For additional information, visit usat Provider.MedMutual.com.

Fall 2014 Issue

Curbing Measles Outbreaks

In 2014, cases of measles in the U.S. reached the largest single year total since

the disease was declared eliminated in the year 2000. Recent outbreaks are the

result of secondary importation of measles from endemic areas outside the U.S.

As of June 29, 2014, there were 369 documented cases of measles in Ohio thisyear, believed to be traced back to an unvaccinated traveler to the Philippines.

Remember to assess immunization status for both child and adult patients. TheAdvisory Committee on Immunization Practices (ACIP) recommends that routinevaccination include the two-dose measles series at ages 12 to 15 months and at ages 4to 6. Infants who will be traveling outside the U.S. can be vaccinated as early as 6 months.

For a link to the most up-to-date ACIP schedules, visit Provider.MedMutual.comand select Tools & Resources then Care Management/Main.

Eye on Quality 1

Vaccine Information at Your Fingertips

Clinicians now have immediate access to immunization schedules with the VaccineSchedules App from the Centers for Disease Control and Prevention (CDC).

The app includes recommended immunization schedules for children, adolescentsand adults from the Advisory Committee for Immunization Practices (ACIP).Changes, updates or corrections to the schedules are released through app updatesto ensure clinicians remain current on the recommended schedules.

Features of the app include:� Vaccine name hyperlinks that open as pop-ups with dosing information� Catch-up schedules with minimum dosing requirements� Convenient links to vaccine resources and websites to learn about:- Vaccine shortages and delays - Traveler’s Health Clinician Information Center- Vaccine conversations with patients - ACIP vaccine acronyms

For more information, visit CDC.gov/vaccines/schedules/hcp/schedule-app.html.

2 Eye on Quality Fall 2014 Issue

The CDC’s Advisory Committee on Immunization Practices (ACIP) isrecommending preferential use of the Live Attenuated Influenza Vaccine(LAIV: FluMist) for eligible children ages 2 to 8 who have no contraindicationsor precautions.

In Canada and the United Kingdom, LAIV is already the preferred influenzavaccine for children age 2 to 17 based on recommendations by the CanadianNational Advisory Committee on Immunization and the UK’s JointCommittee on Vaccination and Immunization. The World HealthOrganization’s Strategic Advisory Group of Experts has stated that, whenavailable, LAIV provides higher levels of protection in young children.

It is recommended that individuals age 6 months and older receive the fluvaccine every year. Vaccination rates for all age groups are still lagging atapproximately 40 percent.

Flu Vaccine Update

Statistics from recent studies provided by the CDC indicate:

� The administration of the flu vaccine reduced children’s risk of flu-related pediatric intensive careunit (PICU) admission by 74 percent during the 2010 to 2012 flu seasons.

� There was a 71 percent reduction in flu-related hospitalizations among adults of all ages and a 77percent reduction among adults age 50 and older during the 2011 to 2012 flu season compared tothe previous flu season.

� In one study, the flu vaccine produced a 79 percent reduction in hospitalizations among people withdiabetes and a 52 percent reduction in hospitalizations among people with lung disease.

� Giving the flu vaccine to a pregnant woman was 92 percent effective in preventing hospitalizationof her newborn for flu.

If FluMist is not available, ACIP recommends vaccination with the flu shotas opposed to waiting until the FluMist is delivered. Increasing vaccinationrates is paramount. For more information, visit CDC.gov/flu.

Billing Preventive Medicine Services

Effective immediately, Healthcare Common Procedure Coding System (HCPCS) Codeswill not be reimbursed when billed in conjunction with preventive medicine services.

� Preventive examinations or screenings that use HCPCS codes G0101, G0102, Q0091, S0610, S0612and/or S0613 are not separately payable when billed with preventive medicine Current ProceduralTerminology (CPT) codes 99381 through 99397.

� Pap smear code Q0091 is not separately payable when billed with annual gynecological examHCPCS codes S0610 or S0612.

� An annual GYN exam that includes a breast exam without pelvic exam S0613 is not separatelypayable when billed with annual gynecological exam HCPCS codes S0610 or S0612.

These services should not have been billed separately in the past. They will not bereimbursed separately in the future.

Eye on Quality 3

We are pleased to present the results of Medical Mutual’s 2014 (2013 measurement year)Healthcare Effectiveness Data Information Set (HEDIS®) audit below. Measures that have notdemonstrated improvement are indicated in teal, with those falling more than 10 percent inbold. We are always striving to improve these measures and the health of our members. We askfor your help in encouraging our members to obtain recommended screenings, immunizationsand examinations. For more information about HEDIS measurements, visit NCQA.org.

2014 Quality of Care Audit Results

2014 HEDIS Audit ResultsEffectiveness of Care: Prevention and Screening 2012 2013Adult BMI Assessment 63.94% 74.78%Breast Cancer Screening (annual mammography) 66.47% 69.50%Cervical Cancer Screening 72.05% 73.58%Colorectal Cancer Screening 56.00% 58.13%Chlamydia Screening (ages 16 to 25) 33.50% 38.55%Effectiveness of Care: Behavioral Health Follow-up for Children Prescribed ADHD Medication (Initiation Phase) 37.11% 36.48%Follow-up for Children Prescribed ADHD Medication (Continuation/Maintenance Phase) 41.18% 40.73%Antidepressant Medication Management: Acute Phase Treatment 72.89% 67.31%Antidepressant Medication Management: Continuation Phase Treatment 57.43% 52.13%Follow up after Mental Health Hospitalization: 7 Days 58.60% 46.54%Follow up after Mental Health Hospitalization: 30 Days 79.61% 69.29%Childhood Immunization Status by Age 2Combo 2 (4 DTaP, 3 IPV, 1 MMR, 2 Hib, 3 HepB, 1 VZV) 80.63% 82.08%Combo 2 (4 DTaP, 3 IPV, 1 MMR, 3 Hib, 2 HepB, 1 VZV, 4 pneumococcal conjugate) 77.93% 79.20%Effectiveness of Care: Respiratory ConditionsAppropriate Testing for Children with Pharyngitis 81.11% 82.28%Appropriate Treatment for Children with URI 80.34% 82.47%Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 20.19% 21.38%Use of Spirometry in the Assessment and Diagnosis of COPD 36.03% 36.38%Pharmacotherapy Management of COPD Exacerbation: Bronchodilator Therapy 74.24% 81.67%Pharmacotherapy Management of COPD Exacerbation: Systemic Corticosteroid 70.41% 76.76%Effectiveness of Care: Medication ManagementDisease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 86.88% 87.37%Effectiveness of Care: CardiovascularLDL-C Control (<100 mg/dL) for Patients with Cardiovascular Conditions 51.13% 38.44%Controlling High Blood Pressure 63.19% 63.70%Comprehensive Diabetes CareHbA1C Screening 88.78% 87.19%HbA1C Poor Control 32.33% 33.61%Dilated Retinal Exam 58.53% 47.42%LDL-C Screening 82.75% 81.86%LDL-C Control 38.19% 44.76%Nephropathy Monitoring 84.25% 83.69%B/P Control <140/80 39.13% 36.77%B/P Control <140/90 57.36% 64.39%

4 Eye on Quality Fall 2014 Issue

Medical Mutual is pleased to announce:� The adoption of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. This 300-page guidelinehas evidence-based recommendations for the treatment of heart failure. American College of CardiologyFoundation/American Heart Association. Updated 2013.

� The adoption of the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to ReduceAtherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/AmericanHeart Association. This is an 85-page evidence-based guideline with a new treatment approach, identifyingfour groups with recommended statin therapy. Updated 2013.

� Review and updating of the Continuity of Care Guidelines (Behavioral Health). The front of this documentcontains a summary of Medical Mutual’s guidelines for communication between the behavioral healthspecialist and the primary care provider. The second page contains a sample Behavioral Health SummaryCommunication Form, which can be used to send a written summary of the behavioral health consultationto the referring provider. Medical Mutual. Updated 2014.

� Review and updating of the Continuity of Care Guidelines (Medical/Surgical). The front of this documentcontains Medical Mutual’s guidelines for communication between the primary care provider and the (non-behavioral health) specialist when referring patients. A useful communication form for providers can befound on the back of the guidelines. Medical Mutual. Updated 2014.

It is our hope the following provider specialties will find these guidelines useful in daily practice:� Endocrinology � Family Practice � General Practice� Geriatrics � Internal Medicine � Pediatrics� Psychiatry � Psychology

Additional guidelines that can be easily accessed from Provider.MedMutual.com include: � Alcohol Screening � Low Back Pain� Attention Deficit/Hyperactivity Disorder (ADHD) � Major Depression: � Asthma – Behavioral Health Providers � Chronic, Non-Malignant Pain – Primary Care Providers� Chronic Obstructive Pulmonary Disease (COPD) � Preventive Care� Diabetes Mellitus � Pulmonary Medicine� Hypertension � Tobacco Dependence

The 2014 Advisory Committee on Immunization Practices (ACIP) guidelines for child/adolescent and adultimmunizations are available on Provider.MedMutual.com by selecting Tools & Resources, Care Managementand Main.

All available guidelines can be easily accessed by visiting Provider.MedMutual.com and selecting Tools &Resources then Guidelines.

Guidelines Update

If you would prefer to receive a copy ofMedical Mutual’s guidelines by mail:

� Call the Clinical Quality Improvement(CQI) department at: (800) 586-4523

� Write to us at:Medical MutualMZ: 01-5B-75012060 East 9th StreetCleveland, OH 44115

� Email us at:ClinicalQuality@MedMutual.com

When making your request, pleaseindicate which guidelines you wouldlike to receive.

Do you have a comment or suggestion? We are always interested inhearing from providers regarding our efforts to partner with you inproviding the highest quality of care to our members. Contact theClinical Quality Improvement (CQI) Department at (800) 586-4523or write to us at the address to the right.

We Would Like to Hear from You

Medical MutualMZ: 01-5B-75012060 East 9th StreetCleveland, OH 44115

Eye on Quality 5

Contacting Medical Mutual

The Care Management department is available to address inquiries regarding utilizationmanagement functions such as inpatient admissions, denials, appeals and referrals (includingbehavioral health services), Monday through Friday, excluding holidays, from 8:15 a.m. to4:15 p.m. EST. Please refer to the telephone numbers on the member’s ID card.

Case Management services are available to help coordinate care, provide information oncommunity services and arrange patient education. Call (800) 258-3175 for more information.

Medical Policy Update

Policy Service200117 Continuous Glucose Monitoring200310 Endoscopic and Laparoscopic Therapies for Treatment of Gastroesophageal Reflux200611 Vagus Nerve Stimulation200807 Infliximab (Remicade)200808 Rituximab (Rituxan)200913-CC Certolizumab pegol (Cimzia)201001-CC Golimumab (Simponi)201007 Light Therapies for Treatment of Vitiligo2011-D Applied Behavioral Analysis201401 Genetic Testing for Hereditary Cardiovascular Genetic Disorders (New)

201402 Bone Growth Stimulation (Invasive & semi-invasive) (New)

201403-CC Golimumab (Simponi Aria) (New)

94022 Bone Mineral Density Studies

The Corporate Medical Policies (CMPs) listed in the table below were developedor revised between January 1, 2014, and March 31, 2014.

CMPs are subject to change. They are regularly reviewed, updated, added or withdrawn.For a complete list of CMPs, please visit Provider.MedMutual.com and select Tools &Resources, Care Management and Corporate Medical Policies. The same section alsocontains information regarding Prior Approval and Investigational Services.

To streamline the review process for medications requiring prior approval under medicalbenefits, Medical Mutual is providing access to ExpressPAth, an online application thatfurnishes a quick and efficient response to these requests. The ExpressPAth training webinarpresents how to:

� Use ExpressPAth to submit drug review requests� Check the status of prior approval requests

The training webinar is recommended for all staff responsible for submitting medical drugprior approval requests. To register for a webinar training session or to obtain access toExpressPAth, contact expresspathregistration@express-scripts.com.

Electronic Prior Approval for Specialty Medications

6 Eye on Quality Fall 2014 Issue

To assist your patients who are pregnant and those diagnosed with certain chronicdiseases, you can enroll a qualifying Medical Mutual member in our DiseaseManagement and Maternity Program. In addition to maternity, this program isavailable for eligible members diagnosed with one or more of the followingconditions:

� Asthma � Depression� Chronic obstructive pulmonary disease � Diabetes� Chronic pain conditions � Heart failure� Coronary artery disease

Because many of the above conditions co-exist in the same individual, this programcan provide the intensive support necessary to make your management moreeffective. Enrollment in the proper program provides structured education andsupport by trained health coaches. Your enrolled patients benefit from routinemonitoring and education on complication management. The program also stressesthe importance of following a prescribed treatment plan.

Disease Management and Maternity Program

To enroll a patient in the MedicalMutual Disease Management andMaternity Program, please call usat (800) 861-4826.

Check Out Our Provider Manual

Medical Mutual’s Provider Manual is reviewed in its entirety during the course of the year andupdated as appropriate. When changes are made, an annotation of “new” or “revised” appearsin the updated section’s Table of Contents.

Provider Manual sections reviewed in the second quarter of 2014 include Plan Guidelines,Claims Submission and Glossary of Terms. To view the most recent version of the ProviderManual, visit Provider.MedMutual.com and select Tools & Resources then Provider Manual.

Effective July 30, 2014, the following prescription medications require prior approvalwhen requested under the member’s medical benefit through Medical Mutual:*

� Alpha1-Proteinase Inhibitors (Aralast NP,™ Glassia,™ Prolastin,® Prolastin®-C, Zemaira®)� Cetuximab (Erbitux®), I Denosumab (Xgeva®), I Doxetaxel (Docefrez™)� Omalizumab (Xolair®)� Paclitaxel (Abraxane,® Onxol®), I Pemetrexed (Alimta®)� Zoledronic acid (Zometa®)

This list is subject to change. For additional information on services and prescriptionmedications requiring prior approval or that are considered investigational, visitProvider.MedMutual.com and select Tools & Resources, Care Management andCorporate Medical Policies.

*When these medications are provided under a member’s prescription drug benefit, please contact the pharmacy benefitmanager at the number listed on the member’s identification card for prior approval requirements.

Prescription Drug Prior Approval Update

Eye on Quality 7

Select Providers for:� Tools & Resources� Products & Services� Become a Network Provider� Health & Wellness

Select Tools & Resources, Care Management, ClinicalQuality for:

� Mission– Quality Improvement Program Description– Quality Improvement Program Evaluation– Technology Assessment Program Description– Affirmation Statement

� Accessibility Standards� Clinical Guidelines� Medical Necessity Criteria� Patient Safety� Discharge Planning

Select Tools & Resources, Clinical Credentialing for:� Office Site and Medical Record DocumentationStandards

� Accessibility Standards� Sample Forms and Policies

Select Tools & Resources, Contact Us for:� Contacting the Care Management Department

Select Tools & Resources, Forms for:� Online Provider Services� Forms

Select Tools & Resources, Rx Benefit Management for:� Prescription Formulary� Pharmaceutical Education� Prior Authorization� Clinical Services� Home Delivery Practices

Select Tools & Resources, Corporate Medical Policies for:� Medical Policies� Predetermination� Investigational Services

Select Tools & Resources, Newsletters & Bulletins for:� Newsletters/Bulletins

Select Tools & Resources, Provider Manual for:� Provider Manual

Select Health & Wellness, Disease and MaternityManagement Program for:

� Medical Mutual Disease Management and MaternityProgram

Select Quick Links for:� Member Rights and Responsibilities

For Your Information

We remain committed to supplying you with the programs, information and support needed to ensurethe health and well-being of our members and the communities we serve. Access our website,Provider.MedMutual.com, for the following:

Pulmonary Medications Now Require Step Therapy

Effective April 30, 2014, a coverage review approval is required before certain medications used to treatasthma or chronic obstructive pulmonary disease (COPD) will be covered by the member’s health plan.

We have implemented new preferred drug step therapy requirements for the following non-preferred medications:� Members with asthma and COPD will be required to first try Dulera® or Symbicort® before Advair®* and Breo® Ellipta.™

� Members with asthma will be required to first try Asmanex,® Pulmicort® or QVAR® before Flovent® and Alvesco.®

Medical Mutual’s Coverage Management programs, such as prior approval and step therapy, help ensurebrand-name drugs are prescribed according to evidence-based outcomes and sound medical practices.Frequently, there are no clear clinical differences between these drugs and other preferred medications.

By following these quality parameters, we are also helping our customers save money and curb spending trends.

*Advair Diskus® will be covered for members under age 12 without step therapy and Advair Diskus® or Breo® Ellipta™ will be covered for members whocannot use typical metered-dose inhalers. However, the prior approval process must be completed in order to bypass the step criteria requiring Dulera®

or Symbicort.®

2060 East Ninth StreetCleveland, Ohio 44115-1355

© 2014 Medical Mutual of OhioX4037 R9/14

EYE ON QUALITY IS PUBLISHED FOR NETWORK PHYSICIANS SERVING MEDICAL MUTUAL

In This Issue1Curbing Measles Outbreaks2Flu Vaccine Update32014 Quality of Care Audit Results4Guidelines Update5Medical Policy Update6Disease Management and Maternity Management6Prescription Drug Prior Approval Update7Pulmonary Medications Now Require Step Therapy8For Your Information

Medical Spotlight

Flu Vaccine Update2014 Quality of Care Audit Results

Vaccine Info at Your Fingertips