January 2024
Most SoonerCare members will get their health care services covered in a new way next year – through SoonerSelect dental and health. The dental open enrollment period closed on Jan. 10, 2024. Enrollment for the health plans opens on Feb. 1, 2024 and runs through March 10, 2024.
SoonerCare members transitioning to SoonerSelect are asked to review the health plans and select the one that is right for them. They should compare benefits and, if they have a primary care physician they want to keep, they should pick the plan with that provider in the plan’s network. If they don’t select a plan, OHCA will choose one for them.
You can help remind your patients of the importance of reviewing these plans by downloading any of our free flyers today. Visit OHCA's publications page and scroll down to the flyer section. Flyers come in different designs and are available in both English and Spanish. All flyers include the open enrollment dates. Just download the ones of your choice and hang them in your office.
In the last year, the FDA approved three new products related to respiratory syncytial virus (RSV). The RSV vaccines AREXVY and ABRYSVO™ were initially approved for the prevention of lower respiratory tract disease (LRTD) caused by RSV in individuals ages 60 years and older. The FDA later expanded the approved indication for ABRYSVO to include pregnant individuals at 32-36 weeks gestational age for the prevention of LRTD and severe LRTD caused by RSV in infants from birth through 6 months of age.
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For pediatric patients, Beyfortus™ (nirsevimab-alip), a long-acting RSV F protein-directed fusion inhibitor, is approved to prevent RSV LRTD in neonates and infants born during or entering their first RSV season. It is also approved to be used for children up to 24 months of age who remain vulnerable to severe RSV disease through their second RSV season.
The Advisory Committee on Immunization Practices (ACIP) recommends one dose of nirsevimab for all infants under 8 months of age born during or entering their first RSV season. ACIP also recommends that nirsevimab be given to children 8-19 months of age who are at increased risk of severe RSV disease and entering their second RSV season. Nirsevimab is now available through the Vaccines for Children (VFC) program.
The American Academy of Pediatrics (AAP) provided guideline updates in response to the recent changes in RSV infection patterns and the availability of new and existing agents. Their Committee on Infectious Diseases (COID) determined that the literature and data support a reaffirmation of the 2014 AAP recommendations for SYNAGIS® palivizumab prophylaxis. Additionally, the AAP provided the following guidance:
- If nirsevimab is administered, palivizumab should not be administered later that season.
- If palivizumab was administered initially for the season and fewer than five doses were administered, the infant should receive one dose of nirsevimab. No further palivizumab should be administered.
- If palivizumab was administered in season 1 and the child is eligible for RSV prophylaxis in season 2, the child should receive nirsevimab in season 2, if available. If nirsevimab is not available, palivizumab should be administered as previously recommended.
Current SoonerCare coverage for both palivizumab and nirsevimab has recently changed to reflect the recommendations of both ACIP and AAP. Nirsevimab does not require PA; however, SoonerCare members must receive nirsevimab through the VFC program. Approval of palivizumab requires a patient-specific, clinically significant reason the member cannot receive nirsevimab in addition to its current PA criteria which is based on AAP guidelines.
Nirsevimab does not require PA; however, SoonerCare members must receive nirsevimab through the VFC program. Additionally, the prescriber must confirm that the member has not already received nirsevimab for the current RSV season. Concomitant use of both palivizumab and nirsevimab will not be approved.
For most people, it’s goal-setting time again! However, we know these can be set year-around and take time to master. Seeking support and accountability are key. SoonerCare is ready to help by providing medical nutrition therapy to your qualifying patients. Learn more about our nutrition counseling benefit and refer them today!
When a SoonerCare member wishes to change therapists to one with a different provider, a new prior authorization (PA) is required along with supporting documentation. A previous plan of care may be used in the documentation with a written statement on record from the new provider along with progress notes towards the established goal(s).
