April 2024 Newsletter

Spring in Our Steps

Springtime – it’s a time when nature awakens around us and the world seems full of freshness, beauty, renewal and hope. Here at the health plan, we have an extra spring in our step this season – and it’s because of you. We’ve noticed all the hard work you’ve done recently to help our members receive the absolute best care, partnering with us and coordinating with the many resources we offer. We can’t thank you enough. It’s because of your skill, knowledge and dedication that our members are experiencing renewal, hope and vibrant health, just like the springtime blooming all around us.

Our members need help finding YOU.

As you know, it’s vital that your patients – and potential patients – have access to accurate, up-to-date information about your practice in our provider directory. To ensure this accuracy, the No Surprises Act, the Illinois Department of Human Services, the Illinois Department of Insurance, and the Centers for Medicare & Medicaid Services all require that providers review and update their information quarterly or whenever there’s a significant change.

Patients must be able to call the phone number listed in our provider directory and make an appointment with that specific provider at that location.

We know paperwork is often time-consuming, so to help you meet this requirement, we’ve partnered with LexisNexis^® Risk Solutions. They’ll be beginning their second-quarter outreach to you in the next several weeks via phone or email to help you verify that your provider information is accurate and up to date.

If you have any questions or have concerns with your updates, please contact your provider relations specialist or call our Provider Services team at (800) 851-3379, Option 3.

If you need to send updated provider demographic information to us, please send that information to Provider.Updates@HealthAlliance.org.

Thank you for your cooperation in this important initiative.

Upgrades to Our Provider Portal

You talked and we listened! We’re excited to announce that we’ve implemented several new features to our online provider portal, Tapestry Link. These new features are the result of requests from you, our provider community, and they aim to create a better user experience in the portal.

New Features

• The Submitted CRM tab has been updated with new and improved functionality.
• The New Authorization tab is now fully operational.
• You may now search for prior authorization requirements that are specific to the patient’s health plan.
• Reference numbers are now provided when checking prior authorization requirements.
• The new-user request process is more seamless and user friendly.

It’s our goal to make your job easy as you’re caring for our members, and we believe these upgrades will have a positive impact. We look forward to hearing your feedback.

Please reach out to our Customer Solutions team or your provider relations specialist if you have any questions regarding these changes. Thank you for all that you do.

***

Help us move the needle.

Together we can help people live their healthiest lives. Find reminders, tips and more in this section, to guide improvements in patient outcomes. Help us move the needle.

Tips to Help Your Patients with Asthma

With your help – including education, guidance and proper care – most of your patients with asthma should be able to control their disease. Here are some of the most important messages and tips you can give to your patients, from the American Lung Association^®. These will help lead them to better outcomes and improved quality of life.

• Provide encouragement and hope. Remind your patients that they can still be active, healthy and well while living with asthma, and that it shouldn’t hold them back from doing the things they want to do.
• Remind them to visit their primary care provider every six to 12 months – or more frequently if they’re having symptoms.
• Check to make sure they’re taking their asthma drugs as prescribed.
• Teach them how to monitor their asthma daily – and how to treat symptoms quickly when they arise.
• Ask them what makes their asthma symptoms worse. Help them be aware of – and avoid if possible – their triggers.
• Give them tips, information and resources on how to create healthy environments – for example, at home and at work/school.

Finally, help your patients create a written “asthma action plan” that includes listing their known triggers, steps to prevent symptoms, actions to take during asthma episodes and more.

Help reduce hospital readmissions among diverse populations.

There’s a lot of guidance on how to prevent avoidable hospital readmissions. But despite all the information and tips available to providers, less is known, specifically, about the barriers faced by minority populations and how these relate to readmissions. You can help change this. Here are some high-level recommendations from the Centers for Medicare & Medicaid Services for how you – and your fellow providers – can help collect important data so we can begin to learn more.

By collecting and analyzing data, we can start to gain a better understanding of how certain risk populations, settings and individual characteristics relate to readmissions. Here is some of the key information providers can track:

• Data on who is readmitted, for what health condition, because of what factors, from what location and at what cost.
• Race/Ethnicity: Racial and ethnic minority populations are more likely to be readmitted for chronic health conditions. Collecting this data in a standardized way can help us understand why. Self-reported data is considered the most reliable.
• Language: Ask patients what their preferred spoken and written languages are. People with limited proficiency in English are at higher risk for readmission.
• Education: Your patients with lower health literacy might be at higher risk for avoidable readmissions.
• Disability: Often, people with disabilities have more complex hospital admissions – knowing this at the outset, and preparing accordingly, can help plan better transitions of care, which can prevent readmissions.
• Social Determinants of Health: Screen patients regarding their social supports, housing, transportation, access to healthy foods and access to community resources. These factors might affect risk of readmission.
• Primary/Regular Care: Assess whether your patients have a primary care provider and/or a regular source of healthcare. Not having these might affect their risk of readmissions. Proactively identify which of your patients might need referrals to a primary care provider.

