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Provider Medica Connections


July 2016

General News | Clinical News | Pharmacy News | Administrative News | SelectCare/LaborCare News

General News

Medica selects CVS Caremark as new pharmacy benefits manager

Medica recently selected CVS Caremark as its new pharmacy benefits manager (PBM), beginning later this year. CVS Caremark will be implemented as the new PBM in two stages: First, effective with September 1, 2016, dates of service, CVS Caremark will become the PBM for Medica individual and family business (IFB) members. Then, effective with January 1, 2017, dates of service, CVS Caremark will become the PBM for all other Medica members (in commercial, Medicare, and Minnesota Health Care Programs products).

A comprehensive, integrated pharmacy management program is critically important in a dynamic and ever-changing health care environment. Through its new relationship with CVS Caremark, Medica hopes to enhance quality outcomes while achieving greater cost efficiencies. Medica will share more details on the PBM change in the coming months as transition plans are finalized. This will include information on CVS Caremark drug prior authorization, claim submission and appeals.

Note: MedImpact will continue to serve as Medica’s PBM for all members other than IFB members through December 31, 2016. Also, at this time, specialty pharmacy and mail-order services for Medica members will continue to be administered as they are today.

Nichole White joins Medica as new VP of pharmacy

Nichole White, RPh, MBA, has recently joined the health management team at Medica as vice president of pharmacy services, a newly added position. White reports to Jana Johnson, senior vice president for health and provider services at Medica. “Nichole will play an important role in Medica’s ongoing efforts to integrate pharmacy, medical and mental health programs,” said Johnson. “Our aim is to ensure that our members receive the highest quality of care and services through evidence-based, value-added programs in partnership with our network providers.”

White was previously vice president and general manager for the health plan division at Express Scripts, one of the largest pharmacy benefit managers (PBMs) in the nation. “Nichole’s prior experience will prove valuable as we transition to Caremark as our new PBM,” said Johnson. Prior to working at Express Scripts, White worked in the medication therapy management practice at Fairview Pharmacy Services.

Annual notice:
Compliance, FWA trainings required for Medicare providers

The Centers for Medicare and Medicaid Services (CMS) requires that Medicare providers complete general compliance training and fraud, waste, and abuse (FWA) training. The training requirement applies to all organizations that provide health care services or administrative services for Medicare beneficiaries, and also applies to the organizations' downstream and related entities. Although Medicare-certified (or deemed) providers are exempt from the FWA portion of the training, they are still required to complete general compliance training.

Medica makes the Medica Standards of Conduct, Compliance Reporting Policy, and links to the CMS general compliance training and FWA training available on Medica also requires that a compliance officer or equivalent person for a provider group complete and sign a Compliance Program Attestation and return it to Medica. This is due by August 26, 2016.

Providers are strongly encouraged to use the general compliance and FWA training materials created by CMS.  Providers who produce their own training must include all of the CMS content.  Learn more and take the trainings (click on “Provider Training”).

As a reminder, training is required at the time of a Medicare provider's initial contract and then annually thereafter. Providers should maintain records of all training for 10 years. Records should include dates and methods of training, materials used for training, and training logs identifying employees who received training. Medica, CMS, or agents of CMS may request such records to verify that training occurred

MCHA member claims no longer accepted by Medica

If a Medica member's ID card indicates Minnesota Comprehensive Health Association (MCHA) as the health plan, it should be considered outdated and therefore should not be used to submit claims. Due to timely filing requirements by state law, the final deadline for MCHA claims has already passed. Despite this, Medica continues to receive claims for MCHA member services, even for 2016 dates of service. These claims are denied for lack of current coverage.

As a reminder, MCHA formally shut down operations effective December 31, 2015. Members formerly enrolled in MCHA should have selected new plan coverage by now.

(Update to “MCHA requests that providers submit MCHA claims soon” article in the March 2015 edition of Medica Connections.)

