Washington August Newsletter

Online Claims Reprocessing Inquiries Coming Soon

We’re moving claims reprocessing inquiries onto Your Health Alliance for providers.

You’ll be able to track the status on inquiries easily on the site, and it will eliminate tedious and time-consuming paperwork. You can send inquiries for many reasons, including:

• Timely filing
• Coding
• No preauthorization
• Reimbursement questions

We plan for this feature to launch September 15.

UM Types of Additional Documentation Needed

There are certain types of commonly requested procedures or services that are missing important documentation, which can lead to delays in the preauthorization process. To reduce the delays, we’ve taken the commonly requested preauthorizations and detailed the additional information we need when you’re submitting the request. When requesting these procedures or services, you can submit additional documentation through Clear Coverage (CC) or the Preauthorization tab of Your Health Alliance (YHA) for providers.

New Contracted Provider Information Change Form

Now, it’s easier than ever to keep us in the loop. Use our new Contracted Provider Information Change/Update Form to notify us of any new information or changes to your current practice structure, including:

• Location, correspondence, or remit/pay to address change
• Adding a new location
• Provider NPI change
• Provider termination
• New clinic name
• Tax ID changes
• Provider TIN changes
• Provider panel closed
• Phone number change
• PCP status change

Once you’ve filled out your contracted provider information and the details of your change, email your finished form to PSC@healthalliance.org.

Visit Provider.HealthAlliance.org to find the form under the Provider Materials, or log into YourHealthAlliance.org for providers to find the form on the Forms and Resources page.

2016 Provider Manuals Available

You can find provider manuals for all of our plans, including Medicare, on the Forms & Resources page of Your Health Alliance. In them, you’ll find more information about:

• Our Quality Improvement program, including its purpose, goals, objectives, scope, structure, key personnel, and technical resources and systems
• Our complex case management program and how to refer a member
• How to access and request our utilization management and pharmaceutical management criteria
• Affirmative statement about incentives related to UM decision making
• When decision timeframes begin for nonurgent preservice requests received after business hours
• How to use our pharmacy management procedures and processes, including our formulary, pharmaceutical classes, tier information, preauthorization, managed dose limitations, step-therapy, generic substitution, pharmacy savings programs, and how to request a medical exception
• Our disease management programs, including what we do and how you and your patients can access program services
• A comprehensive list of clinical guidelines, including nonpreventive and preventive, as well as behavioral health
• Preventive care guidelines for all age groups
• Members’ rights and responsibilities

New Statin Use and Adherence HEDIS^® Measures

The National Committee of Quality Assurance (NCQA) added two new measures to the 2016 HEDIS^® audit — Statin Therapy for Patients with Cardiovascular Disease and Statin Therapy for Patients with Diabetes. Both of these measures are administrative measures, which means data is collected via claims submitted to us. To get accurate results, claims information must be complete, reflecting the appropriate diagnosis, as well as any conditions or medications that may exclude the member from the denominator.

Statin Therapy for Patients with Cardiovascular Disease

Reflects the percentage of members, males 21-75 years and females 40-75 years, who have had a diagnosis of clinical atherosclerotic cardiovascular disease and were dispensed at least one high or moderate-intensity statin medication during the measurement year. The adherence rate is also measured to show members who remained on the statin medication for at least 80% of the treatment period.

Statin Therapy for Patients with Diabetes

Reflects the percentage of members with diabetes between the ages of 40-75 who were dispensed a prescription for a statin during the measurement year. The adherence rate is also measured to show members who remained on the statin medication for at least 80% of the treatment period.

