CONNECTIONS A Provider’s Link to AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast 1

December 2017

CONNECTIONSA Provider’s Link to AmeriHealth Caritas Pennsylvania

and AmeriHealth Caritas Northeast

Dr. Gaspere C. (Gus) Geraci was recently named as Market Chief Medical Officer for AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast (referred to collectively as the Plans).

Dr. Geraci is board-certified in family practice, quality assurance, utilization review, and medical management with more than 35 years of clinical and teaching experience in the health care field.

In his new role, Dr. Geraci will lead quality assurance efforts and manage relationships with the local medical community for the Plans.

“Having served in a broad range of leadership roles in Pennsylvania’s medical and health care fields, Dr. Geraci brings a breadth of knowledge that will benefit both members and providers,” said Marge Angello, Market President for the Plans. “We are thrilled to have him join us.”

Prior to joining the Plans, Dr. Geraci was chief medical officer for the Pennsylvania Medical Society, where he guided physicians through quality- and value-based medicine and payments, and measured and improved physician engagement for health systems, employers, and hospitals.

“This is an energizing opportunity, and I’m eager to work with the top-rated Medicaid health plan in Pennsylvania as they continue their mission, and provide their members with the care and services they need to be healthy and stay well,” said Dr. Geraci.

A graduate of Jacobs School of Medicine, Dr. Geraci is a fellow of the American Academy of Family Practice and the American Institute of Healthcare Quality, as well as a member of the American Medical Association, Dauphin County Medical Society, and Pennsylvania Medical Society.

We welcome Dr. Geraci to the AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast family!

Welcome Dr. Gaspere C. (Gus) Geraci, Our New Market Chief Medical Officer

In this issueWelcome Dr. Gaspere C. (Gus) Geraci, Our New Market Chief Medical Officer .......................................1

Our NCQA Medicaid Health Insurance Plan ratings .........................2

HEDIS® medical record collection starting soon ...........................................3

Language services and your practice ...........................................4

Translation services ..............................4

Did you know you are a mandated reporter? .............................5

Information and resources about stroke and the F.A.S.T. mobile application for our members ............6

Protecting member privacy ..............6

What is covered and what is not covered by our plans .......................7, 8

The dangers of detergent pods .......................................9

Telephonic Psychiatric Consultation Service Program (TiPS) ...................10

Dental corner

OBs: Have you asked about dental visits? ............................. 11, 12

The opioid epidemic and dentistry ....................................13

Pharmacy news

Formulary updates ................. 14, 15

Safety edits for opioid medications for all members ......................................16

Pharmacy prior authorization: No phoning or faxing — just one click away! ........................17

Report suspected fraud, waste, or abuse ...................................17

2Call AmeriHealth Caritas Pennsylvania Provider Services at 1-800-521-6007 or AmeriHealth Caritas Northeast Provider Services at 1-888-208-7370.

AmeriHealth Caritas Pennsylvania is the top-rated Medicaid plan in Pennsylvania and one of the highest-rated health insurance plans in the nation, with a rating of 4.5 out of 5 in the National Committee for Quality Assurance’s (NCQA’s) Medicaid Health Insurance Plan Ratings 2017 – 2018.

AmeriHealth Caritas Northeast received a Medicaid Health Insurance Plan Rating of 4 out of 5, according to the NCQA’s Medicaid Health Insurance Plan Ratings 2017 – 2018, an improvement from its 3.5 out of 5 rating in 2016.

“We wholeheartedly devote ourselves to the well-being of our members and the communities we serve, and make it a priority to adapt to ever-changing member needs,” said Marge Angello, Market President for AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast. “We are increasing access to care, developing new ways to deliver

health care services, and building strategies to address social factors adversely impacting the health of our members.”

Our plans earned their ratings based on strong results from the Healthcare Effectiveness Data and Information Set (HEDIS®), a tool that measures performance on important dimensions of care and service, as well as the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey, which measures members’ satisfaction with their overall health care experience.

“Through member engagement and a consistent presence in the community, we gain perspective on the health issues affecting our members, and valuable insight into how we can meet the needs of our members,” said Lori Sheffy, Director of Quality Management for AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast.

