Q2 2025 newsletter

REQUIREMENTS: Effective immediately and by June 1, 2025: (1) Billing team and prescribing providers must implement prior authorization requirement for amitriptyline tablets, doxepin capsules/solution, and imipramine tablets for members age 70+ who are newly prescribed these medications. Existing members on these drugs are exempt. Submit prior auth electronically via devoted.com/providers coverage determination form or fax to 1-855-633-7673. (2) Update billing system rules to enforce Modifier PN usage for off-campus outpatient clinic services per updated guidance. (3) Implement Modifier Q6 billing protocol for provider terminations per new requirements—train billing staff on proper application when providers terminate from practice. (4) Reinstate step therapy requirements for ophthalmic anti-VEGF treatments effective May 1, 2025 (retroactively). Reference Part B Step Therapy List for specific medications. (5) Immediately begin monitoring and tracking polypharmacy metrics: Use of Multiple Anticholinergic Medications (Poly-ACH) and Concurrent Use of Opioids and Benzodiazepines (COB). Access Stars Polypharmacy Detail Report via provider portal/SFTP for claims-level review of patient prescriptions. (6) All providers and staff must complete SNP Model of Care training annually before delivering care to SNP members. Non-compliance will result in claim denials and potential network contract issues.