Your Key to the 1199SEIU Benefi t Funds

New Prior Authorization Processfor Certain Drugs Begins August 1, 2008

Your Key to the 1199SEIU Benefi t Funds

for Certain Drugs Begins August 1, 2008

Your Key to the 1199SEIU Benefi t Funds

for Certain Drugs Begins August 1, 2008

330 West 42nd StreetNew York, NY 10036-6977

Presorted StandardU.S. POSTAGE PAID

New York, NYPermit No. 3700

SUMMER 2008

Refer to Participating Providers So Your 1199SEIU Patients Don’t Pay the BillWhen you refer your 1199SEIU patients to a specialist or a facility, radiology, lab services, or any other ancillary services, be sure to refer them to an 1199SEIU participating provider. Referring within our network of credentialed providers helps our members get the high quality care they are entitled to with no out-of-pocket costs.

For a complete list of participating specialists, lab and radiology providers, visit our website at www.1199SEIUBenefi ts.org.

• For radiology services: Medfocus (888) 910-1199

• For diagnostic testing: Laboratory Corporationof America (LabCorp) (800) 788-9091

• Quest Diagnostics (800) 877-7530

• Bendiner and Schlesinger (877) 240-0349

• Centralized Lab Services (718) 786-2300

Back in October of last year, the 1199SEIU Benefi t Funds instituted a “Step Therapy” program for the medication Nexium, requiring members to try the less-costly omeprazole before using Nexium. Due to the success of this program, we will now be extending step therapy to other medications, which became effective Friday, August 1, 2008.

Under the 1199SEIU Benefi t Fund’s Step Therapy policy, our members must fi rst try established, lower-cost, clinically appropriate medications before moving on to other, more costly medications such as preferred brand names. Of course, if the medication is not effective in treating the member’s condition, you can request authorization for the higher-cost medication.

This means that 1199SEIU providers must follow a new authorization process when prescribing certain medications. (Please see a list of medications in the chart below).

In addition to the medications listed below, certain cancer therapy, Pulmonary Arterial Hypertension (PAH) and miscellaneous hormone drugs will also be included in this Step Therapy policy. A Medco representative will be in contact with you to advise of the affected medications and provide further details.

To arrange an authorization review, call Medco toll-free at (800) 417-1764, 8:00 am to 9:00 pm, Monday through Friday. You will also need to submit the necessary clinical documentation to Medco. If you fail to do so, your 1199SEIU members’ prescriptions may be rejected or they may be subject to expensive out-of-pocket costs.

Medications Subject to Step Therapy Prior Authorization Rules

Step Therapy Category Preferred Brand Non-Preferred Brand

Anemia*Note: Patients who have been taking Procrit or Epogen for less

than 8 weeks will be permitted to remain on the Non-Preferred Brand for 8 weeks. Proper documentation is still required.

• Aranesp • Procrit• Epogen

Hepatitis C*Note: All patients who are taking Pegasys prior to August 1, 2008,

will be allowed to remain on the Non-Preferred Brand medication and be “grandfathered” into the system. Proper documentation is still required.

• Peg Intron • Pegasys

Growth Hormone • Norditropin• Humatrope• Nutropin• Tev Tropin

• Genotropin• Saizen• Omnitrope• Accretropin

There’s Still Time to HelpStrengthen Our Network

The 1199SEIU Benefi t Fund Credentialing Com-

mittee is still in the process of re-credentialing our

providers. If you are a board-certifi ed participating

provider, come join our Committee and help make

our network the best it can be. As a peer reviewer, you

have the chance to use your expertise to ensure that

our providers are being credentialed accurately. To

join the Committee, or for more information, please

contact Stephanie Price at sprice@1199funds.org.

Check Eligibilityand Claims Status24 Hours a Day

The 1199SEIU Benefi t Fund now offers you an

automated system to check the eligibility of National

Benefi t Fund and Greater New York members, as well

as the status of your pending claims. You can also

check eligibility and claims for 1199SEIU Home Care

members for services rendered up to April 1, 2008.

This service is available 24 hours a day, seven days

a week. Just call (888) 819-1199 and have your tax

ID number, member ID number and the member’s

date of birth on hand.

Message

from the

Executive

DirectorAt the 1199SEIU Benefi t Fund, our members’ health is our top priority. So, we do all we can to give you the tools you need to provide our members with the best possible care. From our Provider Relations Department to our 24-hour automated system to check claims and eligibility status, we are providing services to help work hand in hand with you.

Good patient care depends upon our membersand providers understanding the scope of thebenefi ts we provide, and how to access them. And that’s what you’ll read about inside this issue of 1199SEIU Provider Connections.

Working together, we can ensure that our members – your patients – are receiving the quality care that they need.

Mitra Behroozi

Have Your Claims Processed Fasterby Using Correct Billing Codes

The more accurately you fi ll out your claims, the quicker the 1199SEIU Benefi t Fund can process your claims.

• Anesthesia Services: Bill for Anesthesia Services using a CPT Anesthesia Code from 00100 to 01999.

Using CPT surgical codes should be limited to providing pain management services.

• Radiology Services: When billing for radiology services involving both limbs, affi x modifi ers LT/RT to the

CPT code and the number of units. If you use modifi er 50 (bi-lateral procedure), do not add 2 units as

the modifi er 50 already applies 2 units to any CPT code.

If the defi nition of a CPT code indicates multiple views, the claim line should be billed with one unit, unless the

service is bilateral, in which case the modifi ers LT/RT should be posted. If the CPT defi nition encompasses

a number of items, only one unit should be billed. For example, use CPT code 11900 (intralesional injection)

for up to and including 7 lesions, and CPT code 11901 (intralesional injection) for more than 7 lesions.

Refer 1199SEIU MembersWith Chronic Conditions toOur Health Coaching Service

The 1199SEIU Benefi t Fund has added health coaching by

telephone to our suite of wellness services for 1199SEIU

members. Now when you treat one of our members for

asthma, diabetes or high blood pressure, you can also

refer them directly to our Health Coaches, who can support

your course of treatment and answer their questions even

when they can’t visit the doctor.

Over the past few months, our Health Coaches have been

reaching out to members with a history of these conditions.

But if you are seeing an 1199SEIU member who is newly

diagnosed with diabetes, high blood pressure, asthma, or

another chronic condition, let them know about this added

support. It just takes one call to reach out to a Health Coach,

and our coaches will follow up with ongoing support.

Our Health Coaches are available around-the-clock, and

there’s no limit to how many times a member can call.

1199SEIU members can call the Health Coach line toll-free

at (866) 935-1199, at any time of the day or night, to reach

a trained healthcare professional.

Nurse Helpline Gives

Members Access to Advice 24/7

In addition to health coaching, we also offer a 24-Hour

Nurse Helpline. A trained professional is always on

hand to answer members’ questions on any health topic

at all – from the difference between two medications

to quitting smoking to a child’s fever in the middle

of the night. Refer your 1199SEIU patients to the

24-Hour Nurse Helpline at (866) 935-1199.

Toll-Free 1199SEIU Health Coaching

and 24-Hour Nurse Helpline: (866) 935-1199