENBREL

SOLN

25MG/0.5ML

T5

PA

ENBREL SURECLICK

SOLN

50MG/ML

T5

PA

HUMIRA

KIT

40MG/0.8ML

T5

PA

HUMIRA

KIT

20MG/0.4ML

T5

PA

HUMIRA PEN

KIT

40MG/0.8ML

T5

PA

HUMIRA PEN-CROHNS DISEASESTARTER

KIT

40MG/0.8ML

T5

PA

KINERET

SOLN

100MG/0.67ML

T6

PA

LEFLUNOMIDE

TABS

10MG

T2

(ARAVA)

LEFLUNOMIDE

TABS

20MG

T2

(ARAVA)

ORENCIA

SOLN

125MG/ML

T5

PA

Coverage Details

(92:44) Miscellaneous Therapeutic Agents » Immunosuppressive Agents Product Name

Form

Strength

Pref

AZATHIOPRINE

TABS

50MG

T2

Comment

CELLCEPT

SUSR

200MG/ML

T6

CYCLOSPORINE MODIFIED

CAPS

25MG

T2

(NEORAL)

CYCLOSPORINE MODIFIED

CAPS

50MG

T2

(NEORAL)

CYCLOSPORINE MODIFIED

CAPS

100MG

T2

(NEORAL)

CYCLOSPORINE MODIFIED

SOLN

100MG/ML

T2

(NEORAL)

GENGRAF

CAPS

25MG

T2

(NEORAL)

GENGRAF

CAPS

100MG

T2

(NEORAL)

MYCOPHENOLATE MOFETIL

CAPS

250MG

T2

(CELLCEPT)

MYCOPHENOLATE MOFETIL

TABS

500MG

T2

(CELLCEPT)

MYFORTIC

TBEC

180MG

T6

MYFORTIC

TBEC

360MG

T6

RAPAMUNE

SOLN

1MG/ML

T6

RAPAMUNE

TABS

0.5MG

T6

RAPAMUNE

TABS

1MG

T6

RAPAMUNE

TABS

2MG

T6

TACROLIMUS

CAPS

0.5MG

T6

(PROGRAF)

TACROLIMUS

CAPS

1MG

T6

(PROGRAF)

TACROLIMUS

CAPS

5MG

T6

(PROGRAF)

ZORTRESS

TABS

0.5MG

T6

ZORTRESS

TABS

0.75MG

T6

ZORTRESS

TABS

0.25MG

T6

(IMURAN)

(92:56) Miscellaneous Therapeutic Agents » Protective Agents Product Name

Form

Strength

Pref

MESNEX

TABS

400MG

T4

Coverage Details

Comment

Comment

(92:92) Miscellaneous Therapeutic Agents » Other Miscellaneous Therapeutic Agents Product Name

Form

Strength

Pref

Coverage Details

ARCALYST

SOLR

220MG

T5

PA

CYSTADANE

POWD

T4

461

462

CYSTAGON

CAPS

150MG

T2

ELMIRON

CAPS

100MG

T4

PA

KUVAN

TBSO

100MG

T5

PA

ORFADIN

CAPS

10MG

T5

PA

SENSIPAR

TABS

30MG

T3

PA

SENSIPAR

TABS

60MG

T3

PA

SENSIPAR

TABS

90MG

T3

PA

ZAVESCA

CAPS

100MG

T4

PA

463

PRESCRIPTION DRUGS BENEFITS

FHCP Members are eligible for a prescription drug benefit for which they pay a specified copayment for prescription drugs ordered by their physician. In order to take advantage of this benefit, the member’s prescription must meet certain criteria.

The prescription must: • • • •

Be written by licensed prescriber; Be for a drug included in the FHCP Formulary (provided under separate cover); Be filled at a FHCP Pharmacy or Affiliated Pharmacy (see attached list); Meet the Guidelines outlined in the Benefits section of this handbook (see attached)

Whenever possible, please direct the patient to have their prescription filled at the FHCP Pharmacy rather than an affiliate. The FHCP Formulary is available to every FHCP Provider. If you need a copy for your office, please call the Pharmacy at FHCP’s Holly Hill facility at (386) 676-7173. Please refer to the FHCP Formulary when requesting a drug to be added. The FHCP Pharmacy and Therapeutics Committee meets quarterly to approve additional drugs. Any questions concerning the prescription drug benefits, please contact Lois Billingsley, R.Ph., Administer of Pharmacy Services at (386) 676-7173 or (800) 232-0216.

464 PHARMACY SERVICES AND HOURS The following pharmacies are the only pharmacies permitted to fill and dispense FHCP prescriptions: FHCP Pharmacy 350 N. Clyde Morris Blvd. Daytona Beach 386.248.0832 386.238.3263 Fax 1.800.321.1227 TTY# Florida Relay 7-1-1 M-F, 8:30 am - 6:00 pm Closed Sat. and Sun.

FHCP Pharmacy 239 N. Ridgewood Ave. Edgewater 386.423.4212 386.428.9713 Fax TTY# Florida Relay 7-1-1 M-F 8:30 am - 6:00 pm Sat., 9:00 am - 1:00 pm Closed Sun.

FHCP Pharmacy 740 Dunlawton Ave., Suite 150 Port Orange 386.767.0563 386.761.7095 Fax TTY# Florida Relay 7-1-1 M-F, 8:30 am - 6:00 pm Sat., 9:00 am - 1:00 pm Closed Sun.

FHCP Pharmacy 939 N. Spring Garden Ave. DeLand 386.736.7318 386.943.8123 Fax TTY# Florida Relay 7-1-1 M-F, 8:30 a.m - 6:00 pm Sat., 9:00 am - 1:00 pm Closed Sun.

FHCP Pharmacy 2777 Enterprise Road Orange City 386.774.5961 386.774.7592 Fax 1.800.390.3427 TTY# Florida Relay 7-1-1 M-F, 8:30 am - 6:00 pm Sat., 9:00 am - 1:00 pm Closed Sun.

FHCP Mail Order Pharmacy P.O. Box 11696 Daytona Beach 386.676.7126 386.676.7165 Fax 1.800.232.0216 TTY# Florida Relay 7-1-1 M-F, 8:30 am - 5:30 pm Closed Sat. and Sun. NOT OPEN TO PUBLIC

FHCP Pharmacy 1340 Ridgewood Avenue Holly Hill 386.676.7120 386.676.7128 Fax 1.800.232.0216 TTY# Florida Relay 7-1-1 M-F, 8:30 am - 6:00 p.m Sat., 9:00 am - 5:00 pm Closed Sun.

FHCP Pharmacy 309 Palm Coast Parkway Palm Coast 386.446.9447 386.446.6983 Fax TTY# Florida Relay 7-1-1 M-F, 8:30 am - 6:00 pm Sat., 9:00 am - 1:00 pm Closed Sun.

Web Address www.fhcp.com

MANDATORY GENERIC RULE - When a generic medication is available and is not obtained by the member, whether at the member’s request or the prescribing physician’s request, or when a prescription is written for a drug that is not on Florida Health Care Plans drug formulary, it will not be covered. Florida Health Care Plans will provide a discount off of the Average Wholesale Price (AWP) for non-formulary drugs to Medvantage and Group members. These prescriptions can then only be dispensed by FHCP Pharmacies. Please refer to your FHCP Co-payment Schedule for the appropriate discount. Non-formulary drugs or brand name drugs that are generically available and not dispensed generically are not covered if purchased from Walgreens. An HMO with a Medicare Contract

OVER Rev. 1/12

465 PHARMACY SERVICES AND HOURS The following pharmacies are the only pharmacies permitted to fill and dispense FHCP prescriptions: FHCP Pharmacy 4932 W. State Road 46 Ste. 1000 Sanford, FL 32771 407.732.7950 407.732.7956 Fax TTY# Florida Relay 7-1-1 M-F 8:30 am – 6:00 pm Sat., 9:00 am – 1:00 pm Closed Sun.

FHCP Pharmacy 1021 S. Washington Ave. Titusville, FL 32780 321.567.7500 321. 567.7501 Fax TTY# Florida Relay 7-1-1 M-F 8:30 am - 6:00 pm Sat., 9:00 am - 1:00 pm Closed Sun.

FHCP Pharmacy 1954 Rockledge Blvd Ste. 107 Rockledge, FL 32955 321.567.7503 321.567.7504 Fax TTY# Florida Relay 7-1-1 M-F 8:30 am - 6:00 pm Sat., 9:00 am - 1:00 pm Closed Sun.

FHCP Pharmacy 785 N. Wickham Road Suite 104 Melbourne, FL 32935 321.567.7505 321.567.7506 Fax TTY# Florida Relay 7-1-1 M-F 8:30 am - 6:00 pm Sat., 9:00 am - 1:00 pm Closed Sun.

FHCP Mail order Pharmacy

Web Address www.fhcp.com

P.O. Box 11696 Daytona Beach, FL 32120 386.676-7126 386.676-7165 Fax 800.232-0216

TTY# Florida Relay 7-1-1 M-F, 8:30 am – 5:30pm Closed Sat. and Sun. NOT OPEN TO PUBLIC

MANDATORY GENERIC RULE - When a generic medication is available and is not obtained by the member, whether at the member’s request or the prescribing physician’s request, or when a prescription is written for a drug that is not on Florida Health Care Plans drug formulary, it will not be covered. Florida Health Care Plans will provide a discount off of the Average Wholesale Price (AWP) for non-formulary drugs to Medvantage and Group members. These prescriptions can then only be dispensed by FHCP Pharmacies. Please refer to your FHCP Co-payment Schedule for the appropriate discount. Non-formulary drugs or brand name drugs that are generically available and not dispensed generically are not covered if purchased from Walgreens. An HMO with a Medicare Contract

OVER

466

467

468

469

FHCP PRIOR AUTHORIZATION MEDICATION FORM DATE: Provider Name:

AUTH#: Provider Signature:

Specialty: Contact Person:

Provider Phone: Provider Fax:

Routine

Urgent Phone: 386-238-3230 or 800-352-9824 If your request is urgent, you must call the Central Referral Department prior to submitting your request.

Patient Name:

FHCP #:

DOB:

Patient Home Phone: Patient Alternate Phone: Medication Requested & Duration of Therapy (Please specify name, strength, dosing schedule and route of administration)

Diagnosis:

ICD10 Code:

Alternatives tried:

Is this a new medication or Ongoing Medication

Reason for the Medication:

Please fax completed form with CLINICAL NOTES and MED LIST to FHCP Central Referrals at 386-238-3253 or 877-659-3427

You may view the formulary online at www.fhcp.com by clicking on the Provider Tab; then either the Provider Services or Forms tab. On the right-hand side, click on Formulary under "Related Documents" to determine whether a medication requires prior authorization.

THE SECTION BELOW IS FOR FHCP INTERNAL USE ONLY APPROVED BY FLORIDA HEALTH CARE PLANS FOR:

CVS Caremark Signature: Rev. 08-12-15, 10-1-15

FHCP Pharmacy Date:

Provider Office Infusion

FHCP Infusion Approved

Denied

470 FHCP CONTRACTING PHARMACIES Walgreen Pharmacy 3010 S. Ridgewood Avenue Edgewater 386.427.5208 Fax# 386.427.9840 M-F, 8:00 am - 10:00 pm Sat., 9:00 am - 6:00 pm Sun., 9:00 am - 5:00 pm

Walgreen Pharmacy 205 E. Granada Boulevard Ormond Beach 386.677.8849 Fax# 386.673.7661 M-F, 9:00 am - 9:00 pm Sat., 9:00 am - 6:00 pm Sun., 9:00 am - 5:00 pm

Walgreen Pharmacy 7815 U.S. Highway 17-92 Fern Park 407.331.0968 Fax# 407-331-7904 M-F, 9:00 am - 9:00 pm Sat., 9:00 am - 5:00 pm Sun., 9:00 am - 5:00 pm

THE FOLLOWING FHCP CONTRACT PHARMACIES CAN FILL FHCP PRESCRIPTIONS AFTER HOURS AND FOR EMERGENCY PRESCRIPTIONS ONLY. After hours is defined as: Monday through Friday, 6:00 pm to 8:00 am as well as holidays when FHCP pharmacies are closed, and all day Saturday and Sunday.

Walgreen Pharmacy 1420 Beville Road Daytona Beach 386.257.5773 Pharmacy Not Open 24 Hours

Walgreen Pharmacy 790 W. Granada Boulevard Ormond Beach 386.672.7107 Open 24 Hours

Walgreen Pharmacy 1650 Dunlawton Avenue Port Orange 386.322.3267 Open 24 Hours

Walgreen Pharmacy 100 E. International Spdwy. DeLand 386.738.4371 Open 24 Hours

Walgreen Pharmacy 897 Saxon Boulevard Orange City 386.775.5336 Open 24 Hours

Walgreen Pharmacy 1109 Palm Coast Pkwy. W. Palm Coast 386.445.7041 Open 24 Hours

471

FHCP CONTRACTING PHARMACIES Walgreens Pharmacy

Walgreens Pharmacy

7415 N. Highway 1 Cocoa, FL 32927 321.213-6233 Non-Preferred Pharmacy M-F, 9:00 am – 9:00 pm Sat., 9:00 am – 5:00 Pm Sun., 10:00 am – 6:00 pm

2200 N. Highway A1A Melbourne, FL 32903 321.773-2022 Non-Preferred Pharmacy M-F, 9:00 am – 9:00 pm Sat., 10:00 am – 6:00 pm Sun., 10:00 am – 6:00 pm

Walgreens Pharmacy

Walgreens Pharmacy

4150 N. Atlantic Ave Cocoa Beach, FL 32931 321.799-9112 Non-Preferred Pharmacy Open 24 Hours

1213 Palm Bay Rd. NE Melbourne, FL 32905 321.676-4502 Non-Preferred Pharmacy M-F, 9:00 am – 9:00 pm Sat – Sun, 10:00 am – 6:00 pm

Walgreens Pharmacy

Walgreens Pharmacy

7780 N. Wickham Rd. Melbourne, FL 32940 321.254-1072 Non-Preferred Pharmacy Mon – Sun, 7:00 am – 12:00 am

3495 Bayside Lakes Blvd. SE Palm Bay, FL 32909 321.409-2828 Non-Preferred Pharmacy M-F, 9:00 am – 9:00 pm Sat-Sun, 10:00 am – 6:00 pm

Walgreens Pharmacy

Walgreens Pharmacy

1160 Malabar Rd. SE Palm Bay, FL 32907 321.956-9626 Non-Preferred Pharmacy Open 24 Hours

175 Malabar Rd. NW Palm Bay, FL 32907 321.728-4055 Non-Preferred Pharmacy M-F, 9:00 am -9:00 pm Sat-Sun, 10:00 am – 6:00 pm

Walgreens Pharmacy

Walgreens Pharmacy

113 Maitland Ave. Altamonte Springs, FL 32701 407.331-4698 Non-Preferred Pharmacy Open 24 Hours

7815 Hwy. 17-92 Fern Park, FL 32720 407.331-0968 Non-Preferred Pharmacy M-F, 9am -9pm Sat-Sun 9am -5pm

472 Walgreens Pharmacy 785 Lockwood Blvd. Oviedo, FL 32765 407.359-2453 Non-Preferred Pharmacy M-F, 9:00 am – 9:00 pm Sat – Sun 9:00 am – 5:00 pm

Walgreens Pharmacy

5205 Red Bug Lake Rd. Winter Springs, FL 32708 407.696-2242 Non-Preferred Pharmacy Open 24 Hours

THE FOLLOWING FHCP CONTRACT PHARMACIES CAN FILL FHCP PRESCRIPTIONS AFTER HOURS AND FOR EMERGENCY PRESCRIPTIONS ONLY. After hours is defined as: Monday through Friday, 6:00 pm to 8:00 am as well as holidays when FHCP pharmacies are closed, and all day Saturday and Sunday.

Walgreens Pharmacy

Walgreens Pharmacy

2475 US 1 Mims, FL 32754 321.267-1788 Non-Preferred Pharmacy M-F, 9:00 am – 9:00 pm Sat – Sun, 10:00 am -6:00 pm

4600 S. Washington Ave. Titusville, FL 32780 321.269-7573 Non-Preferred Pharmacy Mon-Sun, 8:00 am – 10:00 pm

Walgreens Pharmacy

Walgreens Pharmacy

1106 Clearlake Rd. Cocoa, FL 32922 321.632-3150 Non-Preferred Pharmacy M-F, 8:00 am – 10:00 pm Sat, 9:00 am – 6:00 pm Sun, 9:00 am – 5:00 pm

1350 N. Wickham Rd. Melbourne, FL 32935 321.254-5507 Non-Preferred Pharmacy Open 24 Hours

473

Walgreens Pharmacy 1109 Palm Coast Pkwy Palm Coast, FL 32137 386.445-7041 Non-Preferred Pharmacy Open 24 Hours

Walgreens Pharmacy 4024 W. Lake Mary Blvd. Lake Mary, FL 32746 407.549-3115 Non-Preferred Pharmacy M-F, 9:00 am – 9:00 pm Sat- Sun, 9:00 am- 5:00 pm

Walgreens Pharmacy

7085 County Road 46A Lake Mary, FL 32746 407.833-0276 Non-Preferred Pharmacy M-F, 9:00 am – 9:00 pm Sat-Sun, 9:00 am – 5:00 pm

Walgreens Pharmacy

2501 French Ave. Sanford, FL 32773 407.321-0518 Non-Preferred Pharmacy Open 24 Hours

474

FLORIDA HEALTH CARE PLANS ENBREL ORDER For treatment of Rheumatoid Arthritis, Psoriatic Arthritis, Plaque Psoriasis or Ankylosing Spondylitis Date:

Auth. #:

A. Member Name:

Referring Provider Name:

Med. Record #:

Date of Birth:

Referring Provider Phone #:

Home Phone#:

Work Phone#

Referring Provider FHCP #:

Cell #:

Provider Signature:

Subscriber #:

Copy to:

Parent/Guardian Name:

Allergies:

Type of Referral:

1. Height

URGENT

ROUTINE

Weight

2. Date of last PPD

+

-

3. Is prescriber a dermatologist or rheumatologist?

Requirement: PPD must be within the last 12 months. Yes

No

4. Does the patient have a history of Rheumatoid Arthritis? Mild Moderate Severe 5. Does the patient have a history of Psoriatic Arthritis? Mild Moderate Severe

Yes

Yes

No

No

6. Does the patient have chronic moderate to severe Plaque Psoriasis that covers 10% or greater body surface area or debilitating palmer/planter Plaque Psoriasis ? Yes No 7. Does the patient have a history of Spondylosing Anklyosis? Mild Moderate Severe

Yes

8. Does the patient have hot, red or swollen joints despite therapy?

No

Yes

9. Does the patient have X-ray changes consistent with Rheumatoid Arthritis? 10. Does the patient have significant loss of function despite therapy?

Yes

No Yes

No

No

THIS SECTION IS ONLY FOR THOSE SERVICES THAT REQUIRE PRE-AUTHORIZATION This Form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s PCP or the Referring Provider.

APPROVED BY FLORIDA HEALTH CARE PLANS FOR: Signature: TO:

Date: FROM:

Phone #:

This document is privileged and confidential. It is intended solely for the use of the recipient named above. If the reader/recipient of this document is not the intended recipient, you are hereby notified that any distribution, copying or disclosure of the contents of this document is prohibited. If you have received this document in error, please notify FHCP immediately by the telephone or fax number indicated above and return the original facsimile message to us at P. O. Box 9910, Daytona Beach, FL 32120.

475 FAILED TREATMENTS FOR RA, PSORIATIC ARTHRITIS, AND ANKYLOSING SPONDYLITIS* Has the patient taken methotrexate ≥20mg/week for at least 3 months within past 6 months? Yes No dose/week If yes, was the treatment successful?

Yes

No

If the patient has not taken methotrexate, is it contraindicated? Yes No (Note: mild and transient [<2 UNL] AST/ALT elevations in absence of liver disease/pathology are not contraindications to continuation or initiation of MTX therapy). Patients who have a methotrexate failure or contraindication must try an alternative DMARD prior to Enbrel Authorization. Has patient tried combination MTX + DMARD for at least 3 of the last 6 months? DMARD and dose

Yes

No

If MTX treatment is contraindicated or not tolerated has patient tried an alternative DMARD Combination for at least 3- 6 months within the past 6 months (i.e. hydroxychloroquine or sulfasalazine)? Yes No Alternative DMARDs and dose * If use is for ankylosing spondylitis, has patient failed on at least two NSAIDs at maximum tolerated dose? Yes No NSAIDs and Dose Is patient/caregiver able to administer medication?

Yes

No

PLAQUE PSORIASIS TREATMENT FAILURES* 1) Patient has tried at least a 3 month trial of either of the following systemic therapies: methotrexate (dosed at least 15-25mg/week) or soriatane within the past 6 months? Yes No Drug/dose_________________________________________________________________ Was systemic therapy effective?

Yes

No

If the patient has not taken methotrexate, is it contraindicated? Yes No (Note: mild and transient [<2 UNL] AST/ALT elevations in absence of liver disease/pathology are not contraindications to continuation or initiation of MTX therapy) 2) Patient has tried (or use is contraindicated) at least 15 sessions of phototherapy within the past 6 months? Yes No Treatment/duration _________________________________________________________ Was phototherapy effective?

Yes

No

* Approved coverage will be the FDA approved dosing of 50 mg SC administered up to twice weekly for 3 months, followed by 50mg SC administered once per week for remainder of referral period. For Physician Signature: “I attest to the fact that, in my professional opinion, this patient meets the guidelines for Enbrel injections.” Requesting Provider Signature:________________________Date:

476 FLORIDA HEALTH CARE PLANS

Referral Form for Synvisc, Hyalgen or Euflexxa Date:

Auth. #: Referring Provider Name:

A. Member Name: Med. Record #:

Date of Birth:

Referring Provider Phone #:

Home Phone#:

Work Phone#

Referring Provider FHCP #:

Cell #:

Provider Signature:

Subscriber #:

Type of Referral:

URGENT

ROUTINE

(please check)

Parent/Guardian Name: 1. 2. 3. 4. 5.

Request for: Synvisc Hyalgen Is patient: Medicare Commercial Height Weight Knee DJD Mild Mod Severe Does patient have a large effusion? Yes No

Euflexxa Left Knee BMI

Right Knee Bilateral Knees Weight is not a Medicare exclusion.

FAILED CONSERVATIVE TREATMENTS 6. Does patient have PUD, GER, intolerance to NSAID? Yes No Other agents tried for DJD: Dates A. B. C.

Responses

Must have failed at least three (3) with at least one (1) month trial. 7. Has Physical Therapy been tried?

Yes

No

8. Has patient had Synvisc, Hyalgen or Euflexxa inject before?

Yes

No

If yes, any reaction?

For Physician Signature: “I attest to the fact that in my professional opinion, this patient meets the Medicare guidelines for above indicated request.”

(Patient Name)

Requesting Provider Signature:

Date:

Yes

No

MEDICAL DIRECTOR / DESIGNEE USE ONLY APPROVED # of Visits DISAPPROVED

NOT A COVERED BENEFIT

Form letter to Dr.

LACK OF MEDICAL INFORMATION TO RENDER DECISION & Patient.

Appeals rights sent

See blue Denial Form (attached)

Signature:

Date:

Provider of Service:

Date:

Date Referring Provider Notified: 21-112/10-06x

Name of Notifier:

Copy Sent to Pharmacy

477

FORTEO PATIENT CONSENT FORM I have read the Patient Medication Guide for Forteo and am aware that this medication has been associated with Bone Cancer in mice. It is not yet known if Forteo can increase risk of Cancer in Humans. Forteo is not approved for use past 2 years.

Patient's Name (type or print)

MRN

Date of Birth

Patient or Authorized Healthcare Surrogate Signature

Relationship

Date/Time

Witness Name (type or print)

Witness Signature

Date/Time

Physician’s Name (type or print)

Physician's Signature

Date/Time

478 FLORIDA HEALTH CARE PLANS

REFERRAL FORM FOR PATIENTS WITH HEP C ⊕ PCR Date:

Auth #: Referring Provider Name:

A. Member Name: MRN #:

Date of Birth:

Referring Provider Phone #:

Home Phone#:

Work Phone#

Referring Provider FHCP #:

Cell #:

Provider Signature:

Subscriber #:

Type of Referral:

ROUTINE

URGENT

(please check)

Parent/Guardian Name:

1. Any alcohol within 6 months?

Yes

No

If yes, not eligible.

2. Does patient have psychiatric history?

Yes

3. Substance abuse within 6 months?

Yes

4. Is patient on contraception?

Yes

No

If no, not a covered benefit.

5. Hepatotoxic meds have been considered & stopped if possible?

Yes

No

If no, not a covered benefit.

6. Is patient immunized with Hep A, Hep B & Pneumovax?

Yes

No

Need to have started Hep A&B vaccine and received Pneumovax or show evidence of immunity.

7. Has patient signed a Patient Agreement Form?

Yes

No

If no, not eligible. (This must be attached).

No

If psychiatric illness, must have psychiatric clearance prior to therapy and copy of clearance must be attached.

No

If yes, not a covered benefit.

If patient eligible with attached criteria and all requirements are attached to this, referral will be approved and receive an Auth #. The patient can then take their prescription to a FHCP Pharmacy and pay the applicable co-pay and start treatment under GI, Infectious Disease or Dr. Warner supervision.

THIS SECTION IS ONLY FOR THOSE SERVICES THAT REQUIRE PRE-AUTHORIZATION This Form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s PCP or the Referring Provider.

APPROVED BY FLORIDA HEALTH CARE PLANS FOR:

Signature:

Date:

TO: 06-600-05 Rev. 1/28/11

FROM: 01/25/13

Phone #:

Page 1 of 2

479

Patient Agreement for Hepatitis C Treatment with Antivirals I,

, agree to the following:

1.

I will not drink alcohol of any kind during my treatment. I understand that drinking alcohol with liver disease is contraindicated.

2.

I will not use illegal substances during my treatment.

3.

I understand the side effects of antivirals (if applicable).

4.

I am committed to complete the total therapy, including paying my co-payments $ per month through the entire course of treatment. I will not stop the medication unless it is by a doctor’s order. Genotype 1 = 28 to 48 weeks, if I have good response Genotype 4, 5 & 6 = 48 weeks, if I have a good response at 12 weeks. Genotype 2 & 3 = 24 weeks, if I have a good response at 12 weeks. Coinfected HIV/HCV: all genotypes 48 weeks, if I have a good response at 12 weeks

5.

I understand that I will not be eligible to restart antiviral treatment if I stop the medication for any reason other than a doctor’s order.

6.

I understand my Hep C virus level will be re-evaluated at 4 weeks, 8 weeks, 12 weeks and 24 weeks of therapy and, if virus is still present, I may no longer be eligible for therapy.

7.

I agree to re-pay FHCP the cost of my antivirals if I do not fulfill the above requirements.

____________________________________________ Signature

Page 2 of 2

06-600-05 Rev. 02/11

01/25/13

_________________________________ Date

480

Patient Agreement for Hepatitis C Treatment with Antivirals I,

, agree to the following:

1.

I will not drink alcohol of any kind during my treatment. I understand that drinking alcohol with liver disease is contraindicated.

2.

I will not use illegal substances during my treatment.

3.

I understand the side effects of antivirals (if applicable).

4.

I am committed to complete the total therapy, including paying my co-payments $ per month through the entire course of treatment. I will not stop the medication unless it is by a doctor’s order. Genotype 1 = 28 to 48 weeks, if I have good response Genotype 4, 5 & 6 = 48 weeks, if I have a good response at 12 weeks. Genotype 2 & 3 = 24 weeks, if I have a good response at 12 weeks. Coinfected HIV/HCV: all genotypes 48 weeks, if I have a good response at 12 weeks

5.

I understand that I will not be eligible to restart antiviral treatment if I stop the medication for any reason other than a doctor’s order.

6.

I understand my Hep C virus level will be re-evaluated at 4 weeks, 8 weeks, 12 weeks and 24 weeks of therapy and, if virus is still present, I may no longer be eligible for therapy.

7.

I agree to re-pay FHCP the cost of my antivirals if I do not fulfill the above requirements.

____________________________________________ Signature

Page 2 of 2

06-600-05 Rev. 02/11

01/25/13

_________________________________ Date

481 FLORIDA HEALTH CARE PLANS

REFERRAL FORM FOR HIV+ PATIENTS WITH HEP C ⊕ PCR Date:

Auth #: Referring Provider Name:

A. Member Name: Med. Record #:

Date of Birth:

Referring Provider Phone #:

Home Phone#:

Work Phone#

Referring Provider FHCP #:

Cell #:

Provider Signature:

Subscriber #:

Type of Referral:

URGENT

ROUTINE

(please check)

Parent/Guardian Name:

1. Any Alcohol within 6 months?

Yes

No

If yes, not eligible.

2. Does patient have psychiatric history?

Yes

3. Substance abuse within 6 months?

Yes

4. Is patient on contraception?

Yes

No

If no, not a covered benefit.

5. Hepatotoxic meds have been considered & stopped if possible?

Yes

No

If no, not a covered benefit.

6. Is patient immunized with Hep A, Hep B & Pneumovax?

Yes

No

Need to have started Hep A&B vaccine and received Pneumovax or show evidence of immunity.

7. Has patient signed a Patient Agreement Form?

Yes

No

If no, not eligible. (This must be attached).

No

If psychiatric illness, must have psychiatric clearance prior to therapy and copy of clearance must be attached.

No

If yes, not a covered benefit.

If patient eligible with attached criteria and all requirements are attached to this, referral will be approved and receive an Auth #. The patient can then take their prescription to a FHCP Pharmacy and pay the applicable co-pay and start treatment under GI, Infectious Disease or Dr. Warner supervision.

THIS SECTION IS ONLY FOR THOSE SERVICES THAT REQUIRE PRE-AUTHORIZATION This Form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s PCP or the Referring Provider.

APPROVED BY FLORIDA HEALTH CARE PLANS FOR:

Signature: TO:

Date: FROM:

Phone #:

This document is privileged and confidential. It is intended solely for the use of the recipient named above. If the reader/recipient of this document is not the intended recipient, you are hereby notified that any distribution, copying or disclosure of the contents of this document is prohibited. If you have received this document in error, please notify FHCP immediately by the telephone or fax number indicated above and return the original facsimile message to us at P. O. Box 9910, Daytona Beach, FL 32120.

06-600-04 Rev. 1/28/11

Page 1

482 Patient Agreement for Hepatitis C Treatment with PEG-Interferon for HIV+ Patients I,

, agree to the following:

1.

I will not drink alcohol of any kind during my treatment. I understand that drinking alcohol with liver disease is contraindicated.

2.

I will not use illegal substances during my treatment.

3.

I understand the side effects of Peg-intron and ribavirin.

4.

I am committed to complete the total therapy, including paying my co-payments of Tier 4 copay of $ through the entire course of treatment. I will not stop the medication unless it is by a doctor’s order. Genotype 1, 4, 5 & 6 = 48 weeks, if I have a good response at 12 weeks. Genotype 2 & 3 = 24 weeks, if I have a good response at 12 weeks. Coinfected HIV/HCV: all genotypes 48 weeks, if I have a good response at 12 weeks

5.

I understand that I will not be eligible to restart Peg-intron treatment if I stop the medication for any reason other than a doctor’s order.

6.

I understand my Hep C virus level will be re-evaluated at 4 weeks, 12 weeks and 24 weeks of therapy and, if virus is still present, I am no longer eligible for therapy.

7.

I agree to re-pay FHCP the cost of my PEG-interferon if I do not fulfill the above requirements.

____________________________________________ Signature

Page 2 06-600-04 Rev. 2/11

_________________________________ Date

483

FLORIDA HEALTH CARE PLANS REMICADE ORDER Date:

Auth. #:

A. Member Name:

Referring Provider Name:

Med. Record #:

Date of Birth:

Referring Provider Phone #:

Home Phone#:

Work Phone#

Referring Provider FHCP #:

Cell #:

Provider Signature:

Subscriber #:

Copy to:

Parent/Guardian Name:

Allergies:

Type of Referral:

URGENT

Administer PPD

ROUTINE

Weight

REMICADE Dose Pre-medicate with:

DIAGNOSIS CODE Frequency

NONE

Benadryl 25mg PO Benadryl 50mg PO Repeat as needed. Tylenol 650mg PO Repeat as needed Prednisone 40mg PO Prednisone 40mg IV Other If B/P decreases between 15 & 20 mmHg, or patient experiences symptoms indicating Hypersensitivity (urticaria, dyspnea, hypotension, heart rate decrease, dizziness, chest pain) stop infusion and give Benadryl 25mg PO Tylenol 650mg PO Other

Benadryl 50mg PO Repeat as needed Prednisone 40mg Po Prednisone 40mg IV * Refer to Centocor Algorithm for Remicade ____________________________ Physician Signature REASON FOR REFERRAL: (Attach all supporting documentation)

THIS SECTION IS ONLY FOR THOSE SERVICES THAT REQUIRE PRE-AUTHORIZATION This Form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s PCP or the Referring Provider.

APPROVED BY FLORIDA HEALTH CARE PLANS FOR:

Signature: TO:

Date: FROM:

Phone #:

This document is privileged and confidential. It is intended solely for the use of the recipient named above. If the reader/recipient of this document is not the intended recipient, you are hereby notified that any distribution, copying or disclosure of the contents of this document is prohibited. If you have received this document in error, please notify FHCP immediately by the telephone or fax number indicated above and return the original facsimile message to us at P. O. Box 9910, Daytona Beach, FL 32120.

PROCEDURE FOR ORDERING REMICADE

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Remicade is a monoclonal antibody agent known to be effective in the treatment of Crohn’s Disease and Rheumatoid Arthritis, Ulcerative Colitis, Ankylosing Spondylitis, and Psoriatic Arthritis. Approval for treatment of Crohn’s Disease is based on failure of both an anti-inflammatory agent (5-ASA compounds, sulfasalazine, Dipentum, Pentasa, Asacol & Rowasa) and an immunosuppressant (purinethol, azothioprine, methotrexate). Intermittent steroids and antibiotics used to manage exacerbations and maintain remission are not sufficient to satisfy immunosuppressant and anti-inflammatory trials. Approval for treatment of Ulcerative Colitis is based on history of moderate to severe ulcerative colitis in patients who have contraindications to or have failed both therapeutically effective doses of Aminosalicilates (sulfasalizine 46g/day, mesalamine 2-4.8g/day, balsalazide 6.75g/day, olsalazine 1.5-3g/day), and an Immunomodulator (6mercaptopurine or azothioprine) or continuous corticosteroid. Approved injections will be covered at weeks 0,2,6, and then every 8 weeks at the labeled dosage (5mg/kg). Approval for treatment of rheumatoid arthritis (RA), And Psoriatic Arthritis is based on failure of Humira (2nd in line to Enbrel failures). Note: Remicade is only indicated for treatment of RA in combination with methotrexate. PROCEDURE: 

Ordering physician will send completed Remicade order (form 21-110) and supporting documentation to the FHCP Referral Department



Order must include dose of REMICADE, frequency, Pre-medication order and orders to follow if reaction to infusion



Documentation of PPD within one year or order for PPD before first treatment.



If approved, Referral Department will notify physician office and send signed form to FHCP Infusion Clinic:  Daytona Facility  Orange City Facility  Palm Coast Facility  Edgewater Facility



Infusion Clinic will call patient to set up appointment for PPD



Infusion Clinic Nurse will place and read PPD, and assess for any s / s infection



If patient has a previous positive PPD, order chest x-ray with copy to Infusion Clinic



Infusion nurse will assess for signs and symptoms of TB and document on nurse assessment and Remicade order form



Infusion Clinic Nurse will send order for Remicade to Pharmacy



Clinic will schedule patient for appointment for Remicade infusion



Medicare patients will pick up medication at Pharmacy and bring with him/her to appointment at Infusion Clinic, all other members Remicade will be shipped to infusion clinic.



Ordering physician will provide patient with information and educational materials

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Synagis Referral Form 2012 - 2013 Date:

Referring Physician’s Name:

Phone #:

Patient’s Name:

Fax:

DOB:

Gestational Age:

weeks

MRN:

Last Synagis Dose

Birth Weight:

Please circle any of the following diagnoses: Prematurity

Chronic Lung Disease Congenital Heart Disease

Apnea

Cystic Fibrosis

BPD

Other:

Please circle any of the following risk factors: Daycare

Oxygen dependent

Multiple birth

Siblings

Smoke exposure

Parent’s Name: Parent’s Address: Phone Numbers: Home:

Work:

Please fax this form to Central Referrals at 386-238-3253 and send your prescription to the Pharmacy. Thank you for this referral.

