The Population Health Program (PHP) works to engage members in managing their own health, improve the utilization of primary and preventive services and reduce risk of hospitalizations and high cost interventions. Fundamentally, the PHP helps
members take charge of their health and their healthcare, altering cost and quality trends through efficient and effective member interventions. The PHP is embedded in the member experience of the health plan and will be a significant contributor to customer satisfaction and retention.
Member Engagement
In a high performing health system, patient engagement is crucial. Medical literature demonstrates that patients who are informed and supported with coordinated care will have a better consumer experience and better health outcomes. The definition of patient engagement varies widely in the public health literature, but it is defined here to frame the operational process and outcome measures:
■ selection of a primary physician
■ completion of the online or telephonic General Health Assessment (GHA) in English or Spanish
■ regular visits to a primary physician
■ adherence to recommended preventive services
■ referral and/or adherence to the disease management program
■ response to outreach from the PHP
PHP Member Engagement Approaches
A variety of tactics are available to support patient outreach and engagement, which is conducted on a telephonic and electronic platform. The program design is
engineered to leverage efficiencies through the use of electronic means, including:
■ standardized emails and text message campaigns
■ condition specific push notifications
■ physician alerts (admissions and Emergency Room visits, etc)
■ scheduling of visits with physicians
■ targeted mailings
■ telephone call(s) with Wellness Coaches (personal coaching)
■ referrals to case management
■ website content
■ use of incentives
Patient Education Materials
At the core of the member experience is the Member Center of the Health Republic website. The website is designed to facilitate the engagement process through selec-tion of a primary physician, compleselec-tion of the GHA and exploraselec-tion of a large library of interactive health resources. Completion of the GHA is likely to trigger further exploration of the available resources by members.
Role of the Wellness Coach
The Wellness Coach is charged with enhancing the engagement of at-risk members through motivational interviewing strategies. The highest priorities are to encourage members to select a physician and complete the GHA. The Wellness Coaches conduct campaigns (e.g. targeted mailings, telephone and email) to promote regular screenings and use of preventive services. They also engage members who might benefit from better coordination of care (such as persons who use the emergency department and fail to follow up with their primary physician). Additional campaigns may focus on medical and behavioral risk factors.
Role of StatDoctors for Telemedicine Services
Health Republic encourages our members to manage their healthcare at all times while reducing the risk of hospitalizations and unnecessary high cost interventions. To achieve this goal, Health Republic partners with StatDoctors so members can immediately
access care and treatment nationwide* and at any time. A free service to all members, StatDoctors are board-certified emergency medicine physicians who can evaluate, diagnose and treat a variety of minor medical conditions online or over the phone.
These physicians can also send electronic prescriptions to your pharmacy. Providers can refer Health Republic members to this service for after hour services. More information about this program is available at https://healthrepublicny.org/for-mem-bers/stat-doctors/. *STATDOCTORS™ operates subject to applicable state laws. All services may not be available in all states.
Case Management
Case Management is a standard component across all Health Republic plans and seeks to enhance coordination of services for members at high risk. Our Case Managers are Registered Nurses and Licensed Social Workers who review and coordinate services for members with multiple and complex needs (e.g., cardiac care, complex pediatric care, complex behavioral healthcare, medical psychiatric coordination, oncology, transplants, dialysis). Case Management services may also be provided as part of the discharge planning process for a hospital admission.
Once we decide that a member is a good candidate for Case Management and the member or caregiver agrees to it, we make an individualized plan. We work with the member, the member’s family, physician(s) and other healthcare professional(s). The assessment process leads to the development of a Case Management plan that meets the member’s specific needs. The plan includes member-specific deficits, goals and objectives. There are targeted activities to meet these goals and objectives. The Case Manager helps the member achieve his or her health goals, and they work to resolve any identified issues or barriers. We regularly reassess the individualized plan to
determine the member’s progress in meeting the goals and objectives. As the member’s condition progresses or regresses, we modify the plan accordingly. Once the stated goals and objectives are met, the member is discharged from Case Management; this is usually within an average of 30 to 90 days.
Health Republic welcomes referrals from treating physicians to our Case Management program. Physicians who believe that their patient would benefit from Case Manage-ment should call 888-990-5702, select prompt 3 and then prompt 2.
Reimbursement for Care Coordination Services
Health Republic provides reimbursement for a variety of services that support effective care coordination and improve patient health. Examples include telephone or online evaluation and management services, and transitional care management services.
Providers are also reimbursed for counseling on smoking cessation, alcohol and substance abuse and preventive medicine for individual and group sessions.