Providers need to regularly update demographic data, per CMS

As previously published, Centers for Medicare and Medicaid Services (CMS) rules require additional information for Medica’s provider directories as well as regular updates to them, beginning in 2016. The new rules state, among other things, that provider directories be accurate and updated regularly, in compliance with CMS guidance. As a result, providers need to update their practitioner and site-level demographic data in Medica’s directories as soon as they know of a change to that data, and to regularly review their demographic information for accuracy. See more details.

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Clinical News

Effective September 1, 2016:
Medica to implement new coverage policy

The following benefit determination will be effective beginning with September 1, 2016, dates of service. This new policy will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.

Wireless pulmonary artery pressure monitoring systems

Medica has reviewed wireless pulmonary artery pressure monitoring systems (e.g., CardioMEMSTM) and has determined that this new technology is investigative and therefore will not be covered.

Wireless pulmonary artery pressure monitoring systems are intended to measure pulmonary artery pressure in previously hospitalized individuals with heart failure. The miniature, wireless sensor is implanted in the pulmonary artery, and does not require batteries or leads. A portable, external electronic device transmits pressure readings directly to a secure website for viewing and interpretation by the individual’s clinician. Use is intended to reduce hospitalizations due to further heart failure exacerbations.

The complete text of the policy that applies to the determination above will be available online or on hard copy:

  • See Medica’s coverage policies as of September 1, 2016; or
  • Call the Medica Provider Literature Request Line for printed copies of documents, toll-free at 1-800-458-5512, option 1, then option 5, ext. 2-2355.

Effective September 1, 2016:
Medica policies and clinical guidelines to be updated

Medica will soon update one or more utilization management (UM) policies, coverage policies, Institute for Clinical Systems Improvement (ICSI) guidelines, and Medica clinical guidelines, as indicated below. These policies will be effective September 1, 2016, unless otherwise noted.

Coverage policies — New

Wireless Pulmonary Artery Pressure Monitoring Systems for Monitoring Heart Failure (CardioMEMS)

Coverage policies — Revised
These versions will replace all previous versions.

Digital Breast Tomosynthesis (effective 6/15/2016; see details)
Genetic Testing for Inherited Susceptibility to Malignant Melanoma (formerly Genetic Testing for Malignant Melanoma (MM))
Whole Exome/Genome Sequencing (effective 6/15/2016; see details)  

These documents will be available online or on hard copy:

How providers can help seniors reduce the risk of falling

In the United States, one-third of seniors over 65 years of age fall per year, making this the leading cause of injury for seniors, as well as a leading cause of accidental death ___ Annually, about two million falls result in a visit to the emergency room. Although the risk of falling increases with each decade of life, it is encouraging to know that falls can be prevented, as they are not an inevitable part of aging.


The Centers for Disease Control and Prevention (CDC) stresses the importance of older adults integrating balance and strength into daily life through regular exercise. Experts who have studied falls encourage people to take measures to protect themselves against falls as they do against other preventable medical conditions.

Providers can play a key role in helping seniors stay safe by encouraging them to do the following:

  • Go to exercise classes that can help prevent falls, especially classes that include balance drills such as alternating on one foot and then the other
  • Exercise with purposeful movement and coordination to increase leg strength, balance, gait and walking ability
  • Appropriately hydrate by drinking plenty of water
  • Understand medication side effects
  • Get annual vision checkups
  • Carry items in from the car slowly and deliberately, taking extra trips as needed.
  • Remove throw rugs or other objects that may cause them to trip and fall, plus ensure that they have ample lighting in their home

Among older adults, falls are the No. 1 cause of fractures, hospital admissions for trauma, loss of independence, and injury deaths. In 2013, the total cost of fall injuries was $34 billion, and the National Council on Aging (NCOA) expects this financial toll to increase as the population ages, reaching $67 billion by 2020.

Falls, with or without injury, also have a quality-of-life impact. A growing number of older adults fear falling and may limit their activities and social engagements. This can cause further decline in physical health, depression, isolation and a feeling of helplessness.

By taking time to evaluate patients’ personal risk factors, such as those mentioned above, providers can help seniors stay out of the hospital as well as maintain a higher quality of life. For more about reducing the risk of falls, refer to the CDC or NCOA.