The annual 92523 evaluation for speech therapy is only covered once a year, but if a member had a 92523 evaluation by the previous provider more than six months prior, a second evaluation may be requested. If less than six months, a new prior authorization must be obtained within 10 months of the previous PA. Questions about previously filed PAs may be emailed to therapyadmin@okhca.org.
Check out the OHCA Provider Newsletter • December 2023, “Therapy Prior Authorization FAQs.”
For general questions regarding claims/reimbursement, policy, provider portal usage, enrollment/eligibility, or general inquiries pertaining to SoonerCare, please send an email to SoonerCareEducation@okhca.org or call 1-800-522-0114.
The Oklahoma Health Care Authority is asking its partner providers to help the agency improve. The agency is distributing its annual Provider Survey to all SoonerCare rendering providers (those with more than 25 claims in 6 months). OHCA uses the feedback from providers to improve SoonerCare for members and enhance the provider experience with OHCA. OHCA is sending each rendering provider a postcard with a QR code to complete the survey online. Watch for the Provider Survey postcards in February.
Health care providers in a variety of clinical settings can play a critical part in helping their patients quit using tobacco. SoonerCare reimburses providers who use the Five A’s approach with their patients for tobacco cessation. If you are a provider or clinic interested in integrating tobacco cessation best practices into routine patient care, visit SoonerQuit for more information.
Depression is less common among pediatric patients than adult patients; however, a significant percentage of children are still affected. More than 4% of children ages 3-17 were diagnosed with depression from 2016 to 2019, according to the Centers for Disease Control and Prevention (CDC). Depression can impact a child’s social life, school performance and their overall well-being.
While treatment includes lifestyle modifications, patients often require psychotherapy or pharmacotherapy to manage symptoms. Medications used to treat depression carry a potential risk of suicide and should be used with caution. In particular, paroxetine carries an increased risk compared to other agents in its class. If medications are part of a treatment plan, they should always be tapered if discontinued.
Depression Treatment Recommendations
Children ages 3-5:
Mild: Psychosocial interventions.
Moderate to severe: Psychosocial interventions with or without adjunctive pharmacotherapy (after 12-24 psychotherapy sessions).
Pharmacotherapy:
- 1st line: Fluoxetine
- Initiation: 6 to 8 weeks to establish efficacy.
- Continuation: 6 to 8 months to determine need for long-term use.
- Similar medications such as tricyclic antidepressants (TCA) and bupropion are not recommended due to lack of efficacy and safety concerns, including an increased seizure risk for those using bupropion.
Children ages 6-18:
Mild: Active monitoring and support for 6 to 8 weeks. Transition treatment to moderate to severe if symptoms do not improve.
Moderate to Severe: Psychotherapy with or without adjunctive pharmacotherapy (after 6-8 weeks of psychotherapy). Pharmacotherapy may be used as initial treatment based on the severity of symptoms.
Pharmacotherapy:
- 1st line: selective serotonin reuptake inhibitors (SSRIs)
- Fluoxetine is FDA-approved for children 8 years of age and older for the treatment of depression and has the most robust data supporting its use in this population.
- Escitalopram is FDA-approved for adolescents 12 years of age and older.
- Selective serotonin and norepinephrine reuptake Inhibitors (SNRI) may be used after failure of at least 1 SSRI but should not be used first line.
Relapsing Depression: Cognitive behavioral therapy (CBT) in combination with pharmacotherapy.
SoonerCare covers for several related screening tools, psychotherapy, counseling, and antidepressant medications. Additional information can be found on the Behavioral Health and Substance Abuse Services and the Oklahoma Child and Adolescent Psychiatry and Mental Health Access Program websites. For SoonerCare medication coverage-related questions, including antidepressant medications, please contact the Pharmacy Help Desk at 405-522-6205, option 4, or toll-free at 800-522-0114, option 4.
Here are some handy links for prescribers on the SoonerCare Pharmacy page.
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Forms include the Prior Authorization (PA) Amendment created to facilitate small changes to an existing PA (e.g., change of pharmacy, strength or drug regimen).