As we move closer to a new year, let’s work together to ensure that every interaction with our members counts as an opportunity to help them get the care they need to stay healthy. We look forward to our continued partnership with our providers in providing the best care possible for our members.

AmeriHealth Caritas Pennsylvania AmeriHealth Caritas Northeast

NCQA Medicaid Health Insurance Plan Ratings 2017

Questions? Visit our website at www.amerihealthcaritaspa.com or www.amerihealthcaritasnortheast.com. 3

HEDIS® medical record collection will be starting soonThe Pennsylvania Department of Human Services (DHS) requires annual quality reporting by all health plans contracted with DHS for the HealthChoices program. AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast will use the data collected from your medical records to support our annual quality reporting to DHS. Disclosure and use of the medical records for this purpose is considered health care operations and is permissible under the Health Insurance Portability and Accountability Act (HIPAA) regulations ((45 C.F.R. 164.502(a)(1)(ii)).

We have contracted with PalmQuest Inc. to assist us with this year’s medical record review. PalmQuest is a quality management company utilizing licensed nurses that have significant experience in medical record review and quality measurement. PalmQuest and anyone conducting the medical reviews on their behalf are required to comply with HIPAA. We appreciate your cooperation in working with the PalmQuest nurse in scheduling a site visit and in providing all of the requested records free of charge.

FAQsWhen will medical records be requested?

Providers may be contacted by PalmQuest starting in January 2018. We must have all record collection completed by mid-April 2018 for submission to the National Committee for Quality Assurance (NCQA) and to DHS.

Because I am receiving this notification, does it mean I will be contacted for medical records?

Not necessarily. Members are randomly selected for inclusion in the HEDIS medical record collection process; your office may or may not receive any requests for records.

Will I be reimbursed for copies of medical records?

Only if there is specific language in your contract that states we pay for copies of medical records. Typically, we do not reimburse for medical records related to HEDIS data collection.

Will our medical record vendors like CIOX or MRO be reimbursed for records?

Only if there is specific language in your contract that states we pay for medical records. Typically, we do not reimburse for medical records related to HEDIS data collection.

Does HIPAA permit me to release records to your vendor, PalmQuest?

Yes. Disclosure and use of the medical records for this purpose is considered health care operations under HIPAA regulations ((45 C.F.R. 164.502(a)(1)(ii)).

Is my office required to participate in HEDIS data collection? What is my responsibility?

Yes, your contract requires your participation with quality audits. Your office is responsible for responding to PalmQuest in a timely manner when they are requesting an appointment for an onsite visit to review medical records.

When should our records be made available?

Medical records should be made available on the date of the onsite review, or by fax, secure email, or mail. Medical records should be provided to PalmQuest in the time they have designated.

4Call AmeriHealth Caritas Pennsylvania Provider Services at 1-800-521-6007 or AmeriHealth Caritas Northeast Provider Services at 1-888-208-7370.

Language services and your practiceDid you know…?

• During the past year, our Pennsylvania health plans used interpreter services in 83 different languages and dialects — including all 15 required Pennsylvania languages identified by the federal government (see list below).

• The migration into Pennsylvania has changed over the past 25 years. In 2015, 6.5 percent of Pennsylvanians identified as foreign born, more than double the 3.1 percent in 1990. But more importantly, the place of birth trends have changed dramatically.

Place of birth 1990 2000 2015

Africa 2.5% 5% 8%

Asia 29% 36% 40%

Europe 53% 36% 21%

Latin America 12% 20% 29%

Percentage foreign born 3.1% 4.1% 6.5%

Source: www.migrationpolicy.org/data/state-profiles/state/demographics/PA

So it comes as no surprise that DHS recently released guidelines for all Medical Assistance (MA) providers. PA DHS MA Bulletin 99-17-11 reminds MA providers of their responsibility to provide language services free of charge to all individuals who have Limited English Proficiency (LEP), vision limitations, and/or auditory limitations.

The MA Bulletin reinforces Section 1557 of the Patient Protection and Affordable Care Act of 2010. The final rule defines covered entities as health programs or activities receiving federal financial assistance. Information about the final rule is available at: www.hhs.gov/civil-rights/for-individuals/section-1557.

The federal guidelines:

• Provide language assistance services, including interpreter/translation services. Note: Providers should not use family members, low-quality video remote interpreting services, or rely on unqualified staff and/or translators when providing language services.

• Make available appropriate auxiliary aids and services, such as alternative formats and sign language interpreters, free of charge, when necessary for effective communication.

• Post statements that language services are available in the top 15 non-English languages spoken in Pennsylvania.

• Use top 15 non-English language taglines in large-sized significant communications, such as outreach publications or written notices. Note: Examples are in the MA Bulletin.

• Use Spanish and Russian taglines in small-sized significant communications, such as postcards.

• Display notice of individuals’ rights that includes information about LEP communication help.

The top 15 written non-English languages in the Commonwealth as determined by DHS are:

Spanish

Russian

Chinese (Simplified/Mandarin)

Vietnamese

Arabic

Nepali

Korean

Cambodian (Khmer)

French

Burmese

Haitian Creole

Portuguese (Brazil)

Bengali

Albanian

Gujarati

Translation servicesTo help ensure our members continue to have access to the best possible health care and services in their preferred language, we are extending to our network providers the opportunity to contract with Language Services Associates (LSA) at our low, corporate telephonic rates.

Go to the Provider section of our website at www.amerihealthcaritaspa.com → Providers → Initiatives → Cultural Competency or www.amerihealthcaritasnortheast.com → Providers → Initiatives → Cultural Competency to review a description of services and a letter of commitment for complete details and contact information. You may address any questions you have to LSA, since this relationship will be between your office and LSA. Feel free to call them at 1-215-259-7000, ext. 55316.

Questions? Visit our website at www.amerihealthcaritaspa.com or www.amerihealthcaritasnortheast.com. 5

What is child abuse?Child abuse occurs when a parent or caregiver causes injury, death, emotional harm, or risk of serious harm to a child. There are many forms of child abuse such as child maltreatment, neglect, physical abuse, sexual abuse, exploitation, and emotional abuse.¹

Did you know you are a mandated reporter?Under the Child Protective Services Law, all providers, particularly emergency, critical care, and urgent care providers, must be on the alert for signs of suspected child abuse and are considered mandated reporters under this law. Mandated reporters must know their legal responsibility to report such suspicions and are held to a higher standard of responsibility; there can be serious consequences when suspected abuse is not reported.²

Additional resources addressing mandatory reporter requirements include:

• Juvenile Law Center, Child Abuse and the Law at www.jlc.org/resources/publications/child-abuse-and-law.

• The Center for Children’s Justice, Child Protection FAQs: Reporting Child Abuse in Pennsylvania at www.c4cj.org/Child_Abuse_in_PA.php.

When must mandated reporters report suspected abuse?Mandated reporters are required to make a report of suspected child abuse, whether it is physical or sexual, if there is reasonable cause to suspect that a child is a victim of abuse.²

How do mandated reporters report suspected abuse?Call ChildLine at 1-800-932-0313. ChildLine is a 24-hour toll-free reporting system operated by DHS to receive reports of suspected child abuse.

Once the initial report has been made, you must complete form CY 47 and forward it to the county children and youth agency in your area within 48 hours. The CY 47 reporting form is available at www.keepkidssafe.pa.gov/resources/forms/index.htm.

For additional information, go to:

AmeriHealth Caritas Pennsylvania www.amerihealthcaritaspa.com/provider/initiatives/childabuse/index.aspx

AmeriHealth Caritas Northeast www.amerihealthcaritasnortheast.com/provider/initiatives/child-sex-abuse- prevention.aspx

¹www.childhelp.org/child-abuse/

²www.keepkidssafe.pa.gov

Did you know you are a mandated reporter?

6Call AmeriHealth Caritas Pennsylvania Provider Services at 1-800-521-6007 or AmeriHealth Caritas Northeast Provider Services at 1-888-208-7370.

Information and resources about stroke and the F.A.S.T. mobile application for our membersAccording to the American Heart Association/American Stroke Association, women have more strokes than men, and strokes kill more women than men.