Due by July 15, 2016:
Quality complaint reports required by State of Minnesota

Medica requires its Minnesota-based network providers to submit second-quarter 2016 quality-of-care complaint reports to Medica by July 15, 2016.

The State of Minnesota requires that providers report quality complaints received at the clinic to the enrollee's health plan. All Minnesota-based providers should submit a quarterly report form, even if no Medica members filed quality complaints in the quarter (in which case, providers should note “No complaints in quarter” on the form).

Providers can now send reports by e-mail to Otherwise, reports can still be sent by fax to 952-992-3880 or by mail to:

      Medica Quality Improvement
      Mail Route CP405
      PO Box 9310
      Minneapolis, MN 55440-9310

Report forms are available by:

Note: Providers submitting a report for multiple clinics should list all the clinics included in the report. Providers who have questions about the complaint reporting process may:

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Pharmacy News

Effective September 1, 2016:
Medica to update commercial, IFB, MHCP drug lists

Medica has reviewed the following products, with their respective coverage status to be effective September 1, 2016. As indicated in the table below, these changes will apply to the Medica Commercial Preferred Drug List; the Preferred Drug List for individual and family business (IFB) members and small group plan members; and the Medica List of Covered Drugs for Minnesota Health Care Programs (MHCP). The Medica MHCP formulary applies to the following products: Medica Choice CareSM (including Minnesota Senior Care Plus program, or MSC+), Medica MinnesotaCare, Medica AccessAbility Solution® (Special Needs Basic Care program, or SNBC), and Medica DUAL Solution® (Minnesota Senior Health Options program, or MSHO), for non-Part D drugs. These changes will not apply to the Medica Medicare Part D formulary.

Note: As mentioned above, Medica will switch to CVS Caremark as its pharmacy benefit manager (PBM) in the coming months, starting with IFB effective September 1, 2016. Although the Preferred Drug List for IFB members will not be immediately affected by this PBM change, providers will need to work with CVS Caremark to request prior authorization and formulary exceptions for IFB members. More details on these steps will be outlined soon.

Generic name (brand name) Commercial/ IFB formulary status Medica MHCP formulary status Current preferred alternatives Restrictions and comments Approved therapeutic indications
aripiprazole lauroxil (Aristada®) Commercial/ IFB tier 3 Non-formulary Abilify Maintena, Risperdal Consta Treatment of schizophrenia
buprenorphine film(Belbuca®) Commercial/ IFB tier 3 Non-formulary morphine sulfate ER, tramadol Treatment of chronic, severe pain
dichlorphena-mide (Keveysis®) Commercial/ IFB tier 3 Non-formulary aceta-zolamide, metha-zolamide Treatment of primary hyper- and hypokalemic periodic paralysis
glycopyrrolate (Seebri Neohaler®) Commercial/ IFB tier 3 Non-formulary Atrovent HFA, Combivent Respimat, ipratropium bromide, Spiriva Respimat Treatment of chronic obstructive pulmonary disease
asfotase alpha (Strensiq®) Specialty tier 1 Formulary Specialty Specialty drug  Treatment of perinatal, infantile and juvenile-onset hypophosphatasia
insulin degludec (Tresiba®) Commercial/ IFB tier 3 Non-formulary Lantus, Toujeo
Treatment of diabetes mellitus
indacaterol/ glycopyrrolate (Utibron Neohaler®) Commercial/ IFB tier 3 Non-formulary Atrovent HFA, Combivent Respimat, ipratropium bromide, Spiriva Respimat Treatment of chronic obstructive pulmonary disease
patiromer (Valtessa®) Commercial/ IFB tier 3 Non-formulary sodium polystyrene sulfonate  Treatment of hyperkalemia
rolapitant (Varubi®) Commercial/ IFB tier 3  Non-formulary Emend  Quantity limit  Prevention of chemotherapy- induced nausea and vomiting

Medica drug formularies are available online or on paper:

Medication request forms
A uniform formulary exception request form should be used when requesting a formulary exception. It is important to fill out the form as completely as possible and to cite which medications have been tried and failed. This includes the dosages used and the identified reason for failure (e.g., side effects or lack of efficacy). The more complete the information provided, the quicker the review, with less likelihood of Medica needing to request more information. To request formulary exceptions, providers can:

Effective September 1, 2016:
Medica to update drug coverage policies

Medica will soon update the following drug coverage policies, effective with September 1, 2016, dates of service.