Approved ________________________________________ Date ____________________________

486 Guidelines for Use of Synagis® 2012 – 2013 In Accordance with American Academy of Pediatrics Committee on Infectious Diseases Policy Statement: Modified Recommendations for the Use of Palivizumab for Prevention of Respiratory Syncytial Virus Infections

(08.24.09)

Indications: 1. Children under 2 years of age with bronchopulmonary dysplasia or chronic lung disease who require medical therapy (02, albuterol, diuretics or corticosteroids) within the previous 6 months, maximum of 5 doses per year. 2.

Premature infants born at <32 weeks gestation under 6 months of age at the start of RSV season maximum of 5 doses per year.

3.

Premature infants born at <28 weeks gestation and under 12 months of age at the start of RSV season maximum of 5 doses per year

4.

Premature infants born at 32-35 weeks gestation and under 3 months of age at the start of the RSV season with at least 1 risk factor of : Attendance in daycare or One or more sibling or child < 5 years living permanently in child’s household. Approved for up to 3 doses or until they reach 90 days of age.

5.

Children under 2 years of age with uncorrected and hemodynamically significant congential heart disease (conditions requiring medications for CHF or: dilated cardiomyopathy, moderate-severe aortic stenosis, moderate-severe ventricular septal defect). A postoperative dose after cardiopulmonary bypass may be warranted if continued prophylaxis is indicated, maximum of 5 doses per year

6.

May be considered for neuromuscular, immune deficient and cystic fibrosis children under 2 years old. maximum of 5 doses per year

Contraindications: Allergy to Synagis® or other components of the product. Treatment of acute RSV disease (infection control measures are most effective). Prior to initiating Synagis® therapy: The parent should agree to monthly injections during the RSV season. Payment preauthorization is verified by a member of the outpatient healthcare team. A single prophylactic dose may be given to a patient meeting the above criteria before discharge from the hospital. Prophylaxis Timeframe: Monthly injections starting August 1, 2011 and ending May 1, 2012 based on the last three years of Florida RSV surveillance data (myflorida.com). Year round monthly prophylaxis should be considered for infants with oxygen dependence congenital heart disease, immune deficiency and cystic fibrosis. Please call the undersigned at (386) 676-7135 with any questions.

Wendy Myers, M.D. President & Chief Medical Officer WM/sb

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Pharmacist Review Request: Medication Therapy Management Referral Source:

Phone # (Name)

Patient Name:

Med Rec #:

PCP:

Patient Address: Patient Phone Number: Reason for Referral: Program

Specialist:

MHS:

Complex-Gen:

Relevant Diagnosis – all that apply () Diabetes I or II PVD COPD/Asthma CHF (NYHA Class) CAD Others (list) CKD / ESRD

Any additional information:

Risk Factors Hx. Falls Lives Alone Confused Not Aware of Dx Other

MTMP:

Other: Medication Compliance HTN Afib Hyperlipidemia Mental Health Dx. Other

Allergies:

Medication Intolerances:

Completed By: Date: Send to: Kristen Foli, PharmD Clinical Pharmacist Florida Health Care Plans 1340 Ridgewood Avenue Holly Hill, FL 32117 Phone # 386/_676-7132_ Fax #: 386/_615-4054__ 03-301-24

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SECTION 9 RISK AND QUALITY MANAGEMENT

Adverse Occurrence Reporting / Adverse Occurrence Reporting Form Quality Management / Performance Improvement Plan Policy Credentialing of Providers for Florida Health Care Plans, Inc. Policy

.

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505

Patient Bill of Rights must be maintained at all times!

PRIVACY A-B-C’S: A. Discussion between you and the patient must be conducted in a private area, not in a public hallway. B. Do not discuss the patient or their condition in the presence or hearing range of other patients, with co-workers or among friends. C. Personnel not directly involved in a patient’s care must have the patient’s permission to be present when care is given. You have the responsibility to ask permission to look at some manifestation of their disease if you are interested only in enlarging your scope of knowledge, but not giving care to that patient.

Members have a right to expect that all communications and records pertaining to their care will be treated as confidential. To protect and maintain this right, be careful... A.

Not to leave a medical record in a place where it could be read by someone other than the member or authorized personnel.

B.

Requisitions should contain no information other than that needed to process an order.

C.

Confidential patient information cannot be given to any person, other than the patient, without the patient’s written permission, unless that person has the patient’s Power of Attorney.

D.

Remind health care personnel and volunteers that members’ records are confidential, not to be discussed at any time.

506 PURPOSE OF RISK MANAGEMENT 1) Prevention – early detection of any possible areas of risk helps the organization prevent accidents and injury. Early reporting of potential medical errors is necessary for prevention. 2) Improvement – meaning to do some things better, whether it is a service, a process, or a product. Improving the way we provide services to patients helps us improve the health of the community and reduces the organization’s financial risk. 3) Compliance and Regulations – regulatory agencies have standards for quality improvement and safety within our facilities. These standards require a Risk Management program to minimize the risk of injury and adverse incidents to patients. 4) Benefits – by identifying and reducing risk, we maintain a safe environment. This benefits patients, visitors, employees, the organization and the community. WHAT IS CONSIDERED A REPORTABLE EVENT? A reportable event is any happening outside of the usual, routine, normal, customary or ordinary activities of the organization, including but not limited to: • • • • • • •

Member, visitor, staff, volunteer or student injuries Medication or treatment variances Damage, theft, or loss of facility property An event that did not reach the patient, but could have if the risk had not been identified (also known as a “near miss”) Adverse drug reactions Physical or verbal abuse of a member Delay in care REPORTING ADVERSE EVENTS

• •

• • • • •

All events should be reported using the electronic occurrence reporting system. Events are NEVER submitted by a paper copy. To report an event, start by going to the FHCP intranet. Click on the “star” in the upper right hand corner of the page. Under “favorites” click on “FHCP” and then scroll down to “Report and Incident”. Make sure to include all essential information, such as the identity of the person involved in the incident, the exact time and place of the incident and the name of the doctor you notified. Make sure to document any unusual occurrences that you witnessed. Record the events and the consequences for the patient in enough detail that administrators can decide whether or not to investigate further. DO NOT include opinions, judgments, or assumptions about whom or what caused the incident. You can voice your opinions to your supervisor later. Make sure to only describe what you saw and heard and any actions taken by you at the scene. Unless you saw a patient member fall, write “found member lying on the floor”.

507 • • • • • •

Please do not offer suggestions in the event reporting system about how to prevent the incident from happening again in the future. That is normally part of the investigative follow-up. Do not admit that you are at fault or blame someone else. Do not include detailed statements from witnesses and descriptions of remedial action, as these are normally part of an investigative follow-up. Do not place documentation in the medical record than an incident report was completed. If needed, there is an instructional video on the first page of the electronic incident reporting system. The link for the electronic reporting system is: http://ems.fhcp.local/EMS_PROD/

If you need assistance reporting an event, please contact the Clinical Risk Manager at 5042 for assistance. Code 15 •





Code 15 incidents are defined as an adverse event, whether occurring in the facility or arising from healthcare delivered prior to admission to our facilities; in which healthcare personnel could exercise control; or that which is associated in whole or in part with medical intervention, rather than the condition for which such intervention occurred. A Code 15 event is an unexpected event involving death or serious physical injury. It specifically includes: o The loss of limb, or function o Medication errors that results in death, paralysis, coma or major loss of function o Inpatient suicide, or suicide following elopement from an inpatient setting o Surgery performed on the wrong patient, wrong side of the body or wrong organ o Infant abduction or a discharge to the wrong family o Sexual assault, homicide, or assault resulting in death or major permanent loss of function o Fall that results in death or major permanent loss of function o Blood transfusion reactions involving blood incompatibilities o Infections resulting in death o Surgical fires Under Florida Law, these events are required to be reported to AHCA (Agency for Healthcare Administration) within 3 business days with a follow-up investigation report within 15 days of the event occurrence. Contacting the Risk Manager after Hours



The Risk Manager should be notified at extension 5042 during normal business hours and through the Call Center at (386) 254-4242 after hours and on weekends in the event of a serious event: o Any event resulting in death o Any event deemed urgent by staff

508 o

Any other incident that may present significant public embarrassment to the organization. Abuse/Misconduct Reporting Policy









Every instance of known, suspected or alleged abuse occurring within the facility or on facility grounds, including all locations, or prior to the patient’s arrival, shall be reported to the Risk Manager by the quickest means available. Sexual abuse is defined as: o An act of a sexual nature committed for the sexual gratification of anyone upon or in the presence of a vulnerable adult, without the vulnerable adult’s informed consent, or upon a minor. A Vulnerable Adult is defined as: o 18 years or older whose ability to perform the normal activities of daily living or to provide for his or her own care or protection is impaired due to mental, emotional, physical, or developmental disability or disjunction, or brain damage, or the infirmities of aging. Sexual misconduct or abuse includes but is not limited to: o Acts of fondling o Exposure of a vulnerable adult or minor’s sexual organs o The use of a vulnerable adult or minor to solicit or engage in prostitution or sexual performance

If there are any questions on how to report or what to report, please contact the Clinical Risk Manager at 5042 for assistance.

509 ADVANCE DIRECTIVES

*An Advance Directive is a written or oral statement, which is made and witnessed in advance of serious illness or injury, about how you want medical decisions made on your behalf. Two forms of Advance Directives include a Living Will and a Health Care Surrogate Designation. An Advance Directive allows you to state your choices about health care or to name someone to make those choices for you, if you become unable to make decisions about your medical treatment. *A Living Will generally states the kind of medical care you want or do not want if you become unable to make your own decisions. Florida law provides a suggested form for a Living Will but you may use some other form. You may wish to speak to an attorney or physician to be certain you have completed the Living Will in a way so that your wishes will be understood. A copy of the Living Will should be given to your doctor’s office to be filed in your medical record, but keep a copy for yourself. *A Health Care Surrogate designation is a signed dated and witnessed document naming another person (such as a husband, wife, child or close friend) as your agent to make medical decisions for you if you should become unable to make them for yourself. You can include instructions about any treatment you want or wish to avoid. Florida law provides a suggested form but you may use some other form. You may wish to name a second person to stand in if your first choice is not available. A copy of your Health Care Surrogate form should be given to your doctor’s office to be filed in your medical record. Keep a copy for yourself and give a copy to your health care surrogate(s). *You may use one or both documents, or combine them into a single document that describes treatment choices in a variety of situations. Keep a card or note in your wallet stating you have an Advance Directive and where it can be found. You may cancel these documents at any time. Changes should be written, signed and dated, but you can also change an Advance Directive by oral statement. If you make changes to your Advance Directives, make sure your doctor, lawyer and/or family member has the latest copy. The patient and practitioner should discuss Advance Directives (all adults) at each patient physical to insure current documentation of the patients wishes. PATIENT SAFETY & ADVANCE DIRECTIVES Rev. 4/06, 2/10

Occurrence Reports Information 4/06, 2/10

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SECTION 10 INFECTION CONTROL FHCP Infection Control Plan Policy Florida Department of Health/CDC Links Florida DOH Reportable Diseases/Conditions in Florida Listing CDC 2012 STD Treatment Guidelines Chart Florida DOH Practitioner Disease Report Form Florida DOH/Animal Incident Report Form with Instructions

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569

Florida Department of Health – Rabies Prevention and Control in Florida Guide - 2014 http://www.floridahealth.gov/%5C/diseases-and-conditions/rabies/_documents/rabiesguide2014-web.pdf

Florida Department of Health – Healthcare Practitioner Reporting Guidelines of Notifiable Diseases or Conditions in Florida 2014 http://www.floridahealth.gov/diseases-and-conditions/disease-reporting-andmanagement/_documents/reportable_diseases/_documents/Guidelines-Health%20Care%202014-06-26.pdf

CDC – Sexually Transmitted Diseases Treatment Guidelines, 2010 http://www.cdc.gov/mmwr/pdf/rr/rr5912.pdf

570

Reportable Diseases/Conditions in Florida Practitioner List (Laboratory Requirements Differ)

Effective June 4, 2014 !

http://floridahealth.gov/diseasereporting

!

+ !  

! 

!  

+

   

! 

+     

!    

! 

Outbreaks of any disease, any case, cluster of cases, or exposure to an infectious or non-infectious disease, condition, or agent found in the general community or any defined setting (e.g., hospital, school, other institution) not listed that is of urgent public health significance Acquired immune deficiency syndrome (AIDS) Amebic encephalitis Anthrax Arsenic poisoning Arboviral diseases not otherwise listed Botulism, foodborne, wound, and unspecified Botulism, infant Brucellosis California serogroup virus disease Campylobacteriosis Cancer, excluding non-melanoma skin cancer and including benign and borderline intracranial and CNS tumors Carbon monoxide poisoning Chancroid Chikungunya fever Chikungunya fever, locally acquired Chlamydia Cholera (Vibrio cholerae type O1) Ciguatera fish poisoning Congenital anomalies Conjunctivitis in neonates <14 days old Creutzfeldt-Jakob disease (CJD) Cryptosporidiosis Cyclosporiasis Dengue fever Dengue fever, locally acquired Diphtheria Eastern equine encephalitis Ehrlichiosis/anaplasmosis Escherichia coli infection, Shiga toxinproducing Giardiasis, acute Glanders Gonorrhea

http://floridahealth.gov/chdepicontact



! 

 



+  

!      

! ! 

!  

+ 

Granuloma inguinale Haemophilus influenzae invasive disease in children <5 years old Hansen’s disease (leprosy) Hantavirus infection Hemolytic uremic syndrome (HUS) Hepatitis A Hepatitis B, C, D, E, and G Hepatitis B surface antigen in pregnant women or children <2 years old Herpes B virus, possible exposure Herpes simplex virus (HSV) in infants <60 days old with disseminated infection and liver involvement; encephalitis; and infections limited to skin, eyes, and mouth; anogenital HSV in children <12 years old Human immunodeficiency virus (HIV) infection HIV, exposed infants <18 months old born to an HIV-infected woman Human papillomavirus (HPV), associated laryngeal papillomas or recurrent respiratory papillomatosis in children <6 years old; anogenital papillomas in children <12 years old Influenza A, novel or pandemic strains Influenza-associated pediatric mortality in children <18 years old Lead poisoning Legionellosis Leptospirosis Listeriosis Lyme disease Lymphogranuloma venereum (LGV) Malaria Measles (rubeola) Melioidosis Meningitis, bacterial or mycotic Meningococcal disease Mercury poisoning Mumps Neonatal abstinence syndrome (NAS) Neurotoxic shellfish poisoning Pertussis Pesticide-related illness and injury, acute

 +

Report immediately 24/7 by phone upon initial suspicion or laboratory test order Report immediately 24/7 by phone Report next business day Other reporting timeframe

! !  

! ! 

!   

! 

!

 

  

! ! ! 

! 

! 

!

Plague Poliomyelitis Psittacosis (ornithosis) Q Fever Rabies, animal or human Rabies, possible exposure Ricin toxin poisoning Rocky Mountain spotted fever and other spotted fever rickettsioses Rubella St. Louis encephalitis Salmonellosis Saxitoxin poisoning (paralytic shellfish poisoning) Severe acute respiratory disease syndrome associated with coronavirus infection Shigellosis Smallpox Staphylococcal enterotoxin B poisoning Staphylococcus aureus infection, intermediate or full resistance to vancomycin (VISA, VRSA) Streptococcus pneumoniae invasive disease in children <6 years old Syphilis Syphilis in pregnant women and neonates Tetanus Trichinellosis (trichinosis) Tuberculosis (TB) Tularemia Typhoid fever (Salmonella serotype Typhi) Typhus fever, epidemic Vaccinia disease Varicella (chickenpox) Venezuelan equine encephalitis Vibriosis (infections of Vibrio species and closely related organisms, excluding Vibrio cholerae type O1) Viral hemorrhagic fevers West Nile virus disease Yellow fever

*Section 381.0031 (2), Florida Statutes (F.S.), provides that “Any practitioner licensed in this state to practice medicine, osteopathic medicine, chiropractic medicine, naturopathy, or veterinary medicine; any hospital licensed under part I of chapter 395; or any laboratory licensed under chapter 483 that diagnoses or suspects the existence of a disease of public health significance shall immediately report the fact to the Department of Health.” Florida’s county health departments serve as the Department’s representative in this reporting requirement. Furthermore, Section 381.0031 (4), F.S. provides that “The department shall periodically issue a list of infectious or noninfectious diseases determined by it to be a threat to public health and therefore of significance to public health and shall furnish a copy of the list to the practitioners…”

571 Florida Department of Health, Practitioner Disease Report Form Complete the following information to notify the Florida Department of Health of a reportable disease or condition, as required by Chapter 64D-3, Florida Administrative Code (FAC). This can be filled in electronically. Patient Information

Medical Information

SSN:

MRN:

Last name:

Date onset:

Date diagnosis:

First name:

Died:

Yes

No

Unk

Middle:

Hospitalized:

Yes

No

Unk

Parent name:

Hospital name:

Male Female Unk

Gender:

Pregnant: Death date:

Birth date:

American Indian/Alaska Native Asian/Pacific Islander Black

Race:

Ethnicity:

Yes No Unk

Treated: White Other Unk

Hispanic Non-Hispanic Unk

Date discharged:

Yes

No

Unk

No

Unk

Specify treatment:

Laboratory testing:

Address: ZIP:

Date admitted:

Insurance:

Yes

Attach laboratory result(s) if available.

Provider Information

County:

City:

State:

Physician:

Home phone:

Address:

Other phone:

City:

State:

Emer. phone:

Phone:

Fax:

Email:

Email:

Reportable Diseases and Conditions in Florida

Notify upon suspicion 24/7 by phone

ZIP:

Notify upon diagnosis 24/7 by phone

HIV/AIDS and HIV-exposed newborn notification should be made using the Adult HIV/AIDS Confidential Case Report Form, CDC 50.42A (revised March 2013) for cases in people ≥13 years old or the Pediatric HIV/AIDS Confidential Case Report, CDC 50.42B (revised March 2003) for cases in people <13 years old. Please contact your local county health department for these forms (visit http://floridahealth.gov/chdepicontact to obtain CHD contact information). Congenital anomalies and neonatal abstinence syndrome notification occurs when these conditions are reported to the Agency for Health Care Administration in its inpatient discharge data report pursuant to Chapter 59E-7 FAC. Cancer notification should be directly to the Florida Cancer Data System (see http://fcds.med.miami.edu). All other notifications should be to the CHD where the patient resides. To obtain CHD contact information, see http://floridahealth.gov/chdepicontact. See http://floridahealth.gov/diseasereporting for other reporting questions.

Amebic encephalitis Anthrax Arsenic poisoning Arboviral disease not listed here Botulism, infant Botulism, foodborne Botulism, wound or unspecified Brucellosis California serogroup virus disease Campylobacteriosis Carbon monoxide poisoning Chancroid Chikungunya fever Chikungunya fever, locally acquired Chlamydia Cholera (Vibrio cholerae type O1) Ciguatera fish poisoning Conjunctivitis in neonate <14 days old Creutzfeldt-Jakob disease (CJD) Cryptosporidiosis Cyclosporiasis Dengue fever Dengue fever, locally acquired Diphtheria Eastern equine encephalitis Ehrlichiosis/anaplasmosis Escherichia coli infection, Shiga toxinproducing Giardiasis, acute

Comments

Revised June 4, 2014

Glanders Gonorrhea Granuloma inguinale Haemophilus influenzae invasive disease in child <5 years old Hansen's disease (leprosy) Hantavirus infection Hemolytic uremic syndrome (HUS) Hepatitis A Hepatitis B, C, D, E, and G Hepatitis B surface antigen in pregnant woman or child <2 years old Herpes B virus, possible exposure Herpes simplex virus (HSV) in infant <60 days old HSV, anogenital in child <12 years old Human papillomavirus (HPV), laryngeal papillomas or recurrent respiratory papillomatosis in child <6 years old HPV, anogenital papillomas in child <12 years old Influenza A, novel or pandemic strains Influenza-associated pediatric mortality in child <18 years old Lead poisoning Legionellosis Leptospirosis Listeriosis Lyme disease Lymphogranuloma venereum (LGV) Malaria Measles (rubeola)

Melioidosis Meningitis, bacterial or mycotic Meningococcal disease Mercury poisoning Mumps Neurotoxic shellfish poisoning Pertussis

Staphylococcal enterotoxin B poisoning Streptococcus pneumoniae invasive disease in child <6 years old Syphilis

Pesticide-related illness and injury, acute

Tuberculosis (TB) Tularemia

Plague Poliomyelitis

Syphilis in pregnant woman or neonate Tetanus Trichinellosis (trichinosis)

Typhoid fever (Salmonella serotype Typhi)

Psittacosis (ornithosis)

Typhus fever, epidemic

Q Fever Rabies, animal

Vaccinia disease Varicella

Rabies, human Rabies, possible exposure Ricin toxin poisoning Rocky Mountain spotted fever or other spotted fever rickettsiosis Rubella St. Louis encephalitis Salmonellosis Saxitoxin poisoning (paralytic shellfish poisoning) Severe acute respiratory disease syndrome associated with coronavirus infection Shigellosis Smallpox Staphylococcus aureus infection, intermediate or full resistance to vancomycin (VISA, VRSA)

(chickenpox) Venezuelan equine encephalitis Vibriosis (infections of Vibrio species and closely related organisms, excluding Vibrio cholerae type O1) Viral hemorrhagic fevers West Nile virus disease Yellow fever Outbreaks of any disease, any case, cluster of cases, or exposure to an infectious or non-infectious disease, condition, or agent found in the general community or any defined setting (e.g., hospital, school, other institution) not listed above that is of urgent public health significance. Please specify:

572

SUMMARY OF THE 2012 CDC SEXUALLY TRANSMITTED DISEASES (STD) TREATMENT GUIDELINES These guidelines for treatment of STDs reflect recommendations of the CDC STD Treatment Guidelines. These outlines focus on STDs encountered in outpatient settings and are not an exhaustive list of effective treatments. Please refer to the complete CDC document for more information at www.cdc.gov/std/treatment/2010/std-treatment-2010-rr5912.pdf.  

DISEASE

RECOMMENDED TREATMENT

ALTERNATIVES (use only if recommended regimens are contraindicated)

SYPHILIS ADULTS PRIMARY, SECONDARY OR EARLY LATENT (<1 YEAR) ADULTS LATE LATENT (>1 YEAR) OR LATENT OF UNKNOWN

• Benzathine penicillin G 2.4 million units IM once

• Benzathine penicillin G 2.4 million units IM for 3 doses at 1 week intervals (total 7.2 million units)

DURATION

NEUROSYPHILIS

CHILDREN PRIMARY, SECONDARY OR EARLY LATENT (<1 YEAR) CHILDREN LATE LATENT (>1 YEAR) OR LATENT OF UNKNOWN DURATION

CONGENITAL SYPHILIS HIV INFECTION PREGNANCY

(For penicillin-allergic non-pregnant patients only) • Doxycycline 100 mg orally 2 times a day for 14 days OR • Tetracycline 500 mg orally 4 times a day for 14 days (For penicillin-allergic non-pregnant patients only) • Doxycycline 100 mg orally 2 times a day for 28 days OR • Tetracycline 500 mg orally 4 times a day for 28 days • Procaine penicillin 2.4 million units IM once daily PLUS probenecid 500 mg orally 4 times a day, both for 10-14 days

• Aqueous crystalline penicillin G 18 - 24 million units per day, administered as 3-4 million units IV every 4 hours or continuous infusion, for 10-14 days • Benzathine penicillin G 50,000 units/kg IM once, up to   adult dose of 2.4 million units • Benzathine penicillin G 50,000 units/kg IM (up to adult   dose of 2.4 million units) for 3 doses at 1 week intervals (up to total adult dose of 7.2 million units) See complete CDC guidelines. Same stage-specific recommendations as for HIV-negative persons. Penicillin is the only recommended treatment for syphilis during pregnancy. Women who are allergic should be desensitized and treated with penicillin. Treatment is the same as in non-pregnant patients for each stage of syphilis.1

GONOCOCCAL INFECTIONS ADULTS, ADOLESCENTS AND CHILDREN ≥45 KG UROGENITAL, PHARYNGEAL, RECTAL

ADULTS AND ADOLESCENTS CONJUNCTIVAL CHILDREN <45 KG NEONATES OPHTHALMIA NEONATORUM

♦ Ceftriaxone 250 mg IM once PLUS2 • Azithromycin 1 g orally once (preferred) OR • Doxycycline3 100 mg orally 2 times a day for 7 days • Ceftriaxone 1 g IM once plus lavage the infected eye with saline solution once • Ceftriaxone 125 mg IM once • Ceftriaxone 25-50 mg/kg IV or IM once (maximum 125 mg)

INFANTS BORN TO INFECTED MOTHERS

Note: Use of any alternative regimens for gonorrhea should be followed by a test-of-cure4 in one week. For urogenital or rectal infections ONLY, and ONLY if ceftriaxone is not available: ♦ Cefixime 400mg orally once PLUS2 ♦ Azithromycin 1 g orally once (preferred) OR ♦ Doxycycline3 100 mg orally 2 times a day for 7 days For severe cephalosporin allergy: ♦ Azithromycin 2 g orally in a single dose

CHLAMYDIAL INFECTIONS ADULTS AND CHILDREN AGED >8 YEARS

CHILDREN <45 KG AND NEONATES

PREGNANCY

• Azithromycin 1 g orally once OR • Doxycycline3 100 mg orally 2 times a day for 7 days • Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days7 • Azithromycin 1 g orally once OR • Amoxicillin 500 mg orally 3 times a day for 7 days

• Erythromycin base 500 mg orally 4 times a day for 7 days5 OR • Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days5 OR • Levofloxacin6 500 mg orally once a day for 7 days OR • Ofloxacin6 300 mg orally 2 times a day for 7 days See complete CDC guidelines for alternatives.

• Erythromycin base 500 mg orally 4 times a day for 7 days (or 250 mg orally 4 times a day for 14 days) OR • Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days (or 400 mg orally 4 times a day for 14 days)

NONGONOCOCCAL URETHRITIS

EPIDIDYMITIS

ADULT MALES

• Azithromycin 1 g orally once8 OR • Doxycycline 100 mg orally 2 times a day x 7 days

ADULT MALES

• Ceftriaxone 250 mg IM once PLUS • Doxycycline 100 mg orally 2 times a day for 10 days

• • • •

Erythromycin base 500 mg orally 4 times a day for 7 days5 OR Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days5 OR Levofloxacin6 500 mg orally once a day for 7 days OR Ofloxacin6 300 mg orally 2 times a day for 7 days

9

• Levofloxacin6 500 mg orally once a day for 10 days OR • Ofloxacin6 300 mg orally twice daily for 10 days

PELVIC INFLAMMATORY DISEASE (outpatient management) ADULT FEMALES

PREGNANCY

 

• Ceftriaxone 250 mg IM once OR • Cefoxitin 2 g IM once plus probenecid 1 g orally once   OR   • Other third generation cephalosporin See complete CDC guidelines for alternatives. PLUS • Doxycycline 100 mg orally 2 times a day for 14 days WITH OR WITHOUT • Metronidazole11 500mg orally twice a day for 14 days Patients should be hospitalized and treated with the appropriate recommended parenteral IV therapy (see complete CDC guidelines).

  1

Tetracycline/doxycycline contraindicated; erythromycin not recommended because it does not reliably cure an infected fetus; data insufficient to recommend azithromycin or ceftriaxone. Dual therapy for gonococcal infection now recommended for all patients with gonorrhea regardless of chlamydia test results. Doxycycline not recommended during pregnancy, lactation, or for children <8 years of age. 4 Test-of-cure for gonorrhea should be performed with culture or with nucleic acid amplification (NAAT) if culture is not available. If NAAT positive, confirmatory culture recommended. If treatment failure suspected after alternative regimen use, treat using ceftriaxone 250 mg IM PLUS azithromycin 2 g orally once, and perform test-of-cure in one week. If treatment failure suspected after recommended regimen use, culture, perform antimicrobial susceptibility testing, notify and consult with the state health department, and/or consult with an infectious disease specialist, an STD/HIV Prevention Training Center (www.nnptc.org), or CDC. 5 If patient cannot tolerate high dose erythromycin schedules, change to lower dose for longer (see under pregnancy alternatives). 6 Quinolones not recommended for use in patients <18 years of age, and are contraindicated in pregnant women. 7 Efficacy of treating neonatal chlamydial conjunctivitis and pneumonia is about 80%. A second course of therapy may be required. An association between oral erythromycin and infantile hypertrophic pyloric stenosis (IHPS) has been reported in infants aged less than 6 weeks treated with this drug. See complete CDC guidelines for more information. 8 Infections with M. genitalium may respond better to azithromycin. 9 Recommended regimen of ceftriaxone and doxycycline is for epididymitis most likely caused by gonococcal and/or chlamydial infection. Given increase in quinolone resistant gonorrhea, alternative regimen of ofloxacin or levofloxacin is recommended only if epididymitis is not found to be caused by gonorrhea or if infection is most likely caused by enteric gram-negative organisms. 2

3

♦ Indicates revision from previous CDC STD Treatment Guidelines

 

Version 11-2012

573

 

DISEASE

RECOMMENDED TREATMENT

ALTERNATIVES

(use only if recommended regimens are contraindicated)

CHANCROID ADULTS

• • • •

Azithromycin10 1 g orally once OR Ceftriaxone10 250 mg IM once OR Ciprofloxacin6 500 mg orally 2 times a day for 3 days OR Erythromycin base 500 mg orally 3 times a day for 7 days

 

BACTERIAL VAGINOSIS (BV) ADULT FEMALES

PREGNANCY13

• Metronidazole11 500 mg orally 2 times a day for 7 days OR • Metronidazole gel 0.75%, 5 g intravag. once a day for 5 days OR • Clindamycin cream 2%, 5 g intravag. at bedtime for 7 days • Metronidazole11 500 mg orally 2 times a day for 7 days OR 250 mg orally 3 times a day for 7 days OR • Clindamycin 300 mg orally 2 times a day for 7 days

♦ Tinidazole12 2 g orally once daily for 3 days OR ♦ Tinidazole12 1 g orally once daily for 5 days OR • Clindamycin 300 mg orally 2 times a day for 7 days OR • Clindamycin ovules 100 mg intravag. at bedtime for 3 days

 

TRICHOMONIASIS ADULTS

PEDICULOSIS PUBIS

• Metronidazole11 2 g orally once OR • Tinidazole12 2 g orally once

• Metronidazole11,14 500 mg orally 2 times a day for 7 days

• Permethrin 1% cream rinse applied to affected area and washed off after 10 minutes OR • Pyrethrins with piperonyl butoxide applied to affected area and washed off after 10 minutes

• Malathion 0.5% lotion applied for 8-12 hours and washed off OR • Ivermectin16 250 mcg/kg orally once, repeated in 2 weeks

• Permethrin 5% cream applied to all areas of the body from the neck down and washed off after 8-14 hours OR • Ivermectin16 200 mcg/kg orally, repeated in 2 weeks

• Lindane17 1% 1 oz of lotion or 30 g of cream applied thinly to all areas of the body from neck down and washed off after 8 hours

15

  SCABIES

 

GENITAL HERPES SIMPLEX: See complete CDC guidelines for the management of herpes in pregnancy and in the neonate. ADULTS FIRST CLINICAL EPISODE

ADULTS EPISODIC THERAPY FOR RECURRENCE

ADULTS SUPPRESSIVE THERAPY FOR RECURRENCE

HIV INFECTION

400 mg orally 3 times a day for 7-10 days OR   200 mg orally 5 times a day for 7-10 days OR 18 • Famciclovir 250 mg orally 3 times a day for 7-10 days OR • Valacyclovir 1 g orally 2 times a day for 7-10 days • Acyclovir 800 mg orally 2 times a day for 5 days OR   400 mg orally 3 times a day for 5 days OR 800 mg orally 3 times a day for 2 days OR • Famciclovir18 125 mg orally 2 times a day for 5 days OR 1000 mg orally 2 times a day for 1 day OR ♦ 500 mg orally once, followed by 250 mg orally 2 times a day for 2 days OR • Valacyclovir 500 mg orally 2 times a day for 3 days OR 1 g orally once a day for 5 days • Acyclovir 400 mg orally 2 times a day OR   18 • Famciclovir 250 mg orally 2 times a day OR • Valacyclovir 500 mg orally once a day OR 1 g orally once a day Higher doses and/or longer therapy recommended. See complete CDC guidelines. • Acyclovir

GENITAL WARTS  

 

            10

External or Perianal • PROVIDER-ADMINISTERED Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1-2 weeks if necessary OR Podophyllin resin 10%-25%19 in a compound tincture of benzoin. Limit application to < 10 cm2 and to < 0.5 ml. No open wounds or lesions should exist in the area of application. Allow to air dry. Wash off 1-4 hours after application. Repeat weekly if necessary OR Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80% -90%. Apply small amount only to warts. Allow to dry. If excess amount applied, powder with talc, baking soda or liquid soap. Repeat weekly if necessary OR Surgical removal • PATIENT-APPLIED Podofilox 0.5% solution or gel.19 Apply 2 times a day for 3 days, followed by 4 days of no therapy, 4 cycles max. Total wart area should not exceed 10 cm2 and total volume applied daily not to exceed 0.5 ml. OR Imiquimod 5% cream. Apply once daily at bedtime 3 times a week for up to 16 weeks. Wash treatment area with soap and water 6-10 hours after application. OR ♦ Sinecatechins 15% ointment.19,20 Applied 3 times a day for up to 16 weeks. Do not wash off.

Urethral Meatus Cryotherapy with liquid nitrogen OR Podophyllin 10%-25%19 in a compound tincture of benzoin. Treatment area must be dry before contact with normal mucosa. Repeat weekly if necessary.

Vaginal Cryotherapy with liquid nitrogen. Cryoprobe not recommended (risk of perforation and fistula formation) OR TCA or BCA 80%90%. Apply small amount only to warts. Allow to dry. If excess amount applied, powder with talc, baking soda or liquid soap. Repeat weekly if necessary.

Anal Cryotherapy with liquid nitrogen OR TCA or BCA 80%-90%. Apply small amount only to warts. Allow to dry. If excess amount applied, powder with talc, baking soda or liquid soap. Repeat weekly if necessary OR Surgical removal Many persons with anal warts may also have them in the rectal mucosa. Inspect rectal mucosa by digital examination or anoscopy. Warts on the rectal mucosa should be managed in consultation with a specialist.

Because data are limited concerning efficacy of ceftriaxone and azithromycin regimens in HIV-infected persons, these regimens should be used for such patients only if follow-up can be ensured. Consuming alcohol should be avoided during treatment and for 24 hours thereafter. Multiple studies and meta-analyses have not demonstrated an association between metronidazole use during pregnancy and teratogenic or mutagenic effects in newborns. In lactating women administered metronidazole, withholding breastfeeding during treatment and for 12-24 hours after last dose will reduce exposure of infant to metronidazole. 12 Consuming alcohol should be avoided during treatment and for 72 hours thereafter. Tinidazole safety during pregnancy not established. Interruption of breastfeeding is recommended during treatment and for 3 days after last dose. 13 Oral therapy preferred for treatment of pregnant women with BV because of possibility of subclinical upper genital tract infection. 14 The 7 day metronidazole regimen may be more effective than single dose metronidazole in women coinfected with trichomoniasis and HIV. 15 Lindane no longer recommended because of toxicity. Pregnant or lactating women should be treated either with permethrin or pyrethrins with piperonyl butoxide. 16 Ivermectin not recommended for pregnant or lactating women, or children who weigh <15 kg. 17 Lindane no longer recommended as first line therapy because of toxicity. Lindane not to be used immediately after a bath, in persons with extensive dermatitis and women who are pregnant or lactating, or children aged < 2 years. 18 Famciclovir efficacy and safety not established in patients <18 years of age. 19 Imiquimod, sinecatechins, podophyllin, and podofilox should not be used during pregnancy. 20 Sinecatechins not recommended for HIV-infected persons, immunocompromised persons, or persons with clinical genital herpes. Version 11-2012 ♦ Indicates revision from previous CDC STD Treatment Guidelines 11

 

574 ANIMAL BITE REPORT

1. Case Number:

RABIES CONTROL INVESTIGATION Date of Report: 2. Name (Last, First):

3. Sex: □Male

6. Address (No. & Street):

7. Name of Parent/Guardian (if victim is a minor):

4. Age: □ Female

(City)

11. Time and Date of Attack:

12. Circumstances of Attack:

□ K-9 (Police Action) □ Sick/Hurt

□ Unknown □ Unprovoked □ Playful □ Other _____________________________ Telephone:

13. Animal Owner (Custodian): 14. Address (No. & Street):

(City) □ Owned □ Stray □ Wild 17. License Number:

□ Other (specify)__

16. Description (Breed, Color, Etc.): □ Normal

20. Vaccination Status: □ Vaccinated □ Unvaccinated 21. Animal Location:

□ Abnormal

□ Unk.