One in five women is at risk of having a stroke. Last year, 795,000 people suffered strokes in the United States.¹

Every 40 seconds, someone in the United States has a stroke. It can happen anywhere. The faster the stroke is treated, the more likely the patient will recover.¹

How can you help?Encourage your patients to download the free F.A.S.T. mobile app.* It can help in the event they experience signs and symptoms of a stroke.

The following is also a good resource for your patients: StrokeAssociation.org/WarningSigns.

F.A.S.T. is an easy way to remember the sudden signs and symptoms of a stroke.

• Face drooping.

• Arm weakness.

• Speech difficulty.

• Time to call 911.

For more information about the F.A.S.T. mobile app and other stroke prevention resources, please visit www.stroke.org.

¹ www.stroke.org*Standard messaging and data rates apply.

Protecting member privacyAmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast are committed to protecting the privacy of members’ health information, and to complying with applicable federal and state laws that protect the privacy and security of members' health information. Consistent with this commitment, we have established basic requirements for the use or disclosure of members’ protected health information (PHI). For a complete and detailed description of our routine uses and disclosures of PHI, as well as our internal protection of oral, written, and electronic PHI, please visit:

www.amerihealthcaritaspa.com → Providers → Communications → HIPAA/5010/ICD-10 or

www.amerihealthcaritasnortheast.com → Providers → Communications → HIPAA Resource Center.

Questions? Visit our website at www.amerihealthcaritaspa.com or www.amerihealthcaritasnortheast.com. 7

What is covered and what is not covered by AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast?Covered benefitsOur members are entitled to all of the benefits provided under the Pennsylvania Medical Assistance program.

Benefits include, but are not necessarily limited to, the following:

• Ambulance.

• Behavioral health services.*

• Chemotherapy and radiation therapy.

• Dental care.

• Durable medical equipment (DME) and medical supplies.

• Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services.

• Family planning.

• Home health care.

• Hospitalization.

• Laboratory services.

• Nursing facility services.

• Obstetrical/gynecological services.

• Other specialty care services.

• Pharmacy services.

• Primary care services.

• Physical, occupational, and speech therapy.

• Rehabilitation services.

• Renal dialysis.

• Vision care.

* Under the HealthChoices program, behavioral health services are coordinated through, and provided by, the member’s behavioral health managed care organization (BH-MCO). These services are not part of the plan’s benefit package, but are available to all plan members through the BH-MCOs.

(continued on page 8)

8Call AmeriHealth Caritas Pennsylvania Provider Services at 1-800-521-6007 or AmeriHealth Caritas Northeast Provider Services at 1-888-208-7370.

What is covered and what is not covered by AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast?(continued from page 7)

Services not covered*Some services that are not covered by the Pennsylvania Medical Assistance program and/or our plans include, but are not limited to, the following:

• Services that are not medically necessary.

• Services rendered by a health care provider that does not participate in our plans, except for:

¨ Medicare-covered services.

¨ Emergency services.

¨ Family planning services.

¨ Services otherwise prior authorized by our plans.

• Cosmetic surgery, such as tummy tucks, nose jobs, face lifts, and liposuction.

• Experimental treatment and investigational procedures, services, and/or drugs.

• Home modifications (for example, chair lifts).

• Acupuncture.

• Infertility services.

• Paternity testing.

• Any service offered and covered through another insurance program, such as Workers’ Compensation, TRICARE, or other commercial insurance that has not been prior authorized by our plans. However, Medicare-covered services provided by a Medicare provider do not require prior authorization.

• Motorized lifts for vehicles.

• Services provided outside the United States and its territories. Our plans are prohibited from making payments for services provided outside of the United States and its territories.

• Private duty (also known as shift care) skilled nursing and/or private duty home health aide services for members 21 years of age or older.

• Services not considered a “medical service” under Title XIX of the Social Security Act.

When in doubt about whether our plans will pay for health care services, please contact the AmeriHealth Caritas Pennsylvania Provider Services department at 1-800-521-6007 or the AmeriHealth Caritas Northeast Provider Services department at 1-888-208-7370.