Members with the following conditions are allowed to be excluded from both measures:

• Pregnancy
• Having in vitro fertilization procedure
• Current prescription for clomiphene
• End stage renal disease
• Cirrhosis
• Myalgia
• Myositis
• Myopathy
• Rhabdomyolysis

To determine if potential exclusions were being submitted via claims, Health Alliance did a review of members meeting criteria for inclusion in the measure, but were not taking a statin medication. Results showed that some members are not on a statin due to muscle pain, or the record simply documented intolerance to statin; however, the intolerance was not reflected in the claim. Most of the allowed exclusions can be coded during the measurement year or the year prior to the measurement year; however, myalgia, myositis, myopathy, or rhabdomyolysis need to be coded annually if that is the reason the patient cannot tolerate the statin. See the list of conditions and codes accepted as exclusions by NCQA for muscle pain and muscle disease below. Providers can receive other diagnosis codes accepted as exclusion by contacting the Quality Medical Management department at 1-800-851-3379, ext. 8112.

HEDIS 2016 (Measurement Year 2015) Results

Since these are new measures, national benchmarks are not yet available.

Statin Therapy for Patients with Cardiovascular Disease

Statin Therapy for Patients with Diabetes

Each of the HEDIS guidelines measure care recommended by national guidelines of the American Diabetes Association and the ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Please discuss the benefits of statin use with your patients and, if you have patients who cannot tolerate one of the statins, be sure and code the reason.

Committee Completes Annual Clinical Guidelines Review

To support NCQA goals and help practitioners make even better decisions about appropriate health care in specific clinical circumstances, the Health Alliance Quality Improvement Committee annually reviews and updates adopted clinical guidelines.

We adopt evidence-based, nationally recognized sources for clinical guidelines, which are listed below, complete with links to additional information.

You can also find these guidelines, as well as other helpful resources, on Your Health Alliance by choosing Clinical Guidelines from the menu in the footer of the page. If you prefer a paper copy of a guideline, contact our Quality and Medical Management Department at 1-800-851-3379, ext. 8112. Alcohol Misuse

• National Institute on Alcohol Abuse and Alcoholism Helping Patients Who Drink Too Much, a Clinician’s Guide

Asthma

• Institute for Clinical Systems Improvement (ICSI) Guidelines for the Diagnosis and Management of Asthma
• National Heart, Lung, and Blood Institute (NHLBI) Guidelines for the Diagnosis and Management of Asthma

Attention Deficit Hyperactivity Disorder

• ICSI Primary Care Guidelines for Attention Deficit Hyperactivity Disorder for School-Age Children and Adolescents

Cholesterol Control

• ACC/AHA Guidelines on the Treatment of Blood Cholesterol
• ACC/AHA Pocket Card Guidelines: Cholesterol Adult Management

Chronic Obstructive Pulmonary Disease (COPD)

• ICSI Guidelines for the Diagnosis and Management of COPD
• Global Initiative for Chronic Obstructive Lung Disease (GOLD) (Only allowed 1 free download)

Congestive Heart Failure (CHF)

• ACCF/AHA Guideline for the Management of Heart Failure

Coronary Artery Disease (CAD)

• 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease
• 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease
• 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Heart Disease
• AHA/ACC Pocket Card Guidelines: Stable Ischemic Heart Disease

Depression in Adults

• ICSI Guideline for Adult Depression in Primary Care

Diabetes

• American Diabetes Association Standards of Medical Care in Diabetes

Hypertension

• Journal of the American Medical Association 2014 Guidelines for the Management of High Blood Pressure in Adults

Migraines and Headaches

• ICSI Guidelines for the Diagnosis and Treatment of Headache
• AAN/AHA Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults

Osteoporosis

• ICSI Guidelines for the Diagnosis and Treatment of Osteoporosis

Potentially Inappropriate Medication (PIM) Usage in Older Adults

• American Geriatrics Society Updated Beers Criteria

Preventive Care

• ICSI Guidelines for Preventive Services for adults
• ICSI Guidelines for Preventive Services for Children and Adolescents
• U.S. Preventive Services Task Force Recommendations for Primary Care Practice
  • For perinatal care info, use the perinatal care and obstetric and gynecologic category filters on the right to narrow your results.
• Health Alliance’s Preventive Care Guidelines Brochure

Tobacco Use

• ICSI Healthy Lifestyles Guidelines
• ICSI Guidelines for Preventive Services for Adults
• ICSI Guidelines for Preventive Services for Children and Adolescents