□ Unknown

VET:

□ Unable to Locate Animal

23. Cause of Death: □ Illness □ Injury 24. Quarantine Released:

□ Did Not See Animal

(Zip)

□ Male □ Female

□ Spayed/Neutered □ Unaltered □ Unknown Date: □ Yes

Vaccination Date:

Rabies Tag No.:

□ Animal Confined

□ Euthanasia Date:

□ Provoked

(State)

19. Prior Bite History:

__________

22. If at owner’s home, has Quarantine Agreement been signed?

25. Veterinarian □ Did

(Zip)

Telephone:

10. Place of Attack:

18. Behavior:

(State)

8. Address (if different than above):

9. Source of Information (Person or Office):

15. Type of Animal: □ Dog □ Cat

5. Telephone:

Estimated Age: From:

□ No □ 1 Year Vaccine □ 3 Year Vaccine □ 4 Year Vaccine

From Date:

□ Yes

To Date:

□ No

Date: By: 26. Head examination is: □ Requested

□ Not Warranted

27. Remarks: Date:

By:

Telephone:

28. Head Sent to Lab: 29. Results: □ POSITIVE □ NEGATIVE □ UNSATISFACTORY 30. Victim Notified By: □ Person □ Phone □ Mail 31. □ Case Closed

Date:

32. Person Completing Form:

DH 4042, 10/06 Stock No. 5744-000-4042-4

Date:

By:

By: Telephone:

575 Instructions for completing the form “Animal Bite Report”, 6/07 The purpose of this form is to collect information about animal bites in the context of a rabies control investigation. It should be used by county health department staff when conducting an animal bite investigation. 1. Case Number: Provide the number assigned to the case being investigated. This number is intended for internal tracking and will be specific to each county. 2. Name: Provide the first and last name of the bite victim. 3. Sex: Indicate if the victim is male or female. 4. Age: Provide the victim’s age. 5. Telephone: Enter the victim’s contact telephone number. 6. Address: Enter the victim’s address, including number and street, city, state, and zip code. 7. Name of Parent/Guardian: If the victim is a minor, enter the name of a parent or guardian. 8. Address: Enter the parent/guardian’s address, if different from that of the victim. 9. Source of Information: Indicate the name and contact telephone number of the person or office providing the information for the report. 10. Place of Attack: Enter the geographic location where the bite occurred (i.e. victim’s home, owner’s home, etc.). 11. Time and Date of Attack: Indicate the time and date when the attack took place. 12. Circumstances of Attack: Check the appropriate box to describe the circumstances surrounding the bite. If there is relevant information that is not captured by the check boxes, please write it in the space provided. 13. Animal Owner: Enter the name and contact telephone number of the animal’s owner or custodian. 14. Address: Enter the animal owner’s address, including number and street, city, state, and zip code. 15. Type of Animal: Check the box next to the type of animal involved in the bite. If “other”, write the type of animal in the space provided. Indicate whether the animal is owned, wild, or stray. Indicate the gender and whether or not the animal has been spayed or neutered. If the animal has definitely not been spayed or neutered, select the “Unaltered” box. Enter the estimated age of the animal. 16. Description: Provide a description of the animal, including the breed, color, and other relevant identifying information. 17. License Number: If the animal is licensed, indicate the license number, the date the license was issued, and the dates for which the license is valid. 18. Behavior: Indicate if the animal’s behavior at the time of the bite was normal, abnormal, or unknown. 19. Prior Bite History: Indicate whether the animal has a history of prior bites. 20. Vaccination Status: Indicate whether the animal has been vaccinated against rabies. Write in the name of the providing veterinarian, the vaccination date, the tag number, and check the box to indicate whether the animal received a 1-, 3-, or 4-year vaccine. 21. Animal Location: Check the box to indicate if the animal was unable to be located, or if the animal is being confined. If the animal is being confined, write in the dates of confinement. 22. Quarantine Agreement: If the animal is being confined at the owner’s home, indicate whether the owner signed a Home Quarantine Agreement form (see the Rabies Guidebook for an example). 23. Cause of Death: If the animal is dead, indicate the cause of death by checking the appropriate box, and writing in the date of death. 24. Quarantine Released: Indicate if the animal has been released from quarantine. If yes, write in the date of the release and the name of the person authorizing the release. 25. Veterinarian: Check the box to indicate whether the animal has been seen by a veterinarian. 26. Head Examination: Check the box to indicate if an examination of the animal’s head has been requested or is not warranted. 27. Remarks: Enter any additional remarks regarding the investigation that were not captured elsewhere in the form. 28. Head Sent to Lab: Enter the date the head was sent, and the name and contact telephone number of the person submitting the head for testing. 29. Results: Check the appropriate box to indicate if the head tested positive or negative for rabies, or if the results were unsatisfactory. DH 4042, 10/06 Stock No. 5744-000-4042-4

576

30. Victim Notified: Check the appropriate box to indicate the method by which the victim was notified of the laboratory results. Enter the date the victim was notified, and the name of the person who contacted the victim. 31. Case Closed: Check the box to indicate if the case has been closed. Enter the date of closure, and the name of the person who closed the case. 32. Person Completing Form: Enter the name and contact telephone number of the person completing the form.

DH 4042, 10/06 Stock No. 5744-000-4042-4

577

SECTION 11 SKILLED NURSING FACILITY (SNF) Skilled Nursing Facility Benefits Frequently Asked Questions and Answers

SKILLED NURSING FACILITY BENEFIT

578

BENEFITS: In order to be covered for a Skilled Nursing Facility (SNF) stay, FHCP members must meet the following criteria: 1.

The member requires skilled care on a daily basis. This can be either skilled nursing or therapy services. The admission has been arranged and pre-approved by FHCP at a contract SNF. See the appropriate FHCP Provider Guidelines for the SNF names and addresses. Physician services are provided by FHCP’s staff or approved physician. The services can only be provided at a level that cannot be offered at a less restrictive environment such as HHC level or outpatient level.

2. 3. 4.

If the above criteria are met, the current level of SNF coverage for various FHCP groups, per calendar year is as follows: FHCP Medicare Senior Care: Plan Codes 455-459

Up to 100 days for each spell of illness** Days 1-20 = $0 copay/day Days 21-100 = $160 copay/day

Plan Codes 460

Up to 100 days for each spell of illness** Days 1-20 = $0 copay/day Days 21-100 = $160 copay/day

Plan Codes 461-462

Up to 100 days for each spell of illness** Days 1-20 = $0 copay/day Days 21-100 = $160 copay/day

Group Group State of Florida Small Group

*Call Program Mgmt. for Benefits Non*Call Program Mgmt. for Benefits 60 days per calendar year Varies per plan, please see plan specific benefits on Physician Access Inquiry (PAI)

** A “spell of illness” – also popularly called a “benefit period” – is a period of consecutive days that begins with the first day (not included in a previous spell of illness) in which a patient is furnished inpatient hospital or extended care services by a qualified provider and ends when the beneficiary has been neither an inpatient of a hospital nor of a SNF for 60 consecutive days. A beneficiary may have more than one spell of illness per year. *Program Management – (386) 615-4024 or 1 (800) 352-9824, Ext. 4024

579 SKILLED NURSING FACILITY FREQUENTLY ASKED QUESTIONS AND ANSWERS: The following are frequently asked questions and answers regarding nursing home coverage for FHCP members. Please remember that only skilled nursing home care is covered by FHCP, regardless of the group under which the member is covered. 1. WHAT IS SKILLED CARE? Care that requires a trained licensed medical person to render. Example: injections, sterile dressings, IV therapy, tube feedings, physical, occupational or speech therapy. Many variables are involved in establishing what level of care a patient is receiving. Each case is reviewed individually as to whether it meets nationally recognized guidelines such as Medicare guidelines for skilled care or Milliman. 2. WHAT IS CUSTODIAL CARE? Custodial care is given to assist a member with their “activities of daily living”. For example: bathing, eating, dressing, etc. Members may also need close supervision for safety reasons or to insure they take their medication, etc. These services do not require the services of a trained licensed medical professional. While a member may need help 24 hours a day, the type of help described above is considered to be custodial and is not covered by FHCP. 3. HOW MANY DAYS ARE COVERED? Coverage is limited to the point when skilled nursing services are no longer required or the amount of benefit days per members policy is exhausted, whichever comes first. 4. WHAT IS MEDICAID? Medicaid is indigent health care assistance provided by the State Of Florida. It is not related to the Medicare program. Medicaid eligibility is based on a recipient’s monthly income, savings, other assets, etc. Should a member desire more information regarding Medicaid eligibility, he or she should contact the Department of Health and Rehabilitation Services, Aging and Adult Services Division. 5. WHAT NURSING HOME(S) DOES FHCP USE? A current list of contracted facilities (Skilled Nursing facilities) is noted in your Network’s Referral Instructions. When FHCP covers an admission, the member must utilize the contracted and approved facility. The admission will be arranged in advance by FHCP upon the patient’s discharge from the hospital. If the member is private pay or Medicaid, the member may go wherever he or she desires. 6. DOES FHCP COVER ALL MEDICATIONS IN THE NURSING HOME? If FHCP covers the skilled admission, the medications are also covered. If FHCP does not cover the admission, the medications are not covered. Some nursing homes will allow family members to purchase drugs at the FHCP Pharmacy and bring them to the nursing home.

580 7. DOES FHCP COVER DURABLE MEDICAL EQUIPMENT (DME) IN THE NURSING HOME? Most DME is included in the nursing home’s daily rate charges. The only DME covered over and above the daily rate at the nursing home would be non-reusable items such as catheters, ostomy supplies, tube feeding supplies, etc., when a patient has exhausted his SNF days or skilled level of care under FHCP’s guidelines. 8. DOES FHCP COVER LAB WORK PERFORMED IN A NURSING HOME? Yes, we cover lab charges whether the patient is covered by FHCP, Medicaid or private pay. 9. DOES FHCP HAVE A PHYSICIAN THAT VISITS PATIENTS IN THE NURSING HOME? Yes, we have physicians who are assigned to visit various skilled nursing facilities in our service area or the patient’s family may elect to pay for transport to the PCP’s office. 10. DOES THE PHYSICIAN ALSO VISIT THE FHCP PATIENTS THAT ARE PRIVATE PAY OR MEDICAID? No – Custodial patients, if able, can be transported to the physician’s office to be seen. If unable or unwilling they will be seen by the SNF physician Team. 11. IF THE PATIENT IN THE NURSING HOME WANTS TO COME TO FHCP TO BE SEEN BY A PHYSICIAN OTHER THAN THE NURSING HOME PHYSICIAN, IS THIS ACCEPTABLE? Generally, confusion is created if one physician is seeing a patient in the nursing home and another primary care physician also sees the patient. This should be discouraged unless the patient has a strong desire to see another physician. 12. DO WE PROVIDE TRANSPORTATION FOR PATIENTS TO SEE PHYSICIANS AT FHCP? Yes, if the patient is on skilled level of care at the time of appointment. Transportation arrangements must be pre-approved by FHCP in order to be covered.

581

SECTION 12 COURIER SERVICES Courier Services Description Hours of Operation / Telephone /Fax

582

FLORIDA HEALTH CARE PLANS COURIER SERVICES Our regular Florida Health Care Plans Courier Service consists of the pickup and delivery of inter-office mail, medication, x-ray films, lab specimens and supplies. Regular hours of operation are: Monday through Friday, 8:00 a.m. to 4:30 p.m. Telephone: Fax:

(386) 425-4382 (386) 238-6078

If the phone is busy, please leave a message. For local pickup (Daytona, Port Orange and Ormond): Monday through Friday, 4:30 p.m. to 6:30p.m.

Call Pager:

1/17

(386) 820-3525

583

SECTION 13 DOCUMENTS AND FORMS DEPARTMENT Procedure for Ordering Forms Forms Requisition

584

DOCUMENTS AND FORMS DEPARTMENT Florida Health Care Plans has a Documents and Forms Department located in the FHCP Holly Hill Facility. All documents and forms needed by both Staff and Contracted Network Physicians are available.

INSTRUCTIONS: Complete the appropriate forms requisition. The upper portion of the form must be completed. You must include the quantity you are requesting in the box next to the appropriate form title. If a form is not listed, please write the form number on the requisition. This is located in the lower left hand corner of the form. If a form number is unavailable, please send a copy of the form with the order. Orders can be sent by fax (386 / 676-1703), or by courier, to the FHCP Documents and Forms Department in Holly Hill. ALL ORDERS MUST BE RECEIVED BY THURSDAY MORNING TO BE PROCESSED BY THURSDAY AFTERNOON. ORDERS SHOULD ARRIVE IN YOUR OFFICE ON FRIDAY OR THE FOLLOWING MONDAY.

For assistance or urgently needed supplies, please call the FHCP Documents and Forms Department at 386 / 676-7100, ext. 7252.

585

586

587

FHCP FORMS REQUISITION

588

FOR CONTRACTED PHYSICIANS

OFFICE/DR. NAME:

OFFICE ADDRESS:

DATE:

***FAX ORDERS TO 386-676-1703

FORM # 01-216

DESCRIPTION/FORM

QTY.

QTY. ORDERED

VACCINE INFO SHEETS

QTY. ORDERED

WELL BABY/ WELL CHILD

QTY. ORDERED

ANTICIPATORY GUIDELINES

U/S APPOINTMENT CARDS

Each

CHICKENPOX

2 WEEKS

PRENATAL

01-218

BONE DENSITY APPOINTMENT CARD

Each

DTaP

2 MONTHS

NEWBORN

01-828

RADIOLOGY REQUEST

Each

DTaP - SPANISH

4 MONTHS

2ND WEEK

01-829

ULTRASOUND REFERRAL FORM

Each

HIB

6 MONTHS

1 MONTH

02-600

REFERRAL TO MINOR SURGICAL CLINIC

Each

HEPATITIS A

9 MONTHS

2 MONTHS

02-610

ECG REPORT

Each

HEPATITIS B

12 MONTHS

4 MONTHS

02-663

FHCP SCREENING MAMMO LIST

Each

PNEUMO/POLY.

15 MONTHS

6 MONTHS

02-694

COMFORT ASSESSMENT GUIDE

Each

MMR

18 MONTHS

9 MONTHS

08-716

REHAB SERVICE REQUEST

Each

POLIO (IPV)

2-3 YEARS

1 YEAR

09-607

PEDIATRIC HISTORY FORM

Each

PNEUMO/CONJUG.

4-5 YEARS

15 MONTHS

09-801

TEMP AUTHOR/CONSENT TO TREAT

Each

Td

6-9 YEARS

18 MONTHS

12-921

FL DO NOT RESUSCITATE

Each

Tdap

10-13 YEARS

2 YEARS

14-501

PRE-ADM/PRE-OP CHECKLIST

Each

MENINGOCOCCAL

14 YRS. & OLDER

3 YEARS

17-105

REFERRAL FOR DIABETES ED

Each

17-120

PSA TESTING INFO SHEET

Each

PATIENTS WITH HEP C PCR

Each

31-917 PHYSICIAN ORDERS

21-123 SCREENING COLONOSCOPY

5 YEARS

21-121 21-501

REFERRAL FORM

Each

SURVIVAL SKILLS

21-124 SCREENING COLONSCOPY (WEST)

6 YEARS

FOR DIABETES INTER-DEPT ENV

02-554 COLORECTAL CANCER SCREENING

8 YEARS

QTY. ORDERED

4 YEARS

24-301

ADVANCE DIRECTIVES

Each

27-120

PRESCRIPTION PAD (CHECK OFF)

100/Pad

27-201

PHARMACY REQUISITION

Each

11-14 YEARS

27-202

PHARMACY CREDIT MEMO

Each

15-17 YEARS

30-111

PERSONAL B/P & MED RECORD

Each

18-21 YEARS

30-910

PRESCRIPTION PADS

100/Pad

38-503 HEALTHY KIDS EYE CONSULT REQ.

(PLEASE ORDER VACCINE - WELL BABY & ANTICIPATORY BY “ /EA.”)

10 YEARS

(REVISED 4/06)

589

SECTION 14 OUTPATIENT LABORATORY TESTING Outpatient Laboratory Testing LabCorp Advantages Genetic Testing Locations LabCorp Requisition

590

LABCORP LabCorp is the exclusive HMO provider of outpatient laboratory services to FHCP members. Each FHCP HMO Provider is issued a FHCP account number to be used when ordering Lab studies for FHCP members only. Use of the separate account number requires the offices to use a special LabCorp/FHCP requisition for their FHCP members. LabCorp and FHCP have linked the accounts of all FHCP providers together. By using the FHCP account with LabCorp, it facilitates the flow of information between Provider offices relating to patient care, referrals and overall care management of FHCP members. LABCORP DRAW STATIONS: Appointments are not necessary but wait time will be longer without an appointment. Online appointment scheduling available at www.LabCorp.com or by phone at 1(800) 877-5227, Option 3. Appointments should be made at least one day in advance. All Genetic Testing for FHCP members must have prior authorization from FHCP’s Central Referrals in Holly Hill. Please do not send a FHCP member directly to a lab without prior authorization. Only requests that are medically necessary will be considered. FHCP requests that FHCP members use the facilities listed below for Routine and STAT lab collections. Offices can make arrangements for specimen collection directly by LabCorp, as long as the correct FHCP requisition and/or account number are used for the FHCP member.

Rev. 1-16-2015

591 LABORATORY LOCATIONS FHCP Center – Daytona Beach 350 North Clyde Morris Blvd. (386) 238-3285 Mon.-Fri.: 7:00 a.m. to 5:00 p.m. *No Appointment Necessary FHCP Center – Holly Hill 1340 Ridgewood Ave. (386) 676-7136 Mon.-Fri.: 7:00 a.m. to 3:30 p.m. *No Appointment Necessary FHCP Center – Orange City 2777 Enterprise Rd. (386) 774-2550 Mon.-Fri.: 7:00 a.m. to 3:00 p.m. *No Appointment Necessary FHCP Center – Ormond Beach 461 South Nova Road. (386) 671-4337 Mon.-Fri.: 7:00 a.m. to 4:00 p.m. *No Appointment Necessary FHCP Center – Palm Coast 309 Palm Coast Pkwy. (386) 447-9685 Mon.-Fri.: 7:00 a.m. to 3:30 p.m. *No Appointment Necessary FHCP Center – Port Orange 740 Dunlawton Ave. (386) 763-1000, Ext. 6312 Mon.-Fri.: 7:00 a.m. to 3:30 p.m. *No Appointment Necessary FHCP Center – DeLand 937 North Spring Garden Ave. (386) 736-1948 Mon.-Fri.: 7:00 a.m. to 3:00 p.m. *No Appointment Necessary

LabCorp., Inc. - Altamonte Springs 393 Center Point Cir., Ste. 1457 (407) 834-0804 Mon.-Fri.: 6:00 a.m. to 3:00 p.m. Sat.: 8:00 a.m. to 12:00 p.m. - No Drug Screens Sat. Drug Screens: Mon-Fri: 8 a.m. to 11:30 a.m. & 1:00 p.m. to 1:30 p.m. *No Appointment Necessary LabCorp., Inc. - Apopka 1706 E. Semoran Blvd., Ste. 114 (407) 814-0281 Mon.-Fri.: 6:30 a.m. to 3:30 p.m. Drug Screens: 8 a.m. to 2:30 p.m. Lunch: 12:00 p.m. – 1:00 p.m. *No Appointment Necessary LabCorp., Inc. - Casselberry 1239 SR 436, Walmart 101 (407) 678-0169 Mon.-Fri.: 7:00 a.m. to 7:00 p.m. Sat.: 7:00 a.m. to 5:00 p.m. Sun.: 9:00 a.m. to 5:00 p.m. *No Appointment Necessary LabCorp., Inc. – DeLand 929 N. Spring Garden Ave., Ste. 927-B (386) 822-9000 Mon.-Fri.: 6:00 a.m. to 3:00 p.m. Drug Screens: 8:00 a.m. to 2:00 p.m. *No Appointment Necessary LabCorp., Inc. – Edgewater 602 W. Indian River Blvd., Ste. 1&2 (386) 424-7346 Mon.-Fri.: 6:00 a.m. to 3:00 p.m. No Drug Screens *No Appointment Necessary

592 LabCorp., Inc. - Lake Mary 2500 W. Lake Mary Blvd., Ste. 112 (407) 268-4253 Mon.-Fri.: 6:30 a.m. to 12:00 p.m. & 1:00 p.m. to 3:30 p.m. No Drug Screens *No Appointment Necessary LabCorp., Inc. - Longwood 705 W. State Rd 434, Ste. J K (407) 331-0182 Mon.-Fri.: 6:30 a.m. to 3:30 p.m. Drug Screens: 8:00 a.m. to 11 a.m. & 1:00 p.m. to 2:30 p.m. *No Appointment Necessary LabCorp., Inc. - Oviedo 1000 W. Broadway St., Ste. 204 (407) 359-2132 Mon.-Fri.: 7:00 a.m. to 4:00 p.m. No Drug Screens *No Appointment Necessary LabCorp., Inc. – Port Orange 3510 S. Nova Rd. Ste., 109 & 110 (386) 788-5004 Mon.-Fri.: 6:00 a.m. to 3:00 p.m. No Drug Screens *No Appointment Necessary LabCorp., Inc. - Sanford 910 Lexington Green Ln. (407) 330-0300 Mon.-Fri.: 6:30 a.m. to 3:30 p.m. Drug Screens: 7:00 a.m. to 11:00 a.m. & 1:00 p.m. to 2:30 p.m. Lunch: 12:00 p.m. to 1:00 p.m. *No Appointment Necessary

Rev. 01/11/17

LabCorp., Inc. - Titusville 2405 Garden St., Ste. 2 (321) 264-1863 Mon.-Fri.: 6:30 a.m. to 3:30 p.m. Lunch – 12:00 p.m. – 1:00 p.m. Drug Screens: 8:00 a.m. to 11 a.m. & 1:00 p.m. to 3:00 p.m. *No Appointment Necessary LabCorp., Inc. – Merritt Island 725 N. Courtenay Pkwy. (321) 449-9411 Mon.-Fri.: 6:30 a.m. to 3:30 p.m. Lunch – 12:00 p.m. – 1:00 p.m. Drug Screens: 8:00 a.m. to 11:30 a.m. & 1:00 p.m. to 2:30 p.m. *No Appointment Necessary LabCorp., Inc. – Melbourne 1678-B West Hibiscus Blvd., (321) 676-6481 Mon.-Fri.: 6:30 a.m. to 3:30 p.m. Drug Screens: 8:00 a.m. to 11:30 a.m. & 1:00 p.m. to 2:00 p.m. *No Appointment Necessary LabCorp., Inc. – Sebastian 13000 US Highway 1, Ste. 3 (321) 581-8707 Mon.-Fri.: 7:00 a.m. to 4:00 p.m. Lunch-12:00 p.m.-1:00 p.m. *No Appointment Necessary

593

LABORATORY LOCATIONS Parrish Medical Group Diagnostic Imaging Center 6045 Columbia Blvd., Ste. 108A, Titusville, FL (321) 268-6674 Mon.-Fri.: 7:00 a.m. to 2:30 p.m. Parrish Healthcare Center at Port St. John 5005 Port St. John Pkwy., Port St. John, FL (321) 636-9393 Mon.-Fri: 7:00 a.m. to 4:00 p.m. Parrish Medical Center 951 N. Washington Ave., Titusville, FL (321) 268-6134 Mon.-Fri: 6:30 a.m. to 6:30 p.m. Sat: 7:00 a.m. to 12pm (noon) Parrish Medical Center Health & Fitness 2210 Hwy. 50, Titusville, FL (321) 268-6721 Mon.-Fri: 6:30 a.m. to 2:45 p.m. Melbourne Medical Lab 95 Bulldog, Ste.103, Melbourne, FL (321) 255-8020 Mon.-Fri: 7:30 a.m. to 5:00 p.m. Wuesthoff-Crane Creek/Melbourne 2222 S. Harbor City Blvd., 4th Flr., Melbourne, FL (321) 255-8020 Mon.-Fri: 7:00 a.m. to 3:00 p.m. Wuesthoff-Eau Gallie/Melbourne 716 St. Clair St., Melbourne, FL (321) 255-8020 Mon.- Thurs: 7:30 a.m. to 11:00 a.m. Closed on Friday

594 LABORATORY LOCATIONS Wuesthoff-Merritt Island 2400 N. Courtenay Pkwy., Merritt Island, FL (321) 255-8020 Mon.-Fri: 7:00 a.m. to 4:00 p.m. Wuesthoff-Port St. John 7227 N. U.S. Hwy 1, Port St. John, FL (321) 255-8020 Mon., Tues., Thurs: 7:30 a.m. to 12:00 p.m. Closed Wed. & Fri. Wuesthoff-Suntree/ Viera 6963 N. Wickham rd., Melbourne, FL (321) 255-8020 Mon., Tues., Thurs., Fri.: 7:00 a.m. to 4:00 p.m. Wed.: 7:00 a.m. to 12 p.m.(noon)

595

596

597

SECTION 15 PREFERRED FITNESS PROGRAM Preferred Fitness Program Gym List for Preferred Fitness Medicare Members Gym List for Preferred Fitness Members

598

Dear Medicare Member, Welcome to Florida Health Care Plans “Preferred Fitness” program. Good health is your best defense against illness and disease. At Florida Health Care Plans, we are dedicated to maximizing your health and well-being. In order to help you achieve your personal health and fitness goals, we invite you to take advantage of this unique fitness program. The program is a value added service available to all Medicare beneficiaries enrolled in one of FHCP's Medicare plans. Preferred Fitness will help you improve your health, reduce your risk of future disease, increase your energy, and meet new friends! We have contracted with a variety of quality Health & Fitness facilities throughout Volusia and Flagler Counties. Please find attached a list of participating facilities. You may visit our website at www.fhcp.com. Click on the “Medicare” tab. Under “Programs”, click on the “Preferred Fitness Program” link. This will take you to the Preferred Fitness Program page. The gyms are listed by region. Knowledge is the key to success. Having a better understanding about your current health status will aid in your success. We strongly recommend you take advantage of our FREE Fitness Evaluation. A list of facilities authorized to perform the evaluation is included. The Fitness Evaluation will be performed by Physical Therapist, Occupational Therapist or Exercise Physiologist. They will create a personalized exercise prescription based on your evaluation. You may take that prescription to any of our listed facilities, which will be happy to set up a routine based on those recommendations. You may repeat the Fitness Evaluation every 6 months from the date of the last one, allowing you to monitor your individual progress. A healthy, active lifestyle can increase your energy, reduce your risk of future disease, and help you look and feel great. Enroll today and get started on the path towards a healthier you! Should you have any questions, comments or suggestions concerning the program, please contact Member Services at 1-(877)-615-4022. Hours of operation are 7 days a week, 8 a.m. to 8 p.m. The hearing impaired may call TRS Relay by simply dialing 711.

599

MEDICARE GYM LIST Refer to: http://www.fhcp.com/medicare/documents/medicare-preferred-fitness-gym-list.pdf

MEMBER GYM LIST Refer to: http://www.fhcp.com/health/documents/preferred-fitness-plan-gym-list.pdf

600

SECTION 16 FORMS FHCP Forms

Breast Cancer Screening and Mammography ECG Order Infusion Therapy Physician Orders Insurance Information Form Surgical & Special Procedures Form Prior Authorization Medication Form Admission Notification Form Radiology Requisition Bone Density Test Card Referral for Diabetes Education or Nutritional Counseling Referral Form Referral to Minor Surgical Clinic (MSC) Rehabilitation Services Request Screening Colonoscopy (East, Southeast & Flagler County Networks) Screening Colonoscopy (West Volusia Network) TMJ Screening Questionnaire Ultrasound Dept. Appointment Form Ultrasound Referral Form Order for Childhood Vaccines

601

Breast Cancer Screening and Mammography The Best Prevention is Early Detection Frequently asked questions: How many women get breast cancer? Excluding cancers of the skin, Breast Cancer is the most common cancer among American women. The chance of developing invasive breast cancer at some time in a woman's life is a little less than 1 in 8. The chance of dying from breast cancer is about 1 in 35.1 Some alarming statistics for 2011 in the United States1: • An estimated 230,480 new cases of invasive breast cancer occurred among women. • Approximately 39,520 women died from breast cancer. • Only lung cancer accounts for more cancer deaths in women. • About 2,140 new cases of breast cancer will be diagnosed among men, accounting for about 1% of all breast cancers. In addition, approximately 450 men will die from breast cancer. Who should be screened? Routine screening for breast cancer starting at age 40 is recommended once a year. For women age 20 – 39, Clinical Breast Exam (CBE) should be performed every three years during your woman’s health exam with your Physician. Women at risk may benefit from earlier mammography testing. Who is at risk? • Every woman is at risk – 1 woman in every 8 will get breast cancer in their lifetime.1 • Besides being female, age is the most important risk factor for breast cancer. 1 • Increased risk factors: - If your mother or sister had breast cancer, you are more likely to develop breast cancer, especially if they had it at an early age. - Radiation therapy to the chest that was given more than 10 years ago, especially in women younger than 30 years old, may increase a woman’s risk of developing breast cancer. How is breast cancer found? Mammograms are the best tests for finding breast cancer early. Mammograms allow doctors to look for early signs of breast cancer, sometimes up to three years before it can be felt.2 A clinical breast examination (CBE) is an exam of your breasts performed by your doctor and is very valuable when done along with a mammogram. There is no better tool in the fight against breast cancer than early detection. When detected at its early stages, the five-year survival rate is 90%.1 Breast cancer death rates have been on the decline since 1990, with larger decreases in women younger than 50. This is probably the result of finding the cancer earlier and better treatment. Right now there are more than 2 ½ million breast cancer survivors in the United States. (Continued on back)

602

How do I schedule a Mammogram and where do I go? It is your responsibility to call and make an appointment for your yearly routine screening. From the list below, contact the facility most convenient for you to schedule an appointment. Facilities noted with an asterisk (*) require a written prescription. Call your physician if you are planning to use one of these facilities. Twin Lakes Imaging Center 1890 LPGA Boulevard, Suite 110 Daytona Beach, FL 32117 (386) 274-5454 Hours: 8:00 a.m. to 4:45 p.m. (Also 3rd Sat/month)

Palm Coast Imaging Center 3 Pine Cone Drive, Suite 101 Palm Coast, FL 32137 (386) 446-5200 Hours: 8:00 a.m. to 4:35 p.m.

Port Orange Imaging Center 1195 Dunlawton Avenue Port Orange, FL 32127 (386) 322-1616 Hours: 7:30 a.m. to 4:45 p.m. (Until 5:35 p.m. on some days)

* Florida Hospital Fish Imaging 1053 Medical Center Drive, Suite 151 Orange City, FL 32763 (386) 917-5428 Hours: 7:00 a.m. to 5:00 p.m.

* Florida Hospital-DeLand 701 W. Plymouth Avenue DeLand, FL 32720 (386) 943-4522 Hours: 7:30 a.m. to 5:30 p.m. (Wed. only) 7:30 a.m. to 3:30 p.m. (Mon, Tues, Thurs & Fri)

* Florida Hospital-Flagler 60 Memorial Medical Parkway Palm Coast, FL 32164 (386) 586-4402 Hours: 7:30 a.m. to 4:30 p.m.

* Bert Fish Medical Center 401 Palmetto Street New Smyrna Beach, FL 32168 (386) 424-5044 Hours: 8:00 a.m. to 4:00 p.m. (screening) 8:30 a.m. to 2:30 p.m. (diagnostic)

Town Center Imaging 21 Hospital Drive Palm Coast, FL 32164 (386) 445-4400 Hours: 8:10 a.m. to 4:35 p.m.

St. Augustine Imaging Center 190 Southpark Boulevard, Suite 101 St. Augustine, FL 32086 (904) 827-9191 Hours: 8:10 a.m. to 4:40 p.m.

* LAD Imaging, LLC 1555 Saxon Boulevard, Suite 401 Deltona, FL 32725 (386) 860-9336 Hours: 7:00 a.m. to 4:30 p.m. (Mon – Fri) Saturdays 7:00 a.m. to 12 Noon

* Requires a written prescription. How can I learn more? National Cancer Institute Cancer Information Service Telephone: 1-800-4-CANCER Internet Address: http://www.cancer.gov

Susan G. Komen Breast Cancer Foundation Telephone: 1-800-IM AWARE or 800-462-9273 Internet Address: www.komen.org/

Y-Me National Breast Cancer Hotline Telephone: 1-800-221-2141, 1-800-986-9505 (Spanish) Internet Address: http://www.networkofstrength.org/ 1

American Cancer Society. Breast Cancer Facts & Figures 2011.. Available at: http://www.cancer.org/index Centers for Disease Control and Prevention (CDC), Breast Cancer and You: What You Need to Know. Available at: http://www.cdc.gov/cancer/breast/pdf/BreastCancerFS.pdf

2

603

Date:

FLORIDA HEALTH CARE PLANS

ECG ORDER Name:

MRN:

Physician:

Fax #:

Diagnosis:

Plan #:

Routine

Medication:

Pre-Op Stat

D.O.B.

Sex:

BP:

Comments:

Abnormal EKG:

Reviewed by Dr.:

Symptomatic:

Evaluated by Dr.:

Chart/EKG’s pulled: 06-606-05/1-00

604 FLORIDA HEALTH CARE PLANS INFUSION THERAPY PHYSICIAN ORDERS Date:

MRN:

1. Patient Name: SS#:

Phone #:

Address: Allergies:

City: Weight:

2. Administer Medications as follows: a. b. c. d. 3. Venous Access: Peripheral Mid line Catheter 4. Routine flush: as follows

DOB: Diagnosis: Dx Code: State:

, IV q , IV q , IM q , SQq

Hickman

with each dose, cc’s NSS, Drug,

hrs; times hrs; times hrs; times hrs; times

Infusaport PICC line q day,

Zip: Height:

q week, q month cc’s NSS, then

Groshong

cc’s of

Units of Heparin

5. Lab Request:

6. Consult FHCP Pharmacist in dosing medication according to lab results. Yes No 7. ANAPHLACTIC PROTOCOL: A. If reaction occurs: STOP IV administration of medication immediately. Start 2nd IV 14 – 16 gauge. Start IV – NSS wide open. B. Administer Epinephrine 1:1000/SQ. as follows: 1. Adults (over 12 years) -0.3ml q 10 min. x 2. 2. 6-12 years -0.2 ml q 10 min x 2. 3. 2-6 years – 0.15 ml q 10 min. x 2. 4. Infant – 2 years (0.05 ml – 0.1 ml) q 10 min. x 2 C. Call 911 and notify MD. D. Administer 0² via N/C if Resp <12 or signs of airway obstruction 8. ALLERGIC REACTION PROTOCOL: A. If reaction occurs: Stop IV administration and KVO with 50 ml NSS. B. Administer Benadryl: 1. Adults (over 12 years) – 50 mg IM or IV push. 2. 6-12 years – 1-2 mg/kg IM or IV push. 3. Under 6 years, Benadryl 1-2 mg/kg IM or IV push up to 50mg. C. Notify MD of Reaction. D. 0² PRN Dr. Signature: T.O. Dr.: Nurse Signature:

Date:

Phone: Date: Date:

Fax: Time: Time:

If no time frame is specified, order must be renewed yearly or at stop order date whichever come first. 02-120/5-08X

605

Florida Health Care Plans, Inc. Insurance Information Form

Notice to FHCP Patients Please notify your FHCP Physician when you are seeing him/her as a result of injuries sustained from any type of accident. If you have any questions regarding FHCP coverage of treatment for your injury, please contact Donna Pacifico at (386) 676-7123 or 1-800-352-9824. Mailing Address: P. O. Box 9671, Daytona Beach, 32120. Today’s Date: Check One:

Date of Accident/Injury: Workers Compensation

MRN: Auto Accident

Other (Fall)

ATTENTION: IF YOU CHECKED “Other” PLEASE CALL Donna Pacifico at (386) 676-7123. Name of Patient:

Social Security”:

Address:

Telephone # - (Home):

City:

(Work):

Your Auto Insurance Carrier Information Name of Your Insurance Co.:

Phone #:

Insurance Co. Address: Policy #:

Claim #:

State accident occurred:

Insured: Initial Emergency Treatment received at:

I authorize the above referenced Insurance Carrier to make payment of medical benefits directly to Florida Health Care Plan, Inc. for services rendered to me as a result of the above auto accident. Furthermore, I authorize the release of any medical or other information necessary to process this claim.