Questions? Visit our website at www.amerihealthcaritaspa.com or www.amerihealthcaritasnortheast.com. 9

The dangers of detergent podsPediatricians and other health care providers need to counsel parents and other caregivers about the dangers of detergent pod exposure and the need for safe storage and careful use of these products.

Many parents use liquid laundry detergent pods because they are convenient, but young children have increasingly suffered injury from the chemicals inside of them.

In an analysis of 2013 data by the American Association of Poison Control Centers, 4,692 of the 10,877 reported pod-related exposures required medical attention, more than all other laundry detergent related injuries.¹

What happens when pods are ingested or inhaled?

• The child could have difficulty breathing.

• Vomiting can occur.

• Coughing and/or choking can happen.

• Eye irritation may occur.

• Pain and burning can occur in the mouth and lips.

Suggestions for parents:• Keep poisonous household products out of your

children’s sight and reach.

• Use child-resistant packaging. If it’s not childproof, don’t use it.

• Explain to children that they should not eat or smell the pods. They are not candy.²

Instructions to parents if children ingest or inhale these pods:

• Rinse the mouth or eye area for 20 minutes immediately with cool water.

• Call Poison Control at 1-800-222-1222.

• Go to the emergency room or call 911, if needed.

• Log on to poison.org to use the innovative webPOISONCONTROL® tool for online guidance based on age, substance, and amount swallowed.

For information on this communication or other communications to providers, please visit:

AmeriHealth Caritas Pennsylvania www.amerihealthcaritaspa.com/provider/communications/index.aspx

AmeriHealth Caritas Northeast www.amerihealthcaritasnortheast.com/provider/communications/index.aspx

¹ The Problem with Laundry Detergent Pods. Consumer Reports. July 2015. Accessed September 2017. www.consumerreports.org/cro/magazine/2015/07/the-problem-with-laundry-detergent-pods/index.htm.

² Take Poison Prevention Week Seriously. National Capital Poison Center. March 2017. Accessed September 2017. www.poison.org/press/take-poison-prevention-week-seriously-mar-2017.

10Call AmeriHealth Caritas Pennsylvania Provider Services at 1-800-521-6007 or AmeriHealth Caritas Northeast Provider Services at 1-888-208-7370.

Telephonic Psychiatric Consultation Service Program (TiPS)Has your office taken advantage of this child psychiatry consultation service?TiPS is a new Pennsylvania HealthChoices program designed to increase the availability of child psychiatry consultation teams telephonically to PCPs and other prescribers of psychotropic medications, for children insured by Pennsylvania’s Medical Assistance (Medicaid) program. The program provides real-time peer-to-peer resources to the PCP that desires immediate consultative advice for children (up to age 21) with behavioral health concerns.

Why TiPS?Access to child psychiatry has been a significant problem nationwide for years, as documented in the Surgeon General's report of 2000. Increasing prevalence of child behavioral health issues coupled with a stagnant workforce has only exacerbated the situation. Children's PCPs end up meeting this need even though they may not feel completely prepared to do so.

TiPS team members can:• Help PCPs effectively meet the needs of youth with

common mental health conditions like attention-deficit/hyperactivity disorder (ADHD) and mild depression.

• Make care connections for children requiring specialty psychiatric care and/or medications not appropriately managed in the primary care setting.*

*TiPS psychiatrists do not prescribe medications.

TiPS core services• Telephone and face-to-face consultations. Phone

inquiries can be patient-specific or general questions regarding behavioral health care or community resources.

• Care coordination. TiPS care coordinators are highly skilled in identifying and maintaining up-to-date behavioral health resources in communities.

How to enroll in TiPSCall your TiPS team at 1-267-426-1776.

Once you are enrolled, your TiPS team will work with you and your staff either in person or by phone to:

• Explain how to access services.

• Answer questions.

• Discuss expectations.

Do you know your Account Executive? Your Account Executive is your liaison with AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast. They are responsible for orientation, continuing education, and problem resolution for our network providers. To access our listing of provider Account Executives, please visit:

www.amerihealthcaritaspa.com → Providers → Communications → Contact information for providers or

www.amerihealthcaritasnortheast.com → Providers → Communications → Contact information

Call your Account Executive:

• To arrange for orientation or in-service meetings.