PHARMACY
Programs and Covered Services
Pharmacy services are a covered benefit for Health Republic members. A comprehensive and up-to-date formulary is available on the Health Republic website at www.healthre-publicny.org in the For Providers section of the website. Pharmacy services are provided by US Script and its network of participating pharmacy providers.
Some medications require step therapy, prior authorization (PA) or have limitations on age, dosage and/or maximum quantities. If there are any questions, providers may call the US Script Help Desk at 855-339-4803. A list of participating pharmacies is available from the US Script website at www.usscript.com.
Members should present their Health Republic member ID card to pharmacy staff when accessing pharmacy services. The US Script corporate logo and phone number appear on the member ID card. All prescriptions must be filled at a US Script participating pharmacy. Health Republic may require prior authorization of certain pharmaceuticals.
Medication Formulary
Health Republic has partnered with US Script to provide a robust pharmacy benefit for our members. To access the most recent version of the medication formulary, visit https://healthrepublicny.org/for-providers/index/.
Pharmacy and Therapeutics Committee Process
The US Script Pharmacy and Therapeutics Committee (P&T) process includes the selection of drugs considered to be the top choices based on their safety, effectiveness and value for our formulary.
The P&T process is led by an independent group of practicing doctors, pharmacists and other healthcare professionals responsible for the research and decisions surrounding our drug list/formulary. This group meets regularly to review new and existing drugs and to choose the top medications for our formulary.
The P&T process also helps improve customer health through programs such as drug utilization review, medication safety promotion and compliance encouragement.
US Script uses a balanced approach to drug list/formulary management, based on a combination of research, clinical guidelines and member experience. The latest developments and submission guidelines from around the world are considered when developing and maintaining this list.
Health Republic plans have adopted a medication formulary that is based on the bench-mark requirements provided by the New York State Department of Health and is consis-tent with other formularies for plans on the NY State of Health Marketplace. Providers
are encouraged to consider the comparative cost and efficacy of pharmaceutical alternatives when prescribing medication for Health Republic members.
When a step therapy or prior authorization is required, the prescriber should contact US Script directly. A provider can assist a member in filing a request for an exception to cover a non-formulary prescription by the same method. All prescription coverage exception determinations are made by US Script.
Quantity Limitations
Quantity limitations have been implemented on certain medications to ensure the safe and appropriate use of the medications. Quantity limitations are approved by the US Script P&T Committee and noted throughout the formulary. Please refer to our medi-cation formulary for additional information on our quality limitations, which is listed as needed.
Step Therapy
Medications requiring step therapy are listed with an “ST” notation throughout the formulary list. The US Script claims system will automatically check the member profile for evidence of prior or current usage of the required agent. If there is evidence of the required agent on the member’s profile, the claim will automatically process. If not, the claims system will notify the pharmacist that a prior authorization is required.
Age Limits
Some medications on the formulary may have age limits. These are set for certain drugs based on US Food and Drug Administration (FDA) approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.
Pharmacy Prior Authorization Process
The formulary includes a broad spectrum of generic and brand name drugs. Clinicians are encouraged to prescribe from the formulary. Some preferred drugs require prior authorization and are listed with a “PA” notation throughout the formulary.
Specific Exclusions
The following drug categories are not part of the formulary:
■ oral vitamins and minerals (except those listed in the formulary)
■ drugs and other agents used for cosmetic purposes or for hair growth
■ Over-the-Counter (OTC) drugs (except those listed in the formulary)
Pharmacy Drug Tiers
Drug tiers have been structured to allow member co-payments to match the underlying ingredient cost.
Tier 0 – Preferred Preventive Drugs
Preferred preventive drugs are required as part of the Affordable Care Act. This includes treatments or drugs for purposes such as smoking cessation or birth control.
Tier 1 - Preferred Generic Drugs
The lowest cost generic medications in any drug class are placed in this category.
Generic drugs are chemically identical to brand drugs but are priced at a fraction of the cost and offer an excellent value to the member. To gain FDA approval, a generic drug must:
■ contain the same active ingredients as the branded drug (inactive ingredients may vary)
■ be identical to the brand drug in strength, dosage form, safety and route of administration
■ be of the same quality, performance characteristics and use indications
■ be manufactured under the same strict standards of the FDA’s good manufacturing practice regulations required for branded products
If a generic is chosen, the provider must leave blank the “DAW” (Dispense As Written) box on the prescription materials. This way, the pharmacist will fill the prescription with the generic drug.
Tier 2 - Preferred Brand Drugs
A listing of formulary brand drugs that are available at a lower co-pay than drugs in the non-preferred drug category. This generally happens when there are several equally effective, FDA-approved brand name drugs by different manufacturers for treatment of a particular condition.