Drug coverage policies — Revised
These versions will replace all previous versions.

Intra-articular Hyaluronan Therapy (Viscosupplementation)
Human Papillomavirus (HPV) Vaccine

These updated drug coverage policies will be available online or on hard copy:

Effective September 1, 2016:
Medica to expand specialty-drug split-fill program

Medica will soon expand its current specialty-drug split-fill program, effective September 1, 2016. The drugs being added are:

  • Baraclude
  • Epivir
  • Gleevec
  • Odomzo

The split-fill requirement will be applied only for members who start new prescriptions for these drugs on or after September 1. And these four drugs are in addition to 18 drugs already included in the split-fill program: Afinitor, Bosulif, Erivedge, Inlyta, Jakafi, Nexavar, Sprycel, Sutent, Tafinlar, Tarceva, Targretin, Tasigna, Votrient, Xalkori, Xtandi, Zolinza, Zykadia and Zytiga.

Note: The split-fill program applies to both the brand and generic formulations for products that have a generic equivalent.

The split-fill program exists due to the fact that a patient may need to try multiple medications to find one that works or is tolerated, particularly for cancer treatment. By splitting the prescription fill, a specialty pharmacy can monitor the medication and determine if it is effective after the first 14 or 15 days before dispensing additional medication. During the first fill, the member will receive a 14- or 15-day supply and pay 50 percent of the required copayment. If the specialty pharmacy determines that the member is tolerating the therapy, a full supply will be dispensed subsequently and thereafter. If the pharmacy identifies side effects or problems during an assessment, the remaining supply of medication will be held. Doing so avoids medication waste, saving costs for patients as well as payers. Furthermore, if an adverse event is noted, the specialty team can respond according to established protocols and can contact the physician as necessary.

This program applies to Medica commercial and individual and family business (IFB) members.

(Update to “Medica to expand oral oncology split-fill program” article in the May 2015 edition of Medica Connections.)

Effective September 1, 2016:
Upcoming changes to Medica Part D drug formularies

Medica posts changes to its Part D drug formularies on 60 days prior to the effective date of change. The latest lists will notify Medicare enrollees of drugs that will either be removed from the Medica Part D formulary or be subject to a change in preferred or tiered cost-sharing status effective September 1, 2016. Medica also notifies affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly. As of July 1, 2016, view the latest Medicare Part D drug formulary changes.

Medica periodically makes changes to its Medicare Part D formularies: the Medica Prime Solution® Part D closed formulary (4-tier + specialty tier) and the Medica DUAL Solution® Part D closed formulary. The Medica Medicare Part D drug formularies are available online or on paper:

Medication request forms
A medication request form should be used when requesting a formulary exception. It is important to fill out the form as completely as possible and to cite which medications have been tried and failed. This includes the dosages used and the identified reason for failure (e.g., side effects or lack of efficacy). The more complete the information provided, the quicker the review, with less likelihood of Medica needing to request more information. To request formulary exceptions, providers can:

  • Download a Medica coverage determination form.
  • Call MedImpact at 1-800-788-2949.

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Administrative News

Provider College administrative training topic for August

Medica CollegeThe Medica Provider College offers educational sessions on various administrative topics. As published last month, the following class is available by webinar for all Medica network providers, at no charge.

Training class topic
"Advanced Claim Edits, Post-Payments and Pre-Payment Edits" (class code: APPE). This class translates the claim submission process into three components: advanced claim edits or “ACE” edits, which take place at the clearinghouse level; post-payments, which are audits constructed after a claim has been processed and paid; and pre-paid edits, which occur during a coding review prior to claim processing and output. Participants will learn how Medica has enhanced its overpayment detection and recovery program through the implementation of a pre- and post-pay claims editing solution. This class will help providers identify if a claim was denied due to one of these edits, what the denial means, and the appropriate process to appeal those denials. It will also go over the new ACE edit policy that Medica launched on January 1, 2016, which flags missing or potentially inaccurate claim information prior to submitting a claim. This ACE policy allows providers to correct their claim in “real time” to help them avoid receiving pre-pay and post-pay adjustments and denials.