• For service calls.

• To respond to any questions or concerns.

• To report any changes in your status, such as phone number, address, Taxpayer Identification Number, or additions/deletions of physicians at your practice.

Questions? Visit our website at www.amerihealthcaritaspa.com or www.amerihealthcaritasnortheast.com. 11

OBs: Have you asked about dental visits?Pregnant women and mothers of babies and young children are focused on so many things that they may not consider the importance of their own oral health. When seeing these patients, OBs can open discussion by asking, “Have you seen your dentist this year?”

Remind your patients that cavities (known as tooth decay or dental caries) and gum disease are caused by bacteria in the mouth and are preventable with good hygiene, a reduced-sugar diet, and regular dental care. Preventing cavities and gum disease with regular and early visits saves money by eliminating the need for expensive dental treatments later on.

Educate patients on the following important steps to take:

• Brush and floss twice a day for two minutes (“2 x 2”) with fluoride toothpaste.

• Limit sugary drinks (juice, soda, sports drinks) and sticky, sugary snacks.

• Schedule dental checkups every six months (or more frequently if recommended by a dentist).

Let your patients know that dental care (including exams, cleanings, and X-rays with shielding) is safe during pregnancy — and recommended.

Moreover, untreated problems can cause health issues for moms and their babies. For example, teeth may become weak from acid reflux or vomiting due to morning sickness.

Encourage your patients to combat this problem by:

• Rinsing with water, mouthwash, or fluoride rinse immediately after vomiting.

• Waiting 10 – 15 minutes to brush after vomiting. Enamel is weaker during that time due to recent stomach acid exposure and can be worn away by brushing.

Dental corner

(Continued on page 12)

12Call AmeriHealth Caritas Pennsylvania Provider Services at 1-800-521-6007 or AmeriHealth Caritas Northeast Provider Services at 1-888-208-7370.

OBs: Have you asked about dental visits?(Continued from page 11)

Dental corner

Share with your patients these common myths — and actual facts —about prenatal and infant oral health.

Myth: It’s none of the dentist’s business if I’m pregnant because being pregnant doesn’t affect my mouth.

Fact: It’s important for your dentist and hygienist to know that you are pregnant or trying to become pregnant. Pregnant women are at greater risk for certain oral health conditions. These conditions include gum disease, also known as “pregnancy gingivitis,” and growths within the mouth, called “pregnancy tumors.” Both conditions are treatable, so be sure to visit your dentist.

Myth: Pregnant women should avoid seeing the dentist until after they deliver.

Fact: The best time to visit the dentist for a cleaning and checkup is before you become pregnant to ensure a healthy mouth. You should also visit the dentist during your pregnancy to get your regularly scheduled care.

Myth: Pregnant women should avoid dental work, especially X-rays.

Fact: If you’re pregnant, you face a higher risk for gum disease, so make sure to visit your dentist for regular cleanings, exams, and any other treatment needed. Dental X-rays are also considered safe during pregnancy with proper protection, according to the American Congress of Obstetricians and Gynecologists (ACOG). X-rays can be essential in detecting serious problems, such as hidden decay, bone loss, and inflamed tooth pulp.

Myth: Morning sickness is unpleasant but harmless.

Fact: Repeated vomiting can cause serious damage to your teeth. Stomach acid dissolves tooth enamel, weakening your teeth’s defense against decay.

Myth: Women lose a tooth for each child they have given birth to.

Fact: Although more of an “old wives tale” than a myth, this is not true. Hormonal changes during pregnancy can cause gingivitis (inflamed or bleeding gums). Tooth loss is unlikely if you brush your teeth and floss twice a day and see your dentist every six months.

Myth: Pregnancy leaches calcium from your teeth.

Fact: A fetus does not take calcium from its mother’s teeth. This myth likely originated because pregnant women face a higher risk of tooth decay. Pregnancy is a critical time to consume calcium — this essential nutrient helps your growing fetus develop properly and lowers your own risk of osteoporosis (bone loss) later in life.

Myth: Children do not need to see the dentist until age 3.