Date

Insured or Authorized Person’s Signature

Worker Compensation Insurance Information Please Provide FHCP with a Copy of the Notice of Injury Filed with Your Employer. Employer Name:

Telephone #:

Employer Address: Workers Compensation Carrier’s Name: Carrier’s Address: Carrier’s Telephone #: 32-302/3-02 RX

Adjuster’s Name:

606

FLORIDA HEALTH CARE PLANS SURGICAL & SPECIAL PROCEDURE FORM Phone: 386-238-3230 Fax: 386-238-3253 Section 1 (Please complete all areas) Date:

Auth #:

Patient Name:

Medical Record #:

S.S. #:

Address: Date of Birth:

Phone/Home:

In Case of Emergency Notify:

Work: Telephone:

Primary Care Physician:

Cell: Relationship:

Surgeon:

Diagnosis:

ICD-10 Code:

CPT Code: (Circle One)

Routine

Urgent

(Circle One)

Inpatient

Outpatient

* 23 Hour Observation

* Documentation is required to support 23 hr obs status

Facility: Comments – (Relating to actual surgery, if any): Surgical/Special Procedure:

Date of Procedure:

Time:

Pre-Op Joint Replacement Class:

Admission Date (if inpatient):

Attendance Date:

Section 2 (Available for your office use) Special Equipment / Drugs:

Anesthesia: (circle one)

General

MAC

Spinal

Regional Block

IV Sedation

Local

Section 3 (This section is for FHCP internal use only): This form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s PCP or the Referring Provider. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Approved / Disapproved

Date:

14-501 REV. 12-04-09 FHCP – 125 – Revised 07/13/12, 12/13/13 Reviewed 07-11-14, 10/1/15

By:

607

Admission Notification Auth #: Date of Notification: Member Name: FHCP #: Date of Admit: Diagnosis Code: Diagnosis: Admitting Doctor: Admitting Hospital Code: Admitting Hospital: Physical Address: Main Hospital #: UR #: Caller's Name: Caller's Callback #:

Obs or Full Inpatient?: ER or Direct?: Transferred?: Requested clinicals faxed to FHCP at: 386-615-4058 Please check one of the following below: Attn: Med / Surg UR Case Manager Attn: Mental Health UR Case Manager

Additional Notes:

608

609

FHCP RADIOLOGY REQUISITION P. O. BOX 9910 – DAYTONA BEACH, FL 32120 FFS: NAME:

DOB:

REFERRING PHYSICIAN:

NO

MRN:

PROV. #:

PCP:

YES

DATE ORDERED:

PROV. #:

EXAM DATE:

DIAGNOSIS: CONSENT: I do herby certify that to the best of my knowledge I am NOT pregnant. I further understand that this releases FHCP from any and all liabilities concerning medically necessary x-rays.

Smoker:

LMP:

PPD/

YRS

WITNESS:

GENERAL RADIOLOGY DESCRIPTION Abdomen (AP) Spine) (KUB) Abdomen (Supine & Upright) Abdominal w/Oblique’s A-C Joints Acute Abdomen Series Ankle, (2 Views) (R-L) Ankle, (4 Views) (R-L) Bone Age Studies (Ht, Wt, Sex) Bone Mineral Density (Central) Chest, Decubitus Chest, Lordotic Chest, Oblique Chest, PA & Lat Chest, Single View Clavicle (R-L) Consultation Elbow, (2 Views) (R-L) Elbow, (4 Views) (R-L) Facial Bones Facial Bones Limited Femur (R-L) Finger(s) (R-L) Foot, (2 Views) (R-L) Foot, (3 Views) (R-L) Forearm (R-L) Hand (Complete) (R-L) Hand (Limited) (R-L) Hip (R-L) Hips – BILATERAL Hips – PEDS Hips Bilateral WITH PELVIS Humerous (R-L) Joint Survey Knee, (2 Views) (R-L) Knee, (3 Views) (R-L) Knee, (4 Views) (R-L) Long Bone Survey (PEDS) Lower Extremity – PEDS

X

CPT CODE 74000 74020 74010 73050 74022 73600 73610 77072 77080 71035 71010 71022 71020 71010 73000 76140 73070 73080 70150 70140 73550 73140 73620 73630 73090 73130 73120 73502 73522 73521 73523 73060 77077 73560 73562 73564 77076 73592

Diagnosis Code

DESCRIPTION Metastatic Bone Survey Nasal Bones Neck, Soft Tissue Orbits OS Calcis (R-L) Paranasal Sinuses Pelvis (AP) Ribs – BILATERAL Ribs Bilateral w CHEST Ribs, Unilateral (R-L) Sacroiliac Joints Sacrum & Coccyx Scanogram, Bone Length Study Scapula (R-L) Scoliosis (1 Veiw) Scoliosis (2 Views) Shoulder (1 View) Shoulder (2 Views, R-L) Shunt Services Skull Spine, Cerv, Complt w/Flex Ext Spine, Cervical (3 Views) Spine, Cervical (5 Views) Spine, Lum, Complt w/Flex Ext Spine, Lumbar Flex & Ext. Spine, Lumbosacral (3 Views) Spine, Lumbosacral (5 Views) Spine, Single View Spine, Thoracic Spine, Thor, Complt w/Flex Ext Spine, Thoracolumbar (2 Views) Sternoclavicular Joints Sternum Tibia & Fibula (R-L) Toe(s) (R-L) Upper Extremity – PEDS Wrist, (2 Views) (R-L) Wrist, (4 Views) (R-L)

X

CPT CODE 77074 70160 70360 70200 73650 70220 72170 71110 71111 71100 72202 72220 77073 73010 72081 72082 73020 73030 75809 70260 72052 72040 72050 72114 72120 72100 72110 72020 72072 72074 72080 71130 71120 73590 73660 73092 73100 73110

Diagnosis Code

FLORIDA HEALTH CARE PLANS RADIOLOGY DEPARTMENT 350 N. CLYDE MORRIS BLVD., SUITE 4, DAYTONA BEACH, FL 32114

Your paperwork for your Bone Density test has been sent to the Radiology Department. It is your responsibility to call and make an appointment per Dr. Please contact the Radiology Department as soon as possible, Monday-Friday between the hours of 8 a.m. and 4:30 p.m., At 386-238-3229 or 1-800-321-1227. The hearing impaired may call TTY/TDD TRS Relay 7-1-1 NOTE: Please show up on time for your scheduled appointment or you will be rescheduled. PLEASE KEEP THIS AS YOUR APPOINTMENT CARD. Exam:

Date:

Time:

Reminder: If possible, please wear elastic waist pants. Thank you H1035-NR176 02/17/12 01-120-01 1-27-12

610

611 REFERRAL FOR DIABETES EDUCATION OR NUTRITIONAL COUNSELING Name:

Medical Record #:

Phone #: For FFS Only:

Cell Phone #:

DOB:

Primary Insurance:

Group #:

Policy #:

Effective date of coverage:

Education covered:

Yes

No

Co-pay: $

Secondary Insurance:

Policy #:

Diagnosis: Newly Diagnosed Type 1 Controlled/Uncontrolled _____ Type 2 Controlled/Uncontrolled _____ Morbid Obesity _____ Other

Gestational _____ Impaired Fasting Glucose ______ Pre-Diabetes ______ Obesity ______

Diabetes Self-Management (DSMT): (Medicare-10hrs initial DSMT in 12 mo. period, plus 2 hrs. follow-up annually) Initial DSMT Group (10 hours=4 Sessions)

Glucometer Training:

Follow-up DSMT (2 hours)

Yes

No

Insulin Start Training:

Type of Insulin:

Amount of Insulin:

Initial 1:1 DSMT Training

How Often:

Pre-diabetes Training Group (1 session)

Patients with special needs requiring individual DSMT training (Check all that apply): Vision

Hearing

Physical

Language Limitations

Other

Obesity Weight-Management Program: (3-step 12-month program) Eat Right Move Right Weight Management Program Other Nutritional Counseling: Healthy Heart Eating (Cholesterol Class) Lab Information: (Attached recent labs- Required to document diabetes diagnosis) Weight: HgbA1C:

Height: Cholesterol:

Physician Name and Provider Number

BMI: HDL:

Glucose: LDL:

Triglycerides:

Date

Call (386) 676-7133 to schedule an appointment, and then send referral (along with labs and progress notes) to: FHCP Diabetes/Health Education Department, 1340 Ridgewood Ave., Holly Hill, FL 32117 URGENT REFERRALS (insulin starts, gestational): Call first to schedule an appointment then FAX orders to: (386) 226-4519. Scheduling Use Only: Create task in E H R 17-105/1-09 06-606-04/Rev. 10/10/11, 05/03/12

612

FLORIDA HEALTH CARE PLANS REFERRAL FORM Phone: 386-238-3230 Fax: 386-238-3253 Date:

A.

Auth #:

Member Name:

Referring Provider Name:

MRN:

Date of Birth:

Contact/Caller Name:

Home Tel:

Work Tel:

Referring Provider Phone #:

Cell #:

Referring Provider FHCP #:

Subscriber #:

Provider Signature:

Parent / Guardian Name:

B. REFERRAL STATUS:

Referral at Patient Request Only

Routine

Is this the result of an auto or work accident?

Urgent

Yes

No

*** For urgent cases requiring prior authorization, the provider office must call Central Referrals Department at (386) 238-3230. *** Please refer to your Network Referral Instructions for assistance in completing all HMO referrals.

C. REFERRAL IS FOR: With Contrast

Without Contrast

With & Without Contrast

 DME (equipment needed) Length of need for DME required (except for Nebulizers) Eval

D. DIAGNOSIS CODE

Follow Up

2

nd

Opinion

E. REASON FOR REFERRAL – TO BE COMPLETED BY CLINICIAN (Attach all Supporting Documentation)

F. Appointment with:

Date:

Time:

Notes:

Confirmed with:

By:

On:

G. THIS SECTION IS ONLY FOR THOSE SERVICES THAT REQUIRE PRE-AUTHORIZATION This Form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s PCP or the Referring Provider.

APPROVED BY FLORIDA HEALTH CARE PLANS FOR:

Signature: 21-501 REV. 4/05, 2/07, 02/11, 05/13, 12/13, 05/14, 09/15

Date:

613 FLORIDA HEALTH CARE PLANS

REFERRAL TO MINOR SURGICAL CLINIC (MSC)

DATE:

386-238-3295 FOR APPOINTMENT FAX: 386-238-3273

FROM: DR.

MEMBER NAME:

PHONE:

DOB:

FHCP#:

PLEASE CIRCLE: 1. SKIN LESIONS

2. CYST (No Ganglions)

3. LIPOMA

4. OTHER

DESCRIPTION:

SIZE:

Less than 1CM

1-2.5 CM

(>2.5CM Use FHCP referral for consultation with Gen. Surg)

SHAPE:

REGULAR

IRREGULAR

COLOR:

BROWN

BLACK

RAISED RED

FLAT

MULTI-COLORED

HALO

LOCATION(S): ALLERGIES:

IS PATIENT CURRENTLY TAKING BLOOD THINNERS? (ASPIRIN, COUMADIN, ETC.) YES

NO



If YES, stop 5 days prior to day of procedure, if approved by prescribing M.D.



Remind patient to take blood pressure medicine day of procedure.

APPOINTMENT CONFIRMED WITH: DR. DATE:

TIME:

NOTE: Suspected melanomas are to be seen in consult by General surgeon, NOT in minor surgery. 06-606-09 05/03

614

Florida Health Care Plans

REHABILITATION SERVICES REQUEST Note to Member: You must bring this form and your insurance information with you to your appointment. Name:

Date:

MRN:

Referred by:

Phone:

Diagnosis: Type of Therapy Service(s):

Physical

Occupational

Speech

__________________________________________________________________________________________ Area to be Treated:

X Week for

Weeks

Therapist to Evaluate and Treat Include the following service(s), if needed: Hot Packs

TENS

ROM

Cold Packs

Paraffin

Neck Exercise

Ultrasound

Iontophoresis

Back Exercise

Phonophoresis

Fluidtherapy

Scar Management

Massage

Biofeedback

ADL Training

Electric Stimulation

Strengthening

Splinting, dynamic

Pelvic Traction

Stretching

Splinting, static

Cervical Traction

Stretching

Gait Training

Independent Exercise Program

WB Status

OTHER:

Precautions/Limitations: M.D. Signature: FHCP – A2412 – 7/04

08-716/9-99RP

615

SCREENING COLONOSCOPY (EAST, SOUTHEAST AND FLAGLER COUNTY NETWORKS) Your doctor has requested that you make an office visit appointment to discuss having a Screening Colonoscopy. It is your responsibility to contact the office listed below to schedule an appointment. ADVANCED GI Beatrice Bratu, M.D. Ammar Hemaidan, M.D. Saud Suleiman, M.D. Hassan Zulfiqar, M.D. Issam R. Nasr, M.D. Samir L. Habashi, M.D. 1890 LPGA Blvd., Suite 270 Daytona Beach, FL 32117

315 Palm Coast Parkway Palm Coast, FL 32137

1690 Dunlawton Ave., Suite 210 Port Orange, FL 32127 386 / 763-4920

H1035-FHCP2505-6/08 21-123 FHCP-11A

616

SCREENING COLONOSCOPY (WEST VOLUSIA NETWORK) Your doctor has requested that you make an office visit appointment to discuss having a Screening Colonoscopy. It is your responsibility to contact one of the offices listed below to schedule an appointment.

Beatrice Bratu, M.D. Ammar Hemaidan, M.D. Saud Suleiman, M.D. Hassan Zulfiqar, M.D. Issam R. Nasr, M.D. 27777 Enterprise Blvd. Orange City, FL 32763 (386) 764-4920 Kalyani Gaddipati, M.D. 917 Rinehart Road, Suite 2051 Lake Mary, FL 32746 (407) 936-2444 Nitin Parikh, M.D. 1053 Medical Center Dr., Suite 251 Orange City, FL 32763 (386) 775-4720 Lenkala Mallaiah, M.D. 311 N. Mangoustine Ave. Sanford, FL 32771 (407) 321-4570 1565 Saxon Boulevard, Suite 102 Deltona, FL 32725 (386) 789-5400

Bharat C. Patel, M.D. Martin Gino F. Prado, M.D. David Elijah, M.D. 1070 N. Stone Street, Suite D DeLand, FL 32720 (386) 822-9410 NOTE: FHCP members have to either reside in or be assigned to a PCP in West Volusia County to be referred to this group. Felix A. Navarro, M.D. 1403 Medical Plaza Suite 206 Sanford, FL 32771 (407) 322-9530

Drive,

Donald Garrow, M.D. Vishal Gupta, M.D. Jigneshkumar Patel, M.D. 2728 Enterprise Road, Suite 100 Orange City, FL 32763 (386) 668-2221

617

TMJ SCREENING QUESTIONAIRE Please attach this form to a FHCP Referral Request and forward to the FHCP Dental Department, 350 N. Clyde Morris Blvd., Daytona Beach, FL 32114

Patient Name

Medical Record Number

Referring Physician

Questions: Yes 1. Does the patient have difficulty, pain or both when opening his/her mouth, for instance when yawning? 2. Does the patient’s jaw “get stuck”, “locked” or go out? 3. Does the patient have difficulty or pain (or both) when chewing, talking or using his/her jaws? 4. Is the patient aware of noises in his/her jaw joints? 5. Does the patient’s jaws regularly feel stiff, tight or tired? 6. Does the patient have pain in or about the ears, temples or cheeks? 7. Does the patient have frequent headaches, neck aches or toothaches? 8. Has the patient had a recent injury to the head, neck or jaw? 9. Has the patient been aware of any recent changes in his/her bite? 10. Has the patient been previously treated for unexplained facial pain or a jaw joint problem?

No

618 FLORIDA HEALTH CARE PLANS

ULTRASOUND REFERRAL FORM Date Ordered: A.

B.

NAME:

DOB:

MRN:

REFERRING PHYSICIAN:

PROV. #:

PCP:

PROV. #:

ULTRASOUND EXAM REQUESTED Description Abdomen Complete Abdomen Limited Aorta Gallbladder Breast Renal Pelvic Transvaginal Testicular Thyroid Bakers Cyst Carotid Lower Extremity – Venous – Unilateral Lower Extremity – Venous – Bilateral Lower Extremity – Arterial – Duplex – Unilateral Lower Extremity – Arterial – Duplex – Bilateral ABI, Single Level Segmental Pressures (Multiple Sites) Segmental Pressures (Post Exercise) Echocardiogram Echocardiogram with microbubbles Other

CPT Code 76700 76705 76775 76705 76641/76642 76775 76856 76830 76870 76536 76881 93880 93971 93970 93926 93925 93922 93923 93924 93306 93306

C.

Diagnostic Code:

D.

WRITTEN DIAGNOSIS AND “REASON FOR REQUEST” (ALSO IF FOLLOW – UP FROM OUTSIDE DIAGNOSTIC TEST, PLEASE ATTACH REPORT)

E.

APPOINTMENT DATE: TIME: C & D MUST BE COMPLETED FOR APPOINTMENT TO BE SCHEDULED

01-912 / 4-8-16

619

EXAM

PREPARATION

ABDOMEN

N.P.O. after midnight. (Nothing to eat or drink after midnight the evening before the exam.) N.P.O. after midnight. (Nothing to eat or drink after midnight the evening before the exam.) No preparation. Complete drinking 32 oz. of water one hour before exam. Do not empty your bladder.

AORTA BREAST PELVIC RENAL TESTICULAR THYROID CAROTID

No preparation. No preparation. No preparation. No preparation. Only performed at Daytona facility.

LOWER EXTREMITY

No preparation. Only performed at Daytona facility.

620 Order and Consent Form for Human Papillomavirus (HPV) Vaccine

Human Papillomavirus Vaccine (HPV) is an inactivated (not live) vaccine. This vaccine is expected to prevent most genital warts and cervical cancers related to a sexually transmitted virus. It is administered in a three doses series: now; 2 months and 6 months. This consent to administer is to ensure that you are planning to accept all three doses of the vaccine and if applicable incur the financial responsibility for its cost if your eligibility status changes and it is no longer a covered benefit. HPV vaccine does not appear to cause any serious side effects. However, some patients have experienced: pain at the injection site; redness or swelling at the injection site; mild fever (100 - 102 F) and skin irritation. This is a new vaccine and I understand that new side effects may become apparent in the future. I am willing to take the risk of future problems that are not known at this time. 1. Patient Name

Phone Number

2. DOB

FHCP #

3. Social Security Number

Ht

Wt

4. Allergies 5. Have you had 2 varicella?

Yes

No

I,

Have you had a Menactra shot?

Yes

No

, relationship to patient

Consent to the above for (patient’s name) Signature

Date

Physician Order: Administer HPV in a three dose series: First Dose: Second Dose: Third Dose:

Now, IM x one 2 months after first dose, IM x one 6 months after first dose, IM x one

Additional Orders

Dr. Signature

CPT: 90649 ICD-9: V05.8 Admin: 90471

For Office Use Only: 02-205-14

9/13

Date

Phone

DAYTONA BEACH 350 Clyde Morris Blvd. 386-238-3297

EDGEWATER 239 N. Ridgewood Ave. 386-427-4868

LAKE MARY 2550 W. Lake Mary Blvd. 407-878-0910

ORANGE CITY 2777 Enterprise Rd. 386-774-2550

PALM COAST 309 Palm Coast Pkwy. 386-445-7073

PORT ORANGE 740 Dunlawton Ave. 386-763-1000

621

FLORIDA HEALTH CARE PLANS P.O. BOX 9910 AUTH #: DAYTONA BEACH, FL 32120 CENTRALS REFERRALS DEPARTMENT FAX – 386-238-3253 PHONE – 386-238-3215 / 1-800-729-8349

PRECERTIFICATION FORM **REQUEST FOR PRECERTIFICATION IS REQUIRED PRIOR TO THE DATE OF SERVICE. THIS FORM IS INTENDED TO REPRESENT THE PROVIDER’S ORDER FOR SERVICES OR SUPPLIES** PLEASE FAX ALL PERTINENT CLINICAL INFORMATION TO FHCP AT THE NUMBER LISTED ABOVE. THIS MAY INCLUDE LABS, RADIOLOGY, PATHOLOGY REPORTS & OTHER DIAGNOSTIC STUDIES INCLUDING H&P AND/OR PROVIDER NOTES. TAX ID #: DATE: TYPE OF REFERRAL:

REQUESTING PROVIDER NAME:

ROUTINE

CONTACT/CALLER NAME: EXT:

PHONE NUMBER: Patient Name:

FAX: Date of Birth:

FHCP Medical Record #:

A.

URGENT

Patient Phone #(s):

Surgical Procedure:

CPT Code:

Diagnosis:

ICD-10 Code:

Surgical Procedure Date:

Surgeon:

Facility Name: Inpatient

Outpatient

Pre-Op Testing Date:

B.

23 Hour OBS * Admit Date Expected Length of Stay *Documentation is required to support 23 Hour OBS status Physicians Pre-op Visit Date:

OFFICE VISIT / TEST REQUESTED: (Name Provider or Test) Test Initial evaluation Follow up With Contrast Appt Date:

Test Without Contrast

Test With & Without Contrast

Testing Facility Name:

DX:

ICD-10 Code:

**** THIS SECTION FOR INTERNAL USE ONLY**** Payment will not be authorized for services beyond those indicated below. ****

Approved by Florida Health Care Plans for:

Signature: ______________________________________________________________________Date:__________________________ 21-125/12-07-09XR 09/09/13 Revised 08-20-14, 10/1/15

622 LABEL

ORDER FOR CHILDHOOD VACCINES Patient Name:

DOB:

VACCINE

DOSE

DTaP

1

2

Hep A

1

2

Hep B

1

2

3

HIB

1

2

3

IPV

1

2

3

MMR

1

2

Pediarix

1

2

3

Pentacel

1

2

3

Pneu Conj

1

2

3

Rotavirus

1

2

3

Varicella

1

2

Meningococcal

1

Tdap

1

2

Influenza (6-35 mths)

1

Influenza (3yrs & up)

1

MRN:

AMOUNT

ROUTE

0.5 ml

IM

0.5 ml

IM

0.5 ml

IM

4

0.5 ml

IM

4

0.5 ml

IM or SC

0.5 ml

SC

0.5 ml

IM

4

0.5 ml

IM

4

0.5 ml

IM

2 ml

Oral

0.5 ml

SC

0.5 ml

IM

0.5 ml

IM

2

0.25 ml

IM

2

0.5 ml

IM

3

3

4

5

Other:

Physician Signature

Date

Additional Comments:

When ordering HPV you must use FHCP Form # 02-205-14, Order and Consent Form for HPV. 03-308-04 11/02/11

623

SECTION 17 ELECTRONIC DATA INTERCHANGE (EDI) VPAY – ELECTRONIC FUNDS TRANSFER (EFT) AGREEMENT AVAILITY

624 Electronic Funds Transfer (EFT) Agreement Reason for Submission: New EFT enrollment:

_

STONEEAGLE SERVICES, INC. 111 West Spring Valley Rd. Suite 100 Richardson, Texas 75081

Change EFT enrollment: ___

Provider Information: * Indicates required fields. Incomplete fields and signatures may cause your enrollment form to be delayed or returned. *Provider Name (complete legal name of institution, corporate entity, practice or individual provider) (“Provider”)

*Tax Identification Number (EIN ___ or SSN ___) (intentionally blank) *Primary Billing Street Address

*City

*State/Province

*Zip Code

Country Code

*Primary Contact Name and Email (for EFT issues)

*Primary Billing Phone No. + ext. (for EFT issues)

*Primary Billing Fax Number (for EFT issues)

*Primary Contact Name and Email (for general billing – if same as EFT, put “same”)

*Primary Billing Phone No. + ext. (for general billing)

*Primary Billing Fax Number (for general billing)

EFT- Direct Deposit/ Provider’s Financial Institution Information: *Financial Institution Name

* Financial Institution Street Address

*City

Branch Location

*Phone No. + ext.

*Provider’s Account Number (where funds will be deposited)

*Type of Account ___ Checking

*State/Province

___ Savings

*Zip Code

___ Deposit Only

*Routing/ABA Number (financial institution’s 9-digit routing number found on a check, NOT a deposit slip)

[ATTACH VOIDED CHECK] NOTE: A voided check from the Provider’s account or a letter from the financial institution on financial institution letterhead specifying the Provider’s name, the account and the routing/ABA number must be returned with the signed EFT Agreement.

625 TERMS AND CONDITIONS: 1. Enrollment. StoneEagle Services, Inc. (d/b/a VPay®) (“SE”) is a service provider to multiple payers of Provider claims. Accordingly, Provider acknowledges and agrees that SE requires Provider to complete and execute a separate EFT Agreement for each payer on whose behalf SE is acting (unless otherwise agreed by SE in writing). In addition, only those providers that have the above provider name, tax identification number and billing street address will be enrolled for EFT (direct deposit) payments. Any other providers under the same tax identification number, but different name and billing street address will require separate enrollment. If you have more than one bank account to enroll, please fill out a separate enrollment form for each account and include a bank letter or voided check for each account. Provider acknowledges and agrees that, pursuant to the requirements of the governing body on Electronic Remittance Advices (835s), enrollment information submitted by Provider must be, and will be, shared with the Payer and/or their agent(s) responsible for delivery of the ERA/835. 2. Credits. SE agrees and Provider authorizes SE to make claim payments to Provider by initiating fund transfers that result in payment to Provider by credit to Provider’s bank account. 3. Debits. Neither party shall initiate a transaction in connection with a payment for the purpose of debiting a bank account of the other party, with the sole exception of transactions initiated by SE to reverse entries of previous fund transfers due to erroneous credits or debits. 4. Provider Information. With respect to fund transfers pursuant to this EFT Agreement, SE and its processing financial institution(s) are entitled to rely on the information provided by Provider, including regarding Provider’s financial institution. In addition, Provider shall immediately provide SE with accurate, complete and timely information, including any changes to information regarding its financial institution. 5. Receipt of Payment. A payment to Provider pursuant to this EFT Agreement shall be considered timely received by Provider if the applicable fund transfer is completed no later than five (5) days after the due date, excluding weekends and holidays. In addition, SE and/or the party on whose behalf SE may be acting shall not be in breach of this EFT Agreement or subject to other penalty or loss of discount if the fund transfer was properly initiated and timely by SE, but was otherwise delayed because of the failure of the fund transfer system, rejection by Provider’s financial institution or due to any other circumstances beyond SE’s control. 6. Limitation of Liability. Except for the payment to Provider of any funds debited by SE in breach of this EFT Agreement, SE specifically disclaims any and all liability that may arise under this EFT Agreement, including, without limitation, any other form of actual damages or any indirect, special, incidental, punitive or consequential damages. 7. Indemnification. Provider agrees to indemnify and hold harmless SE, SE processing financial institution(s) and SE’s customers (collectively, “Indemnitees”) from and against any and all expenses, penalties (including fines or fees), liabilities and/or damages of any kind whatsoever in connection with any claims, suits, actions, demands, assessments or proceedings, threatened, asserted or filed against an Indemnitee, or incurred in the defense of any of the foregoing (including reasonable attorneys’ fees incurred and/or those necessary to successfully establish the right to indemnification), to the extent related to the actions of Provider, Provider’s financial or any agent or independent contractor of either, or arising from SE’s reliance on information provided by Provider pursuant to this EFT Agreement. 8. Costs. Provider is solely responsible for any fees and other charges assessed by its financial institution. In addition, SE reserves the right to charge Provider a fee for a fund transfer pursuant to this EFT Agreement to the extent permitted by applicable law; provided, however, SE must give Provider at least thirty (30) days written notice before any such fee may be assessed. To avoid any properly notice fees, Provider must terminate this EFT Agreement pursuant to the terms and conditions hereof. 9. Changes. Either party may change its designation of any account, financial institution or other applicable service provider by written notice to the other party. Any such change shall be effective no less than thirty (30) days after the other party receives such notice. 10. Suspension and Termination. Either party may suspend actions under this EFT Agreement upon not less than five (5) days written notice to the other party. Either party may terminate this EFT Agreement upon fifteen (15) days written notice to the other. Notwithstanding such suspension or termination, this EFT Agreement shall remain in effect as to all fund transfers that have been initiated by SE and not cancelled prior to suspension or termination of this EFT Agreement. If this EFT Agreement is suspended or terminated by Provider, Provider agrees to receive all claim payments to be made by SE to Provider during such suspension or after such termination via a card network utilizing a debit or credit card transaction (including, without limitation, a straight-through payment, if applicable) until Provider has notified SE that future payments be made in an alternative manner. 11. Notices. Any notice required by the EFT Agreement shall be given in writing by certified mail, return receipt requested, or by overnight mail service to the party’s address set forth in this EFT Agreement, and if notice is by Provider to SE, Provider shall also deliver such written notice to SE via facsimile in the same manner as the original EFT Agreement. 12. No Implied Waiver. A failure by either party to take any action with respect to any breach by the other party of any of the terms, covenants, or conditions of this EFT Agreement shall not in any respect limit, prejudice, diminish, or constitute a waiver of any rights of such party to act with respect to any prior, contemporaneous, or subsequent breach or with respect to any continuation or repetition of the original breach. The provisions of this paragraph may only be waived by a party by a written acknowledgement of such waiver by such party. 13. Governing Law. This EFT Agreement and the obligations of the parties hereunder will be interpreted, construed and enforced in accordance with the laws of the State of Texas, without regard to its choice of law rules. 14. Miscellaneous. This EFT Agreement contains the entire agreement between the parties with respect to the electronic fund transfers (direct deposit) to Provider’s designated financial institution and supersedes all prior agreements with respect thereto. No other agreements, representations, warranties or other matters, whether oral or written, will bind the parties with respect to the subject matter hereof. The parties acknowledge and agree that neither party nor their respective Representatives have made any representations or promises, and no party is relying upon any such representations or promises, in entering this EFT Agreement except as expressly set forth herein. Each party relies exclusively upon its own judgment. This EFT Agreement shall not be modified, in whole or in part, except in writing executed by each of the parties. This EFT Agreement and the rights and obligations set forth herein shall inure to the benefit of, and be binding upon, the parties and each of their respective successors and assigns. The invalidity or unenforceability of any particular provision, or part of any provision, of this EFT Agreement shall not affect the other provisions, and this EFT Agreement shall be construed as if such invalid or unenforceable provisions or parts were omitted. This EFT Agreement may be executed in any number of counterparts. Facsimile and PDF signatures are deemed effective.

626

Authorization Agreement:

NOTE: By signing below, I hereby agree that I have read and agree to the terms and conditions of this EFT Agreement. Signature #1 Name:

Authorized health care professional may be MD, OD, CFO, CEO, etc. Title:

Signature: Signature #2 Name:

Date: Supervisor-level authorized health care professional may be Office Manager, Billing Manager, etc. Title:

Signature:

Date:

Form completed by First Name & Last Name:

Contact Email Address:

Contact Phone Number + extension:

Fax Number:

NOTE: Email address may be used for 835 set up, to request additional information, and to send completed information.

Office Use Only: StoneEagle Services, Inc., d/b/a VPay®, 111 West Spring Valley Road, Suite 100, Richardson, Texas 75081 Authorized VPay Representative Name: Title:

Authorized VPay Representative Signature:

Date:

Payment Information TPA or Payer currently sending payments (one form per TPA/Payer): FHCP

PLEASE FAX COMPLETED and SIGNED FORM (all 3 pages), WITH A VOIDED CHECK AND/OR BANK LETTER TO VPAY AT (972) 367-6597

627

AVAILITY FHCP uses Availity a n d R e l a y H e a l t h as our clearinghouses for the receipt of Professional (837P) and Institutional (837I) electronic claim files. Our payer ID is 59322. For those providers who are not yet sending their claims to FHCP electronically, we request that you begin doing so in HIPAA compliant format. FHCP is in compliance with established requirements for submitting claims in version 5010 of the HIPAA transaction set standards. FHCP also offers providers the opportunity to receive payment and your remittance advice electronically. This helps to speed delivery of both funds and claim determination data. To enroll, please complete the following form and submit to VPay our claim payment partner. Please note FHCP is a health plan choice on Availity’s website for EDI files and claims may also be manually entered into the Availity system should your practice management software be unable to generate electronic claims. If you have any questions about AVAILITY access, please contact Availity Client Support at 800 / AVAILITY (282-4548) or [email protected] Functions through AVAILITY Member Eligibility Status – both individual and batch status requests are accepted (270 / 271) including the members PCP assignment. FHCP Benefit Plan/Service Coverage Inquiries (summarized general benefits and enhanced, more specific benefit information) (270 / 271)** Real-time member deductible and out-of-pocket balances for the current year (270 / 271)** Provider claims Status Information in batch or individual mode (276 / 277)

If you have any questions in reference to this memo, please contact Steve Berberich at 386 / 6154085, or [email protected] Thank you. ** Benefit and deductible information is provided for HMO and Out of Network benefit levels only. Option 2 (EPN) benefit information for EPN providers is currently not available.

628

SECTION 18 UTILIZATION Utilization Management Medical Policies (Medical Coverage Guidelines) Medical and Clinical Guidelines Bariatric Surgery Policy New Technology & Organizational Determinations Policy Utilization Management Program Policy Pre-Service (Central Referrals) Central Referral Dept. Guidelines for Processing Medical Referrals that Require Pre-Authorization – Prospective Initial Organizational Determinations for Medicare Members Policy Referrals for Second Opinion Policy Concurrent Review (Case Management) Concurrent Review for FHCP Members Skilled Nursing Facility Utilization Policy Discontinuation of Medicare Advantage Members’ Home Health Care and Skilled Nursing Facility Services Policy Medications Requiring Prior Authorizations Policy FHCP Prior Authorization Medication Form Retrospective Authorization Process Policy Post Service (Claims) Medicare Subscriber Claims Review and Processing Policy Non-Medicare Subscriber Claims Review and Processing Policy Appeal Process Complaint/Grievances and Appeals (Non-Medicare Large & Small Group & Healthy Kids Subscribers) Policy Medicare PART C Organization Determinations & Appeals Policy

629

Utilization Management Florida Health Care Plans Utilization Management Program encompasses the evaluation and determination of coverage for, and appropriateness of medical care services, behavioral health services and benefits, as well as providing assistance to clinicians and members ensuring appropriate use of resources. All requests and referrals are managed by the Central Referrals Department, Case Management Department and Member Services Department. Referrals are reviewed, along with all pertinent documentation, for approval or denial based on evidence based medical necessity criteria. FHCP uses MCG CareGuide, CMS guidelines, and internally developed guidelines to assure the consistency with which medical necessity decisions are made. A referring Provider may discuss a request with a Utilization Management Physician or request guidelines utilized to make a decision by calling: Central Referrals Department - 386-238-3230 or 800-352-9824 and ask for Referral Department or ext. 3230, Case Management Department 386-676-7187 or 866-676-7187, Member Services Department 386-615-4022 or 877-615-4022. UM decision making is based only on appropriate care and coverage. Florida Health Care Plans does not reward staff for making denials, and does not use financial incentives that reward underutilization. For more information about the Referral Process or Utilization Management Process, go to the FHCP Website, www.fhcp.com, click on the Providers tab, then click on Medical guidelines under the Providers tab. In the column on the left, click on Medical/Clinical Guidelines.

630

631

632 Medical and Clinical Guidelines Medical Guidelines Florida Health Care Plans uses medical policies that serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the medical policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law.

Medical policy does not constitute plan authorization, nor is it an explanation of benefits. Medical policies can be highly technical and complex and are discussed here for informational purposes. The medical policies do not constitute medical advice or medical care. Treating health care professionals are solely responsible for diagnosis, treatment and medical advice. Florida Health Care Plans members should discuss the information in the medical policies with their treating health care professionals.

Medical technology is constantly evolving and these medical policies are subject to change without notice, although Florida Health Care Plans will use good faith efforts to provide advance notice of changes that could have a negative impact on benefits. Additional medical policies may be developed from time to time and some may be withdrawn from use. The medical policies generally apply to all of Florida Health Care Plans' fully-insured benefits plans. Additionally, some benefit plans administered by Florida Health Care Plans such as some self-funded employer plans or governmental plans, may not utilize Florida Health Care Plans medical policy. Members should contact the FHCP Member Services Department toll-free at 877-615-4022 for specific coverage information.

The doctors, hospitals, and other providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom Florida Health Care Plans has no control or right of control. If you would like to request a hard copy of an individual medical policy, please contact the member's health plan at the number on the back of their identification card.

