Medicaid Asthma Management Matrix

	Anthem Blue Care	CHNCT	PHS	Preferred One
Pharmacy Benefit Spacer device covered Prior Authorization	__ Yes __ No __ Yes __ No	X Yes __ No __ Yes X No	__ Yes __ No __ Yes __ No	__ Yes __ No __ Yes __ No
DME Benefit (*Prior authorization) (limit #/year) 1=Prior authorization 2=no prior authorization	PA limit per year ___ spacer device ___ ___ vaporizers ___ ___ humidifiers ___ ___ nebulizers ___ ___ inhalers/ ___ related supplies ___ mattress/ ___ pillow covers	PA limit per year _2_ spacer device __0_ _1__ vaporizers __ 1_ _1_ humidifiers __1_ _2_ nebulizers _2 __ _2_ inhalers/ _ 0__ related supplies _1_ mattress/ 0__ pillow covers	PA limit per year ___ spacer device ___ ___ vaporizers ___ ___ humidifiers ___ ___ nebulizers ___ ___ inhalers/ ___ related supplies ___ mattress/ ___ pillow covers	PA limit per year ___ spacer device ___ ___ vaporizers ___ ___ humidifiers ___ ___ nebulizers ___ ___ inhalers/ ___ related supplies ___ mattress/ ___ pillow covers
Policy on non-formulary drug/DME		Any non-covered item is reviewed on a case-by-case basis.
Patient DME Education	Available ___Yes ___No Who: Where: Reimbursement _______	Available X Yes ___No Who: DME Vendor Where: Hospital, Clinic or Home depending on the vendor Reimbursement contract is inclusion with the vendor of the DME	Available ___Yes ___No Who: Where: Reimbursement _______	Available ___Yes ___No Who: Where: Reimbursement _______

MCO Asthma Case Management (CM)

Anthem Blue Care	CHNCT	PHS	Preferred One
Available: ___Yes ___No Criteria:_____________________ Who is covered:_______________ ____________________________ What is covered:______________ ____________________________ No. of visits allowed: __________ Frequency of visits: ___________ Other comments:______________ ____________________________ Coordinate w/provider: _________ ___________________________ School-based health clinic: ______ ____________________________ Community clinic: ____________ ____________________________	Available: X Yes ___No Criteria: PCP referral or Hospital admission for Asthma. Who is covered: All members Currently enrolled in CHNCT. What is covered: Home visits, DME, medications No. of visits allowed: No limit: based on medical necessity. Average use is 3 visits Frequency of visits: As indicated by medical necessity. Other comments:______________ ____________________________ Coordinate w/provider: Yes School-based health clinic: Yes, if member obtains treatment at school Community clinic: Through member's PCP	Available: ___Yes ___No Criteria:_____________________ Who is covered:_______________ ____________________________ What is covered:______________ ____________________________ No. of visits allowed: __________ Frequency of visits: ___________ Other comments:______________ ____________________________ Coordinate w/provider: _________ ___________________________ School-based health clinic: ______ ____________________________ Community clinic: ____________ ____________________________	Available: ___Yes ___No Criteria:_____________________ Who is covered:_______________ ____________________________ What is covered:______________ ____________________________ No. of visits allowed: __________ Frequency of visits: ___________ Other comments:______________ ____________________________ Coordinate w/provider: ________ ___________________________ School-based health clinic: ______ ____________________________ Community clinic: ____________ ____________________________