You and your staff can gather this information at registration and update it at regular intervals. If you have a standardized data collection system, you can do predictive modeling for readmissions to help you address the factors that most often cause them. If you don’t have a standardized data collection system, you can gather the information from patients who are regularly readmitted via chart review, interviews, focus groups, patient/family councils and multicultural advisory boards. Working together – and using evidence-based means – we can all begin to better understand the issue of avoidable readmissions among minority populations.

Tips to Improve Medication Adherence

Does this sound familiar: You work hard to study your patient’s symptoms and come up with a treatment plan that best fits their condition, only to see them not take their medications correctly (or at all)? At the end of the day, drugs only work if your patients take them as prescribed. Here’s a quick list of tips to help improve your patients’ medication adherence.

• Get to know your patients’ medication behaviors – by openly talking about them. Ask if they have trouble affording, filling, taking or remembering their drugs.
• Write the information down – and have your patients write it down too. Verbal instructions, like on when to take drugs or how often, are easy to forget.
• Be open and honest about side effects. Patients who are told about the side effects in advance are more likely to stick with the drug if they encounter them.
• Keep cost in mind. If your patients are having trouble affording a medication, consider lower-cost alternatives (like generics) and connect your patients to financial assistance (for example, from drug manufacturers or the government).
• Make sure your patients understand. Keep health literacy in mind, and make sure your patients fully understand how to take their medications. Use plain language, and have them repeat the instructions back to you.
• Don’t make the drug regimen too complex. If you can, provide, for example, combination products or medications with once-daily (vs. multiple-per-day) dosing.
• Always follow up. At each visit, ask your patients if they’re taking their meds and if they have any questions about them. Help set them up with medication reminders via text, email or other methods.
• Embrace technology. If it helps the specific patient, set them up with e-pill devices (like automatic pill dispensers, pillboxes, timers or alarms).

Finally, get creative. You know your patients best. Think about what’ll help each specific individual adhere to their medication plan. Together, you can help them achieve more consistent, healthier outcomes.

Source Used for this Article:

Resnick, Richard. “10 Strategies to Improve Patient Compliance with Medication.” Cureatr. 22 January 2020.

Vaccines: Talking with Parents and Guardians

More than ever, it’s key that parents and guardians know the importance of vaccinations for their children. Here are some tips from the CDC for when you talk with families about immunization. As their trusted healthcare provider, your knowledge and voice will make a difference.

• Be open and accessible – answer any questions parents/guardians may have about vaccines. Be sure to let them talk, and make a point to listen. Always be understanding of where they’re coming from and seek to understand their concerns and why they may have them.
• Provide families with educational materials.
• Remind parents/guardians about the safety and effectiveness of vaccines.
• Provide a strong, encouraging recommendation for vaccination. And make sure you state your recommendation clearly, in plain language.
• Discuss the harms of not getting vaccinated. Be specific in telling parents/guardians about the risks and responsibilities they’re taking by not having their child immunized.
• Be proactive in discussing vaccines – state the shots the child needs, and use language that assumes the child will get them. For example, instead of saying, “What do you want to do about vaccines?,” phrase it as, “Your child needs two shots today.”
• Talk person-to-person and bring up your own personal experiences with vaccination.
• If a family refuses to vaccinate their child, bring up vaccines again at the next visit (and each visit) and repeat your strong recommendation.
• If parents/guardians still refuse, ask if there’s anything you can do to help address their concerns or to help them learn more about vaccines. Be willing to schedule extra time to talk through their questions. As a trusted voice, never forget the impact your knowledge and partnership have for the families in your care.

Virtual Visits for Mental Health Needs

Many of our health plans include access to virtual visits that let members connect with board certified psychiatrists and licensed therapists by phone or video, 24/7/365. We encourage you to share this information with your patients who are members of our plans.

These virtual visits are quick and easy to schedule – and they can help your patients deal with everyday mental health issues or more urgent, immediate times of need.

If you have patients dealing with the following needs, they may benefit from virtual visits:

• Anxiety, stress, PTSD, trauma and/or panic disorders.
• Depression, bipolar disorders, and/or grief and loss.
• Addiction and substance issues.
• General help with life changes, relationship support, parenting issues and more.

These virtual options are private, secure and confidential. And they can also help get your patients prescription medications when needed.

Important note: Not all our health plans include virtual visits. Your patients can call the number on the back of their ID card to see if they’re included with their plan.

If their health plan does include virtual visits and they’re interested in trying them out, direct them to hally.com/care or their Hally^® account on the MyChart app to schedule.

More Information to Share with Your Patients

If you think a patient might benefit from virtual visits for their mental or behavioral health needs, here’s some more information you can share with them and their loved ones.

1. Therapy works – and it’s been proven.

Studies consistently show that therapy’s effective in helping lead people to long-term health improvements. In fact, over 75% of patients who seek help with a mental health professional via MDLIVE^® virtual visits report feeling better after just three visits.¹

2. Therapy also helps with day-to-day challenges.

People don’t need to have severe mental health issues or experience a crisis to benefit from these virtual visits. Everyone can feel better by talking to a skilled, caring professional – whether it’s to overcome serious issues or just make better life decisions.