Weight Management

• ICSI Guidelines for the Prevention and Management of Obesity for Adults
• ICSI Guidelines for the Prevention and Management of Obesity for Children and Adolescents

Pharmacy Updates

Medicare & Washington Public Exchange (WA Public) Plans

Formulary Additions – Effective June 1, 2016

• Descovy (emtricitabine and tenofovir alafenamide) – Indicated in combination with other antiretroviral agents for the treatment of HIV-1 infection in adults and pediatric patients 12 years of age and older.
  • WA Public – Tier 5 with no PA
  • Medicare – Tier 5 with no PA
• Odefsey (emtricitabine, rilpivirine, and tenofovir alafenamide) – Indicated (1) as a complete regimen for the treatment of HIV-1 infection in patients 12 years of age and older as initial therapy in those with no antiretroviral treatment history with HIV-1 RNA less than or equal to 100,000 copies per mL and (2) to replace a stable antiretroviral regimen in those who are virologically suppressed (HIV-1 RNA less than 50 copies per mL) for at least 6 months with no history of treatment failure and no known substitutions associated with resistance to the individual components of Odefsey.
  • WA Public – Tier 5 with no preauthorization (PA)
  • Medicare – Tier 5 with no PA
• Taltz (ixekizumab) – Indicated for the treatment of adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.
  • WA Public – Tier 5 with PA
  • Medicare – Non-Formulary
• Tresiba (insulin degludec) – Indicated to improve glycemic control in adults with diabetes mellitus. Note: Not recommended for the treatment of diabetic ketoacidosis.
  • WA Public – Tier 3 with no PA
  • Medicare – Tier 4 with no PA
• Vistogard (uridine triacetate) – Indicated for the emergency treatment of adult and pediatric patients following a fluorouracil or capecitabine overdose regardless of the presence of symptoms, or who exhibit early-onset, severe or life-threatening toxicity affecting the cardiac or central nervous system, and/or early-onset, unusually severe adverse reactions (e.g., gastrointestinal toxicity and/or neutropenia) within 96 hours following the end of fluorouracil or capecitabine administration.
  • WA Public – Tier 6 with no PA
  • Medicare – Tier 5 with no PA
• Xuriden (uridine triacetate) – Indicated for the treatment of patients with a diagnosis of hereditary orotic aciduria (HOA).
  • WA Public – Tier 6 with PA
  • Medicare – Tier 5 with PA
• Zepatier (elbasvir/grazoprevir) – Indicated with or without ribavirin for the treatment of chronic hepatitis C virus (HCV) genotypes 1 or 4 infection in adults.
  • WA Public – Tier 5 with PA
  • Medicare – Non-Formulary

Formulary Additions – Effective August 3, 2016

• Belbuca (buprenorphine) – Indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.
  • WA Public – Tier 3 with preauthorization (PA)
  • Medicare – Tier 4 with quantity limit (QL)
• Briviact (brivaracetam) – Indicated as adjunctive therapy in the treatment of partial onset seizures in patients 16 years of age and older with epilepsy.
  • WA Public – Tier 3 with step-therapy (ST)
  • Medicare – Tier 4 with ST
• Nuplazid (pimavanserin) – Indicated for the treatment of hallucinations and delusions caused by Parkinson’s Disease psychosis.
  • WA Public – Tier 3 with PA
  • Medicare – Tier 4 with PA
• Xtampza ER (oxycodone hydrochloride) – An opioid agonist product indicated for the management of pain severe enough to require daily, around the clock, long term opioid treatment and for which alternative treatment options are inadequate.
  • WA Public – Tier 3 with PA
  • Medicare – Non-Formulary

Tier Changes – Effective August 3, 2016

• Levocetirizine
  • Moved from Excluded to Tier 1 on Commercial
  • Moved from Non Formulary to Tier 2 on Medicare
• Desloratadine
  • Moved from Excluded to Tier 1 on Commercial
  • Moved from Non Formulary to Tier 2 on Medicare
• Eliquis
  • Moved from Tier 3 to Tier 2 on Commercial
  • Moved from Tier 4 to Tier 3 on Medicare

