Expedite

Expedited requests must meet OHA’s definition “that taking the time for a standard resolution could seriously jeopardize the member’s life, health, or ability to attain, maintain, or regain maximum function). By selecting the expedite, the submitter is certifying this statement is true. Please include an explanation of medical necessity for the rush in the Comment of the PA or on the cover letter of the supporting documentation. Expedited requests are not appropriate for billing issues, closely approaching appointments, etc.

Authorization Type

Not sure which Auth/Referral Type to select when submitting a prior authorization (PA)?  After searching for the member and selecting “submit a pre-auth,” decide if the authorization request is for a Pharmacy, Medical or Behavioral Health and select this option. For Medical, the auth/referral type is dependent on the location of the service and then the specialty of the provider.

Location of Procedure	Auth/Referral Type
Inpatient	“Inpatient Surgery/Services”
Outpatient facility/Surgery Center	“Outpatient Surgery/Services”
In Office	Specialty of the delivering provider Example: “Podiatry”

Expanded Coverage for DOACs!

The UHA Pharmacy and Therapeutics (P&T) Committee has decided to expand coverage of Direct Oral Anticoagulants (DOACs) effective July 15th. While these drugs still require prior authorization, we will allow coverage for all FDA-approved indications without a trial and failure of warfarin. However, for conditions where another anticoagulant is preferred based on safety and efficacy data, we will still require the preferred agent:

•Liver disease (LMWH preferred);

•Renal disease with CrCl less than 30 ml/min (warfarin preferred);

•Thrombolytic therapy use (UFH infusion preferred);

•Pregnancy or pregnancy risk (LMWH preferred);

•Valvular disease including mechanical heart valves or moderate to severe mitral stenosis (warfarin preferred);

•Left ventricular thrombi (warfarin preferred); and

•Antiphospholipid syndrome (warfarin preferred), or antithrombin deficiency (warfarin preferred).

The UHA P&T Committee also wants providers to be aware that data are limited on the efficacy and toxicity of DOACs in obese individuals. Based on a 2016 review of available literature, the International Society of Hemostasis and Thrombosis (ISTH) recommends avoidance of these agents in individuals with a body mass index (BMI) >40 kg/m2, or weight ≥120 kg. While we want providers to be aware of this, the Committee has ultimately determined that the decision of whether to use DOACs in obese individuals will be left to the provider’s clinical judgment.

The following table summarizes the approved indications, dosing and treatment costs associated with each drug in this class.

Vision Coverage ReduxIf referring a member for vision services alone, an optometrist may be the best choice.

We need to remind providers that the Oregon Health Plan has limitations on what services are covered for eye conditions.

•Some medical conditions of the eye are covered for diagnosis and treatment. (Those below the line can be considered by exception to rule, based on comorbidity).

•Vision services for refraction and visual acuity correction are limited to:

-Children under 21 years of age

-Pregnant women

-Adults with a few medical conditions, including aphakia, keratoconus, or after cataract surgery

When you refer any OHP member other than those listed above for visual acuity evaluation, the ophthalmologist/optometrist will inform them of their financial liability.  Informing the member of this ahead of time will avoid a lot of confusion/frustration!

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