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Brand Required Drug List. In certain cases, the use of the brand name product is more cost-effective for SoonerCare, and the brand is preferred over its generic equivalent. For these drugs, a patient-specific clinically significant reason to use the generic must be provided.
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Maintenance Drug List. These drugs are covered for a 90-day supply without a quantity or day supply override. And pharmacists are now legally permitted to authorize a 90-day supply for 16 categories of non-controlled maintenance drugs. Please note that not all drugs in each category can be processed for a 90-day supply. Clinical criteria and tier structure rules still apply to certain maintenance drugs.
For SoonerCare drug coverage-related questions, including maintenance drugs, contact the Pharmacy Help Desk at 405-522-6205, option 4, or toll-free at 800-522-0114, option 4.
Q: Why was my PA cancelled?
The reason(s) for PA cancellation are included in the comments section for each canceled PA. Please view the comment provided to you as to the reason for that cancellation. Often, it is a quick fix that must be corrected before resubmitting. If further explanation is needed as to the reason for the cancellation, then please send an email to therapyadmin@okhca.org.
Q: Does a child have to complete a standardized articulation assessment to satisfy the speech part of the comprehensive evaluation for 92523?
No. If the SLP uses clinical judgment (evaluation techniques, skilled assessments) to assess the patient’s speech, the PA must include objective evidence to support their judgment (not parent or caregiver reports). This could include but is not limited to information regarding phonemic inventory such as consonant and/or vowel sounds, sound placement, sound positions, syllable shapes and intelligibility, and any phonological processes present. The diagnosis must be supported by an informal or formal assessment and medical necessity must be shown with sufficient evidence to justify the client’s need for services.
Q: Why did my physical/occupational therapy PA request get its dates reduced?
The dates on two documents are crucial to consider when requesting long-duration coverage. First, if the referring provider’s script indicates a general approach, such as “eval and treat,” with no specified timeline or treatment frequency, then the script is valid for up to 12 months from the date of signature.
Second, the parental consent form date acts as a “stop” to ensure the parent agrees with the POC annually. This second situation is only significant if the parental consent form is signed before the date of the referring provider script. For example, if a referring provider’s script is dated 03/04/2024 and deemed to be valid till 03/04/2025, a “stop” to your PA request set to end on 03/04/2025 would be a parental consent form in the system that is dated on 03/03/24 or sooner. In this example, your PA request end date must be 03/03/25, unless a newly signed/dated parental consent were to be uploaded. Please consider submitting a newly signed and dated parental consent form during each PA request to avoid this complexity.
The Oklahoma ABLE Tech Device Reutilization Program contracts with the Oklahoma HealthCare Authority to provide and manage the equipment reutilization program. This program takes in gently used durable medical equipment (DME) and devices that are no longer needed. DME is then repaired, refurbished, sanitized, and re-distributed to individuals in need across Oklahoma at no cost to them.
2023 was an amazing year! Oklahoma ABLE Tech served 1,423 individuals to help them receive 1,664 devices, including durable medical equipment, assistive technology, and medical supplies. The total value and savings to Oklahomans was $399,538. While ABLE Tech serves all Oklahomans, a significant focus for this program is for SoonerCare members to return unused DME and receive needed DME. We are proud to report that 1,248 SoonerCare members received needed DME, for a total savings value of $310,506.
When SoonerCare purchases a piece of DME for a member, the device then belongs to SoonerCare. ABLE Tech is the agency that collects and reports that activity. In 2023, 1,201 pieces of unused, viable DME purchased by SoonerCare were returned to ABLE Tech for future use, valued at $702,972.
Because this program is 100% reliant on donated gently used equipment, ABLE Tech is proud of the new and long-standing partnerships that assist in collecting this unused equipment across the state. We look forward to making 2024 even more impactful. To learn more about ABLE Tech’s Device Reutilization Program, where to donate, or how to partner with us, visit www.okabletech.org or contact us at atreuse@okstate.edu.
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