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Provider Medica Connections

February 2018

General News | Clinical News | Pharmacy News | Network NewsAdministrative News | SelectCare/LaborCare News

General News


Medica Foundation announces provider grant recipients
2017 behavioral health grants total $300,000

In 2017, the Medica Foundation awarded behavioral health program grants totaling $300,000 to eight nonprofit agencies. These programs focus on helping people with serious mental illness and addictions recover and lead productive lives in their communities. Program grants were awarded to the following provider groups and health care foundations:

  • Center for Victims of Torture (St. Paul) — to open a new facility in Frogtown/North St. Paul serving primarily Karen, Oromo, and Hmong war trauma/torture survivors in partnership with the community and local primary care clinics
  • Comunidades Latinas Unidas En Servicio (St. Paul) — to provide group therapy for Latino immigrants and their families who are facing stress and anxiety due to immigration uncertainties
  • HealthEast Foundation (St. Paul) — to address drug and alcohol abuse within the Karen community through a cross-sector community collaboration (“Karen Chemical Dependency Collaboration”)
  • Reclaim (St. Paul) — to coordinate physical and mental health care, emergency housing, and case management for LGBT homeless youth with an emphasis on young people of color and those with autism spectrum disorders
  • St. David’s Center for Child & Family Development (Minnetonka, Minn.) — to expand services designed to effectively address the complex behavioral needs and traumatic experiences of children with severe emotional disturbances and children in foster care

Details about grant recipients, funding opportunities, giving guidelines and application deadlines are available at For 2018, information on Medica Foundation funding priorities and grant application periods will be available online as of February 1.


Responses due by January 31:
Survey out for providers on patient access to care

As previously noted, Medica would like provider feedback on patient access to care, including activities like care coordination, referrals to specialists and availability of clinic appointments. Medica recently sent out this survey, which is intended for primary care, specialty care and behavioral health provider offices. Survey responses are due by January 31. As a reminder, they are confidential and grouped with other results. Here's the survey.

Medica would like to thank providers for giving their valuable feedback.


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Clinical News


Effective March 19, 2018:
Medical policies and clinical guidelines to be updated

Medica will soon update one or more utilization management (UM) policies, coverage policies and clinical guidelines. These upcoming policy changes will be effective March 19, 2018, unless otherwise noted.

These policies apply to all Medica products including commercial, government, and individual and family business (IFB) products unless other requirements apply due to state or federal mandated coverage, for example, or coverage criteria from the Centers for Medicare and Medicaid Services (CMS).

Monthly update notifications for Medica's policies are available on an ongoing basis. Update notifications are posted on prior to their effective date. The medical policy update notification for changes effective March 19, 2018, is already posted. Changes to policies are effective as of that date unless otherwise noted.

The medical policies themselves will be available online or as a hard copy:

Note: The next policy update notification will be posted in February 2018 for policies that will be changing effective April 23, 2018. These upcoming policy changes will be effective as of that April date unless otherwise noted.


HPV-caused cancers: prevention and detection 

The Centers for Disease Control (CDC) estimates that about 14 million people get a new human papilloma virus (HPV) infection every year in the United States. There are two HPV types: low-risk HPV (wart-causing) and high-risk HPV (cancer-causing). High-risk HPV types have been linked to cancer in both men and women, including cervical cancer, vulvar cancer, vaginal cancer, penile cancer, anal cancer and mouth and throat cancer. The International Agency for Research on Cancer found 13 HPV types cause cervical cancer alone (nearly all cervical cancers are caused by HPV).

Facts about HPV:

  • It is a very common virus.
  • There is no treatment for HPV.
  • Patients who have health problems may be at more risk.
  • Most HPV infections that lead to cancer can be prevented with vaccine.
  • The HPV vaccine protects against both high-risk (cancer-causing) and low-risk (wart-causing) HPV infections.
  • With regular screening, most cervical cancers can be detected early and treated.

The HPV vaccine, recommended to prevent the cancers mentioned above, is approved for both males and females. To work best, the vaccine should be given at 9-14 years of age. Patients should get two doses, with the second dose 6-12 months after the first dose. Patients 15-26 years of age who begin getting vaccinated should receive three shots over a six-month period.

The U.S. Preventive Services Task Force (USPSTF) recommends that women 21-65 years of age receive cytology (a Pap smear) every three years. Or women 30-65 years of age who want to lengthen the screening interval can have screening with a combination of cytology and HPV testing every 5 years. Women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion or cervical cancer are not at risk for cervical cancer and should not need to be screened. (Screening with cytology more often than every three years confers little additional benefit, with large increases in harm.)

For more information, refer to USPSTF, CDC, the American Cancer Society or the American Academy of Pediatrics.


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Pharmacy News


Effective February 1, 2018:
Medica to add new UM policies for medical pharmacy drugs

Medica will soon implement the following new medical pharmacy drug utilization management (UM) policies, effective with February 1, 2018, dates of service. Prior authorization will be required for the corresponding medical pharmacy drugs.

Medical pharmacy drug UM policies — New
Prior authorization will be required.

Drug code Drug brand name Drug generic name
J3590 Fasenra benralizumab
J3590 Hemlibra emicizumab-kxwh
J3590 Mepsevii vestronidase alfa-vjbk
J9999 Yescarta axcabtagene ciloleucel

These policies will apply to Medica commercial members, individual and family business (IFB) members, Minnesota Health Care Programs (MHCP) members and Medica Medicare members in Medica DUAL Solution® (Minnesota Senior Health Options, or MSHO) and Medica Advantage Solution® (Medicare Advantage). They will not apply to Medica Prime Solution® (Medicare Cost) members. The policies will be subject to pre-payment claims edits as well.