Class schedule

Class code Topic Date Time Notes
APPE-WA ACE, Post-Pay, Pre-Pay Aug. 17 1-3 pm Class code with “WA” means offered via webinar in August

For webinar trainings, login information and class materials are e-mailed close to the class date. To ensure that training materials are received prior to a class, providers should sign up as soon as possible.

The time reflected above allows for questions and group discussion. Session times may vary based on the number of participants and depth of group involvement.

The registration deadline is one week prior to the class date. To register for the session listed, providers may do either of the following:

Medica requires referral to in-network laboratory providers

As a reminder, Medica requires network providers to refer laboratory tests or other services to laboratory providers within the Medica provider network, rather than refer them outside the network. Referring to network providers whenever possible is a requirement for network providers according to their contract with Medica. This also ensures that Medica members do not pay more for these services than necessary.

Here's a full list of current Medica network laboratory providers, both independent and health system-based.

Medica Network Independent Laboratory Providers

  • Ambry Genetics Corporation
  • Aurora Medical Park Laboratory LLC
  • B-TEK
  • Esoterix Genetic Laboratories LLC
  • Exact Sciences Laboratories LLC
  • Genoa Healthcare Clinical Laboratory LLC
  • Genomic Health Inc.
  • Kan-Di-Ki LLC
  • Laboratory Corporation of America Holdings
  • Medical Diagnostics Laboratories LLC
  • Medtox Laboratories
  • Myriad Genetic Laboratories Inc.
  • Natera Inc
  • PerkinElmer Laboratories Inc.
  • Progenity Inc.
  • Quest Diagnostics Inc.
  • Sequenom Center for Molecular Medicine LLC
  • Transgenomic Inc.

Medica Network System-Based Laboratory Providers

  • Allina Health System
  • Avera Health
  • CentraCare Health System
  • Children's Health Care
  • Douglas County Hospital
  • Fairview Health Services
  • HealthPartners Medical Group
  • Huron Clinic Foundation
  • HealthEast Medical Laboratory LLC
  • Lake Region HealthCare Corporation
  • Marshfield Clinic
  • Mayo Health System
  • North Memorial Reference Lab
  • Park Nicollet Health Services
  • Sanford Medical Center
  • Trinity Health

Updates to Medica Provider Administrative Manual

To ensure that providers receive information in a timely manner, changes are often announced in Medica Connections that are not yet reflected in the Medica Provider Administrative Manual. Every effort is made to keep the manual as current as possible. The table below highlights updated information and when the updates were (or will be) posted online in the Medica Provider Administrative Manual.

Information updated Location in manual When posted online in manual
Made updates to the annual fraud and compliance training requirements (see above)
"Fraud and Abuse” section, on "Provider Training" tab June 2016
(effective for 2016)
Made regulatory and administrative updates to provider requirements outlined for Medicare, Medicaid and Minnesota Health Care Programs "Special Contracting Requirements" section, in "Government Program Requirements" subsection, under "Provider Requirements for Medicare, Medicaid and Government Programs” June 2016

For the current version, providers may view the Medica Provider Administrative Manual online.

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SelectCare/LaborCare News

Latest Aetna provider bulletin available online

Aetna has published its latest edition of Aetna OfficeLink UpdatesTM (June 2016). Highlights that may be of interest for Medica SelectCareSM network providers include:

  • Reminder to give timely notification of hospital admissions
  • Reminder to accept digital ID cards for eligibility and benefits inquiries
  • New drug class to be added to Aetna's National Precertification List — scheduled for July 2016
  • Payment change for E&M services billed by non-physician providers — scheduled for September 2016
  • Payment change for hemodialysis home visits — scheduled for September 2016

View the June 2016 Aetna provider bulletin.

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Posted: June 29, 2016

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