Medicare

Tier Change – Effective June 1, 2016

• Humulin N, Humulin R, and Humulin 70/30 Vials Only – Moved from Tier 3 to Tier 2

New Policy – Effective August 3, 2016

• Zepatier – Created to establish Medicare D criteria for coverage of Zepatier to meet CMS formulary requirement

WA Public Plans

New Policies – Effective June 1, 2016

• Migranal (dihydroergotamine mesylate) Nasal Spray – Specified criteria for coverage and MDL of 8 units per 30 days
• Orenitram (treprostinil diolamine) – Specified criteria for coverage
• Spritam (levetiracetam) ODT Step-Edit – Specified step-edit criteria for coverage: a previous paid claim of levetiracetam solution, tablets, or capsules
• Sucraid (sacrosidase) – Specified criteria for coverage
• Syprine (trientine hydrochloride) – Specified criteria for coverage

Criteria Changes – Effective June 1, 2016

• Azelaic Acid – Added Azelex to policy
• Diabetes Drug Therapies – Added Synjardy to policy, clarified step-edit time frames where applicable:
  • At least a 90-day supply of specified step therapy drug(s) within the previous 120 days
• Medical Exception for Tier 2 Copayment – Clarified that Tier 2 drugs are not eligible for further tier lowering

Criteria Changes – Effective August 3, 2016

• Anticoagulant, Novel – Removed step through warfarin on all novel anticoagulants and moved Eliquis to parity with Xarelto as a preferred novel anticoagulant
  • Added Eliquis to Xarelto as a step therapy requirement for Savaysa
• ARB (angiotensin II receptor blocker) Generic First Step-Edit – Added olmesartan (generic Benicar) to policy with step therapy through preferred generic ARB
• Erectile Dysfunction Drugs – Specified QL of 4 tablets per 30 days, which is already coded with Optum
• Excluded Drug List – Removed Xyzal and Clarinex from exclusion of non-sedating antihistamines/combinations with an OTC alternative
• Lyrica – Added criteria for coverage of generalized anxiety disorder (GAD)
• Qudexy XR and Trokendi
  • Changed policy from ST to PA
  • Added epilepsy diagnosis to criteria
• Smoking Cessation – Chantix: Specified eligibility of 180 days per 365-day period
• Tysabri – Changed multiple sclerosis prerequisites to two preferred agents
• Xolair – Changed asthma diagnosis age requirement to 6 years or older

Tier Change – Effective August 3, 2016

• Mupirocin Cream
  • Moved from Tier 1 to Excluded
  • Mupirocin ointment available at Tier 1

Removed Preauthorization – Effective August 3, 2016

• Celebrex
• Lidoderm
• Movantik

Managed Dose Limit (MDL) Change – Effective August 3, 2016

• Epinephrine Auto Injectors
  • Added MDL of 4 pens per 30 days
  • Requests for additional quantities would require medical exception

Tier Changes – Effective June 1, 2016

• Crestor – Moved from Tier 2 to Tier 3
  • Generic rosuvastatin now available at Tier 1
• Syprine – Moved from Tier 3 to Tier 5
  • Drug qualifies for specialty
• Orenitram – Moved from Tier 6 to Tier 5
  • PAH drugs sit at Tier 5
• Lupaneta – Moved from Tier 6 to Tier 5
  • Lupron Depot sits at Tier 5
• Noxafil Suspension – Moved from Tier 3 to Tier 5
  • This will place it at the same tier as Noxafil tablets and IV
• Viekira Pak – Moved from Tier 4 to Tier 5
  • Harvoni is available at Tier 4

Tier Changes – Effective October 1, 2016

• Azor
  • Moved from Tier 2 to Tier 3
  • Generic (olmesartan-amlodipine) will be available at Tier 1 in October 2016
• Tribenzor
  • Moved from Tier 2 to Tier 3 on Commercial
  • olmesartan (generic launch in October 2016), amlodipine, and hydrochlorothiazide are available separately at Tier 1