Clinical UM Guidelines Florida Health Care Plans is licensed to use MCG Care Guidelines® to guide utilization management decisions and address medical necessity of services and items. This may include but is not limited to decisions involving pre-certification, inpatient review, level of care, discharge planning and retrospective review. The MCG Care Guidelines® licensed include Ambulatory Inpatient , Surgical Care Guidelines, General Recovery Guidelines, and Behavioral Health Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the clinical UM guidelines. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. A clinical UM guideline does not constitute plan authorization, nor is it an explanation of benefits. Clinical UM guidelines can be highly technical and complex and are discussed here for informational purposes. These guidelines do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. Florida Health Care Plans members should discuss the information in the clinical UM guideline with their treating health care providers. The MCG Care Guidelines® used by FHCP represent the clinical UM guidelines currently available to all benefit plans offered by FHCP.

While the Pharmacy guidelines developed by Florida Health Care Plans are published on this web site, the licensed standard MCG Care Guidelines® are proprietary to MCG and not published on this Internet site. Medical technology is constantly evolving and clinical UM guidelines are subject to change without notice. Additional clinical UM guidelines may be developed from time to time and some may be withdrawn from use. Members should contact the FHCP Member Services Department for specific coverage information. The doctors, hospitals, and other providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and

633 over whom Florida Health Care Plans has no control or right of control. If you would like to request a hard copy of an individual clinical UM guideline or MCG Care Guideline®, please contact the member's health plan at the number on the back of their identification card.

Request for Review Requests for Pre-Certification or Pre-Service Authorization, or if you have new information or new technology information that would be relevent to FHCP's consideration of these policies when the are next reviewed, should be submitted to:

Florida Health Care Plans

Clinical Services Division

1340 Ridgewood Avenue

Holly Hill, Florida 32117

1 800 352 9824 option 9

Please have your patient refer to the applicable endorsement or rider issued with his or her contract, Evidence of

Coverage, member handbook or certificate of coverage to determine coverage. If your patient is unsure about

particular coverage/benefits or has questions, please have the member call the Member Services number on his or

her ID card.

Page Last Updated: 03/03/2015

• •

Privacy Policy Members Rights and Responsibilities



Advanced Directives

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FHCP PRIOR AUTHORIZATION MEDICATION FORM DATE: Provider Name:

AUTH#: Provider Signature:

Specialty: Contact Person:

Provider Phone: Provider Fax:

Routine

Urgent Phone: 386-238-3230 or 800-352-9824 If your request is urgent, you must call the Central Referral Department prior to submitting your request.

Patient Name:

FHCP #:

DOB:

Patient Home Phone: Patient Alternate Phone: Medication Requested & Duration of Therapy (Please specify name, strength, dosing schedule and route of administration)

Diagnosis:

ICD10 Code:

Alternatives tried:

Is this a new medication or Ongoing Medication

Reason for the Medication:

Please fax completed form with CLINICAL NOTES and MED LIST to FHCP Central Referrals at 386-238-3253 or 877-659-3427

You may view the formulary online at www.fhcp.com by clicking on the Provider Tab; then either the Provider Services or Forms tab. On the right-hand side, click on Formulary under "Related Documents" to determine whether a medication requires prior authorization.

THE SECTION BELOW IS FOR FHCP INTERNAL USE ONLY APPROVED BY FLORIDA HEALTH CARE PLANS FOR:

CVS Caremark Signature: Rev. 08-12-15, 10-1-15

FHCP Pharmacy Date:

Provider Office Infusion

FHCP Infusion Approved

Denied

712

FLORIDA HEALTH CARE PLANS ENBREL ORDER For treatment of Rheumatoid Arthritis, Psoriatic Arthritis, Plaque Psoriasis or Ankylosing Spondylitis Date:

Auth. #:

A. Member Name:

Referring Provider Name:

Med. Record #:

Date of Birth:

Referring Provider Phone #:

Home Phone#:

Work Phone#

Referring Provider FHCP #:

Cell #:

Provider Signature:

Subscriber #:

Copy to:

Parent/Guardian Name:

Allergies:

Type of Referral:

1. Height

URGENT

ROUTINE

Weight

2. Date of last PPD

+

-

3. Is prescriber a dermatologist or rheumatologist?

Requirement: PPD must be within the last 12 months. Yes

No

4. Does the patient have a history of Rheumatoid Arthritis? Mild Moderate Severe 5. Does the patient have a history of Psoriatic Arthritis? Mild Moderate Severe

Yes

Yes

No

No

6. Does the patient have chronic moderate to severe Plaque Psoriasis that covers 10% or greater body surface area or debilitating palmer/planter Plaque Psoriasis ? Yes No 7. Does the patient have a history of Spondylosing Anklyosis? Mild Moderate Severe

Yes

8. Does the patient have hot, red or swollen joints despite therapy?

No

Yes

9. Does the patient have X-ray changes consistent with Rheumatoid Arthritis? 10. Does the patient have significant loss of function despite therapy?

Yes

No Yes

No

No

THIS SECTION IS ONLY FOR THOSE SERVICES THAT REQUIRE PRE-AUTHORIZATION This Form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s PCP or the Referring Provider.

APPROVED BY FLORIDA HEALTH CARE PLANS FOR: Signature: TO:

Date: FROM:

Phone #:

This document is privileged and confidential. It is intended solely for the use of the recipient named above. If the reader/recipient of this document is not the intended recipient, you are hereby notified that any distribution, copying or disclosure of the contents of this document is prohibited. If you have received this document in error, please notify FHCP immediately by the telephone or fax number indicated above and return the original facsimile message to us at P. O. Box 9910, Daytona Beach, FL 32120.

713 FAILED TREATMENTS FOR RA, PSORIATIC ARTHRITIS, AND ANKYLOSING SPONDYLITIS* Has the patient taken methotrexate ≥20mg/week for at least 3 months within past 6 months? Yes No dose/week If yes, was the treatment successful?

Yes

No

If the patient has not taken methotrexate, is it contraindicated? Yes No (Note: mild and transient [<2 UNL] AST/ALT elevations in absence of liver disease/pathology are not contraindications to continuation or initiation of MTX therapy). Patients who have a methotrexate failure or contraindication must try an alternative DMARD prior to Enbrel Authorization. Has patient tried combination MTX + DMARD for at least 3 of the last 6 months? DMARD and dose

Yes

No

If MTX treatment is contraindicated or not tolerated has patient tried an alternative DMARD Combination for at least 3- 6 months within the past 6 months (i.e. hydroxychloroquine or sulfasalazine)? Yes No Alternative DMARDs and dose * If use is for ankylosing spondylitis, has patient failed on at least two NSAIDs at maximum tolerated dose? Yes No NSAIDs and Dose Is patient/caregiver able to administer medication?

Yes

No

PLAQUE PSORIASIS TREATMENT FAILURES* 1) Patient has tried at least a 3 month trial of either of the following systemic therapies: methotrexate (dosed at least 15-25mg/week) or soriatane within the past 6 months? Yes No Drug/dose_________________________________________________________________ Was systemic therapy effective?

Yes

No

If the patient has not taken methotrexate, is it contraindicated? Yes No (Note: mild and transient [<2 UNL] AST/ALT elevations in absence of liver disease/pathology are not contraindications to continuation or initiation of MTX therapy) 2) Patient has tried (or use is contraindicated) at least 15 sessions of phototherapy within the past 6 months? Yes No Treatment/duration _________________________________________________________ Was phototherapy effective?

Yes

No

* Approved coverage will be the FDA approved dosing of 50 mg SC administered up to twice weekly for 3 months, followed by 50mg SC administered once per week for remainder of referral period. For Physician Signature: “I attest to the fact that, in my professional opinion, this patient meets the guidelines for Enbrel injections.” Requesting Provider Signature:________________________Date:

714 FLORIDA HEALTH CARE PLANS

Referral Form for Synvisc, Hyalgen or Euflexxa Date:

Auth. #: Referring Provider Name:

A. Member Name: Med. Record #:

Date of Birth:

Referring Provider Phone #:

Home Phone#:

Work Phone#

Referring Provider FHCP #:

Cell #:

Provider Signature:

Subscriber #:

Type of Referral:

URGENT

ROUTINE

(please check)

Parent/Guardian Name: 1. 2. 3. 4. 5.

Request for: Synvisc Hyalgen Is patient: Medicare Commercial Height Weight Knee DJD Mild Mod Severe Does patient have a large effusion? Yes No

Euflexxa Left Knee BMI

Right Knee Bilateral Knees Weight is not a Medicare exclusion.

FAILED CONSERVATIVE TREATMENTS 6. Does patient have PUD, GER, intolerance to NSAID? Yes No Other agents tried for DJD: Dates A. B. C.

Responses

Must have failed at least three (3) with at least one (1) month trial. 7. Has Physical Therapy been tried?

Yes

No

8. Has patient had Synvisc, Hyalgen or Euflexxa inject before?

Yes

No

If yes, any reaction?

For Physician Signature: “I attest to the fact that in my professional opinion, this patient meets the Medicare guidelines for above indicated request.”

(Patient Name)

Requesting Provider Signature:

Date:

Yes

No

MEDICAL DIRECTOR / DESIGNEE USE ONLY APPROVED # of Visits DISAPPROVED

NOT A COVERED BENEFIT

Form letter to Dr.

LACK OF MEDICAL INFORMATION TO RENDER DECISION & Patient.

Appeals rights sent

See blue Denial Form (attached)

Signature:

Date:

Provider of Service:

Date:

Date Referring Provider Notified: 21-112/10-06x

Name of Notifier:

Copy Sent to Pharmacy

715

FORTEO PATIENT CONSENT FORM I have read the Patient Medication Guide for Forteo and am aware that this medication has been associated with Bone Cancer in mice. It is not yet known if Forteo can increase risk of Cancer in Humans. Forteo is not approved for use past 2 years.

Patient's Name (type or print)

MRN

Date of Birth

Patient or Authorized Healthcare Surrogate Signature

Relationship

Date/Time

Witness Name (type or print)

Witness Signature

Date/Time

Physician’s Name (type or print)

Physician's Signature

Date/Time

716 FLORIDA HEALTH CARE PLANS

REFERRAL FORM FOR PATIENTS WITH HEP C ⊕ PCR Date:

Auth #: Referring Provider Name:

A. Member Name: Med. Record #:

Date of Birth:

Referring Provider Phone #:

Home Phone#:

Work Phone#

Referring Provider FHCP #:

Cell #:

Provider Signature:

Subscriber #:

Type of Referral:

URGENT

ROUTINE

(please check)

Parent/Guardian Name:

1. Any alcohol within 6 months?

Yes

No

If yes, not eligible.

2. Does patient have psychiatric history?

Yes

3. Substance abuse within 6 months?

Yes

4. Is patient on contraception?

Yes

No

If no, not a covered benefit.

5. Hepatotoxic meds have been considered & stopped if possible?

Yes

No

If no, not a covered benefit.

6. Is patient immunized with Hep A, Hep B & Pneumovax?

Yes

No

Need to have started Hep A&B vaccine and received Pneumovax or show evidence of immunity.

7. Has patient signed a Patient Agreement Form?

Yes

No

If no, not eligible. (This must be attached).

No

If psychiatric illness, must have psychiatric clearance prior to therapy and copy of clearance must be attached.

No

If yes, not a covered benefit.

If patient eligible with attached criteria and all requirements are attached to this, referral will be approved and receive an Auth #. The patient can then take their prescription to a FHCP Pharmacy and pay the applicable co-pay and start treatment under GI, Infectious Disease or Dr. Warner supervision.

THIS SECTION IS ONLY FOR THOSE SERVICES THAT REQUIRE PRE-AUTHORIZATION This Form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s PCP or the Referring Provider.

APPROVED BY FLORIDA HEALTH CARE PLANS FOR:

Signature: TO:

Date: FROM:

Phone #:

This document is privileged and confidential. It is intended solely for the use of the recipient named above. If the reader/recipient of this document is not the intended recipient, you are hereby notified that any distribution, copying or disclosure of the contents of this document is prohibited. If you have received this document in error, please notify FHCP immediately by the telephone or fax number indicated above and return the original facsimile message to us at P. O. Box 9910, Daytona Beach, FL 32120.

06-600-05 Rev. 1/28/11

Page 1 of 2

717 Patient Agreement for Hepatitis C Treatment with PEG-Interferon I,

, agree to the following:

1.

I will not drink alcohol of any kind during my treatment. I understand that drinking alcohol with liver disease is contraindicated.

2.

I will not use illegal substances during my treatment.

3.

I understand the side effects of Peg-intron and ribavirin

4.

I am committed to complete the total therapy, including paying my co-payments of Tier 4 copay of $ through the entire course of treatment. I will not stop the medication unless it is by a doctor’s order. Genotype 1, 4, 5 & 6 = 48 weeks, if I have a good response at 12 weeks. Genotype 2 & 3 = 24 weeks, if I have a good response at 12 weeks. Coinfected HIV/HCV: all genotypes 48 weeks, if I have a good response at 12 weeks

5.

I understand that I will not be eligible to restart Peg-intron treatment if I stop the medication for any reason other than a doctor’s order.

6.

I understand my Hep C virus level will be re-evaluated at 4 weeks, 12 weeks and 24 weeks of therapy and, if virus is still present, I may no longer be eligible for therapy.

7.

I agree to re-pay FHCP the cost of my PEG-interferon if I do not fulfill the above requirements.

____________________________________________ Signature

Page 2 of 2

06-600-05 Rev. 02/11

_________________________________ Date

718 FLORIDA HEALTH CARE PLANS

REFERRAL FORM FOR PATIENTS WITH HEP C ⊕ PCR Date:

Auth #: Referring Provider Name:

A. Member Name: MRN #:

Date of Birth:

Referring Provider Phone #:

Home Phone#:

Work Phone#

Referring Provider FHCP #:

Cell #:

Provider Signature:

Subscriber #:

Type of Referral:

ROUTINE

URGENT

(please check)

Parent/Guardian Name:

1. Any alcohol within 6 months?

Yes

No

If yes, not eligible.

2. Does patient have psychiatric history?

Yes

3. Substance abuse within 6 months?

Yes

4. Is patient on contraception?

Yes

No

If no, not a covered benefit.

5. Hepatotoxic meds have been considered & stopped if possible?

Yes

No

If no, not a covered benefit.

6. Is patient immunized with Hep A, Hep B & Pneumovax?

Yes

No

Need to have started Hep A&B vaccine and received Pneumovax or show evidence of immunity.

7. Has patient signed a Patient Agreement Form?

Yes

No

If no, not eligible. (This must be attached).

No

If psychiatric illness, must have psychiatric clearance prior to therapy and copy of clearance must be attached.

No

If yes, not a covered benefit.

If patient eligible with attached criteria and all requirements are attached to this, referral will be approved and receive an Auth #. The patient can then take their prescription to a FHCP Pharmacy and pay the applicable co-pay and start treatment under GI, Infectious Disease or Dr. Warner supervision.

THIS SECTION IS ONLY FOR THOSE SERVICES THAT REQUIRE PRE-AUTHORIZATION This Form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s PCP or the Referring Provider.

APPROVED BY FLORIDA HEALTH CARE PLANS FOR:

Signature:

Date:

TO: 06-600-05 Rev. 1/28/11

FROM: 01/25/13

Phone #:

Page 1 of 2

719

Patient Agreement for Hepatitis C Treatment with Antivirals I,

, agree to the following:

1.

I will not drink alcohol of any kind during my treatment. I understand that drinking alcohol with liver disease is contraindicated.

2.

I will not use illegal substances during my treatment.

3.

I understand the side effects of antivirals (if applicable).

4.

I am committed to complete the total therapy, including paying my co-payments $ per month through the entire course of treatment. I will not stop the medication unless it is by a doctor’s order. Genotype 1 = 28 to 48 weeks, if I have good response Genotype 4, 5 & 6 = 48 weeks, if I have a good response at 12 weeks. Genotype 2 & 3 = 24 weeks, if I have a good response at 12 weeks. Coinfected HIV/HCV: all genotypes 48 weeks, if I have a good response at 12 weeks

5.

I understand that I will not be eligible to restart antiviral treatment if I stop the medication for any reason other than a doctor’s order.

6.

I understand my Hep C virus level will be re-evaluated at 4 weeks, 8 weeks, 12 weeks and 24 weeks of therapy and, if virus is still present, I may no longer be eligible for therapy.

7.

I agree to re-pay FHCP the cost of my antivirals if I do not fulfill the above requirements.

____________________________________________ Signature

Page 2 of 2

06-600-05 Rev. 02/11

01/25/13

_________________________________ Date

720

FLORIDA HEALTH CARE PLANS REMICADE ORDER Date:

Auth. #:

A. Member Name:

Referring Provider Name:

Med. Record #:

Date of Birth:

Referring Provider Phone #:

Home Phone#:

Work Phone#

Referring Provider FHCP #:

Cell #:

Provider Signature:

Subscriber #:

Copy to:

Parent/Guardian Name:

Allergies:

Type of Referral:

URGENT

Administer PPD

ROUTINE

Weight

REMICADE Dose Pre-medicate with:

DIAGNOSIS CODE Frequency

NONE

Benadryl 25mg PO Benadryl 50mg PO Repeat as needed. Tylenol 650mg PO Repeat as needed Prednisone 40mg PO Prednisone 40mg IV Other If B/P decreases between 15 & 20 mmHg, or patient experiences symptoms indicating Hypersensitivity (urticaria, dyspnea, hypotension, heart rate decrease, dizziness, chest pain) stop infusion and give Benadryl 25mg PO Tylenol 650mg PO Other

Benadryl 50mg PO Repeat as needed Prednisone 40mg Po Prednisone 40mg IV * Refer to Centocor Algorithm for Remicade ____________________________ Physician Signature REASON FOR REFERRAL: (Attach all supporting documentation)

THIS SECTION IS ONLY FOR THOSE SERVICES THAT REQUIRE PRE-AUTHORIZATION This Form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s PCP or the Referring Provider.

APPROVED BY FLORIDA HEALTH CARE PLANS FOR:

Signature: TO:

Date: FROM:

Phone #:

This document is privileged and confidential. It is intended solely for the use of the recipient named above. If the reader/recipient of this document is not the intended recipient, you are hereby notified that any distribution, copying or disclosure of the contents of this document is prohibited. If you have received this document in error, please notify FHCP immediately by the telephone or fax number indicated above and return the original facsimile message to us at P. O. Box 9910, Daytona Beach, FL 32120.

PROCEDURE FOR ORDERING REMICADE

721

Remicade is a monoclonal antibody agent known to be effective in the treatment of Crohn’s Disease and Rheumatoid Arthritis, Ulcerative Colitis, Ankylosing Spondylitis, and Psoriatic Arthritis. Approval for treatment of Crohn’s Disease is based on failure of both an anti-inflammatory agent (5-ASA compounds, sulfasalazine, Dipentum, Pentasa, Asacol & Rowasa) and an immunosuppressant (purinethol, azothioprine, methotrexate). Intermittent steroids and antibiotics used to manage exacerbations and maintain remission are not sufficient to satisfy immunosuppressant and anti-inflammatory trials. Approval for treatment of Ulcerative Colitis is based on history of moderate to severe ulcerative colitis in patients who have contraindications to or have failed both therapeutically effective doses of Aminosalicilates (sulfasalizine 46g/day, mesalamine 2-4.8g/day, balsalazide 6.75g/day, olsalazine 1.5-3g/day), and an Immunomodulator (6mercaptopurine or azothioprine) or continuous corticosteroid. Approved injections will be covered at weeks 0,2,6, and then every 8 weeks at the labeled dosage (5mg/kg). Approval for treatment of rheumatoid arthritis (RA), And Psoriatic Arthritis is based on failure of Humira (2nd in line to Enbrel failures). Note: Remicade is only indicated for treatment of RA in combination with methotrexate. PROCEDURE: 

Ordering physician will send completed Remicade order (form 21-110) and supporting documentation to the FHCP Referral Department



Order must include dose of REMICADE, frequency, Pre-medication order and orders to follow if reaction to infusion



Documentation of PPD within one year or order for PPD before first treatment.



If approved, Referral Department will notify physician office and send signed form to FHCP Infusion Clinic:  Daytona Facility  Orange City Facility  Palm Coast Facility  Edgewater Facility



Infusion Clinic will call patient to set up appointment for PPD



Infusion Clinic Nurse will place and read PPD, and assess for any s / s infection



If patient has a previous positive PPD, order chest x-ray with copy to Infusion Clinic



Infusion nurse will assess for signs and symptoms of TB and document on nurse assessment and Remicade order form



Infusion Clinic Nurse will send order for Remicade to Pharmacy



Clinic will schedule patient for appointment for Remicade infusion



Medicare patients will pick up medication at Pharmacy and bring with him/her to appointment at Infusion Clinic, all other members Remicade will be shipped to infusion clinic.



Ordering physician will provide patient with information and educational materials

722

Synagis Referral Form 2012 - 2013 Date:

Referring Physician’s Name:

Phone #:

Patient’s Name:

Fax:

DOB:

Gestational Age:

weeks

MRN:

Last Synagis Dose

Birth Weight:

Please circle any of the following diagnoses: Prematurity

Chronic Lung Disease Congenital Heart Disease

Apnea

Cystic Fibrosis

BPD

Other:

Please circle any of the following risk factors: Daycare

Oxygen dependent

Multiple birth

Siblings

Smoke exposure

Parent’s Name: Parent’s Address: Phone Numbers: Home:

Work:

Please fax this form to Central Referrals at 386-238-3253 and send your prescription to the Pharmacy. Thank you for this referral.

Approved ________________________________________ Date ____________________________

723 Guidelines for Use of Synagis® 2012 – 2013 In Accordance with American Academy of Pediatrics Committee on Infectious Diseases Policy Statement: Modified Recommendations for the Use of Palivizumab for Prevention of Respiratory Syncytial Virus Infections

(08.24.09)

Indications: 1. Children under 2 years of age with bronchopulmonary dysplasia or chronic lung disease who require medical therapy (02, albuterol, diuretics or corticosteroids) within the previous 6 months, maximum of 5 doses per year. 2.

Premature infants born at <32 weeks gestation under 6 months of age at the start of RSV season maximum of 5 doses per year.

3.

Premature infants born at <28 weeks gestation and under 12 months of age at the start of RSV season maximum of 5 doses per year

4.

Premature infants born at 32-35 weeks gestation and under 3 months of age at the start of the RSV season with at least 1 risk factor of : Attendance in daycare or One or more sibling or child < 5 years living permanently in child’s household. Approved for up to 3 doses or until they reach 90 days of age.

5.

Children under 2 years of age with uncorrected and hemodynamically significant congential heart disease (conditions requiring medications for CHF or: dilated cardiomyopathy, moderate-severe aortic stenosis, moderate-severe ventricular septal defect). A postoperative dose after cardiopulmonary bypass may be warranted if continued prophylaxis is indicated, maximum of 5 doses per year

6.

May be considered for neuromuscular, immune deficient and cystic fibrosis children under 2 years old. maximum of 5 doses per year

Contraindications: Allergy to Synagis® or other components of the product. Treatment of acute RSV disease (infection control measures are most effective). Prior to initiating Synagis® therapy: The parent should agree to monthly injections during the RSV season. Payment preauthorization is verified by a member of the outpatient healthcare team. A single prophylactic dose may be given to a patient meeting the above criteria before discharge from the hospital. Prophylaxis Timeframe: Monthly injections starting August 1, 2011 and ending May 1, 2012 based on the last three years of Florida RSV surveillance data (myflorida.com). Year round monthly prophylaxis should be considered for infants with oxygen dependence congenital heart disease, immune deficiency and cystic fibrosis. Please call the undersigned at (386) 676-7135 with any questions.

Wendy Myers, M.D. President & Chief Medical Officer WM/sb

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SECTION 19 REFERRAL PROCEDURES Central Referral Department Guidelines for Processing Medical Referrals that Require Pre-authorization – Prospective Initial Organizational Determinations for Non-Medicare Members Central Referral Department Guidelines for Processing Medical Referrals that Require Pre-authorization – Prospective Initial Organizational Determinations for Medicare Members FHCP Referral Form HMO Benefit Plans Referral (Pre-Service/Prior Authorization) Questions and Answers Provider Referral Guide – Volusia/Flagler Counties Provider Referral Guide – Seminole County Provider Referral Guide – Brevard County

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FLORIDA HEALTH CARE PLANS REFERRAL FORM Phone: 386-238-3230 Fax: 386-238-3253 Date:

A.

Auth #:

Member Name:

Referring Provider Name:

MRN:

Date of Birth:

Contact/Caller Name:

Home Tel:

Work Tel:

Referring Provider Phone #:

Cell #:

Referring Provider FHCP #:

Subscriber #:

Provider Signature:

Parent / Guardian Name:

B. REFERRAL STATUS:

Referral at Patient Request Only

Routine

Is this the result of an auto or work accident?

Urgent

Yes

No

*** For urgent cases requiring prior authorization, the provider office must call Central Referrals Department at (386) 238-3230. *** Please refer to your Network Referral Instructions for assistance in completing all HMO referrals.

C. REFERRAL IS FOR: With Contrast

Without Contrast

With & Without Contrast

 DME (equipment needed) Length of need for DME required (except for Nebulizers) Eval

D. DIAGNOSIS CODE

Follow Up

2

nd

Opinion

E. REASON FOR REFERRAL – TO BE COMPLETED BY CLINICIAN (Attach all Supporting Documentation)

F. Appointment with:

Date:

Time:

Notes:

Confirmed with:

By:

On:

G. THIS SECTION IS ONLY FOR THOSE SERVICES THAT REQUIRE PRE-AUTHORIZATION This Form is intended to represent the Provider’s order as well as the Services that have been approved by FHCP. Payment will not be authorized for services beyond those as indicated below. Authorization for additional services must be coordinated through the Member’s PCP or the Referring Provider.

APPROVED BY FLORIDA HEALTH CARE PLANS FOR:

Signature: 21-501 REV. 4/05, 2/07, 02/11, 05/13, 12/13, 05/14, 09/15

Date:

799

What is a Referral? A Referral is an “order” from your Provider indicating you need specialty health services. About ninety percent (90%) of Referrals do not need prior authorization by FHCP in order to be covered. The remaining ten percent (10%) require FHCP review and prior authorization before the service is rendered. Referrals are one of the methods FHCP uses to coordinate and assure necessary care, while protecting Members from unnecessary care. Referrals also drive quality of care and help manage service efficiencies and cost for our Members by giving your Provider needed clinical data to review before your appointment. Prior authorization is not required for any emergency care or urgent care outside of Volusia and Flagler Counties.

1. Do I need a Referral from my PCP to see a Specialist? a.

b.

If you are on an HMO plan, yes, you will need a Referral to see most Specialty Providers. However, there are certain specialists and services listed in the FHCP Directory under the category of “Direct Access” that do not require a Referral from your PCP. If you are on a Point of Service (POS) or Triple Option plan, you will not need Referrals; however, the cost of care outside FHCP’s network will cost you more. Some services will require Pre-Certification. Please see #5 below for additional information.

2. What is a Direct Access? Direct Access means that you do not need a Referral from your treating Provider to access nonemergency care and services from certain HMO participating Providers. You may directly access the services of FHCP HMO Chiropractors, Dermatologists Obstetricians, Optometrists, and Podiatrists, In addition to these Direct Access Providers, there are certain Direct Access services that you can schedule yourself. Direct Access services are screening mammograms, sports medicine assessments, Well Woman’s Assessments with a gynecologist and an appointment with a gastroenterologist to discuss a screening colonoscopy. For a complete listing of HMO Direct Access Providers, refer to the FHCP HMO Provider Directory.

3. Who reviews Referrals that require Prior Authorization? Referrals that require Prior Authorization by FHCP are reviewed in the FHCP Central Referrals Department by Nurses and FHCP’s Utilization Management Physicians. The physician team consists of Primary Care and Specialty Care Providers.

4. Who makes my appointment? As an additional service to our Members, FHCP will often schedule visits for referred services for you. If the Referral does not require Prior Authorization for the service, you or the Provider’s office staff can schedule the appointment. When your approved Referral does require Prior Authorization by one of FHCP’s Utilization Management Physicians, most often the FHCP Central Referrals Department will usually schedule the appointment for you.

800

5. What are some examples of Referrals that require Prior Authorization by FHCP? Some examples include but are not limited to: orders for braces/prosthetics (i.e. back braces and leg braces), genetic testing, referrals to non-participating Providers and hospitals, orders for elective surgeries, a referral to a plastic surgeon and an order for an organ transplant. Effective 5-2-2016, Referrals for Radiation Oncology require prior authorization. FHCP has retained AIM Specialty Health to manage radiation oncology utilization for FHCP. Providers should obtain Prior Authorization through AIM Specialty Health at 844-423-0881 or via their web portal at www.providerportal.com.

6. How will I know if my Referral is denied? FHCP’s Utilization Management Physician Team will notify you and the referring Provider with a written explanation of the denial. The denial letter will outline the reason for the denial and the denial appeal process available to each party.

7. If my Referral is denied, what course of action can I take? You have the right to appeal FHCP’s decision. After discussing your denial with the referring Provider, you may call Member Services at (386) 615-4022, or 1-877-615-4022 for further direction. If you have a hearing or speech impairment, please call us at TRS Relay 711.

801

Examples of Services Requiring Pre-Service Prior Authorization This list is only an example of the services requiring Prior Authorization and is subject to change. For a definitive list of services requiring Prior Authorization, consult your Handbook or call Member Services (386) 615-4022, or 1-877-615-4022. If you have a hearing or speech impairment, call us at TRS Relay 711.

All Out-of-HMO-Network Non-Emergency/Urgent Services require an approved Prior Authorization for the Member to receive services at HMO rates. Balance and Vestibular Testing Braces / Orthotics / Prosthetics Cardiac Rehabilitation Certain medications as identified on the FHCP Formulary Diagnostic Testing: Breast MRI Stereotactic Breast Biopsy Sestamibi Scans Ultrasound Guided Needle Breast Biopsy CT Colonography (Virtual Colonoscopy) Pill Cams Genetic Testing Pet Scans when ordered by a Primary Care Physician Durable Medical Equipment – These Items Only - Mattress Gel Overlays, Wheelchair Cushions, Alternating Pressure Relieving Mattresses, Pumps and Pads, and Mattress Replacement Systems Lymphedema Clinic Non-Participating Providers and Hospitals Organ and Bone Marrow Transplants Physical Medicine & Rehab Services Prior Authorization Medications (Refer to your Pharmacy Rider) Pulmonary Rehabilitation Oral Surgeon & Oral Surgery Plastic Surgeon & Plastic Surgery Radiation Oncology Services Services Performed by a Mid-Wife in the home or a Birthing Center Surgeries (All In-Patient or Out-Patient) Varicose Vein Evaluations & Treatment

802

PROVIDER REFERRAL GUIDE – VOLUSIA FLAGLER COUNTIES

Refer to: http://www.fhcp.com/providers/forms/referralGuidance/Referral%20Guidelines.pdf

PROVIDER REFERRAL GUIDE – SEMINOLE COUNTY Refer to: http://www.fhcp.com/providers/forms/referralGuidance/Referral%20Guidelines%20Se minole.pdf

PROVIDER REFERRAL GUIDE – BREVARD COUNTY Refer to: http://www.fhcp.com/providers/forms/referralGuidance/Referral%20Guidelines%20Bre vard.pdf

803

SECTION 20 Adult Preventative Medicine Recommendations Policy Adult Preventative Medicine Recommendations Recommended Adult Immunizations Schedule FHCP Disease Management Programs Case Management Coordination of Care Program: Community Resource Coordination Referral Case Management Coordination of Care Referral Development of Clinical Review Criteria Policy

804

805

806 PREVENTIVE GUIDELINES To stay healthy, it is important to get the care you need. The table below provides information on screenings, immunizations and gender specific recommendations.

SCREENINGS Weight & Body Mass Index (BMI) Blood Pressure (BP)



Cholesterol, Triglyceride, HDL/LDL



Colon Cancer HIV Lung Cancer

• • •



Adults should be screened for obesity. Those with a BMI of 30 or above should be offered interventions to promote healthy diet and physical activity. Adults should be screened for high BP (140/90 or greater). If a BP measurement taken in a medical setting indicates high BP, additional monitoring should be done outside of that setting for diagnostic confirmation, unless it is clear that treatment should begin right away. Adults without a history of cardiovascular disease (CVD) use a low to moderate dose statin for the prevention of CVD events and mortality when all of the following criteria are met: 1) age 40 to 75; 2) 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking); and 3) a calculated 10-year risk of a cardiovascular event of 10% or greater. Identification of dyslipidemia and calculation of 10-year CVD event risk requires universal lipids screening in adults aged 40 to 75 years. Screen for colorectal cancer starting at age 50 and continuing until age 75. Age 15 to 65, or anyone else at increased risk. Also all pregnant women. Each year, talk to your doctor about a low-dose CT scan if you are age 55 to 80 and currently a heavy smoker (1 pack per day/last 30 years or 2 packs per day/last 15 years), or a heavy smoker who quit in the last 15 years. Discontinue screening once you have not smoked for 15 years. Coverage depends on your benefit plan. Please call Member Services at (386) 615-4022 to determine your cost.

SCREENING RECOMMENDATIONS FOR WOMEN Mammogram

Pap Smear (Cytology)

• • • • • •

Every 1 to 2 years starting at age 50 up to age 74. For women age 40 to 49, discuss the benefits and risks with your doctor. BRCA testing for those at risk (check with your doctor). Every 3 years age 21 to 65 have a Pap test to look for cervical cancer. Every 5 years age 30 to 65 if both cytology & HPV testing are done & you are not high risk. Not needed if you had a hysterectomy with removal of the cervix, and no history of cancer. Stop at age 65 unless increased risk (check with your doctor).

Chlamydia & Gonorrhea



All sexually active women age 24 & younger, and in older women at increased risk for infection (can be a urine test). Screening intervals based on new or persistent risk factors.

Bone Mineral Density (BMD)



BMD test called a DXA scan (low dose x-ray) starting at age 65 to test for osteoporosis; follow-up every 2 years. Test before age 65 if at risk for osteoporosis (ask your doctor).

SCREENING RECOMMENDATIONS FOR MEN Prostate Cancer Abdominal Aortic Aneurysm (AAA)

• •

Discuss the risks and potential benefits of screening with your doctor. Age 65 to 75: One-time AAA screening with ultrasonography if you have ever smoked.

The above Wellness Guidelines were obtained from Published Recommendations. U.S. Preventive Services Task Force, Current as of April 2017. http://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations. Recommended 2017 Immunization Schedules for children birth to 6 years, preteens and teens ages 7-18, and adults may be found at the following link: http://www.cdc.gov/vaccines/schedules/easy-to-read/index.html

INFORMATION FOR ADULT PATIENTS If you are this age,

2016 Recommended Immunizations for Adults: By Age

807

talk to your healthcare professional about these vaccines Flu Influenza

Td/Tdap Tetanus, diphtheria, pertussis

Shingles Zoster

Pneumococcal

PCV13

PPSV23

Meningococcal MenACWY or MPSV4

MenB

MMR Measles, mumps, rubella

HPV Human papillomavirus for women

Chickenpox Varicella

Hepatitis A Hepatitis B

for men

Hib Haemophilus influenzae type b

19 - 21 years

22 - 26 years

27 - 49 years

50 - 59 years

60 - 64 years

1 or 2 doses

65+ year

More Information:

You should get flu vaccine every year.

You should get a Td booster every 10 years. You also need 1 dose of Tdap. Women should get a Tdap vaccine during every pregnancy to protect the baby.

You should get shingles vaccine even if you have had shingles before.

You should get 1 dose of PCV13 and at least 1 dose of PPSV23 depending on your age and health condition.

You should get this vaccine if you did not get it when you were a child. You should get HPV vaccine if you are a woman through age 26 years or a man through age 21 years and did not already complete the series.

For more information, call 1-800-CDC-INFO (1-800-232-4636) or visit www.cdc.gov/vaccines Recommended For You: This vaccine is recommended for you unless your healthcare professional tells you that you cannot safely receive it or that you do not need it. May Be Recommended For You: This vaccine is recommended for you if you have certain risk factors due to your health, job, or lifestyle that are not listed here. Talk to your healthcare professional to see if you need this vaccine.

If you are traveling outside the United States, you may need additional vaccines. Ask your healthcare professional about which vaccines you may need at least 6 weeks before you travel.