These new medical pharmacy drug UM policies will be available online or on hard copy:

Effective April 1, 2018:
Medica plans to update member formularies

Medica is reviewing several medications and will be making changes in coverage status to drug formularies (or drug lists) effective April 1, 2018. For certain Medica members, as noted below, these changes would be effective April 1, 2018, for new prescriptions, but not effective until May 1, 2018, for existing prescriptions.

These upcoming changes may apply to one or more of the following drug formularies:

  • 2018 Medica Commercial Large Group Drug List — effective 4/1 for new prescriptions, 5/1 for existing
  • 2018 Medica Commercial Small Group Drug List
  • 2018 Medica Preferred Drug Lists for individual and family business (IFB)
  • 2018 Medica List of Covered Drugs for Minnesota Health Care Programs (MHCP) — effective 4/1 for new prescriptions, 5/1 for existing
  • 2018 Medica Over-the-Counter (OTC) Drug List for MHCP

The Medica MHCP and OTC formularies apply to the following products: Medica Choice Care℠ (for Minnesota Senior Care Plus program, or MSC+), 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 Medica Medicare Part D drug formularies.

Medica will post changes to its drug formularies on prior to their effective date. To see the latest Medica drug list changes as well as full drug formularies for each member type, refer to

Medication request forms
A 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 submit an exception form or call CVS Caremark.


CMS requires Medicare enrollment to prescribe Part D Drugs

As a reminder, providers who prescribe Part D drugs for Medicare patients need to enroll in or validly opt out of Medicare so their Medicare patients avoid any delays in obtaining prescribed drugs. This enrollment step is required by the Centers for Medicare and Medicaid Services (CMS).

All prescribers must be enrolled by January 1, 2019, to ensure that Part D enrollees continue to get their prescriptions. CMS encourages all providers who prescribe Part D drugs to enroll in this Medicare program now, if they have not already done so. Effective as of January 1, 2019, Medicare Part D may no longer cover drugs that are prescribed by physicians or other eligible professionals who are neither validly enrolled nor opted out of Medicare.

Part D prescribers include physicians, dentists, psychiatrists, residents, nurse practitioners and physician assistants who prescribe drugs for Part D patients, including those in Medicare Advantage plans. For more information, including how to enroll, visit the CMS Part D Prescriber Enrollment website.

Medical pharmacy drug UM program includes Medicare products

As a reminder, Medica’s medical pharmacy drug utilization management (UM) program has expanded to include certain Medica Medicare members, effective January 1, 2018. This expanded program, which continues to be administered by Magellan Rx, now also applies to Medica DUAL Solution® members (in Minnesota Senior Health Options, or MSHO) and Medica Advantage Solution® members (in Medicare Advantage). Learn more about medical benefit drugs and see related drug policies.


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Network News


Effective April 1, 2018:
Medica to update Medicare physician fee schedule

Beginning with April 1, 2018, dates of service, Medica will implement the quarterly update to its Medicare physician fee schedule for applicable Medica products. This fee schedule change will reflect the April 2018 Centers for Medicare and Medicaid Services (CMS) update applicable to reimbursement for injectable drugs and immunizations. The reimbursement impact of this quarterly update will vary based on specialty and mix of services provided.

Details on Medicare changes to drug fees are available online from CMS. Providers who have further questions may contact their Medica contract manager.

Third-quarter PCR checks to be mailed in January 2018

By the end of January 2018, Medica plans to mail to eligible providers the physician contingency reserve (PCR) payment for the third quarter of 2017. This represents a 100-percent return of the third-quarter 2017 PCR withhold, plus interest, for the Medica Prime Solution® Medicare product. Checks will cover PCR withheld for claims with dates of service of July 1, 2017, through September 30, 2017, and dates paid of July 1, 2017, through December 31, 2017.


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Administrative News


Provider College administrative training topic for February

The Medica Provider College offers educational sessions on various administrative topics. The following class is available by webinar for all Medica network providers, at no charge.

Training class topic
"Claim Appeals, Adjustments and Record Submission" (class code: AAR)
This class will discuss the processes that providers should use for submitting claim appeals, claim adjustments and medical records to Medica. This will include the different submission options available as well as the information required and the best ways to make sure that the submissions are viewed and reviewed as intended. Participants will discuss who reviews appeals and how the adjustment process works and what do to if providers don’t agree with the outcome.

Class schedule
Class code Topic Date Time Notes
AAR-WF Claim Appeals, Adjustments and Record Submission Feb. 20 10-11 am Class code with "WF" means offered via webinar in February

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. Register online for the session above.

'Pain management' added as provider specialty designation

As previously published, Medica is adding the new practitioner specialty of Pain Management effective March 1, 2018, to identify practitioners as part of their provider demographics (for instance, available in provider directories for Medica members to use).

Practitioners with the appropriate training or education who would like to request Pain Management as their specialty can submit a Minnesota Uniform Practitioner Change Form, if already credentialed with Medica. Send the form or inquiries to Otherwise, learn more at about submitting initial credentialing applications to Medica.


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SelectCare/LaborCare News


Latest UHC provider bulletin available online

UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (January 2018). Highlights that may be of interest to LaborCare® network providers include:

  • Online system for chemotherapy prior authorization now displays outcome findings
  • Prior authorization now required for chimeric antigen receptor T-cell (CAR-T)
  • New genetic and molecular tests to require prior authorization — scheduled for April 2018
  • New specialty pharmacy medications (Fasenra, Luxturna) to require prior authorization — scheduled for April 2018

View the January 2018 UHC provider bulletin.

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Posted: January 24, 2018

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