Tier 3 – Non-Preferred Brand and Generic Drugs
Drugs in the non-preferred category generally have a similar, more cost effective drug available in either the preferred generic drug category (Tier 1) or the preferred brand drug category (Tier 2). Most new FDA-approved drugs are initially placed in Tier 3 for about six months until the P&T Committee reviews them for safety, efficacy and clinical comparisons. At that time, the drug may be moved into a different tier.
Tier 4 - Specialty Medications
This tier uses a pharmacy vendor to help manage the care of members who need
oral and injectable specialty medications. The vendor verifies eligibility, submits requests for prior authorization and bills the member appropriate co-payments or co-insurance for medications. Providers must order specialty medications directly through the delegated vendor.
Diabetic Drug Benefit
Certain diabetic supplies, insulins and oral antidiabetic medications are classified under a separate benefit from the prescription drug benefit described above. This is called the Diabetic Drug Benefit. These medications and supplies are designated with a black
“c” icon ( ) in the formulary and their co-payments may differ from the standard tier level co-payment associated with your plan. (See your Summary of Benefits for more detailed copay information.) The Diabetic Drug Benefit is designed to assist members’
ongoing management of their diabetes.
Working with US Script
Health Republic works with US Script to administer pharmacy benefits, including the prior authorization process. Certain drugs require PA to be approved for payment by Health Republic.
These include:
■ all medications not listed on the formulary
■ some Health Republic preferred drugs (designated with a “PA” notation on the formulary)
Guidelines for Processing of Prior Authorization requests:
1. Complete the Health Republic/US Script form: Medication Prior Authorization Request Form. This form is located in the For Providers section of the Health Republic website. Be sure to include any pertinent clinical notes/documentation for a complete review.
2. Fax to US Script at 866-399-0929.
3. Once approved, US Script notifies the prescriber by fax.
4. If the clinical information provided does not explain the reason for the requested PA medication, US Script responds to the prescriber by fax, offering formulary alternatives.
5. For urgent or after-hours requests, a pharmacy can provide up to a seventy two (72) hour supply of most medications by calling the US Script Pharmacy Help Desk at: 800-460-8988.
Prior Authorization Contact Information:
US Script Phone: 855-339-4803 Prior Authorization Phone: 866-399-0928
Prior Authorization Fax: 866-399-0929
Clinical Hours: Monday - Friday 10:00 a.m.- 8:00 p.m. (EST) Mailing Address: US Script, 2425 W Shaw Ave., Fresno, CA 93711
When calling, please have patient information, including Health Republic member ID number, complete diagnosis, medication history and current medications, readily available.
■ If the request is approved, information in the online pharmacy claims processing system will be changed to allow the specific member to receive the specific drug.
■ If the request is denied, information about the denial and appeal rights will be provided to the clinician.
Clinicians are requested to utilize the Health Republic formulary when prescribing medication for those patients covered by the Health Republic pharmacy program. If a pharmacist receives a prescription for a drug that requires a PA request, the pharmacist should attempt to contact the clinician to request a change to a product included in the Health Republic formulary.
Exception Requests
In the event that a clinician or member disagrees with the decision regarding coverage of a medication, the clinician may issue an appeal by submitting additional informa-tion to US Script. The addiinforma-tional informainforma-tion may be provided verbally or in writing. A decision will be rendered and the clinician will be notified with a faxed response. If the request is denied, the clinician will be notified of the appeals process at that time.
An expedited pharmacy appeal may be requested at any time the provider believes the adverse determination might seriously jeopardize the life or health of a patient by calling the US Script Prior Authorization department at 866-399-0928. A response will be rendered the same day upon receipt of complete information. In circumstances that require research, a same day response may not be possible.
Working with our Specialty Pharmacy Provider, AccariaHealth
Certain medications are only covered when supplied by Health Republic’s preferred specialty pharmacy provider, AccariaHealth. These products are listed on the formulary as Tier 4. It is preferred that physicians using specialty medications seek prior
authorization before initiating therapy. In most instances, AccariaHealth will be able to support a replacement program with timely delivery of medication to the provider’s office or outpatient facility.
Providers can request that AccariaHealth deliver the specialty drug to the office/mem-ber. If the provider would like AccariaHealth to deliver the specialty drug to the office/
member, call US Script at 866-399-0928 or fax the request form to 866-399-0929 for
prior authorization. If approved, AccariaHealth will contact the provider or member for delivery confirmation.
Mail Order Option
Health Republic offers a 90 day supply (3 month supply) of select maintenance medi-cations through RxDirect. Please contact a US Script Member Service Representative if there are any additional questions regarding this program at 855-339-4803. To transfer a current prescription to mail order, please contact RxDirect at 800-785-4197.
BILLING AND CLAIMS