CS262412

INFORMATION FOR ADULT PATIENTS If you have this health condition,

808 2016 Recommended Immunizations for Adults: By Health Condition

talk to your healthcare professional about these vaccines Flu Influenza

Td/Tdap Tetanus, diphtheria, pertussis

Shingles Zoster

Pneumococcal

PCV13

PPSV23

Meningococcal MenACWY or MPSV4

MenB

MMR Measles, mumps, rubella

HPV Human papillomavirus for women

Chickenpox Varicella

Hepatitis A

Hepatitis B

for men

Hib Haemophilus influenzae type b

Pregnancy SHOULD NOT GET VACCINE

Weakened Immune System

SHOULD NOT GET VACCINE

SHOULD NOT GET VACCINE

HIV: CD4 count less than 200 HIV: CD4 count 200 or greater Kidney disease or poor kidney function Asplenia (if you do not have a spleen or if it does not work well) Heart disease Chronic lung disease Chronic alcoholism Diabetes (Type 1 or Type 2) Chronic Liver Disease

More Information:

You should get flu vaccine every year.

You should get a Td booster every 10 years. You also need 1 dose of Tdap vaccine. Women should get Tdap vaccine during every pregnancy.

Recommended For You: This vaccine is recommended for you unless your healthcare professional tells you that you cannot safely receive it or that you do not need it.

You should get shingles vaccine if you are age 60 years or older, even if you have had shingles before.

You should get 1 dose of PCV13 and at least 1 dose of PPSV23 depending on your age and health condition.

You should get this vaccine if you did not get it when you were a child. You should get HPV vaccine if you are a woman through age 26 years or a man through age 21 years and did not already complete the series.

You should get Hib vaccine if you do not have a spleen, have sickle cell disease, or received a bone marrow transplant.

For more information, call 1-800-CDC-INFO (1-800-232-4636) or visit www.cdc.gov/vaccines May Be Recommended For You: This vaccine is recommended for you if you have certain other risk factors due to your age, health, job, or lifestyle that are not listed here. Talk to your healthcare professional to see if you need this vaccine.

YOU SHOULD NOT GET THIS VACCINE

CS262412

At 1 month of age, HepB (1-2 months), At 2 months of age, HepB (1-2 months), DTaP, PCV, Hib, Polio, and RV At 4 months of age, DTaP, PCV, Hib, Polio, and RV At 6 months of age, HepB (6-18 months), DTaP, PCV, Hib, Polio (6-18 months), RV, and Influenza (yearly, 6 months through 18 years)* At 12 months of age, MMR (12-15

809

2016 Recommended Immunizations for Children from Birth Through 6 Years Old

Birth

HepB

1

2

month



months), PCV (12-15 months) , Hib (12-15 months), Varicella (12-15 months), HepA (12-23 months)§, and Influenza (yearly, 6 months through 18 years)* At 4-6 years, DTaP, IPV, MMR, Varicella, and Influenza (yearly, 6

months

4

months

6

months

HepB

months through 18 years)*

Is your family growing? To protect your new baby and yourself against whooping cough, get a Tdap vaccine in the third trimester of each pregnancy. Talk to your doctor for more details.

you don’t need to start over, just go back to your child’s doctor for the next shot. Talk with your child’s doctor if you have questions about vaccines.

For more information, call toll free 1-800-CDC-INFO (1-800-232-4636) or visit http://www.cdc.gov/vaccines

months

15

months

18

months

19–23 months

2–3

years

4–6

years

HepB RV

RV

RV

DTaP

DTaP

DTaP

Hib

Hib

Hib

Hib

PCV

PCV

PCV

PCV

IPV

IPV

DTaP

DTaP

IPV

IPV Influenza (Yearly)*

Shaded boxes indicate the vaccine can be given during shown age range.

NOTE: If your child misses a shot,

12

MMR

MMR

Varicella

Varicella

HepA§

FOOTNOTES:

* Two doses given at least four weeks apart are recommended for children aged 6 months through 8 years of age who are getting an influenza (flu) vaccine for the first time and for some other children in this age group. §

Two doses of HepA vaccine are needed for lasting protection. The first dose of HepA vaccine should be given between 12 months and 23 months of age. The second dose should be given 6 to 18 months later. HepA vaccination may be given to any child 12 months and older to protect against HepA. Children and adolescents who did not receive the HepA vaccine and are at high-risk, should be vaccinated against HepA.

If your child has any medical conditions that put him at risk for infection or is traveling outside the United States, talk to your child’s doctor about additional vaccines that he may need.

See back page for more information on vaccine­ preventable diseases and the vaccines that prevent them.

810

Vaccine-Preventable Diseases and the Vaccines that Prevent Them

Disease

Vaccine

Chickenpox

Varicella vaccine protects against chickenpox. Air, direct contact

Rash, tiredness, headache, fever

Diphtheria

DTaP* vaccine protects against diphtheria.

Air, direct contact

Sore throat, mild fever, weakness, swollen glands in neck

Hib

Hib vaccine protects against Haemophilus influenzae type b.

Air, direct contact

May be no symptoms unless bacteria enter the blood

Hepatitis A

HepA vaccine protects against hepatitis A.

Direct contact, contaminated food or water

Hepatitis B

HepB vaccine protects against hepatitis B.

Contact with blood or body fluids

Influenza (Flu)

Flu vaccine protects against influenza.

Air, direct contact

Measles

MMR** vaccine protects against measles.

Air, direct contact

Mumps

MMR**vaccine protects against mumps.

Air, direct contact

Pertussis

DTaP* vaccine protects against pertussis (whooping cough).

Air, direct contact

Polio

IPV vaccine protects against polio.

Air, direct contact, through the mouth

Pneumococcal

PCV vaccine protects against pneumococcus.

Air, direct contact

Rotavirus

RV vaccine protects against rotavirus.

Through the mouth

Rubella

MMR** vaccine protects against rubella.

Air, direct contact

Tetanus

DTaP* vaccine protects against tetanus.

Exposure through cuts in skin

* DTaP combines protection against diphtheria, tetanus, and pertussis.

** MMR combines protection against measles, mumps, and rubella.

Disease spread by Disease symptoms

May be no symptoms, fever, stomach pain, loss of appetite, fatigue, vomiting, jaundice (yellowing of skin and eyes), dark urine May be no symptoms, fever, headache, weakness, vomiting, jaundice (yellowing of skin and eyes), joint pain Fever, muscle pain, sore throat, cough, extreme fatigue

Disease complications Infected blisters, bleeding disorders, encephalitis (brain swelling), pneumonia (infection in the lungs) Swelling of the heart muscle, heart failure, coma, paralysis, death Meningitis (infection of the covering around the brain and spinal cord), intellectual disability, epiglottitis (life-threatening infection that can block the windpipe and lead to serious breathing problems), pneumonia (infection in the lungs), death Liver failure, arthralgia (joint pain), kidney, pancreatic, and blood disorders Chronic liver infection, liver failure, liver cancer Pneumonia (infection in the lungs)

Encephalitis (brain swelling), pneumonia (infection in the lungs), death Meningitis (infection of the covering around the brain Swollen salivary glands (under the jaw), fever, and spinal cord) , encephalitis (brain swelling), inflam­ headache, tiredness, muscle pain mation of testicles or ovaries, deafness Severe cough, runny nose, apnea (a pause in Pneumonia (infection in the lungs), death breathing in infants) May be no symptoms, sore throat, fever, Paralysis, death nausea, headache May be no symptoms, pneumonia (infection Bacteremia (blood infection), meningitis (infection of in the lungs) the covering around the brain and spinal cord), death Rash, fever, cough, runny nose, pinkeye

Diarrhea, fever, vomiting

Severe diarrhea, dehydration

Children infected with rubella virus sometimes Very serious in pregnant women—can lead to miscar­ have a rash, fever, swollen lymph nodes riage, stillbirth, premature delivery, birth defects Stiffness in neck and abdominal muscles, Broken bones, breathing difficulty, death difficulty swallowing, muscle spasms, fever Last updated January 2016 • CS261834-D ­

811

2016 Recommended Immunizations for Children 7-18 Years Old

INFORMATION FOR PARENTS

Talk to your child’s doctor or nurse about the vaccines recommended for their age. Flu Influenza

Tdap Tetanus, diphtheria, pertussis

HPV Human papillomavirus

Meningococcal MenACWY

MenB

Pneumococcal

Hepatitis B

7-8 Years

9-10 Years

11-12 Years

13-15 Years

16-18 Years More information:

Preteens and teens should get a flu vaccine every year.

Preteens and teens should get one shot of Tdap at age 11 or 12 years.

Both girls and boys should receive 3 doses of HPV vaccine to protect against HPVrelated disease. HPV vaccination can start as early as age 9 years.

All 11-12 year olds should be vaccinated with a single dose of a quadrivalent meningococcal conjugate vaccine (MenACWY). A booster shot is recommended at age 16.

Teens, 16-18 years old, may be vaccinated with a MenB vaccine.

These shaded boxes indicate when the vaccine is recommended for all children unless your doctor tells you that your child cannot safely receive the vaccine.

These shaded boxes indicate the vaccine should be given if a child is catching-up on missed vaccines.

These shaded boxes indicate the vaccine is recommended for children with certain health or lifestyle conditions that put them at an increased risk for serious diseases. See vaccine-specific recommendations at www.cdc.gov/vaccines/hcp/acip-recs/index.html

This shaded box indicates the vaccine is recommended for children not at increased risk but who wish to get the vaccine after speaking to a provider.

Hepatitis A

Inactivated Polio

MMR Measles, mumps, rubella

Chickenpox Varicella

812 Vaccine-Preventable Diseases and the Vaccines that Prevent Them Diphtheria (Can be prevented by Tdap vaccination)

Diphtheria is a very contagious bacterial disease that affects the respiratory system, including the lungs. Diphtheria bacteria can be passed from person to person by direct contact with droplets from an infected person’s cough or sneeze. When people are infected, the diptheria bacteria produce a toxin (poison) in the body that can cause weakness, sore throat, fever, and swollen glands in the neck. Effects from this toxin can also lead to swelling of the heart muscle and, in some cases, heart failure. In serious cases, the illness can cause coma, paralysis, and even death.

Hepatitis A (Can be prevented by HepA vaccination)

Hepatitis A is an infection in the liver caused by hepatitis A virus. The virus is spread primarily person-to-person through the fecal-oral route. In other words, the virus is taken in by mouth from contact with objects, food, or drinks contaminated by the feces (stool) of an infected person. Symptoms can include fever, tiredness, poor appetite, vomiting, stomach pain, and sometimes jaundice (when skin and eyes turn yellow). An infected person may have no symptoms, may have mild illness for a week or two, may have severe illness for several months, or may rarely develop liver failure and die from the infection. In the U.S., about 100 people a year die from hepatitis A.

Hepatitis B (Can be prevented by HepB vaccination)

Hepatitis B causes a flu-like illness with loss of appetite, nausea, vomiting, rashes, joint pain, and jaundice. Symptoms of acute hepatitis B include fever, fatigue, loss of appetite, nausea, vomiting, pain in joints and stomach, dark urine, grey-colored stools, and jaundice (when skin and eyes turn yellow).

Human Papillomavirus (Can be prevented by HPV vaccination)

Human papillomavirus is a common virus. HPV is most common in people in their teens and early 20s. It is the major cause of cervical cancer in women and genital warts in women and men. The strains of HPV that cause cervical cancer and genital warts are spread during sex.

Influenza (Can be prevented by annual flu vaccination)

Influenza is a highly contagious viral infection of the nose, throat, and lungs. The virus spreads easily through droplets when an infected person coughs or sneezes and can cause mild to severe illness. Typical symptoms include a sudden high fever, chills, a dry cough, headache, runny nose, sore throat, and muscle and joint pain. Extreme fatigue can last from several days to weeks. Influenza may lead to hospitalization or even death, even among previously healthy children.

Measles (Can be prevented by MMR vaccination)

Measles is one of the most contagious viral diseases. Measles virus is spread by direct contact with the airborne respiratory droplets of an infected person. Measles is so contagious that just being in the same room after a person who has measles has already

left can result in infection. Symptoms usually include a rash, fever, cough, and red, watery eyes. Fever can persist, rash can last for up to a week, and coughing can last about 10 days. Measles can also cause pneumonia, seizures, brain damage, or death.

Meningococcal Disease (Can be prevented by meningococcal vaccination)

Meningococcal disease is caused by bacteria and is a leading cause of bacterial meningitis (infection around the brain and spinal cord) in children. The bacteria are spread through the exchange of nose and throat droplets, such as when coughing, sneezing or kissing. Symptoms include nausea, vomiting, sensitivity to light, confusion and sleepiness. Meningococcal bacteria also cause blood infections. About one of every ten people who get the disease dies from it. Survivors of meningococcal disease may lose their arms or legs, become deaf, have problems with their nervous systems, become developmentally disabled, or suffer seizures or strokes.

Mumps (Can be prevented by MMR vaccination)

Mumps is an infectious disease caused by the mumps virus, which is spread in the air by a cough or sneeze from an infected person. A child can also get infected with mumps by coming in contact with a contaminated object, like a toy. The mumps virus causes swollen salivary glands under the ears or jaw, fever, muscle aches, tiredness, abdominal pain, and loss of appetite. Severe complications for children who get mumps are uncommon, but can include meningitis (infection of the covering of the brain and spinal cord), encephalitis (inflammation of the brain), permanent hearing loss, or swelling of the testes, which rarely results in decreased fertility.

Pertussis (Whooping Cough) (Can be prevented by Tdap vaccination)

Pertussis is caused by bacteria spread through direct contact with respiratory droplets when an infected person coughs or sneezes. In the beginning, symptoms of pertussis are similar to the common cold, including runny nose, sneezing, and cough. After 1-2 weeks, pertussis can cause spells of violent coughing and choking, making it hard to breathe, drink, or eat. This cough can last for weeks. Pertussis is most serious for babies, who can get pneumonia, have seizures, become brain damaged, or even die. About two-thirds of children under 1 year of age who get pertussis must be hospitalized.

Pneumococcal Disease (Can be prevented by pneumococcal vaccination)

Pneumonia is an infection of the lungs that can be caused by the bacteria called pneumococcus. This bacteria can cause other types of infections too, such as ear infections, sinus infections, meningitis (infection of the covering around the brain and spinal cord), bacteremia and sepsis (blood stream infection). Sinus and ear infections are usually mild and are much more common than the more serious forms of pneumococcal disease. However, in

If you have any questions about your child’s vaccines, talk to your healthcare provider.

some cases pneumococcal disease can be fatal or result in longterm problems, like brain damage, hearing loss and limb loss. Pneumococcal disease spreads when people cough or sneeze. Many people have the bacteria in their nose or throat at one time or another without being ill—this is known as being a carrier.

Polio (Can be prevented by IPV vaccination)

Polio is caused by a virus that lives in an infected person’s throat and intestines. It spreads through contact with the stool of an infected person and through droplets from a sneeze or cough. Symptoms typically include sore throat, fever, tiredness, nausea, headache, or stomach pain. In about 1% of cases, polio can cause paralysis. Among those who are paralyzed, About 2 to 10 children out of 100 die because the virus affects the muscles that help them breathe.

Rubella (German Measles)

(Can be prevented by MMR vaccination)

Rubella is caused by a virus that is spread through coughing and sneezing. In children rubella usually causes a mild illness with fever, swollen glands, and a rash that lasts about 3 days. Rubella rarely causes serious illness or complications in children, but can be very serious to a baby in the womb. If a pregnant woman is infected, the result to the baby can be devastating, including miscarriage, serious heart defects, mental retardation and loss of hearing and eye sight.

Tetanus (Lockjaw)

(Can be prevented by Tdap vaccination)

Tetanus is caused by bacteria found in soil, dust, and manure. The bacteria enters the body through a puncture, cut, or sore on the skin. When people are infected, the bacteria produce a toxin (poison) that causes muscles to become tight, which is very painful. Tetanus mainly affects the neck and belly. This can lead to “locking” of the jaw so a person cannot open his or her mouth, swallow, or breathe. Complete recovery from tetanus can take months. One out of five people who get tetanus die from the disease.

Varicella (Chickenpox)

(Can be prevented by varicella vaccination)

Chickenpox is caused by the varicella zoster virus. Chickenpox is very contagious and spreads very easily from infected people. The virus can spread from either a cough, sneeze. It can also spread from the blisters on the skin, either by touching them or by breathing in these viral particles. Typical symptoms of chickenpox include an itchy rash with blisters, tiredness, headache and fever. Chickenpox is usually mild, but it can lead to severe skin infections, pneumonia, encephalitis (brain swelling), or even death.

Last updated on 03/28/2016 • CS264259-A

813

Clinical Practice Guideline / Revision Year:

Diabetes 2017

Source:

Standards of Medical Care in Diabetes -2017. Diabetes Care, January 2017, Vol. 40, Supplement 1. American Diabetes Association. http://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf

Annual Review By Quality Management: April 2017

Updated. (previous version 2016)

Hypertension 2014

2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults-Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8.) American Medical Association, 2014. http://jama.jamanetwork.com/article.aspx?articleid=1791497&resultClick=3

Cholesterol Management 2013

Managing Blood Cholesterol in Adults. Systematic Evidence Review From the Cholesterol Expert Panel, 2013. U.S. Department of Health & Human Services, National Institutes of Health, National Heart, Lung, & Blood Institute. http://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/cholesterol-in-adults

Asthma 2007

Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma. Full Report, August 2007. U.S. Department of Health and Human Services, National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

No change.

COPD 2011

Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society . Annals of Internal Medicine, 2 August 2011, Vol 155, No. 3. http://annals.org/article.aspx?articleid=479627

No change.

Quality Management Page 1 of 2

No change.

No change.

814

Clinical Practice Guideline / Revision Year:

Annual Review By Quality Management: April 2017

Source:

Health Care Guideline: Adult Depression in Primary Care. Seventeenth Edition, March 2016. Institute for Clinical Systems Improvement (ICSI). http://www.icsi.org/_asset/fnhdm3/Depr-Interactive0512b.pdf

No change.

ADHD 2014

ADHD, Attention Deficit Hyperactivity Disorder In Primary Care For School-Age Children And Adolescents. Revision Date: March 2014, Tenth Edition, Endorsement Summary by Institute for Clinical Systems Improvement (ICSI) of the American Academy of Pediatrics - ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents, 2011. http://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_be havioral_health_guidelines/adhd/

No change.

Substance Abuse APA 2006; Magellan 2015

Introduction to Magellan’s Adopted Clinical Practice Guidelines For The Assessment and Treatment of Patients With Substance Use Disorders, 2006-2015. Magellan Health Inc. http://www.magellanprovider.com/media/11755/substance_abuse.pdf and Practice Guideline For The Treatment of Patients With Substance Use Disorders. Second Edition, 2006, with Copyright 2010. The American Psychiatric Association (APA) http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/substanceuse.pdf and FHCP’s 2015 Addendum to Clinical Practice Guidelines For Patients With Substance Use Disorders. Located on FHCP’s website, Provider Tab, Medical Guidelines, Clinical Practice Guidelines.

No change.

Depression 2016

Quality Management Page 2 of 2

COMMITTEE

APPROVAL DATE

Disease Management Committee

4-25-17 Electronic Vote

Performance Improvement Council

4-26-17

Health, Wellness, and Disease Management Programs

815

FHCP offers members a variety of health, wellness and disease management programs and services at little or no cost. Members are not limited by the number of programs in which they may participate. For more information, please call the number listed under each program, Monday through Friday from 8 a.m. to 5 p.m. Hearing impaired call TRS Relay 711.

Healthy Lifestyle

Exercise & Fitness

Weight Management “Eat Right, Move Right” is a free 6-week course that promotes a lifestyle change approach to weight loss for members with a Body Mass Index (BMI) over 27. How to be more active, improve eating habits, and change behaviors for permanent weight loss are covered. Members will learn to set realistic goals, use the USDA plate method, manage dining out, and change food shopping habits. For more information, call the Diabetes/Health Education Department at 386-226-4518 or 1-877-229-4518.

Preferred Fitness This free fitness program is provided to all FHCP Medicare members and certain employer groups. Eligible members have access to a variety of quality health and fitness facilities in Volusia, Flagler, Brevard, and Seminole counties. For a current list of facilities, call the Member Services Department at 386-615-4022 or 1-877-615-4022.

Smoking Cessation Tobacco Free Florida (TFF) is a free, statewide smoking cessation and prevention campaign. The program is managed by the Florida Department of Health through the Bureau of Tobacco Prevention. Smokers and smokeless tobacco users interested in assistance with quitting are encouraged to call the Florida Quitline at 1-877-U-CAN-NOW (877-822-6669) to speak with a Quit Coach®. To access TFF’s additional quit smoking resources, visit the Tobacco Free Florida website at www.tobaccofreeflorida.com.

Matter of Balance This program is intended for members of any age and designed to help prevent falls and increase activity levels, balance and coordination. There is no cost to members in the Preferred Fitness Program and a nominal fee for members who are not in the program. Members should call your local YMCA for more information or to register for a class. Synergy Senior Fitness This senior workout program is composed of group for the maturing body, designed to develop muscle tone, strength, endurance, flexibility and balance through gentle, upbeat, fun and supportive classes. For information on class times, locations and registration call 386-931-3485, Monday through Friday between 8 a.m. and 6 p.m. H1035_NR625 (05/04/2016)

Health Education Acute Low Back and Neck Pain This physical therapy program helps members manage acute or chronic low back or neck pain. Open to age 17 and up, all members can contact Ability Health Services (all locations) or Palm Coast Sports Medicine directly. Co-pay/co-insurance and policy limits apply. For more information or to obtain a list of facilities, call the Member Services Department at 386-615-4022 or 1-877-615-4022. Asthma This free program provides educational materials to help members manage asthma and follow their doctor’s treatment plan. Members can also visit any FHCP pharmacy to discuss their asthma medications with a pharmacist. For more information, call the Quality Management Department at 386-676-7100, Ext 7242. Case Management This is a free program offered to members who may benefit from assistance with coordinating their medical, psychosocial, and financial needs. Working with members and their physicians, Case Managers can provide education and resources for members to better understand and comply with their plans of care. The FHCP Case Management Department can be reached by email at [email protected] or by phone at 386-238-3284 or toll free at 1-800-321-1227. Chronic Obstructive Pulmonary Disease (COPD) This free program provides education to members to help them more effectively manage COPD. In addition, members meeting certain criteria may participate in the Medication Action Plan (MAP) program. The MAP Program targets early intervention through medication management when symptoms are worsening. For more information, call the Quality Management Department at 386-676-7100, Ext. 7242. Controlling High Blood Pressure (Hypertension) This free program includes a tool kit that explains the health risks related to high blood pressure. It includes information on measuring blood pressure, the importance of routinely taking medications, diet tips, exercise, and other self-management tools. Included is a coupon for a discount on a home blood pressure monitor. For more information, call the Quality

816 Management Department at 386-676-7100, Ext 7242. FHCP also offers a 2-hour Hypertension Self-Management Class taught by Registered Dieticians. This free class focuses on the DASH diet and low sodium education. To register, call the Diabetes/Health Education Department at 386-226-4518 or toll free 1-877-229-4518. Depression This free program is for members ages 18 and older who have recently been prescribed an antidepressant medication. Educational materials covering the basics of self-management include a discussion of depression, the importance of taking prescribed medications and methods of coping. Members will also receive information on how to contact a behavioral health provider. For more information, call the Quality Management Department at 386-676-7100, Ext. 7242.

Osteoporosis This program is for members who are at risk for or have been diagnosed with Osteoporosis or Osteopenia (fragile bones). Therapists at Ability Health Services will perform an evaluation and physical assessment to determine strength, endurance and activity level. Members can call Ability directly; no referral is needed. Co-pay/co-insurance and policy limits may apply. For more information or to obtain a list of facilities, call the Member Services Department at 386-615-4022 or 1-877-615-4022. Pelvic Health Program In partnership with Ability Health Services, FHCP offers a pelvic health program for conditions such as urinary incontinence and pelvic pain. Members will receive therapy from physical therapists certified in this service. Co-pay/co-insurance and policy limits apply. For more information call the Quality Management Department at 386-676-7100, Ext. 7242.

Diabetes Diabetes This free program provides educational materials to assist members with management of their diabetes. For more information, contact the Quality Management Department at 386-676-7100, Ext 7242. Diabetes Education Program Recognized by the American Diabetes Association (ADA), and conducted by FHCP registered nurses and registered dietitians/Certified Diabetes Educators (CDEs), this free 10-hour diabetes education program covers: diabetes overview, complications, signs and symptoms of high and low blood sugar, lifestyle modifications, medications, nutrition, monitoring guidelines (HgbA1C, blood glucose meters, blood pressure, weight), and foot, skin, and dental care. In addition, CDEs are also available for individual appointments. For more information, contact the Diabetes/Health Education Department at 386-226-4518 or 1-877-229-4518. Diabetes Prevention Program This free two hour class helps members identify risk factors for developing diabetes and covers nutrition, exercise, and behavioral strategies for prevention. A more intense diabetes prevention program is also available. Call the Diabetes/Health Education Department at 386-226-4518 or 1-877-229-4518. Nutrition Game Plan for Diabetes This two hour session is recommended for members who have completed the 10-hour Diabetes Education Program. The class reinforces disease specific nutrition education and answers questions regarding diabetes. For more information, call the Diabetes/Health Education Department at 386-226-4518 or 1-877-229-4518.

Heart Health

817

Heart Disease Members with elevated cholesterol levels who are at risk for heart disease will receive educational materials including self-management information, tips for controlling cholesterol levels and reducing risk factors. For more information, call the Quality Management Department at 386- 676-7100, Ext 7242. Heart Failure This free program is for members with a history of heart failure. Members receive materials including self-management tools and education aimed at decreasing emergency room and hospital admissions. For more information, call the Quality Management Department at 386-676-7100, Ext 7242. Healthy Heart Nutrition Program This free class helps members identify risk factors for heart disease and tips for improving lifestyle to reduce those risks. Call the Diabetes/Health Education Department at 386-226-4518 or 1-877-229-4518.

818 Case Management Coordination of Care Complex Care Program Program Overview: INTRODUCTION: Florida Health Care Plans Case Management Coordination of Care Program is designed to address the needs of all members helping to navigate the health care system, functioning as a health coach, connecting members with community resources, and implementing measures to improve the quality of life and disease-specific outcomes. The case management process is characterized by advocacy, communication, and resource management. OBJECTIVE: To improve the health and quality of life of our members, identify and reduce socio-economic barriers, reduce inappropriate utilization of the emergency department visits, reduce hospitalizations and readmissions, and partner with providers to promote compliance of member’s treatment plan. IDENTIFICATION: Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the services needed. Members are engaged telephonically and face-to-face. The Case

Management Coordination of Care program targets members with acute or chronic disease(s) such as asthma, coronary artery disease (CAD), congestive heart failure (CHF), stroke, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), diabetes, depression, and transplants, etc. Criteria for consideration may include members who require any of the following: • • • • • •

Assistance with issues involving safety and quality of life Member education Assistance with monitoring and treatment Assistance with obtaining needed community resources Assistance with psycho-social or behavioral health needs Any clinical situation in which case management services may enhance continuity of care and quality of life

This program is voluntary and the member has the right to decline or discontinue participation. The Nurse Care Coordinators and Community Resource Coordinators complete a comprehensive assessment to identify self-management of health conditions, psycho-social barriers, and available benefits and/or resources. The staff works with providers (PCP, Specialist, etc) to support the plan of care and promote self-management of the member’s health conditions. Periodic assessments of progress against plan of care and established goals are conducted and modifications to the plan of care are made as needed. The staff communicates findings with providers and/or specialists as needed.

819

Members may be referred:

• • • • •

Telephone Contact: (386) 238-3284 or (800)321-1227 Fax: (386) 238-3271 Website: www.fhcp.com Email: [email protected] E.H.R. Task (internal)

Revised 2/1/17 SMM

820

821 Case Management Services works in partnership with members and providers to stabilize current acute health needs by implementing measures to improve and maintain optimal health. The Case Management Services consists of remote health monitoring with FHCP Interactive Health at Home and/or provides services such as intensive telephonic support following hospitalization or frequent emergency room use, which is a free service for the FHCP members. The Case Management Services does not replace the need for Home Health Care nor performs safety checks or emergency placement. The Interactive Health at Home Remote Monitoring is individualized to the members’ health and comes with the peripherals and software to provide education regarding COPD, CHF, DM, Liver Disease, HTN, and Obesity; the health sessions along with health coaching by the RN Case Manager helps motivate change for improved self-management by the member. The Interactive Health at Home consists of daily monitoring by the clinical team who can notify you when there is a change that requires attention. The Interactive Health at Home remote monitoring system can also provide monthly reports or coordinate with scheduled appointments to give key insights on the health of your patients by providing trends in vital signs. The following peripherals are provided: blood pressure monitor, weights, pulse oximetry, and the ability to manually input daily readings from their own glucometer, blood pressure monitor, scale, or pulse oximetry. The Interactive Health at Home Tool Kit is shipped directly to the member’s home and is a free service of FHCP. The RN Case Manager helps to navigate the member and support system through the health care systems and transitions of care; when appropriate, the members are connected with community resource coordinators who complete a needs assessment to identify the necessary resources available to help reduce the socioeconomic strain that causes barriers to access the appropriate care. The Case Management Services assist members to ensure that they receive the necessary care by immediately addressing their healthcare needs through a variety of interventions. A referral can be submitted to FHCP Case Management Telehealth Services by electronic referral by E.H.R. task, telephone contact 386-238-3284, faxed referral to 386-676-7149, or email: [email protected]

822 Florida Health Care Plans Community Resource Coordination Referral Name: FHCP/Medical Record #:

Referral Date: PCP:

address: Street

DOB:

Apt. #

City Home Number:

State

Zip Cell Number:

Reason for Referral Information Only Auxiliary Needs Nursing Home/ACLF Placement Copayment At Risk Other Additional Information:

Priority Status Within 24 hours Within 5 Working Days Within 10 Working Days Other

REFERRAL SOURCE (Please check one and indicate name)

Medical Doctor Member Services Home Health Nursing Home Case Management Other Completed by:

Send to: Case Management Coordination of Care 330 N. Clyde Morris Blvd Suite #8 Daytona Beach, Florida 32114 Phone: 386-238-3284 Toll Free: 800-321-1227 Fax: 386-238-3271 [email protected]

Date:

823 Case Management Coordination of Care Referral

Referral Source:

Ext: (Name)

Patient Name:

Med Rec #:

PCP:

Patient Address: Patient Phone Number:

Cardiologist

Reason for Referral: Relevant Diagnosis – all that apply () Diabetes I or II PVD COPD/Asthma CHF (NYHA Class) CAD Others (list) ESRD

Risk Factors Hx. Falls Lives Alone Confused Not Aware of Dx Other

Medication Compliance HTN Afib Hyperlipidemia Mental Health Dx. Other

Recent Hospitalization and/ or ER visit within the past 6 months:

If applicable, please include pertinent clinical records with referral: H&P Most recent specialist dictation (i.e. Cardiology, Pulmonology, Oncology, Nephrology, etc.) EF %, Echogram, Cardiac Catheterization dictation, etc. Medication List Any additional information

Completed by:

Send to: Case Management Coordination of Care 330 N. Clyde Morris Blvd Suite #8 Daytona Beach, Florida 32114 Phone: 386-238-3284 Toll Free: 800-321-1227 Fax: 386-238-3271 [email protected] 54-503/8-06 06-23-14

Date:

824

825

826

827

828

SECTION 21 SUBMISSION OF ENCOUNTER DATA Guidelines for Completing CMS 1500 Forms Adolescent Well-Care Visits Routine GYN & Pap Smear for Patients Under 16 Years of Age - OWLS Coding for Well Woman Assessment, Routine Physicals and Follow-up Office Visit for GYN Problem Requiring Repeat Pap Smear - OWLS Program Management Department – Who to Contact Risk Adjustment Payments Medicare+Choice Physician Encounter Data Letter

829

Last Modified: 6/26/2014 Location: FL, PR, USVI Business: Part B

Revised paper claim form CMS-1500 (version 02/12) All paper claims are now required to be submitted using the new CMS-1500 (02/12) form. This implementation has not been delayed and is in effect as of April 1. The National Uniform Claim Committee (NUCC) recently revised the CMS-1500 claim form to align the paper claim form with changes in the 5010 837P and accommodate ICD-10 reporting needs. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised paper claim form, CMS-1500 (version 02/12). The Centers for Medicare & Medicaid Services (CMS) adopted form CMS-1500 (02/12), which replaced the older CMS-1500 claim form (08/05), effective with claims received on and after April 1, 2014. • Medicare began accepting claims on the revised form, (02/12), on January 6, 2014; • As of April 1, 2014, Medicare only accepts paper claims on the revised CMS-1500 claim form, (02/12); and • As of April 1, 2014, Medicare no longer accepts claims on the old claim form CMS-1500 (08/05) The grace period for providers and suppliers to transition to the new form expired on April 1, 2014. The revised form has a number of changes. The two most prevalent changes are new indicators to differentiate between ICD-9 and ICD-10 codes and new qualifiers to identify the role of the provider entered in item 17. • The NUCC created a presentation that reviews the changes in detail. Click here presentation on the CMS-1500 (02/12) paper claim form.

to view the NUCC

Item 17 qualifiers The qualifiers appropriate for identifying an ordering, referring, or supervising role are as follows: • DN -- referring provider • DK -- ordering provider • DQ -- supervising provider Providers should enter the qualifier to the left of the dotted vertical line on item 17. • Note: Claims submitted with a national provider identifier (NPI) and without one of the qualifiers notated above or an invalid qualifier will be returned as an unprocessable claim (RUC). Item 21 and 24E diagnosis changes The revised form uses letters, instead of numbers, as diagnosis code pointers, and expands the number of possible diagnosis codes on a claim to 12. Item 21 • For version 02/12, it may be appropriate to report either ICD-9-CM or ICD-10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set), up to 12 diagnosis codes. • Enter up to 12 diagnosis codes. Note: this information appears opposite lines with letters A-L. Relate lines AL to lines of service in 24E by the letter of the line. Use the highest level of specificity. • Do not provide narrative description in this field. • Do not insert a period in the ICD-9-CM or ICD-10-CM code. • The "ICD Indicator" identifies the ICD code set being reported. Enter the applicable ICD indicator as a single digit between the vertical, dotted lines.

830 • Indicator code set • 9 -- ICD-9-CM diagnosis • 0 -- ICD-10-CM diagnosis Reminder: Regardless of the paper claim form version in effect, providers cannot submit ICD-10 codes for claims with dates of service prior to October 1, 2015. Item 24E • For version 02/12, the reference will be a letter from A-L. Additional changes The following additional changes are also included in the revised form: Item 8 • Form version 02/12: Leave blank. Item 9b • Form version 02/12: Leave blank. Item 11b • Form version 02/12: Enter employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement date preceded by the word, "RETIRED." Provide this information to the right of the vertical dotted line. Item 14 • Form version 02/12: Although this version of the form includes space for a qualifier, Medicare does not use this information; do not enter a qualifier in item 14. ASCA reminder Only providers that meet the Administrative Simplification Compliance Act (ASCA) exception requirements are permitted to submit their claims to Medicare on paper, which must be submitted on a valid CMS-1500 claim form. Those providers meeting these exceptions are permitted to submit their claims to Medicare on paper. More information about ASCA exceptions can be found in Chapter 24 of the Medicare Claims Processing Manual. Source: CMS Internet-only manual (IOM) Pub. 100-04 Medicare Claims Processing Manual, Chapter 24, section 20.4 ; Chapter 26 ; Change request (CR) 8509 ; NUCC website Source: CMS IOM Pub 100-04 (Chapter 24 & 26), CR8509

831

Adolescent Well-Care Visits with Routine GYN & Pap Smear for Patients Under 16 Years of Age Service Provided

CPT Code

Diagnosis Code

Preventive Medicine Code New Patient Code 99383 or 99384 depending on age of patient or Established Patient Code 99393 or 99394 depending on age of patient Add Modifier 51 to Visit Code

Z00.121: Encounter for routine child health examination with abnormal findings – Code also the abnormal findings

AND Routine Annual Physical & Routine GYN & Pap Smear

Routine GYN & Pap Smear Q0091 Screening Papanicolaou Smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory and **G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination Routine GYN & Pap Smear

Routine GYN & Pap Smear

Q0091 Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory and **G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination

Office Visit for GYN Problem Requiring Pap Smear

Appropriate E/M Code

Office Visit for GYN Problem Requiring Pelvic Exam

Appropriate E/M Code

OR Z00.129: Encounter for routine child health examination without abnormal findings AND Z01.411: Encounter for gynecological examination (general) (routine) with abnormal findings – Code also the abnormal findings OR Z01.419: Encounter for gynecological examination (general) (routine) without abnormal findings Z01.411: Encounter for gynecological examination (general) (routine) with abnormal findings – Code also the abnormal findings OR Z01.419: Encounter for gynecological examination (general) (routine) without abnormal findings AND Z30.09: Encounter for other general counseling and advice on contraception Appropriate Diagnosis Code (e.g.: R87.XXX, C53.X, D06.X, N87.X, N88.X) and Z12.4: Encounter for screening for malignant neoplasm of cervix Appropriate Diagnosis Code (e.g.: R87.XXX, C53.X, D06.X, N87.X, N88.X) and Z01.411: Encounter for gynecological examination (general) (routine) with abnormal findings – Code also the abnormal findings or Z01.419: Encounter for gynecological examination (general) (routine) without abnormal findings

**HCPCS code G0101 should only be used when Cervical or vaginal cancer screening; pelvic and clinical breast examination are done. **

832

Well Woman Assessment, Routine Physicals or Follow-up Office Visit for GYN Problem Requiring Repeat Pap Smear Service Provided

CPT Code

Diagnosis Code

Routine Annual Physical

Preventive Medicine Code New Patient Code 99384 thru 99387 depending on age of patient or Established Patient Code 99394 thru 99397 depending on age of patient

Z00.00: Encounter for general adult medical examination without abnormal findings OR Z00.01: Encounter for general adult medical examination with abnormal findings – Note – Code also the abnormal findings Z00.00: Encounter for general adult medical examination without abnormal findings OR Z00.01: Encounter for general adult medical examination with abnormal findings – Note – Code also the abnormal findings AND Z01.411: Encounter for gynecological examination (general) (routine) with abnormal findings – Code also the abnormal findings OR Z01.419: Encounter for gynecological examination (general) (routine) without abnormal findings .

