Prior Authorization (PA) Submission Tips and Requirements:
If there is an authorization that has previously been submitted, but changes are needed before it can be used, please do not submit your request as a new (PA). Please use the “extend authorization” link in the top right corner of the members current PA. This will allow for amended reviews.
Specialist PA Submissions
If the referral to a specialist requires a PA, please send your referral to the specialist to submit. Currently, UHA receives many duplicate submissions from the PCP and the specialist (it is standard for the specialist to submit the request for UHA). The most frequent of these duplications are to Chiropractic, Dermatology and Ortho.
Fast, Supported Requests
UHA works hard to complete our medical reviews in less than the required 14 days. We want to ensure there are no additional barriers for our members due to the processing time of a PA. You can help fast track this process by ensuring:
Keeping Healthcare Local
UHA cares about our members, our providers and our community. One way we can ensure high quality accessible services for our members is by enforcing specialist referrals to stay in Douglas County with our contracted providers (when available.) Not only does it benefit members who may experience barriers to care when traveling out of county, but it also supports our providers and community by creating jobs and keeping dollars local. UHA encourages providers to use the resources available on our website to identify in network (IN), contracted providers before referring to a specialist out of network (OON). This will also help all by lowering the prior authorization denials when submitting to see an OON specialist or vendor when an IN provider is available.
For more information on our network availability, see our website for details: General information – https://www.umpquahealth.com/providers/
Updates from our Behavioral Health Team
Juniper Tree Counseling is now in-network offering services that focus on infant and toddler mental health. All of the counseling staff at Juniper Tree are endorsed by the Oregon Infant Mental Health Association (ORIMHA) and/or have specialty training beyond their Masters degrees in the areas of maternal mental health, Parent-Child Interaction Therapy, Child Parent Psychotherapy, Promoting First Relationships, and many other evidence-based early childhood practices. Clinicians are qualified to offer pregnancy-related mental health care and behavioral health supports for young children.
The System of Care is excited to announce that there are multiple community partners coming together working on tackling exciting grant funded projects. One of these exciting projects will bring eating disorder training to community providers as well as specified and credentialed training for seven local therapists to specialize in treating eating disorders.
The second work group focuses on equitable distribution of specific funding that will provide supports to youth and families in the community. The work group has created a scoring rubric as well as request funding application and other relevant supportive documents. The hope is that this funding will support a shift to a strengths-based perspective of working with youth and families by supporting success, development and growth.
The System of Care is continuously looking for cross system partners interested in collaborating in projects to support youth and family in the community. If you are interested in learning more please feel free to reach out to DouglasSOC@umpquahealth.com
Notification of Insulin Change on UHA Formulary
From the Medical Director:
Clinicians and patients alike are rightfully outraged by the high cost of insulin in the United States.
There are 3 pharmaceutical firms in the US that have acted as a monopoly (99% of market) and raised insulin prices in lock-step ~300% over the last decade. Since insulin is a complex biologic, “generics” are not allowed, but “biosimilars” can be approved. Only recently has there been a fourth firm (Mylan) that has chosen to truly compete.
The Pharmacy and Therapeutics committee approved the adoption of this alternative basal insulin, Semglee, for the UHA formulary. Basaglar and Lantus will be taken off of the formulary as of June 1st, 2021; we will scrutinize “grandfather” requests of these brands critically. We sent letters to all providers of the UHA members who need to be switched to Semglee, which is available in both vial and pen delivery forms. The 70% savings is far too great for our CCO to ignore. We want to be good stewards of taxpayer’s money and this decision strikes a blow for honest competition.
From the Pharmacy Director:
We want inform you of an upcoming change to the Umpqua Health Alliance formulary. Effective June 1, our preferred insulin glargine product will be Semglee vials and pens, which will be available without a prior authorization. On June 1, Basaglar pens and Lantus vials and pens will no longer be covered on our formulary. Like Basaglar, Semglee was approved by the FDA as a biosimilar to Lantus. Pharmacies are not able to automatically substitute Semglee for Basaglar or Lantus, so you will need to send a new prescription for Semglee to the pharmacy. If you do not believe switching to Semglee is appropriate for your patient, you will need to submit a prior authorization request with appropriate documentation for coverage of Basaglar or Lantus.
The FDA’s approval of Semglee was based on two studies (INSTRIDE 1 and 2). For more information on these studies, visit https://secure.medicalletter.org/w1616c.
For the latest information on COVID vaccination in Douglas County, visit Douglas Public Health Network: http://douglaspublichealthnetwork.org/
We have come a long way from 1985 when the Federal Government published the Heckler Report, which found that in the US, 60,000 deaths occurred each year due to health disparities related to racial and ethnic factors. Today, our focus has to be on correcting the structural causes leading to health disparities, especially SDOH-E drivers. A recent article in NEJM highlights the new paradigm in a time perspective: Understanding and Mitigating Health Inequities – Past, Current, and Future Directions, Risa J. Lavizzo-Mourey, M.D., M.B.A., Richard E. Besser, M.D., and David R. Williams, Ph.D., M.P.H.
To read more about this, click here.
Value-based payment webinar series for providers Next webinar May 19
Primary care, behavioral health, and maternity care providers are invited to a five-part webinar series focused on increasing readiness for VBP and taking advantage of the additional flexibility VBPs offer for innovatively redesigning care models. See website for registration, slides and recordings: https://www.oregon.gov/oha/HPA/dsi-tc/Pages/Value-Based-Payment.aspx
Speakers: Art Jones, Jeanene Smith, Janet Meyer (Health Management Associates)
SBIRT webinar training series multiple options February–September
This SBIRT webinar training series is supported by the Oregon Rural Practice-based Research Network’s (ORPRN) ANTECEDENT project. ANTECEDENT focuses on addressing unhealthy alcohol use in Oregon. The project team intends to work with over 80 primary care clinics and provide each clinic with the evidence and tools they need to help patients with moderate to severe alcohol use disorder through the use of screening and brief intervention and medication assisted treatment. See flier for details: https://www.oregon.gov/oha/HPA/dsi-tc/Documents/SBIRT-webinar-series.pdf
Multiple dates for each webinar topic: