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Midwest October Newsletter

October 15, 2015

Medicare Advantage vs. Medicare Supplement Plans

The Medicare Annual Enrollment Period (AEP) is October 15-December 7. During this time, beneficiaries can choose a private Medicare plan to supplement or pay in place of Original Medicare.

Health Alliance offers 2 kinds of Medicare plans:

  • Medicare Advantage (MA) – These plans offer another way to get your Medicare coverage. MA plans pay in place of Original Medicare and cover expenses beyond what Original Medicare covers. Members must continue to pay their Part B premium.
  • Medicare Supplement (Med Supp) – Works with Original Medicare. Only covers expenses that Original Medicare covers, which is about 80% of members’ medical costs after they meet their yearly deductible

A few of the differences between Med Supp and MA plans:

  • MA plans can include drug coverage. Med Supp plans do not. Med Supp members have to purchase a stand-alone prescription drug plan if they want drug coverage.
  • MA plan premiums do not increase because of age. Med Supp plans can get more expensive as a member gets older.
  • Health Alliance MA plans have just one Customer Service number for members to call with questions about any aspect of their plan, and all the bills come from one company. With Med Supp, members still have Original Medicare and often have a separate drug plan, so they’re dealing with multiple call centers and sets of bills.
  • MA plans include lots of extras for no additional cost to the member, like a fitness membership, disease management programs, health coaching, access to our Anytime Nurse Line, and travel coverage through Assist America. Med Supp plans don’t include these extras.

Why MA plans are good for our members, Health Alliance, and our providers:

  • Members get lower premiums and more benefits than a Med Supp plan or Original Medicare.
  • MA plans attract new members and keep our current members happy.
  • MA plans help both Health Alliance and our provider networks grow.

Pharmacy Updates

All Plans

Formulary Additions

  • Unituxin (dinutuximab) – A GD2-binding monoclonal antibody indicated, in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2 (IL-2), and 13-cis-retinoic acid (RA), for the treatment of pediatric patients with high-risk neuroblastoma who achieve at least a partial response to prior first-line multi-agent, multimodality therapy.
    • Commercial – Tier 5 with preauthorization (PA)
    • Medicare – Tier 5 with PA
    • Duals – Tier 2 with PA
    • Medicaid – Covered with PA

Medicaid

Formulary Additions

  • Crestor – Added to formulary with PA
  • Linzess Added to formulary with PA

Coverage Changes

  • Insulin Pens – Effective 11/1/15
    • Health Alliance will no longer cover insulin pens without PA. Coverage of pens will require documentation of a medical condition that prevents the member from injecting insulin using syringes and vials. All existing pen users will be required to transition to vials unless a PA approval has been granted.
  • Test Strip Limits – Effective 11/1/15
    • Health Alliance will cover no more than 50 test strips in 30 days for patients who are not on insulin therapy. PA will be required for coverage of more than 50 test strips in 30 days for these patients.
  • Controlled Substance Prescription Limits
    • Health Alliance will now cover only 3 controlled substance prescriptions in a rolling 30-day period without PA. This policy is being enacted to curb the overuse of controlled substances. Coverage for more than 3 controlled substances within 30 days will require documentation of the following: The provider was aware of all controlled substances filled within the last 30 days, the provider has reviewed the member’s utilization on the Illinois Prescription Monitoring Website, and the member has not gone to more than 3 different pharmacies within the last 30 days.
    • Select members will have PA placed on all controlled substances if they meet one of the following: They have come up on a quarterly fraud, waste, and abuse report, they have reported identity theft involving controlled substance fills, or a provider reports a patient is filling prescriptions for controlled substances under the provider that the provider did not write.
  • Electronic Step Edits and Preauthorizations with Prerequisite Drug – Effective 10/15/15
    • Health Alliance will look back for 90 days of a prerequisite medication in the past 120 days without requiring PA. Current electronic step logic looks for a 30-day supply of medication in the past 180 or 365 days. The change will ensure that only those members who have been compliant with a prerequisite medication will be able to bypass PA.