Fact: Proper care for baby teeth is very important, as they help with chewing, aid in speech development, and lead to proper development of permanent teeth by saving space for them. The American Academy of Pediatric Dentistry (AAPD), American Dental Association (ADA), and the American Academy of Pediatrics (AAP) all recommend a dental visit for children by age 1. Baby teeth are vulnerable to tooth decay as soon as they come into the mouth, which could be as early as when a child is 6 months old.

Questions? Visit our website at www.amerihealthcaritaspa.com or www.amerihealthcaritasnortheast.com. 13

Dental corner

The opioid epidemic and dentistryIn the United States, drug overdose is the leading cause of injury-related deaths. For the past two years, deaths due to opioid overdose have surpassed deaths caused by firearms and even car accidents.¹

Furthermore, 12 percent of prescriptions for immediate-release opioids are written by dentists. In 2012, dentists ranked fourth among medical specialties for their opioid prescribing rates. This may not sound like a major issue, but when you consider that in 2015, U.S. dentists prescribed approximately 200 million opioid dosage units for post-op third molar surgery and only 50 percent (100 million opioid dosage units) were actually used by patients, it becomes significant. The 100 million opioid dosage units that were not used by patients represent a staggering amount of dosages that were free to be used by someone else, stolen, sold, or given to friends and family for potential misuse.²

What can you as a dental provider do to help alleviate this nationwide epidemic?

1. Be aware that for teens, opioid abuse can start with a prescription from a dentist.

2. Consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain management.

3. Know that all prescribers must now query the Pennsylvania Prescription Drug Monitoring Program (PA PDMP) each time a patient is prescribed an opioid drug product or benzodiazepine.³

4. Practice patient assessment and referral to substance abuse programs.

5. Offer patient education that includes safe storage and disposal of medications and patient responsibility in preventing abuse.

Though there is still much to be done in alleviating this national issue, every little bit counts. It should not be forgotten that, first and foremost, awareness—from patients and parents to dentists and dental surgeons—is crucial in help ensuring that prescription opioids for dental work are used appropriately.

¹www.sunrisedentalsolutions.com/dentistry-opioid-epidemic/

²http://digitalenamel.com/opioid-epidemic-dentistrys-response-part-ii/

³ www.health.pa.gov/Your-Department-of-Health/Offices%20and%20Bureaus/PaPrescriptionDrugMonitoringProgram/Pages/Prescribers.aspx#.WftkkV7D9pg

www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-opioids-dental-pain

14Call AmeriHealth Caritas Pennsylvania Provider Services at 1-800-521-6007 or AmeriHealth Caritas Northeast Provider Services at 1-888-208-7370.

Pharmacy news

Formulary updates

Additions — September 2017

Voltaren 100 mg

Ansaid

Clinoril

Aleve

Motrin 100 mg and 200 mg

Oxycodone solution

Intrarosa

Isentress HD

Azelastine drops (with step therapy trial and failure of ketotifen)

Generic Patanol (with step therapy trial and failure of ketotifen)

Additions — July 2017

2017–2018 flu vaccines (for members 9 and older and have a quantity limit of one vaccine per six months)

Basaglar KwikPen

Generic Mylan EpiPen and EpiPen Jr

Additions — June 2017

Ella

Diamox Sequels

Zenpep 40K-136K

Norpramin 75 mg and 100 mg

Linzess 72 mcg capsule

Selzentry 25 mg and 75 mg

Vyvanse chewable

Celebrex

Abreva

Diclofenac 1% gel (with step therapy and ICD-10 code for osteoarthritis of the hand or knee)

Generic Depo-Testosterone (with prior authorization)

Generic Fortesta (with prior authorization)

Generic Androxy (with prior authorization)

(continued on page 15)

Questions? Visit our website at www.amerihealthcaritaspa.com or www.amerihealthcaritasnortheast.com. 15

Pharmacy news

Formulary updates (continued from page 14)

Removals — August 2017

Brand Condylox gel

Lantus and Lantus SoloSTAR pens

Brand EpiPen or EpiPen Jr

Incruse Ellipta (umeclidinium)

For the latest formulary and prior authorization information, please visit our websites.