Preventive Medicine Code New Patient Code 99384 thru 99387 depending on age of patient or Established Patient Code 99394 thru 99397 depending on age of patient Add Modifier 51 to Visit Code AND Routine Annual Physical & WWA

WWA Only

F/U Office Visit for GYN Problem Requiring Repeat Pap Smear

Well Women Assessment Codes HCPCS code Q0091 Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory and HCPCS code G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination Well Women Assessment Codes HCPCS code Q0091 Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory and HCPCS code G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination

Appropriate E& M Code

Z01.411: Encounter for gynecological examination (general) (routine) with abnormal findings – Code also the abnormal findings OR Z01.419: Encounter for gynecological examination (general) (routine) without abnormal findings Appropriate Diagnosis Code (e.g.: R87.XXX, C53.X, D06.X, N87.X, N88.X) And Z12.4: Encounter for screening for malignant neoplasm of cervix

833

WHO TO CONTACT FLORIDA HEALTH CARE PLANS, INC.

Risk Adjustment Department Coding and Risk Adjustment Questions Medicare and Commercial

Contact Information (386) 615-5040 EMAIL: [email protected] FAX: (386) 676-7140

Program Management Department FHCP Plan Benefit Coverage FHCP Member Copay FHCP Claims Submission

(386) 615-4024 (800) 352-9824 ext 4024 FAX: (386) 676-7162

Courier Service

(386) 254-4382

834 RISK ADJUSTMENT PAYMENTS Due to the Balanced Budget Act of 1997 (BBA), as a Medicare Advantage Plan (MAPDP) FHCP must submit to CMS (in accordance with CMS instructions) all encounter data for FHCP Medicare enrollees for service dates 10/01/00 and after. This data includes all physician inpatient, outpatient and clinic services. FHCP will be forwarding to CMS encounter/claims data exactly as submitted to FHCP by each physician provider. As a result, each provider will ultimately be responsible for the accuracy of data submitted on their behalf. It is imperative that your medical record documentation support the data reported. Two key elements involved will be the linkage between the diagnosis code and the procedure (CPT) code and coding the diagnosis with the most specificity available. Incorrect data supplied by providers and submitted to CMS by FHCP will be denied by CMS and returned to FHCP for correction. FHCP will in turn be requesting that providers correct their data and resubmit same to FHCP. Claims data reported by FHCP to CMS will ultimately be used to assign “Risk Scores” to each of our members. Future FHCP premium dollar levels paid by CMS to FHCP will be tied in to these “Risk Scores”. Therefore, for dates of service 10/01/00 and after, providers must submit claims or encounter data to FHCP in CMS-1500 format. FHCP’s Risk Adjustment Department is available to assist provider offices with any coding issues or concerns. Risk Adjustment can be reached in our Holly Hill Facility at (386) 615-5040, or toll free at (800) 3529824, Ext. 5040. Ongoing audits concerning coding accuracy and completeness will be conducted by the Risk Adjustment Department. Your office will be contacted regarding any identified issues. Attached is a letter from Robert A. Berenson, M.D., Director of the Center for Health Plans and Providers, addressing CMS physician and non-physician data requirements.

835

836

837

SECTION 22 HEALTH INFORMATION AND PRIVACY POLICIES Medical Record Policies Introduction Outside Primary Care Physician Orientation Requesting Records for Continuity of Care Medical Record Request Form Procedure for Dictating Medical Records Release of Information for Medical Records Confidentiality of Medical Records Clinical Records Access by Member Subpoenas for Records from Attorneys General Privacy Policy Individual Right to Notice of Privacy Practices Policy Uses and Disclosures of Protected Health Information Policy

838

MEDICAL RECORD POLICIES INTRODUCTION Florida Health Care Plans, Inc. maintains a medical records system that permits prompt retrieval of information. Medical records are legible, documented accurately in a timely manner, electronic and readily accessible to approved health care practitioners. The centralized Medical Record Department provides the following Health Information Services: A.

Develops and maintains a system for the collection, processing, maintenance, storage, retrieval, and distribution of member records.

B.

All clinical information relevant to a member is readily available to the health care practitioner staff.

C.

Except when otherwise required by law, any record that contains clinical, social, financial, or other data on a particular member is treated in a strictly confidential manner and is reasonably protected from loss, tampering, alteration, destruction, and unauthorized or inadvertent disclosure of information.

D.

There is a person designated in charge of medical records whose responsibilities include, but are not limited to:  The confidentiality, security and physical safety of member records  The timely retrieval of individual records upon request  The unique identification of each member record  The supervision of the collection, processing, maintenance, storage, retrieval, and distribution of member records  The maintenance of a predetermined, organized medical record format

E.

Policies concerning medical records address, but are not limited to: • Retention of active records • Retirement of inactive records • Timely entry of data in the records • Release of information contained in records

839 F.

Except when otherwise required by law, the content and format of members’ records are maintained in a uniform manner.

G.

Reports, histories and physicals, progress notes, and other materials (such as laboratory reports, x-ray readings, and consultations) are incorporated into the record in a timely manner.

H.

Records are available to health care practitioners on a 24-hour basis.

I.

A summary of significant past surgical procedures and past and current diagnoses or problems is conspicuously documented in each member’s medical record. This summary is legibly recorded in the same location in all members’ charts. The summary does not repeat problems or diagnoses that recur during ongoing treatment. The summary includes, but not limited to: • • • •

Significant surgical conditions, including major procedures Significant medical conditions, including medical diagnoses of conditions for which the member receives medication or treatment on a repeated continuing basis Any allergies and untoward reactions to drugs Conditions that are likely to significantly influence future care

J.

A medication sheet with prescribed medications are documented and updated as necessary. This summary is legibly recorded and found in the same location in all member charts.

K.

For each member encounter, a note must be dictated the same day of the members encounter and be entered in the member’s medical record using the S.O.A.P. format, unless otherwise approved by the Chief Medical Officer or his/her designee, and shall include the following information pursuant to 59A-12.005 F.A.C.: • Patients name • Member identification number (chart number) • Date of birth • Sex • Date • Chief complaint or purpose of visit • Objective finding of practitioner • Diagnosis or medical impression • Studies ordered, for example: lab, x-ray, EKG, and referral reports • Therapies administered and prescribed • Practitioner’s name and profession (i.e., M.D., R.N., L.P.N., etc., including signature or initials of practitioner. Practitioner shall be responsible for appropriate entries being made on the summary list.

840 L.

Entries in members’ records are legible to the clinical personnel in the organization.

M.

Any notation in a member’s chart indicating diagnostic or therapeutic intervention as part of clinical research is clearly contrasted with entries that are made with regard to provision of care.

N.

When necessary for assuring continuity of care, summaries or records of a member treated elsewhere, (such as by another physician, hospital, ambulatory surgical service, nursing home, or consultant), are obtained.

841 Community Based Primary Care Physicians Orientation RESPONSIBILITIES – Physicians are responsible for maintaining a medical record for each Florida Health Care Plans patient just as they would for their private patients. It is the responsibility of that private office to request any FHCP medical records as needed for their office; It is suggested that as the FHCP patient makes their initial appointment with that office, that the patient’s records be requested at that time. Any chart/record that is needed urgently during regular business hours can be called for by calling 386-238-3200 Ext 3258 or 386-238-3287 or 386-238-3200 Ext 3550. Patients do not need to fill out a medical release form in order to have their medical records sent to an outside provider as long as that provider is within the FHCP Network. It is, however, the outside provider’s responsibility to request the medical record from our office.

DICTATION – When a patient is seen by one of the in-house specialists, the Specialist and the PCP on record will automatically receive a faxed copy of the EHR note. In addition, any outside referral records sent to us will be copied and sent to the patients outside provider as well. Laboratory and X-ray reports come directly from Radiology and from LabCorp. If a member uses LabCorp there is an automatic record placed into the patient’s EHR chart. If Quest, or any other laboratory is used, that company will send the results directly to the ordering physician. If, for any reason, the provider feels they are not getting those reports, they need to contact those individual departments. PRO REVIEW – FHCP is involved with PRO review for compliance with our Medicare contract. FHCP is required to send copies of all patient records to the PRO as requested by them. As a result, the Daytona Medical Records Dept. may be contacting the outside providers for copies of their records for compliance with this review.

842 REQUESTING COPIES OF PATIENT RECORDS PLEASE LIST PATIENT’S FULL NAME AND FHCP NUMBER. THE FHCP NUMBER IS EXTREMELY IMPORTANT, AS WE MAY HAVE 10 PATIENTS WITH THE SAME NAME. MAKE A LIST OF PATIENT’S NAME AND FHCP NUMBER AT THE TIME THE PATIENT MAKES THEIR FIRST APPOINTMENT. PLEASE FAX DAILY TO THE DAYTONA BEACH MEDICAL RECORDS DEPARTMENT. (We DO NOT need a signed release form from the patient). IF MEDICAL INFORMATION IS NEEDED IMMEDIATELY OR ON AN EMERGENCY BASIS DURING REGULAR BUSINESS HOURS, PLEASE CALL 386-238-3287, 386-2383200 EXT 3550, EXT 3258, OR 1-800-321-1227 AND ASK FOR MEDICAL RECORDS DEPARTMENT. IF LINES ARE BUSY DUE TO ASSISTING MEMBERS AT OUR WINDOW PLEASE LEAVE A VOICEMAIL. FOR MENTAL HEALTH RECORDS PLEASE CALL 386-676-7171. We ask that everyone follow the above listed procedure so that the records may be ordered and received before the patient is seen by their outside PCP for the first time. Your assistance and cooperation will be greatly appreciated, and will hopefully eliminate any problems experienced with records requests. Thank you.

843

Medical Record Request Form Provider Name: __________________________________ Date: __________________ Patient Name

FHCP – Med/Record #

Date of Appointment

844 MEDICAL RECORDS Procedure for Dictating Medical Records The attending practitioner shall be responsible for the preparation of a complete and legible record on each member. Its content shall be pertinent and current. Providers / Practitioners shall include identification data, member name and FHCP plan number. Providers are required to use S.O.A.P. method for dictating notes, as follows: S: Subjective O: Objective A: Assessment P: Plan At the completion of dictation, the provider / practitioner is to specify any significant diagnosis to be listed on diagnosis summary sheet. Provider / Practitioner must sign his / her dictation within two (2) working days after receipt, except on-call or part-time providers who shall sign their dictation on the following scheduled workday. DOCTORS: Please dial 386-274-7410 for Daytona Medical Records outside dictation line for emergency and urgent referrals. Also, emergency pre-op history and physicals may be dictated on this line. This is a straight dictation line only. (Cannot back up and listen). Instructions for Call-In Dictation for Florida Health Care Plans DIAL NUMBER:

386-274-7410 – Once connected, follow the prompts. If a busy signal is reached, please try again. If difficulty continues please call Debbie at 274-7401 or Margie at 274-7400

DOCTORS:

Please identify yourself at the beginning of the recording along with the date, name of FHCP member and FHCP chart number. This will help the transcribers identify the member immediately.

845 MEDICAL RECORDS Release of Information from the Medical Record POLICY FOR RELEASE OF INFORMATION Policy Statement The medical record is the property of FHCP and is maintained for the benefit of the member, the physician, and FHCP. Purpose The primary purpose of the medical record is to document the course of the member’s illness and treatment during all periods of care; whether as an inpatient or outpatient. The record is important in medical practice. It serves as an instrument for communicating among physicians and other professionals contributing to the member’s care and as a basis for planning and evaluating that care. The secondary purpose of the medical record is: To serve as a source of substantiation of the member care services and treatment provided. To provide clinical data of interest to researchers and continuing education programs. To meet and support legal and quasi-legal obligations imposed on the hospital and physician. Content and Format The medical record is used by practitioners in the management of member care. Because of this use, the objectives of effective member care should serve as the basis for determining content, methods of organizing clinical information, desired manner and style of recordings, adequacy and timeliness of entries and justification for exclusion or inclusion of information. Ownership Records of the FHCP, including medical records maintained for the benefit of the member, physician and FHCP are regarded as the property of FHCP. The medical information in the record remains privileged and may not be released without proper authorization.

846 MEDICAL RECORDS Release of Information from the Medical Record – (Con’t.) AUTHORIZATION FOR RELEASE OF INFORMATION FHCP Authorization for Release of Information Forms shall meet the following criteria: 1.

The authorization must be in writing.

2.

The authorization must be witnessed and dated.

3.

The authorization must be signed by the member. In case of a minor or someone who is mentally incompetent, the authorization must be signed by the member’s legal guardian or personal representative, a person with POA specific to Medical Records access or next of kin or authorized health care surrogate.

4.

The authorization must be current or within 6 months following signature.

Note: Supporting documentation is required. Note: Proper identification is required for authorization of release. Note: The signature on the authorization, unless notarized, should be compared with the signature in the medical record. VERBAL REQUESTS FOR RELEASE OF INFORMATION Information may be released verbally only to the physician or a hospital where the member is currently being treated. These verbal requests are handled on a “call-back” basis in order to identify the physician or hospital requesting the information. Verbal information should be given only in an urgent or an emergency situation, and ask that a written authorization be forwarded immediately. FEDERAL DRUG AND ALCOHOL ABUSE REGULATIONS PROHIBIT the release of information from the member’s medical record regarding the use of, or possible use of alcohol or drugs WITHOUT A SPECIFIC AUTHORIZATION for such information from the member. STATE OF FLORIDA REGULATIONS REGARDING HIV TESTING AND INFORMATION PROHIBITS the release of information from the member’s record regarding HIV testing, whether testing is negative or positive, WITHOUT SPECIFIC AUTHORIZATION from the member for such information.

847 MEDICAL RECORDS Confidentiality of Medical Records A.

GENERAL. Except as required by law, any member’s records that contains clinical, social, financial, enrollment, or other data shall be treated in a strictly confidential manner, and steps shall be taken to reasonably protect such records from loss, tampering, alterations, destruction and unauthorized or inadvertent disclosure of information.

B.

RELATIONSHIPS WITH MEMBER. All relationships between the physician and member and between the HMO and members are bound by strict duties of secrecy and fidelity. It is the duty of all personnel to be sensitive to these relationships and to ensure that they are not violated.

C.

EMPLOYEE KNOWLEDGE OF CONFIDENTIALITY POLICIES. All HMO staff who are authorized access to member records shall sign a statement that they have read and understand the HMO confidentiality policies. This shall be made part of the person’s personnel record.

D.

VIOLATION OF CONFIDENTIALITY. 1.

Intentional Violation. Any staff of the HMO who intentionally violates the confidentiality of a member’s records shall be subject to immediate termination from employment

2.

Unintentional Violation. For a first offense, the staff person shall be counseled and a letter of warning shall be entered in the personnel record. A second offense shall be the basis for termination.

E.

SECURITY OF RECORDS. All medical records, except ophthalmology and dental, shall be maintained in the Medical Record Office when not being used for authorized purposes. All other medical records are maintained in electronic form.

F.

AUTHORIZED PERSONS. The medical record is a confidential document, access to which should be restricted to the member, to the member’s authorized representative, and to the attending physician and HMO staff members with a legitimate need for such access.

848 MEDICAL RECORDS Confidentiality of Medical Records – (Con’t.) G.

RELEASE OF INFORMATION. 1.

2.

Written Authorization. The release of information requires the member’s written authorization, so as to protect the member from invasion of privacy. To release privileged information, a valid authorization must be in writing and: a. Be addressed to Florida Health Care Plans, Inc. b. Have current date (within 6 months.) c. State clearly the party of whom the information is to be sent d. Bear the signature of the member, or the person legally empowered to act on the member’s behalf e. Authorization must be witnessed (other than by family members). Authorization Required. Authorizations are required for release of information from the following: a. Physicians not on the FHCP staff b. Attorneys c. Insurance Companies d. Schools e. Law Enforcement Agencies – without member consent, a court order or a search warrant is needed f. Immigration Department g. Employers h. Welfare Agencies

849 MEDICAL RECORDS CLINICAL RECORDS ACCESS BY MEMBER 1.

ORIGINAL RECORD OR COPIES: The HMO shall furnish to any member or to such member’s guardian, curator or personal representative, authorized Health Care surrogate, or person with Health Care POA specific to Medical Records access or next of kin, designated in writing, a true and correct copy all member records, including x-rays (except progress notes and consultations report sections of a psychiatric nature). (Fees for copying FHCP records shall be in accordance with Florida Statutes).

2.

Consent for Disclosure: Member records shall have a privileged and confidential status and shall not be disclosed without written consent of the member to whom they pertain except as follows: •

FHCP personnel for use in connection with treatment of the member.



FHCP personnel only for internal administrative purposes associated with treatment.



In any civil or criminal action, unless otherwise prohibited by law, upon the issuance of a subpoena from a court of competent jurisdiction and proper notice by the party seeking such records to the member or his legal representative.

RESPONSIBILITY The Medical Records Director is responsible for overseeing and maintaining the confidentiality, security and physical safety of the member’s medical record.

850 SUBPOENAS AND REQUESTS FOR RECORDS FROM ATTORNEYS When a physician inadvertently receives a request or subpoena for medical records, please immediately forward the request or subpoena to the FHCP Medical Records Department in the Daytona Beach facility for processing. Following this procedure is imperative to ensure the authenticity of the document before the record is pulled and reviewed by the Risk Manager. This procedure is designed to relieve the physician and his / her staff and the organization from risk. FHCP’s Risk Manager and Legal Counsel will communicate and advise the physician as necessary.

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877 FLORIDA HEALTH CARE PLAN, INC. NOTICE OF PRIVACY PRACTICES Effective September 23, 2013

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Our Pledge Regarding Protected Health Information Florida Health Care Plan (FHCP) creates a record of the care and services you receive from FHCP. We need this information to provide you with quality care, administer your health care benefits, and comply with certain legal requirements. This notice applies to all of the records containing protected health information generated by FHCP. We understand that medical information about you and your health is personal and we are committed to protecting it. Florida Health Care Plan (FHCP) will take every reasonable action to protect your health care information including the protection of your verbal, written, and electronic protected health information (e-PHI) using all means necessary while ensuring that the information is readily available to the providers that deliver your health care. FHCP implements appropriate administrative, technical, and physical safeguards to protect your health information across the organization from unintended or unauthorized use, disclosure, modification or loss.

Introduction/Overview This Notice of Privacy Practices describes how FHCP may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. This notice describes the privacy practices of FHCP including: • All divisions and departments of FHCP. • All employees, staff and other FHCP personnel. • All FHCP volunteers and auxiliary staff.

Uses and Disclosures of Protected Health Information for Treatment, Payment or Health Care Operations Your protected health information may be used and disclosed by FHCP’s staff and others outside of our offices that are involved in the delivery of health care services and benefits. Your protected health information may also be used and disclosed to pay your health care bills and to support FHCP’s operations.

878 Following are examples of the types of uses and disclosures of your protected health care information that we are permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with third parties. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment. Payment: We may use or disclose your protected health information, as needed, to bill or make payment for your health care services. This may include certain activities that we take before we approve or pay for your health care services such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, we may ask for a copy of your medical record from a hospital where you received services to ensure that their bill was appropriate. Health Care Operations: We may use or disclose, as-needed, your protected health information in order to support FHCP’s business activities. These activities include, but are not limited to, quality assessment activities, employee review activities, training, licensing, and educational activities, and conducting or arranging for other business activities. For example, we may use your protected health information during medical utilization reviews. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We will share your protected health information with third party “business associates” that perform various activities (e.g., case management, out-of-area claims re-pricing). Whenever an arrangement between FHCP and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives. We may also use and disclose your information for educational activities. For example, your name and address may be used to send you a newsletter.

879 Disclosures of Protected Health Information (PHI) to Plan Sponsors: It is Florida Health Care Plan (FHCP) policy to not disclose PHI to plan sponsors such as a member’s employer. FHCP may provide plan sponsors summary health information in a form that has been deidentified. De-identifying health information includes removing things such as name, date, diagnosis, address, medical record number, and any other unique identifying number or characteristic. This information may be used for obtaining insurance quotes or verifying enrollment status to ensure appropriate billing.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization Other uses and disclosures of your protected health information will be made only with your consent, written authorization or opportunity to object unless required by law as described below. Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes. We may not sell your protected health information without your authorization. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes. You may revoke this authorization, at any time, in writing, except to the extent that FHCP has taken an action in reliance on the use or disclosure indicated in the authorization.

Other Required and Permitted Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Object In certain situations we are required or permitted to use or disclose your protected health information. Your authorization is not required for the following uses or disclosures: Required By Law: We may use or .disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures. Public Health Activities: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. We may disclose protected health information to a school, about an individual who is a student or prospective student of the school, if: • The protected health information disclosed is limited to proof of immunization;

880 • •

The school is required by State or other law to have such proof of immunization prior to admitting the individual; and FHCP obtains and documents the agreement to the disclosure from either; o A parent, guardian, or other person acting in loco parentis of the individual if the individual is an unemancipated minor; or o The individual, if the individual is an adult or emancipated minor.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws. Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on FHCP’s premises, and (6) medical emergency (not on FHCP’s premises) and it is likely that a crime has occurred. Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to

881 permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes. Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. Workers’ Compensation: Your protected health information may be disclosed by us as authorized by and to the extent necessary to comply with workers’ compensation laws and other similar legally-established programs. Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the U.S. Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Authorization or Opportunity to Object You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then we, using our professional judgment and experience, may determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant will be disclosed. We may use and disclose your protected health information in the following instances.

882 Others Involved in Your Health Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. If it is in Your Best Interest: Unless you object, we may use our professional judgment and experience with common practice to make reasonable inferences of your best interest in allowing a person to act on your behalf to pick up filled prescriptions, medical supplies, X-rays, or other similar forms of protected health information. Disaster Relief: Unless you object, we may use or disclose your protected health information to a public or private entity authorized by law or its charter to assist in disaster relief efforts. Deceased Individuals: If an individual is deceased, FHCP may disclose to a family member, or other persons identified who were involved in the individual’s care or payment for health care prior to the individual’s death, the protected health information of the individual that is relevant to such persons involvement, unless doing so is inconsistent with any prior expressed preferences of the individual that is known to FHCP.

Your Rights Following are your rights with respect to your protected health information. You may exercise any of these rights by contacting our Member Services Department as described at the end of this Notice. You have the right to inspect and/or copy your protected health information. This means you may inspect and/or obtain a paper or electronic copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. Applicable copying fees apply for costs associated with labor and supplies for reproducing paper copies and creating electronic copies of your protected health information. A “designated record set” contains medical and billing records and any other records that FHCP uses for making treatment and benefit administration decisions about you. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of

883 your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. FHCP is not required to agree to a restriction that you may request prohibiting FHCP from using your protected health information for the purposes of treatment, payment or health care operations. If FHCP believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If FHCP does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You have the right to restrict release of information for certain services. You have the right to request FHCP to not disclose PHI to a health plan for a health care item or service where you paid in full out of pocket. You have the right to request and receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. You may have the right to have FHCP amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment, health care operations, or authorized disclosures as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures made by FHCP in the six years prior to your request, but, no earlier than the effective date of this Notice, April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. You have the right to a breach notification. You have the right to be notified of any breach of your unsecured protected health information in accordance with Federal Regulations. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

884 Inquiries About This Notice, Exercise Of Privacy Rights, And Complaints If you have a question about this Notice, or you wish to exercise your rights described in this Notice, or you believe your privacy rights have been violated, you may contact us at: Florida Health Care Plan Member Services Department 1340 Ridgewood Avenue Holly Hill, Florida 32117 (386) 615-4022 (877) 615-4022 TTY/TDD: Florida TRS Relay 711 Hours of Operations: 8:00 a.m. – 5:00 p.m. All complaints must be submitted in writing. You will not be penalized for filing a complaint. A complaint may also be filed with the U.S. Department of Health and Human Services at the following address: Office for Civil Rights U.S. Department of Health and Human Services 61 Forsyth Street, S.W., Suite 3B70 Atlanta, GA. 30323 Voice: (404) 562-7886 TDD: (404) 331-2867 FAX (404) 562-7881

Other Uses Of Medical Information Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization except to the extent that FHCP has taken an action in reliance on the use or disclosure indicated in the authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

885

Acknowledgement The undersigned acknowledges that he/she has received a copy of Florida Health Care Plan’s Notice of Privacy Practices. (Please Print) Name: Street Address: City, State, Zip Code: FHCP Member Number:

Signature:

Name

Date

Please return this Acknowledgement to: Florida Health Care Plan Member Services Department 1340 Ridgewood Avenue Holly Hill, Florida 32117

886

SECTION 23 RADIOLOGY DEPARTMENT Facility Locations/Exams Performed Requesting Loan Films/Radiology Reports Radiology Requisition

887

RADIOLOGY DEPARTMENT

FACILITY

EXAMS PERFORMED

FHCP – Daytona Beach 350 N. Clyde Morris Blvd. Daytona Beach, FL 32114 386 / 238-3229 800 / 321-1227 Ext. 3229 Fax: 386 / 238-3292

Routine Radiography/Sports Medicine Bone Density (By Appointment Only) Bone Density Studies for Patients 350 lbs. & under Open for EHCC after hours

FHCP – Ormond Beach 461 South Nova Rd. Ormond Beach, FL 32174 386 / 671-4337 386 / 481-6185

Routine Radiography (By Appointment Only)

FHCP - Palm Coast 309 Palm Coast Parkway Palm Coast, FL 32137 386 / 446-0561 Fax: 386 / 446-0324

Routine Radiography (By Appointment Only)

FHCP -- Port Orange 740 Dunlawton Ave. Port Orange, FL 32127 386 / 763-4910 Fax: 386 / 481-6399

Routine Radiography (By Appointment Only)

FHCP – Orange City 2777 Enterprise Road Orange City, FL 32763 386 / 774-2550 Ext 6823 800 / 390-3427 Ext. 6823 Fax: 386 / 774-4705

Routine Radiography (By Appointment Only) Open for EHCC after hours

888 FHCP – Deland 937 North Spring Garden Ave., Deland, FL 32720 386 / 736-1948 Prompt #6 Fax: 386 / 734-4571

Routine Radiography (By Appointment Only)

FHCP – Edgewater 239 N. Ridgewood Ave. Edgewater, FL 32132 386 / 427-4868 Fax: 386 / 481-6593

Bone Density (By Appointment on Wed Only)

LAD Imaging, LLC 1555 Saxon Blvd., Bldg. 4, Ste. 401 Deltona, FL 32725 386 / 860-9336 Fax: 386 / 860-2225

Bone Density (By Appointment Only)

Palm Coast Imaging 3 Pine Cone Drive, Ste. 101 Palm Coast, FL 32137 386 / 446-5200 Fax: 386 / 446-1866

Bone Density (By Appointment Only)

Town Center Imaging 21 Hospital Drive Palm Coast, FL 32164 386 / 445-4400 Fax: 386 / 597-5675

Bone Density (By Appointment Only)

St. Augustine Imaging 190 Southpark Blvd. St. Augustine, FL 32086 904 / 827-9191 Fax: 904 / 827-9171

Bone Density (By Appointment Only)

889

RADIOLOGY DEPARTMENT

REQUESTING LOAN FILMS Original films may be loaned to FHCP/HPP Plan A member(s) for their scheduled appointments. The geographic limit will be within the affiliated network. The Medical Release Form must be signed by the member for the original films being provided to the affiliate, which will be specific on the release form. The responsibility for the original film(s) will be assumed by the member upon signature of the release form and for the return of the film(s) to FHCP. For inactive members, copies will; be provided at their expense.

RADIOLOGY REPORTS Reports will be sent to the doctor’s office within a 48 hour period in a red interdepartmental jacket. They are marked for “X-Ray Use Only” and should be returned to the Radiology Department for reuse in sending out Radiology reports. NOTE: For true clinical emergencies, the Radiologist will provide a preliminary report (PR). When requesting a preliminary report, please write PR in RED on the Radiology Requisition/Report form. The in-house doctors will receive a written PR report, or be called, and outside doctors will be called. (Requesting a wet reading is not acceptable.) For doctors that are “live” in TWEHR, the PR will be scanned in for your review and electronic signature.

890

FHCP RADIOLOGY REQUISITION P. O. BOX 9910 – DAYTONA BEACH, FL 32120 FFS: NAME:

DOB:

REFERRING PHYSICIAN:

NO

MRN:

PROV. #:

PCP:

YES

DATE ORDERED:

PROV. #:

EXAM DATE:

DIAGNOSIS: CONSENT: I do herby certify that to the best of my knowledge I am NOT pregnant. I further understand that this releases FHCP from any and all liabilities concerning medically necessary x-rays.

Smoker:

LMP:

PPD/

YRS

WITNESS:

GENERAL RADIOLOGY DESCRIPTION Abdomen (AP) Spine) (KUB) Abdomen (Supine & Upright) Abdominal w/Oblique’s A-C Joints Acute Abdomen Series Ankle, (2 Views) (R-L) Ankle, (4 Views) (R-L) Bone Age Studies (Ht, Wt, Sex) Bone Mineral Density (Central) Chest, Decubitus Chest, Lordotic Chest, Oblique Chest, PA & Lat Chest, Single View Clavicle (R-L) Consultation Elbow, (2 Views) (R-L) Elbow, (4 Views) (R-L) Facial Bones Facial Bones Limited Femur (R-L) Finger(s) (R-L) Foot, (2 Views) (R-L) Foot, (3 Views) (R-L) Forearm (R-L) Hand (Complete) (R-L) Hand (Limited) (R-L) Hip (R-L) Hips – BILATERAL Hips – PEDS Hips Bilateral WITH PELVIS Humerous (R-L) Joint Survey Knee, (2 Views) (R-L) Knee, (3 Views) (R-L) Knee, (4 Views) (R-L) Long Bone Survey (PEDS) Lower Extremity – PEDS

X

CPT CODE 74000 74020 74010 73050 74022 73600 73610 77072 77080 71035 71010 71022 71020 71010 73000 76140 73070 73080 70150 70140 73550 73140 73620 73630 73090 73130 73120 73502 73522 73521 73523 73060 77077 73560 73562 73564 77076 73592

Diagnosis Code

DESCRIPTION Metastatic Bone Survey Nasal Bones Neck, Soft Tissue Orbits OS Calcis (R-L) Paranasal Sinuses Pelvis (AP) Ribs – BILATERAL Ribs Bilateral w CHEST Ribs, Unilateral (R-L) Sacroiliac Joints Sacrum & Coccyx Scanogram, Bone Length Study Scapula (R-L) Scoliosis (1 Veiw) Scoliosis (2 Views) Shoulder (1 View) Shoulder (2 Views, R-L) Shunt Services Skull Spine, Cerv, Complt w/Flex Ext Spine, Cervical (3 Views) Spine, Cervical (5 Views) Spine, Lum, Complt w/Flex Ext Spine, Lumbar Flex & Ext. Spine, Lumbosacral (3 Views) Spine, Lumbosacral (5 Views) Spine, Single View Spine, Thoracic Spine, Thor, Complt w/Flex Ext Spine, Thoracolumbar (2 Views) Sternoclavicular Joints Sternum Tibia & Fibula (R-L) Toe(s) (R-L) Upper Extremity – PEDS Wrist, (2 Views) (R-L) Wrist, (4 Views) (R-L)

X

CPT CODE 77074 70160 70360 70200 73650 70220 72170 71110 71111 71100 72202 72220 77073 73010 72081 72082 73020 73030 75809 70260 72052 72040 72050 72114 72120 72100 72110 72020 72072 72074 72080 71130 71120 73590 73660 73092 73100 73110

Diagnosis Code

891

SECTION 24 ULTRASOUND DEPARTMENT Facility Locations/Exams Performed Ultrasound Examinations Ultrasound Studies with CPT Codes and Preparations Ultrasound Referral Form

892 FLORIDA HEALTH CARE PLANS ULTRASOUND DEPARTMENT

FACILITY

EXAMS PERFORMED

Florida Health Care Plans – Daytona Beach 350 N. Clyde Morris Blvd. Daytona Beach, FL 32114 386-238-3270 800/321-1227 Ext. 3303 Fax: 386-238-3256

Ultrasound (By Appointment Only)

Florida Health Care Plans – Palm Coast 309 Palm Coast Parkway Palm Coast, FL 32137 386-238-3270 800/321-1227 Ext. 3303 Fax: 386-238-3256

Ultrasound (By Appointment Only)

Florida Health Care Plans – Orange City 2777 Enterprise Road Orange City, FL 32763 386-238-3270 800/321-1227 Ext. 3303 Fax: 386-238-3256

Ultrasound (By Appointment Only)

Florida Health Care Plans – Port Orange 740 Dunlawton Ave. Port Orange, Fl 32127 386-238-3270 800/321-1227 Ext. 3303 Fax: 386-238-3256

Florida Health Care Plans – Edgewater 239 Ridgewood Ave. Edgewater, FL 32132 386-238-3270 800/321-1227 Ext. 3303 Fax: 386-238-3256

Ultrasound (By Appointment Only)

Ultrasound (By Appointment Only)

** Ultrasound appointments for ALL locations are scheduled with the main ultrasound office in Daytona.**

893

ULTRASOUND EXAMINATIONS

ULTRASOUND EXAMINATIONS are performed at the Daytona Beach, Palm Coast, Orange City, Port Orange and Edgewater facilities. The Daytona Beach ultrasound department is open Monday through Friday (excluding holidays) from 8:00 am to 5:00 pm. The Orange City ultrasound department is open Monday through Friday (excluding holidays) from 8:30 am to 4:00 pm. The Palm Coast ultrasound department is open Monday through Friday (excluding holidays) from 8:00 am to 4:30 pm. The Port Orange ultrasound department is open Tuesday through Thursday from 8:30 am to 4:00 pm (excluding holidays). The Edgewater Ultrasound department is open every Tuesday, Wednesday, and Thursday, and every other Monday and Friday from 8:00 to 4:00 (excluding holidays). Appointments for all facilities are scheduled through the main ultrasound office in Daytona Beach, 386-238-3270.

894 FLORIDA HEALTH CARE PLANS ULTRASOUND STUDIES WITH CPT CODES AND PREPARATIONS

EXAM

CPT CODE

PREPARATION

Complete Abdomen (Pancreas, Liver, Bile ducts, Gallbladder, Spleen, Kidneys)

76700

N.P.O. after midnight. (Nothing to eat or drink after midnight the evening before the exam)

Limited Abdomen/RUQ (Pancreas, Liver, CBD, GB)

76705

N.P.O. after midnight. (Nothing to eat or drink after midnight the evening before the exam)

Aorta

76775

N.P.O. after midnight. (Nothing to eat or drink after midnight the evening before the exam)

Renal/Bladder

76770

Complete drinking 24 oz. of water one hour prior to your appointment time. Do not empty your bladder.

Pelvic/Transvaginal (Uterus/Ovaries/Adnexa)

76856/76830

Complete drinking 32 oz. of water one hour prior to your appointment time. Do not empty your bladder.

Breast

76641/76642

No preparation.

Thyroid

76536

No preparation.

Testicular

76870

No preparation.

Baker’s Cyst

76882

Carotid

93880

No preparation.

Lower Extremity – Venous

93971 (unilateral) 93970 (bilateral)

No preparation.

Upper Extremity – Venous

93971 (unilateral) 93970 (bilateral)

No preparation.

Lower Extremity – Arterial (ABI - Segmental Pressures)

93922 93923 93924

No preparation.

Duplex Scan - Arteries

93925 (bilateral) 93926 (unilateral)

No preparation.

Miscellaneous (palpable lump) Echocardiogram, transthoracic

No preparation.

No preparation. 93306

No preparation.

895 FLORIDA HEALTH CARE PLANS

ULTRASOUND REFERRAL FORM Date Ordered: A.

B.

NAME:

DOB:

MRN:

REFERRING PHYSICIAN:

PROV. #:

PCP:

PROV. #:

ULTRASOUND EXAM REQUESTED Description Abdomen Complete Abdomen Limited Aorta Gallbladder Breast Renal Pelvic Transvaginal Testicular Thyroid Bakers Cyst Carotid Lower Extremity – Venous – Unilateral Lower Extremity – Venous – Bilateral Lower Extremity – Arterial – Duplex – Unilateral Lower Extremity – Arterial – Duplex – Bilateral ABI, Single Level Segmental Pressures (Multiple Sites) Segmental Pressures (Post Exercise) Echocardiogram Echocardiogram with microbubbles Other

CPT Code 76700 76705 76775 76705 76641/76642 76775 76856 76830 76870 76536 76881 93880 93971 93970 93926 93925 93922 93923 93924 93306 93306

C.

Diagnostic Code:

D.

WRITTEN DIAGNOSIS AND “REASON FOR REQUEST” (ALSO IF FOLLOW – UP FROM OUTSIDE DIAGNOSTIC TEST, PLEASE ATTACH REPORT)

E.

APPOINTMENT DATE: TIME: C & D MUST BE COMPLETED FOR APPOINTMENT TO BE SCHEDULED

01-912 / 4-8-16

896

SECTION 25 FLORIDA HEALTH CARE PLANS CALL CENTER Call Center Hours Functions

897

FLORIDA HEALTH CARE PLANS CALL CENTER

The Florida Health Care Plans Call Center is a multi-functional department that is operational 24 hours per day/ 7 days per week providing assistance and direction to providers, staff, hospitals, patients and their families. The Call Center also collects data to assist with the coordination and satisfaction of care and works collaboratively with the Utilization Management Division which consists of the Central Referral Department, Case Management Department and the Member Services Department. They also provide support to the FHCP Medical Practices in collecting hospital medical records for the physicians as well as the Medical Billing Department.

During the hours of 8:00 a.m. to 5:00 p.m. the Call Center may be reached directly by calling (386) 226-4542.

After 5:00 p.m. the Call Center becomes the branch of

communication between Providers, hospitals and patients and may be reached by calling 1-800-352-9824.

898

SECTION 26 HOLIDAYS

Holiday Calendar

899

TO:

All Florida Health Care Plan Employees

FROM:

Dr. Wendy Myers, President and CEO

DATE:

August 16th, 2016

RE:

2017 Holiday Schedule

This memo contains a list of the 2017 holiday schedule and the dates on which they will be observed by Florida Health Care Plans. Any additional holidays or observances an employee wishes to schedule off will fall under Human Resources Policy 7.7, Scheduled Personal Leave Time. ______________________________________________________________________________

Holidays:

Date Observed:

New Year’s Day Observance

January 2nd, 2017

Memorial Day

May 29th, 2017

Independence Day

July 4th, 2017

Labor Day

September 4th, 2017

Thanksgiving Observance

November 23rd and 24th, 2017

Christmas Day

December 25th, 2017

900

SECTION 27 GRIEVANCE & APPEALS

Complaints, Appeals & Grievances Chart Contract Determinations and Appeals Policy Initial Determination and Reconsideration of Coverage of Medicare Beneficiary Claims Policy Non-Medicare Subscriber Claims Review and Processing Policy Medical Staff Bylaws, Rules and Regulations Policy Participating Provider Payment Rate Disputes Policy Non-Par Provider Payment Rate Disputes Regarding Medicare Surgical Assistant Payment Policy

901

Complaints, Appeals & Grievances Medicare (Part C)

First Level

Complaint oral

Grievance written

Response

60 days from event Within 30 days. Complaints may be Satisfaction, Access, Policy & Procedure or Quality. Quality complaints must be responded to in writing with QIO information included.

Second Level

No level 2 as there is no external entity that exits to hear (Medicare Managed Care Manual Chapter 13, Section 20)

Within 30 days No level 2 as there is no external entity that exits to hear (Medicare Managed Care Manual Chapter 13, Section 20)

Response

N/A

N/A

Medicare (Part D)

Complaint oral

60 days from event

Grievance written

First Level

60 days from event

Response

Within 30 days

Within 30 days

Second Level

No level 2 as there is no external entity that exits to hear (Medicare Managed Care Manual Chapter 13, Section 20)

No level 2 as there is no external entity that exits to hear (Medicare Managed Care Manual Chapter 13, Section 20)

N/A

N/A

Response

60 days from event

PreSx Appeal oral or written Standard Appeal Expedited Appeal

Concurrent Appeal oral

PostSx Appeal written

60 days from event

60 days from event

QIO (FMQAInc.) hears appeal directly for Acute Care, SNF, HHC & CORF but services continue until an outcome decision. "Stop Services Date" is discharge date determined by QIO

Within 30 days

Within 24 hours but never to exceed 72 hours

Normally within 24 hours but can take up to 10 days

Within 60 days

Denials are sent automatically to Maximus on Member behalf. Defined by Maximus per case

Denials are sent automatically to Maximus on Member behalf. Defined by Maximus per case

Member may re-appeal denial to QIO. If denied again, "Stop Services Date" is discharge date determined by QIO at their initial review. normally within 24 hours but can take up to 10 days

Denials are sent automatically to Maximus on Member behalf. Defined by Maximus per case

PreSx Appeal oral or written Standard Appeal Expedited Appeal 60 days from event Within 5 days Denials may be sent to Maximus however Member must initiate as described in letter from FHCP with standard Medicare language. Defined by Maximus per case

60 days from event Within 24 hours but never to exceed 72 hours Denials may be sent to Maximus however Member must initiate as described in letter from FHCP with standard Medicare language. Defined by Maximus per case

Concurrent Appeal N/A N/A N/A

60 days from determination

PostSx Appeal written 60 days from determination

N/A

Within 30 days

N/A

Denials may be sent to Maximus however Member must initiate as described in letter from FHCP with standard Medicare language.

N/A

Commercial (Non-Grandfathered) and Exchange Complaint oral

902 Grievance written

PreSx Appeal oral or written Standard Appeal Expedited Appeal

First Level

365 days from event

365 days from event

365 days from event

Response

Within 30 days.

Within 30 days

Second Level

No level 2 as there is no external entity that exits to hear (Medicare Managed Care Manual Chapter 13, Section 20)

No level 2 as there is no external entity that exits to hear (Medicare Managed Care Manual Chapter 13, Section 20)

Response

N/A

N/A

Within 30 days Member initiated Denials may be sent to Maximus as described in letter from FHCP with standard Medicare language. Defined by Maximus per case

Commercial (Grandfathered) Complaint oral

Grievance written

First Level

365 days from event

Response

Within 30 days

Within 30 days

Second Level

No level 2 as there is no external entity that exits to hear (Medicare Managed Care Manual Chapter 13, Section 20)

No level 2 as there is no external entity that exits to hear (Medicare Managed Care Manual Chapter 13, Section 20)

N/A

N/A

Response

365 days from event

365 days from event Within 24 hours but never to exceed 72 hours Member initiated Denials may be sent to Maximus as described in letter from FHCP with standard Medicare language. Defined by Maximus per case

PreSx Appeal oral or written Standard Appeal Expedited Appeal 365 days from event Within 30 days Member initiated denials may be sent to Subscriber Assistance Program (SAP) as described in FHCP letter. Defined by SAP per case

365 days from event Within 24 hours but never to exceed 72 hours Member initiated denials may be sent to Subscriber Assistance Program (SAP) as described in FHCP letter. Defined by SAP per case

Concurrent Appeal oral

PostSx Appeal written

Member may request both an FHCP AND a Maximus review, concurrently. Maximus decision prevails.

365 days from determination

Within 24 hours but never to exceed 72 hours

Within 60 days

If Member did NOT request Maximus review initially (at Level 1), then Member may initiate denial to Maximus as described in FHCP letter. within 24 hours but never to exceed 72 hours

Member initiated Denials may be sent to Maximus as described in letter from FHCP with standard Medicare language. Defined by Maximus per case

Concurrent Appeal oral

PostSx Appeal written

QIO hears appeal directly and services continue until outcome. Stop Services date is date determination from QIO.

365 days from determination Within 60 days

Member initiated denials may be sent to Subscriber Assistance Program (SAP) as described in FHCP letter.

Member initiated denials may be sent to Subscriber Assistance Program (SAP) as described in FHCP letter.

Defined by SAP per case

Defined by SAP per case

903

904

905

906

907

908

909

910

911

912

913

914

915

916

917

918

919

920

921

922

923

924

925

926

927

928

929

930

931

932

933

934

935

936

937

938

939

940

941

942

943

944

945

946

947

948

949

950

951

952

953

954

955

956

957

958

959

960

961

962

963

964

965

966

967

968

969

970

971

972

973

974

975

976

977

978

979

980

981

982

983

984

985

986

987

988

Formulated by: Sherrie Hutchinson, MS-HA, Contract Services Administrator Approved by: ________________________________________________ Wendy Myers, MD, CEO Overview Surgical assistants actively assist the physician performing a surgical procedure. Reimbursement for surgical assistant services is based on whether the assistant is a Physician or other health care professional. Medicare Part B pays for services provided by physicians and certain non-physician practitioners, such as nurse practitioners, physician assistants and clinical nurse specialists. Other categories of non-physician practitioners are not recognized as Medicare providers and thus are not able to bill the program independently for their services. Medicare cannot reimburse a surgical assistant's services if the assistant is an unlicensed practitioner and does not qualify to be a Medicare provider. There is no Medicare provider category for Registered Nurse First Assistant (RNFAs), no separately billable RNFA services, and no separate reimbursement for RNFA services. Payment for first assistant at surgery services performed by other providers, including certified surgical technologists and registered nurse first assistants, is covered as part of the prospective payment to the facility (usually the hospital). Such services are reimbursed as part of the Diagnostic Related Group (DRG), if inpatient, and part of the Ambulatory Payment Class (APC), if outpatient. The services of Registered Nurse First Assistant (RNFA) must not be filed to Medicare Part B as payable services and/or billed to beneficiaries or their secondary insurance. To do so, such providers will be at risk of sanctions for inappropriate billing, which could constitute Medicare fraud. As a bundled service, neither Medicare Part B, nor the patient or their insurance carrier may be billed for the surgical assistant service, surgical assistant or their employers. National Physician Fee Schedule: The Assistant Surgeon Eligible List is developed based on the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule Relative Value File (NPFS) status indicators. All codes in the NPFS with the status code indicator "2" for "Assistant Surgeons" are considered by FHCP, Medicare and Retirement to be reimbursable for assistant surgeon services, as indicated by an assistant surgeon or surgical assistant modifier (80, 81, 82, or AS). All codes in the NPFS with the status code indicator "1" for "Assistant Surgeons" are considered by FHCP to not be reimbursable for assistant surgeon services, as indicated by an assistant surgeon or surgical assistant modifier (80, 81, 82, or AS), and will not be allowed for payment. All codes in the NPFS with the status code indicator "0" for "Assistant Surgeons" are considered by FHCP to be conditionally reimbursable for assistant surgeon services, as indicated by an assistant surgeon or surgical assistant modifier (80, 81, 82, or AS), and will be reviewed with clinical documentation for assistant at surgery eligibility. "Non-Physicians" (i.e., Surgical Technicians, Registered Nurse First Assists or Certified Surgical Technicians) cannot bill CMS/Medicare. Claims received for these provider types cannot be reimbursed by FHCP as they are not recognized by the Medicare program.

989

FHCP’s Medicare standard reimbursement for assistant surgeon services on the Assistant Surgeon Eligible List which are provided by a physician is 16% of the allowable amount for eligible surgical procedures. This percentage is based on the Medicare Fee Schedule in effect at the time of service. Assistant surgeons who are physicians should submit the identical procedure code(s) as the primary surgeon with one of the following modifiers to represent their service(s). FHCP’s Medicare standard reimbursement for assistant surgeon services on the Assistant Surgeon Eligible List which are provided by a health care professional other than a physician (i.e., Physician Assistants, Nurse Practitioners or Clinical Nurse Specialists) is 85% of 16% of the allowable amount for the surgical procedures. This percentage is also based on the Medicare Physician Fee Schedule. Surgical Assistants who are Physician Assistants, Nurse Practitioners or Clinical Nurse Specialists should submit the identical procedure code(s) as the primary surgeon, under the surgeon's provider number, with the following modifier to represent their service(s). Payment for Surgical Services: Current law Provider Surgeon Co-surgeons First assistants: Physician PA/NP/CNS Resident Registered nurse first assistant Surgical technologist

Description/Payment 100 percent of surgical fee 125 percent of surgical fee, equally divided (each surgeon receives 62.5 percent of surgical fee) (See below by Provider Type) 16 percent of surgical fee 85 percent of physician first assistant fee Not paid separately by Medicare Included in facility payment bundle Included in facility payment bundle

NOTE: If an assistant at surgery meets the definition of a covered provider and he/she submits multiple procedure codes, multiple procedure reductions will apply. Only one surgical assistant for each procedure with an Indicator of 2 on the PFFS is a reimbursable service. No exceptions to this policy are made for teaching hospitals or hospital bylaws.

Modifiers Description AS PA, nurse practitioner, or clinical nurse specialist services for assistant at surgery 80 Assistant surgeon 81 Minimum Assistant Surgeon 82 Assistant surgeon (when qualified resident surgeon not available) 62 Two surgeons/co-surgeons Questions and Answers Q: What if hospital by-laws require the attendance of an assistant for all procedures? A: No exceptions will be made to the policy to accommodate hospital bylaws. The NPFS published by CMS will be used to determine benefits for assistants at surgery.

990

SECTION 28

FHCP Interpreter Services Policy Interpreter Services Discrimination is Against the Law

991

992

993

994

995

996

997

998 FHCP INTERPRETER SERVICES LANGUAGE INTERPRETER SERVICES Language other than English Interpretation: 1.

For basic questions, refer to the Intranet and Vigilant Policy Center (VPC) for a list of employees by facility who have a knowledge of the language requested.

2.

If interpretation is beyond a basic question, or the call must meet CMS standards, contact Language Line Services at 1-866-874-3972. • When a call is received and a specific language is requested or required: 1. Keep caller on the line, with line “OPEN” 2. Hit the display prompt on your phone that reads “MORE” 3. Hit the display prompt on your phone that reads “CONFER” 4. Dial: 866-874-3972 5. Enter using your keypad or provide the Call Agent with your 6 digit Client ID: 280077 6. Press 1 for Spanish 7. Press 2 for all other languages & speak the name of the language you need at the prompt. 8. Brief the Interpreter, summarize what the call is about and give any special instructions 9. Hit the display prompt on your phone that reads “CONFER” 10. All parties (you, the member/patient and interpreter are now on the line) 11. Brief the interpreter, summarize what you need and give any special instructions 12. Say “END OF CALL” to the interpreter when the call is complete VERY IMPORTANT: DO NOT HIT THE “CONFER” PROMPT A SECOND TIME (# 8 ABOVE) UNTIL YOU HAVE COMPLETED STEPS 4 – 7 •

This method may also be used when initiating contact to a member/patient who has requested a specific language by initiating the call and starting at a. above.

Once the call is completed, complete an INTERPRETER SERVICE REQUEST FORM in order to provide justification for payment of the billing upon receipt from Language Line. Completed forms should be emailed to Mickey Linse-Weiss in the Compliance Department at [email protected] .

DEAF SERVICES – SIGN LANGUAGE

999

INTERPRETER SERVICES – VOLUSIA/FLAGLER COUNTIES Easter Seals – Deaf & Hard of Hearing Services 386 / 944-7822 SLS Interpreting Services Inc. 386 / 673-1000 American Sign Language Services Corporation d/b/a ASL Services, Inc. (407) 518-7900 Ext. 309 DEAF SERVICES – TTY FLORIDA RELAY SERVICES To make calls through the Florida Relay Center dial 7-1-1

1000 FHCP Staff Interpreters by facility: DAYTONA BEACH SPANISH Adriana Baucom – WorkForce Wellness - ext. 3204 Darlene Divittorio – Ophthalmology - ext. 7103 Ana Morales- Diabetes/Health Ed - 676-7104 ext. 7381 Myriam Simpson – WorkForce Wellness - ext. 3204 FRENCH Bienvenue (DiDi) Santos-Hammacher – Receptionist - 238-3290 HOLLY HILL ARABIC Sam Fleifel – Medical Billing – ext. 7245 GERMAN Susanne Mansfield – Provider Services – ext. 7395 RUSSIAN Irina Milis – Member Services – ext. 7441 SPANISH Judith Torres – Program Management – ext. 7204 ORMOND BEACHSIDE SPANISH Jennine Febus, MCSS, Ext. 6166 (Dr. Tamariz office) ORANGE CITY SPANISH Matilde Shields - Lab Coordinator - (386) 774-2550, ext. 6827 Sonia Toledo - Medical Records – ext. 6866 HINDI Geeta Sahgal, M.D. - Primary Care - (386) 774-2550, ext. 6871 PORT ORANGE SPANISH Mario Cucchiarella, M.D. - Primary Care - 763-1000

PALM COAST SPANISH Gerardo Baldassarri, MD. – Primary Care – ext. 6412 Angela Cabrera-Vargas - Lab – ext. 6472 Maria Elci – Primary Care – ext. 6417 Aida Pacheco - Lab – ext. 6432 Claudia Prado – Primary Care – ext. 6425

1001

1002 Discrimination is Against the Law Florida Health Care Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Florida Health Care Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Florida Health Care Plans: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) •

Provides free language services to people whose primary language is not English, such as: o Qualified Interpreters o Information written in other languages

If you need these services, contact Daria Siciliano, RN-BC, CCM. If you believe that Florida Health Care Plans has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Daria Siciliano, RN-BC, CCM, Manager of Member Services, 1340 Ridgewood Avenue, Holly Hill, FL 32117. Phone: 1-844-219-6137, TTY: TRS Relay 711, Fax: 386-676-7149, Email: [email protected] You can file grievance in person or by mail, fax, or email. If you need help filing a grievance, Daria Siciliano, RN-BC, CCM Manager of Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at http://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

1003

SECTION 29

Glossary of Terms

1004 Access: The patient’s ability to obtain health services. Measures of access include the location of health facilities and their hours of operation, travel time and distance to health facilities, availability of medical services, including scheduled appointments with health professionals and cost of care. Actuary: A person trained in the insurance field that determines policy rates and conducts various other statistical studies. Actuarial Services for Prepaid Healthcare System: Statistical and probability analysis of financial, utilization and demographic trends use to project health plan premiums or cost of specific benefits for a defined population Admissions/1000: The number of hospital admissions per 1,000 health plan members. The formula for this measure is (# of admissions/member month) X 1,000 members X = of months. The disproportionate Adverse Selection: enrollment of high-risk individuals from a given population into one or more health plans usually resulting in a significantly increased utilization of healthcare services. Allied Health Professionals: Licensed healthcare professionals other than physicians (MDs), such as dentists, nurse practitioners, physical therapists, optometrists, psychologists and podiatrists. Ambulatory Care: Health services rendered in a hospital outpatient facility, a clinic or a physician’s office; often used synonymously with the term “outpatient care”. Anniversary Date: The beginning of a subscriber group’s benefit year.

Assignment: Agreement by the provider to accept any reimbursement from a third party payer as payment in full for the services rendered. When a provider accepts assignment, balance billing for charges that were not paid in full is not permitted (except for collection of any deductible, co-payment and/or coinsurance that the patient is required to pay). Average Length of Stay (ALOS): The average number of days in the hospital for each admission. The formula for this measure: total patient days divided by # of discharges for a given period of time. Average Wholesale Price (AWP): The standardized cost of a pharmaceutical calculated by averaging the cost of an undiscounted pharmaceutical charged to a pharmacy provider by a large group of pharmaceutical wholesale suppliers. Beneficiary: Synonymous with enrollee or member. A person eligible to receive benefits from a HMO or insurance policy. Benefit Package: A collection of specific services or benefits that the managed care company is obligated to provide under terms of its contracts with subscriber groups. Benefit Year: A 12 month period that a group uses in the administration of its employee benefits program. Refer to the definition given for the term “anniversary date”. Board Certified: A term used to describe a physician who has passed an examination given by a medical specialty board and who has been certified as a specialist in that medical area. Board Eligible: A term used to describe a physician who is eligible to take the specialty board examination by virtue of having graduated from an approved medical school, completed a specific type and length of training and practiced for a specified amount of time.

1005 Capitation: A fixed rate of payment for a fixed period of time which the provider accepts in return for accepting risk to provide a specified set of health services at any frequency that is necessary. The rate is usually provided on a per member per month (pmpm) basis with adjustments for age and sex. Carve Out: An arrangement whereby an employer eliminates coverage for a specific category of services (e.g. vision care, mental health/psychological services and prescription drugs) and contracts with a separate set of providers for those services according to a predetermined fee schedule or capitation arrangement. Case

Management: The monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high-cost or extensive services.

Centers for Medicaid and Medicaid Services (CMS): The agency within the Department of Health and Human Services which administers federal health financing and related regulatory programs, principally the Medicare, Medicaid and Poor Review Organization programs. Coinsurance: The percentage of the cost of medical care that a patient pays individually. Commercial Plan: Managed care plans offered to non-Medicare eligible groups such as unions or large employers. This is distinguished from a senior plan which is offered to nonworking people over the age of 65. Competitive Medical Plan (CMP): A managed care entry created by the 1982 TEFRA legislation to facilitate the enrollment into Medicare-risk contracts that assume financial risk for medical care on a prospective prepaid basis.

Consolidated Omnibus Budget Reconciliation Act (COBRA): A federal law that, among other things, requires employers to offer continued health insurance coverage to certain employees and their beneficiaries who have had their group health insurance coverage terminated. Coordination of Benefits (COB): A typical insurance provision whereby responsibility for primary payment for medical services is allocated between carriers when a person is covered by more than one employersponsored health benefits program. This coordination avoids the possibility that a person will be reimbursed twice for the same medical services. Concurrent or Continued Stay Review: The concurrent or contemporaneous review of medical necessity, level of care, length of stay, appropriateness of services and discharge planning for patients in medical care facilities. Co-payment: Payment by a patient of a flat dollar amount per unit of service at the time of the service (e.g. $10 per physician office visit). The amount paid should be nominal, but sufficient to incentivize appropriate utilization of health services. Credentialing: The review and verification of a provider’s credentials; i.e. training, experience, malpractice actions and licensure to determine clinical privileges. Current Procedural Terminology, Fourth Edition (CPT-4): A manual that assigns five-digit codes to medical services and procedures to standardize claims processing and data analysis. Days per Thousand: A measurement of the number of days of hospital care used in a year per 1,000 HMO members. The formula is: total hospital days divided by (members months / 12,000).

1006 Deductible: A set dollar amount that a person must pay before insurance coverage for medical expenses can begin. Department of Health and Human Service (DHHS): The cabinet agency of the U.S. government which administers most federal health programs. Drug Formulary: A listing of prescription medications which are approved for use and / or coverage by a health plan or other entity and which will be dispensed through participating pharmacies to a covered person. A drug Formulary is subject to periodic review and modification. Durable Medical Equipment (DME): Equipment which can stand repeated use and is primarily and customarily used to serve a medical purpose. DME is generally not useful to a person in the absence of illness or injury, and is appropriate for use at home. Examples of DME include hospital beds, wheelchairs and oxygen equipment. Eligibility Date: The defined date a covered person becomes eligible for benefits under and existing contract. Enrollee: Synonymous with member or beneficiary. A person eligible to receive or is receiving benefits from a HMO or insurance policy. An enrollee includes both those who have enrolled or “subscribed” and their eligible dependents. Enrollment: The numbers of members belonging to a managed care plan or that are assigned to a physician or medical group under a contract. Also, the process by which a health plan signs up individuals or groups as subscribers.

Enrollment Protection: A form of insurance that a medical group can purchase to protect themselves against part or all losses incurred for physician services, above a specified dollar amount, while caring for HMO enrollees. This insurance can be purchased through an HMO or other insurance company. Also referred to as “stop-loss” or “reinsurance”. Exclusive Provider Organization (EPO): Similar to PPO’s in their organization and purpose. Unlike PPO’s, however, EPO’s limit their beneficiaries to participating providers for their health care services. In other words, beneficiaries covered by an EPO are required to receive all of their covered services from providers that participate in the EPO, similar to an HMO. The EPO does not cover services received from other providers. Experience Rating: A method of determining health plan premiums based on the claims experience of a specific subscriber group. It is not permitted under federal HMO qualification guidelines. Federally Qualified HMO: A HMO that meets certain federally stipulated provisions aimed at protecting consumers; e.g. providing a broad range of basic health services, assuring financial solvency and monitoring the quality of care. HMO’s must apply to the federal government for qualification. The process is administered by the Office of Prepaid Health Care of the Health Care Financing Administration (HCFA), Department of Health and Human Services (DHHS). Fee-For-Service: A system of payment for health care whereby a fee is charged for each service delivered. The traditional method contrasts with that used in the prepaid sector where services are covered by a fixed payment made in advance that is independent of the number services rendered.

1007 Fee-For-Service Equivalency: A quantitative measure of the difference between the amount a physician and / or other provider receives from an alternative reimbursement system, e.g. capitation, compared to fee-forservices reimbursement. Fee Schedule: A listing of charges and established procedures for a specified medical group or practice. Also know as a “fee ticket” or “super bill”. Gatekeeper System: The primary care providers (e.g. family or general practitioners, internist, pediatricians and obstetricians / gynecologists) who have an economic and medical responsibility for managing all referrals for specialty, ancillary and hospital services as a condition of their coverage by the insurer. The word “Gatekeeper” is not the preferred terminology. The word “conductor” or similar terminology implying “coordinator of care” is more desirable. Global Fee: A total charge for a specific set of services, such as obstetrical services that encompass prenatal, delivery and post-natal care. Grievance Procedure: The process by which a health plan member or participating provider can air complaints and seek remedies. Group Model HMO: A HMO model involving contracts with physicians organized as a partnership, professional corporation or other association. The health plan compensates the medical group for contracted services at a negotiated rate, and that group is responsible for compensating its physicians and contracting with hospitals for the care of their patients.

Group Medical Practice: The definition that was adopted by the American Medical Association and most commonly used is “group medical practice is the application of medical services by a number of physicians working in systematic association with the joint use of equipment and technical personnel and with centralized administration and financial organization”. Health Maintenance Organization (HMO): An organized health care system that is responsible for both the financing and delivery of a broad range of comprehensive health care services to an enrolled population for a prepaid, fixed fee. A HMO can be viewed as a combination of health insurer and health care delivery system. Whereas traditional health care insurance companies are responsible for reimbursing covered individuals for the cost of their health care. HMO’s are responsible for providing health care services to their covered members through contracted providers, on a prepaid basis. The five common models of HMO’s are staff, group, network, IPA and mixed models. The primary difference among each of these models is based on how the HMO relates to its participating physicians. Health Plan: A generic term to refer to a specific benefit package offered by an insurer. Also used to pertain to the insurer, e.g. “I signed up for PacifiCare Health Plan”. Hospital Day: A term to describe any twenty-four hour period commencing at 12:00 midnight, or 12:00 noon, whichever is used by a hospital to determine a hospital day, during which a patient receives hospital services at the hospital. In-Area Services: Health care services received within the authorized service area by a participating provider of the health plan. Incurred But Not Reported (IBNR): IBNR is the total gross dollar amount of outside referral charges actually authorized for payment and incurred but not processed through your system.

1008 Independent Physician Association (IPA): Contracts with individual physicians who see HMO members, as well as their own patients, in their own private offices. It is the ability of IPA physicians to see both HMO and private patients in their own offices that principally differentiates an IPA from a group or staff HMO. Physicians in an IPA are paid either on a capitation or a reduced fee-for-service basis. Inpatient Care: Care given to a registered bed patient in a hospital, nursing home or other medical or psychiatric institution. Insured Services: Special procedures or tests performed on a HMO patient which are not considered part of the services to be covered under the normal capitation payment. The provider of care bills the HMO separately for these items, usually at a predetermined price. Managed Care: Any form of health plan that initiates selective contracting for the medical care of patients by a limited number of providers in a network. These plans are usually prepaid and require quality management and utilization management to control necessary use of health services. Management Information System (MIS): A computer software program that is used to compile and analyze data. Management Service Organization (MSO): A legal entity that provides administrative practice management and support services to individual physicians and / or group practices. A physician entity owned by participating physicians contracts with the MSO for services. Usually a direct subsidiary of a hospital, MSO’s may also be owned by investors.

Medicaid: A federal program administered and operated individually by participating state and territorial governments; which provides medical benefits to eligible low income persons needing health care. The cost of the program is shared by the federal and state governments. Medicaid is known as MediCal in California. Medical Director: Medical Group physician responsible for bridging health care delivery between providers and administration, maintaining a provider network for necessary contracted services, direction of utilization and quality management programs. Medical Foundation: Has two components; a notfor-profit, tax-exempt entity, and the physician group, which provides medical services under a professional services contract to the Foundation. The Foundation acquires the business and clinical assets of a group practice and holds the provider number. Medicare: A nationwide, federally-administered health insurance program which covers the cost of hospitalization, medical care and some related services for eligible person who are mostly over the age of 65. Medicare has two parts; Part A covers inpatient cost and Part B covers outpatient costs. Member: Synonymous with enrollee or beneficiary. A person eligible to receive, or one who is receiving benefits from a HMO or insurance policy. This includes both those who have enrolled, or “subscribed” and their eligible dependents. Member Month: One member enrolled in a prepaid plan for one month. A statistical measure used to reflect numbers of services provided per member month.

1009 Mixed Model HMO: A HMO that is a mixture of the relatively distinct staff, group, network or IPA varieties. For example, and HMO that serves a significant proportion of its enrollees within the staff model site, but also contracts with several other groups or IPA entities, may be of this type. A HMO can be mixed-model when assessed within a particular market area or across areas. These types of HMO’s are becoming more common, as HMO’s of one model acquire or merge with previously distinct HMO’s of a different type. The results of such mergers are frequently know as network model HMO’s. Examples of mixed model HMO’s include; FHCP, Cigna and Universal Care. Multi-specialty Group: A group of doctors who represent various medical specialties who work together in a group practice. Network Model HMO: A type of HMO where a network of two or more existing group practices has contracted to care for the majority of patients enrolled in a HMO plan. Sometimes also contracts with individual providers in a fashion similar to an IPA. Providers contracting with this type of HMO are usually free to serve fee-for-service patients as well as those enrolled in other HMO’s and PPO’s. Open Enrollment: The annual period during which people in a “dual choice” health benefits program can choose among the two or more plans being offered. Also refers to the period during which a federally qualified HMO must make its plan available without restrictions to individuals who are not part of a group plan. Outcomes Management: A process of systematically tracking a patient’s clinical treatment and responses to that treatment, including measures of morbidity and functional status. Outliers: Those patients with a specific admitting diagnosis that have either a shorter or longer length of stay than the usual range for that diagnosis.

Out-of-Area: Refers to the treatment given to a HMO member outside the geographical limits of his own HMO. The coverage generally is restricted to emergency services. Outpatient Surgery: Minor surgery performed in a clinic or other non-hospital facility. Participating Provider: A healthcare provider or facility that is contracted by an HMO to provide additional services to the HMO’s member(s). Per Diem: A negotiated daily rate for delivery of all hospital services (single per diem) or selected types of services, such as medical / surgical care or intensive care (multiple per diems), regardless of the actual services provided. Per Member Per Month (PMPM): Generally used by HMO’s and their medical providers as an indicator of revenue, expenses or utilization of services per member per one month period e.g. “We receive a capitation payment of $40 per member per month for our commercial HMO patients”. Per Member Per Year (PMPY): Generally used by HMO’s and their medical providers as an indicator of revenue, expenses or utilization of services per member per year, e.g. “Our commercial patients come in to see the doctor an average or 4.24 times per member per year”. Physician-Hospital Organization (PHO): A legal entity that combines physicians and hospital into a single organization for the purpose of obtaining payer contracts. Doctors maintain ownership of their practices, but accept managed care patients according to the terms of the contract. Point-of Service Plan: A type of HMO plan where the enrollees are not “locked in”, they may leave the HMO and still have certain services covered. Such “out-of-plan” utilization is usually subject to a significant degree of cost sharing (e.g. deductibles), unlike those services delivered within the plan.

1010 Preferred Provider Organization (PPO): Typically, a group of hospitals, physicians and / or pharmacists that contracts on a discounted fee-for-service basis with employers, insurance carriers or a third party administrator to provide services to subscribers. Provider charges are usually 10% to 20% below usual fees. Preventative Care: Comprehensive care emphasizing priorities for prevention early detection and early treatment of conditions, generally including routine physical examination, immunization and well person care. Primary Care: Professional and related services administered by an internist, family practitioner, obstetrician, gynecologist or pediatrician in an ambulatory setting with referral to specialist as necessary. Quality Management: A formal set of activities to assure the quality of services provided. Quality Management includes quality assessment and actions taken to remedy any deficiencies identified through the assessment process. Referral Physician: A physician who has a patient referred to him by another source for examination, surgery or for specific procedures to be performed on the patient, usually because the referring source is not prepared or qualified to provide the needed service. Referring Physician: A physician who sends a patient to another source for examination, surgery or to have specific procedures performed, usually because the referring physician is not prepared or qualified to provide the needed service.

Reinsurance: The practice of a HMO or insurance company of protecting itself or its contracted medical groups against part or all losses. Above a specified dollar amount, incurred in the process of caring for its policyholders. Also referred to as “stop-loss” or “enrollment protection”. Resource Based Relative Value Scale (RBRVS): As of January 1, 1992, Medicare payments are based on a resource-based relative value scale, replacing the customary and prevailing charge mechanism for fee-for-service providers participating in the Medicare program. The objective is that physician fees should reflect the relative value of work performed, their practice expense and malpractice and insurance cost. Service Area: The geographic area served by an insurer or healthcare provider. Skilled Nursing Facility (SNF): A nursing or convalescent home offering skilled nursing care and rehabilitation services. Staff

Model HMO: A health maintenance organization whose physicians (and other health care professionals) are employees of the HMO.

Stop-Loss: The practice of a HMO or insurance company of protecting itself or its contracted medical groups against part or all losses, above a specified dollar amount, incurred in the process of caring for its policyholders. Usually involves the HMO or insurance company purchasing insurance from another company to protect itself. Also referred to as “reinsurance” or “enrollment protection”. Subscriber: The individual who meets the eligibility requirements for enrolling in a health plan, through an employer or individually, and enrolls in a health plans and accepts the financial responsibility for any premiums, co-pays or deductibles.

GLOSSARY OF TERMS

1011

Tertiary Care: Those health care services provided by highly specialized providers such as neurosurgeons, thoracic surgeons and intensive care units. These services often require highly sophisticated technologies and facilities. Third Party Administrator (TPA): Manages claims payment without assuming insurance risk. Third Party Payment: Payment by a financial agent such as a HMO, insurance company or government rather than direct payment by the patient for medical care services. Unbundling: A process of separating a service into its individual components in order to bill each component separately to increase the overall level of reimbursement. Urgent Care Center: A center providing ambulatory and minor emergency services in a facility separate from hospitals. It may have backup affiliation agreements with hospitals. Often called a walk-in clinic. It is usually open outside of regular business hours, does not make appointments and may refer patients back to their personal physician for follow-up care. Utilization Management: Evaluation of the necessity, appropriateness and efficiency of the use of medical services and facilities. Workers Compensation: A state governed system designed to address work-related injuries. Under the system, employers assume the cost of medical treatment and wage losses arising from a worker’s job-related injury or disease, regardless of who is at fault. In return employees give up the right to sue employers, even if injuries stem from employer negligence.

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provider handbook - Florida Health Care Plans

1 PROVIDER HANDBOOK November, 2017 2 PROVIDER HANDBOOK TABLE OF CONTENTS FHCP Section 1 Corporate Profile FHCP Emergency Preparedness FHCP Provid...

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