Medicaid & Commercial

Formulary Additions

  • Plegridy (peginterferon beta-1a)—The first pegylated formulation of interferon beta-1a indicated for the treatment of patients with relapsing forms of multiple sclerosis.
    • Commercial – Tier 5 with PA
    • Medicaid – Covered with PA
    • Medicare and Duals – Non-Formulary
  • Glatopa (glatiramer acetate) – Branded generic of Copaxone.
    • Commercial – Tier 4 with PA
    • Medicaid – Covered with PA
    • Medicare and Duals – Non-Formulary

Criteria Changes

  • Xifaxan – Added coverage for IBS-D indication
  • Xolair – Added daily dose specification and removed immunosuppressant requirement for chronic idiopathic urticaria

Tier Change – Effective 10/1/15

Glumetza – Made Non-Formulary

Commercial

Formulary Additions

  • Hysingla ER (hydrocodone bitartrate extended-release) – The second extended-release formulation of hydrocodone available on the market; part of the extended-release (ER) and long-acting (LA) opioid medication risk evaluation and mitigation strategy (REMS) program.
    • Commercial – Tier 3 with PA
    • Medicare, Duals and Medicaid – Non-Formulary
  • Lemtrada (alemtuzumab) – The first CD52-directed cytolytic monoclonal antibody approved for the treatment of relapsing forms of MS.
    • Commercial – Tier 5 with PA
    • Medicare, Duals and Medicaid – Non-Formulary

Criteria Changes

Removed PA Requirement

  • Crestor
  • Zetia
  • Vytorin
  • Liptruzet

Tier Changes – Effective 10/1/15

Commercial and Exchange

  • Clozapine ODT – Moved from Tier 2 to Tier 3
  • Equetro – Moved from Tier 2 to Tier 3
  • Fazaclo – Moved from Tier 2 to Tier 3
  • Geodon – Moved from Tier 2 to Tier 3
  • Klonopin – Moved from Tier 2 to Tier 3
  • Zenzedi 5mg, 10mg – Moved from Tier 1 to Tier 3
  • Dilaudid Oral Solution – Moved from Tier 2 to Tier 3
  • Vimovo – Moved from Tier 3 to Excluded
  • Duexis – Moved from Tier 3 to Excluded

IPH Members Transitioning to Health Alliance Connect

As of November 1, 2015, Illinois Partnership for Health members in 15 Central Illinois counties will transition to Health Alliance Connect. We will send members new ID cards that identify them as Health Alliance Connect members.

Please send these members’ claims with a date of service of November 1, 2015, and after to Health Alliance Connect, and follow the Health Alliance Connect preauthorization list for them starting November 1.

Multiple Modifiers on Claims

When submitting electronic or paper claims, please indicate the pricing modifiers in the first two positions and processing or informational modifiers in the third and fourth positions.

Supplemental Medicare Benefit

Health Alliance Medicare Advantage members now get $100 per plan year to spend on their choice of supplemental dental, vision, or hearing care. They have the freedom to use it on the services they need, so they can get the most from their coverage.

New Provider Relations Specialist

We would like to introduce the newest addition to our provider relations specialist team, Tina Sims. She is responsible for the Springfield, Macomb, and Quincy service areas, which include Sangamon, Menard, Logan, Christian, Montgomery, Macoupin, Greene, Scott, Morgan, Mason, Cass, Pike, Adams, Brown, Hancock, Henderson, Jersey, and Lee, Iowa, counties.

If you’re a provider in one of these areas, you can reach Tina at 217-337-8491 or Tina.Sims@healthalliance.org.

Mastering Medicaid: Strategies for Improving Care and Lowering Costs

Event Details

  • Monday, October 26, 2015, 10 a.m.-3 p.m.
    The Carle Foundation Hospital – Pollard Auditorium
    602 W. University Ave., Urbana, IL 61801
  • Lunch will be provided
  • Symposium is sponsored by Health Alliance Connect in partnership with Illinois Partnership for Health
  • Register by October 19

About the Symposium

Bringing together clinical and administrative leaders across Illinois, the fall Medicaid symposium will address some of the challenges that both providers and patients face when navigating the Medicaid landscape. The symposium will feature local and national speakers who will share lessons learned and best practices for improving care delivery and reducing costs for Medicaid patients.

Through presentations, case studies, and panel discussions, attendees will learn more about managing ER utilization, care coordination, care management, and patient engagement and outreach efforts. We hope you can join and share some of your own lessons learned and best practices as we come together as a community to provide the best patient care to our Medicaid patients.

Featured Speakers

Richard Sánchez, M.D., M.P.H., FAAP, is a Senior Medical Strategist and Medical Director at Health Integrated. He provides clinical direction across the country—through innovative approaches and strategies—on how to best manage Medicaid, Medicare, and dual-eligible populations.

Jay Bhatt, D.O., M.P.H., M.P.A., serves as the Chief Health Officer of the Illinois Hospital Association. In his role, Dr. Bhatt is responsible for organizing physician activities and providing clinical leadership for the IHA’s Institute for Innovations in Care and Quality. Dr. Bhatt is also an internist at the Erie Family Health Center in Chicago and a physician with Northwestern Medicine.