Pharmacy Services (PerformRxSM)

AmeriHealth Caritas Pennsylvania 1-866-610-2774

AmeriHealth Caritas Northeast 1-888-208-1020

You may also contact your provider Account Executive.

Age limits, quantity limits, or day supply limits

June 2017Methergine 0.2 mg tablets (quantity limit of 28 tablets and seven-day supply)

September 2017

Formulary proton pump inhibitors (no longer have a quantity limit of one per day; the quantity limit has been increased to two per day)

Removals — June 2017

Tekturna

Tekturna HCT

Brand Androgel 1.62%

Methitest

Testred

Axiron

Denavir

Haloperidol decanoate 50 mg/mL ampule

Toviaz

Fanapt

Removals — July 2017

Rectiv ointment

Atripla

Complera

16Call AmeriHealth Caritas Pennsylvania Provider Services at 1-800-521-6007 or AmeriHealth Caritas Northeast Provider Services at 1-888-208-7370.

Safety edits for opioid medications for all members (members with active cancer diagnosis or in hospice or palliative care will be exempt from this requirement)

Stage Date the change starts Dosing limit Day supply limit

1 August 9, 2017 (members new to therapy)

No more than 90 MME combined No more than a 5-day supply

2 October 1, 2017 (member who filled an opioid between May 9, 2017 and August 9, 2017)

No more than 170 MME combined No more than a 14-day supply

3 November 1, 2017 (member who filled an opioid between May 9, 2017 and August 9, 2017)

No more than 150 MME combined No more than a 10-day supply

4 January 1, 2018 (member who filled an opioid between May 9, 2017 and August 9, 2017)

No more than 120 MME combined No more than a 7-day supply

5 February 1, 2018 (member who filled an opioid between May 9, 2017 and August 9, 2017)

No more than 90 MME combined No more than a 5-day supply

Pharmacy news

Pharmacy prior authorization: No phoning or faxing — just one click away!Use our online prior authorization request form to submit pharmacy prior authorization requests instantly. To get started, go to

www.amerihealthcaritaspa.com → Providers → Pharmacy → Online Prior Authorization Request Form or

www.amerihealthcaritasnortheast.com → Providers → Pharmacy → Online PA request form.

www.amerihealthcaritaspa.com www.amerihealthcaritasnortheast.com

ACPA_1799950

AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast Connections Editorial Board

Marge Angello, R.N. Market President

Dr. Gaspere C. Geraci Market Chief Medical Officer

Jeffrey M. Fike, D.D.S. Network Dental Director

Steve Orndorff Director Provider Network Management

Jessica Yasher, R.N., B.S.N. Director Provider Network Management

Elizabeth Flanagan Editor Manager, Provider Communications and Marketing

Julanne Hogan Contributor Provider Communications

Contact us:

provider.communications@ amerihealthcaritaspa.com

providercommunications@ amerihealthcaritasnortheast.com

Report suspected fraud, waste, or abuseProviders who suspect that an AmeriHealth Caritas Pennsylvania or AmeriHealth Caritas Northeast provider, employee, or member is committing fraud, waste, or abuse should notify our Special Investigations Unit as follows:

• Call the toll-free MA Provider Compliance Hotline at 1-866-833-9718, • Email fraudtip@amerihealthcaritas.com, or • Mail a written statement to:

Special Investigations Unit AmeriHealth Caritas Pennsylvania/AmeriHealth Caritas Northeast 200 Stevens Drive Philadelphia, PA, 19113

Information can be left anonymously.

Our Special Investigations Unit supports the efforts of local and state authorities in the prosecution of reported cases of fraud, waste, and abuse. Reports of suspected fraud, waste, and abuse related to our Plans may also be sent directly by:

Phone: 1-844-DHS-TIPS or 1-844-347-8477

Online: www.state.pa.us/

E-mail: omaptips@state.pa.us

Fax: 1-717-772-4655, Attn: OMAP Provider Compliance Hotline

Mail: Bureau of Program Integrity OMAP Provider Compliance Hotline P.O. Box 2675 Harrisburg, PA 17105-2675