| Comprehensive Prescription Benefit Information |
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View the latest Pharmacy News to read more about the 2023 changes related to prescriptions that now require a Prior Authorization, as well as a couple updates for SummaCare’s Medicare members.
Please visit summacare.com/find-your-drug to find SummaCare’s Formularies and Pharmacy Management Procedures for all 2023 SummaCare Commercial and Medicare prescription drug benefits.
A full list of 2023 SummaCare Commercial and Marketplace Formulary changes can be found at summacare.com/member/drug-benefits.
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Click here to read the memo to providers from Tim Oprzadek, director, contracting and network development, about fee schedule adjustments for 2023.
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| Evaluation and Management Audit Sheet |
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Evaluation and Management services refer to visits furnished by physicians and qualified, licensed, non-physician practitioners. Billing for a patient visit requires the selection of the CPT codes that best represents the level of E/M service performed. Also, correct documentation is critical to providing quality care and receiving accurate and timely payments. Please refer to the Evaluation and Management Audit sheet to assist your office with identifying the appropriate codes based upon the AMA CPT E/M Code Guidelines that went into effect January 1, 2021.
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| SummaCare Member Incentives |
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SummaCare offers incentives to help encourage members to seek preventive care and maintain a relationship with their PCP.
Medicare members receive Rewards on their SummaCare Visa card for using key preventive care services, including:
- Annual Wellness Visit $50
- Breast Cancer Screening $10
- Colorectal Cancer Screening $10
Marketplace members who complete an annual physical exam between the following dates will earn the associated Giant Eagle gift card:
Jan 1, 2023 – Apr 30, 2023 = $50
May 1, 2023 – Dec 31, 2023 = $25
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| Colorectal Cancer Screening Measure |
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The NCQA is responsible for changes and updates to all HEDIS Measures and has modified the Colorectal Cancer Screening measure to align with updated guidelines for the U.S. Preventive Services Taskforce. Please take note of the following changes that are effective immediately:
- The age range for this population has been revised from 50–75 years to 45–75 years
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| Kidney Health Evaluation for Patients with Diabetes Measure |
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This measure was revised by the NCQA with input from the National Kidney Foundation. The purpose of this measure is to ascertain the percentage of diabetic patients between the ages of 18–85 who received a kidney health evaluation. To be compliant for this measure, patients must receive both of the following during the year:
- One estimated glomerular filtration rate (eGFR) AND
- One Urine Albumin-Creatinine ratio (uACR)
- A Quantitative Urine Albumin Test combined with A Urine Creatinine Test completed within a four-day timeframe OR
- A Urine Albumin Creatinine Ratio lab value
View the full memo here.
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| Submit All Clinical for Authorizations |
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To facilitate authorization and decrease denials, please submit all clinical when requesting testing/services through eviCore. Submit any results of previous testing, labs, drug lists and current clinical notes.
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| Get Ready for the Healthy Heart Challenge With SilverSneakers®! |
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Did you know that the American Heart Association estimates that 80% of cardiovascular disease can be prevented with a few simple lifestyle changes? The really good news: SummaCare Medicare members can take part* in the Healthy Heart Challenge with SilverSneakers to help get started.
For 7 days beginning February 13, visit the blog at SilverSneakers.com to find:
- New heart-pumping, follow-along workouts
- Strategies to unwind and keep stress in check
- Heart-smart meal and snack ideas
- Easy ways to sit less and move more
- Expert insights to help you understand your heart disease risk and recognize signs of heart problems
- And more!
* SummaCare Medicare members may take part if they are on a plan that includes SilverSneakers or elect SilverSneakers as a Bene-Flex option on the Jade (HMO) plan.
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| Summa Health’s Vitality Magazine |
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Click here to view the fall 2022 issue of Vitality magazine. Read patient stories, new screening guidelines and more Summa news.
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Click here to view the latest Vital Coverage Blog “Eight Ways to Get Some Better Shut-Eye” by Julie Sich, MS ATC, director of quality improvement and provider engagement.
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