ConnectiCare | Office Visit - September 2017
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Passage referral plans expanded for our commercial and Medicare members
After a successful pilot year, we are expanding our "Passage" plans – which require primary care provider (PCP) referrals to specialists – in 2018. More PCPs will accept Passage plans, and plans will be available to more members in both commercial and Medicare Advantage plans.
Members with Passage plans will have to choose a PCP from one of six participating PCP groups in 2018 and get PCP referrals to see specialists in the ConnectiCare network. The six PCP groups are:
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Connecticut State Medical Society ─ Independent Practice Association (including Starling Physicians)
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Middlesex Hospital (new for 2018, for Medicare only)
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ProHealth Physicians
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Prospect Medical Holdings, Inc. (new for 2018)
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Saint Francis Healthcare Partners (new for 2018)
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Sanitas Medical Centers
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Unless noted above, PCPs are participating for both commercial and Medicare plans.
Member ID cards will clearly indicate members who have Passage plans and need referrals for specialists’ care. See illustrations below:
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| Medicare Advantage Member ID Card |
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ConnectiCare Exchange Individual
and
Small Group Member ID Card
(commercial)
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ConnectiCare SOLO & Group Member ID Card
(commercial)
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PCPs: What you need to know about Passage
If you do not belong to one of the participating physician groups, you should not provide primary care services to members with Passage plans. If you do provide such services, we will, unfortunately, have to deny claims and tell members they are responsible for the costs. (For Passage members with individual plans through Access Health CT, the Connecticut insurance exchange, the claims will be paid under their out-of-network benefits.)
Specialists: What you need to know about Passage
Referrals are needed for specialist care of any member with Passage plans. You can find out if a member has a valid referral by going to our provider website. You will need to log in to access the information.
Passage members can see any specialist in the ConnectiCare network as long as members have valid referrals from their Passage PCPs for each specialist.
For example, if a patient needs to see a dermatologist and cardiologist, PCPs will need to submit two separate referrals to ConnectiCare for each of those specialists. If the dermatologist decides the patient needs to see another specialist, the Passage PCP will need to submit a third referral for that third specialist.
Please note, referrals are not needed for each visit a patient has with a single specialist. As long as visits with that single specialist take place between the start and end dates in the PCP’s referral, the visits will be covered.
Without referrals, we will deny claims for specialists’ consultation services and tell members they are responsible for the costs. Expect your patients with Passage plans to ask you to confirm that their referrals remain valid before they have visits.
Referrals are not required when Passage members need hospital and/or ancillary care services, such as radiology and lab work.
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For Exchange plans, OTC drugs or their prescription equivalents will no longer be covered after Jan. 1
We will no longer cover over-the-counter (OTC) drugs or their prescription equivalents for your patients with ConnectiCare plans purchased through Access Health CT, the state insurance exchange, starting Jan. 1, 2018.
The one exception is Nexium OTC, which we will continue to cover as long as it is prescribed by a doctor.
This change is consistent with our policy for your ConnectiCare patients with employer-sponsored coverage.
Your patients with Medicare Advantage plans or employer-sponsored plans for municipalities are not affected by this change in OTC coverage. It’s best to refer to your patient’s formulary before prescribing any medication.
This change may also affect some of our step therapy treatments, so please refer to the pharmacy section of our website for updates.
We are letting your patients know about this formulary change and that it means they will have to pay a store’s listed cost of OTC drugs, such as:
| Therapeutic class |
Medications |
| Antihistamines |
Allegra, Claritin, Xyzal, Zyrtec |
| Gastrointestinal medications |
Axid, Pepcid, Prevacid, Prilosec, Tagamet, Zantac, Zegerid |
| Nasal steroids |
Flonase, Flonase Sensimist, Nasacort, Veramyst, Rhinocort |
| Ophthalmic antihistamines |
Alaway, Zaditor |
| Topical acne products |
Differin Gel 0.1% |
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Online provider directory updated: Check your information
We’ve launched a new navigation and flow in our online provider directory. Check out the provider directory to see the changes. While you’re there, make sure we have the right information for your practice. Our members rely on our provider directory to find doctors quickly and easily.
Check the following information closely:
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Tax ID number
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National provider identification (NPI)
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Address
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Phone number
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Office hours
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Ability to accept new patients
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If any of it has changed, let us know by submitting a provider information update form and following instructions on it.
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