A therapist can help people work through everyday challenges, make more productive choices, learn valuable life skills and achieve goals. Therapy can increase problem-solving skills and confidence, helping people feel stronger when facing challenges.

3. Therapy can help improve overall health and well-being.

Virtual visits for mental and behavioral health can also help improve long-term physical health. According to the American Heart Association^®, people who report positive mental health are more likely to have lower blood pressure, better blood sugar levels and fewer physical symptoms of stress – like migraines, insomnia and digestive issues.²

4. Therapy is very common – many people use it.

The recent pandemic brought mental health to the forefront and increased the number of people reaching out for help. It’s estimated that 52.9 million adults in the U.S. in 2020 faced some type of mental health issue – and 24.3 million, or almost half of them, received therapy or another type of support. More people than ever are recognizing the value of therapy for their health and well-being.^3,4

5. Virtual visits make therapy much more convenient and accessible.

For some people, making an appointment for therapy can be quite hard. It might take weeks to get an appointment and finding the right therapist is often difficult. With our virtual visits, appointments can be scheduled in less than a week and people can choose from hundreds of licensed therapists. They can talk to the same therapist at every session or switch – at any time – to find a better fit. And it’s all from the comfort of home and is private, secure and easy to set up.

Source Used:

¹ Percentage of assessed patients who showed clinical improvement in PHQ-9 or GAD-7 scores after three or more virtual therapy sessions with their MDLIVE provider in 2020.

² Levine, Glenn N., et al. ”Psychological Health, Well-Being, and the Mind-Heart-Body Connection: A Scientific Statement From the American Heart Association.” Circulation. American Heart Association. 25 January 2021.
³ Chamberlin, J. “Survey says: More Americans are seeking mental health treatment.” Monitor on Psychology. American Psychological Association. Vol. 35, No. 7. July/August 2004.

⁴ “Mental Illness.” National Institute of Mental Health. March 2023.

***

Coding Counts:
Specificity in Dementia Coding and Documentation

Supporting documentation and accurate coding are key to making sure your patients receive the care they need. Here are this issue’s tips for you and your staff, focused on dementia coding and documentation.

In 2023, ICD-10-CM expanded the code set to include over 80 new and updated codes to classify dementia. This includes new codes for etiology and greater specificity in classifying whether dementia is mild, moderate or severe. The expanded code set also includes greater specificity in classifying complications related to dementia. The categories for dementia coding are as follows:

• F01 – Vascular dementia.
• F02 – Dementia in disease classified elsewhere (including Alzheimer’s, Parkinsonism and more).
• F03 – Unspecified dementia, including senile dementia and primary degenerative dementia.

Make sure you also assess the severity of dementia – it’s very important to document whether dementia is mild, moderate or severe. It’s also important to document any behavioral disturbances that the patient exhibits in dementia, such as agitation, aggressive behavior or wandering. When the etiology of dementia is known, it’s important to clearly document this during the visit with the patient. In those cases, two ICD-10-CM codes may best describe the patient’s condition.

From a coding perspective, if details are not documented during a visit with the patient, they cannot be captured within the ICD-10-CM code set. It’s important to document etiology, severity and complications of conditions so that the most specific code that describes the condition can be used.

We thank you for your attention to detail and professionalism, and we’re always here to help. To find more coding resources, visit our Coding Counts page. Thank you for your continued care and dedication to our members’ health.

Questions?

Please contact us at CodingCounts@HealthAlliance.org.

Updates to High Cost Medical Drugs List

See the table below for changes to the High Cost Medical Drugs List with effective dates.

Note: Medications removed from the High Cost Medical Drugs List may still require prior authorization.

Note: This article/table only applies to our Health Alliance^TM branded Commercial plans (the plans we refer to as Midwest and Carle in the Pharmacy Updates section below). It does not apply to Health Alliance Northwest or Reid Health Alliance Medicare branded plans.

Note: This article/table does not apply to any of our Medicare plans (no matter what their brand/name).

Midwest – Pharmacy Updates

All Plans

Oncology/Hematology

New Drug Reviews/ Policies

• Jesduvroq (daprodustat)—Treatment of anemia due to chronic kidney disease (CKD) in adults who have been receiving dialysis for at least 4 months
  • Formulary placement recommendations
    • Commercial—Non-Formulary
    • Medicare—Non-Formulary
  • Veopoz (pozelimab)—Treatment of adult and pediatric patients 1 year of age and older with CD55-deficient protein-losing enteropathy (PLE), also known as CHAPLE disease
    • Formulary placement recommendations
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary
    • Fabhalta (iptacopan)—Treatment of adults with paroxysmal nocturnal hemoglobinuria (PNH)
      • Formulary placement recommendations
        • Commercial— Non-Preferred Specialty Pharmacy with PA and MDL (#60/30)
        • Medicare—Non-Formulary
      • Adzynma (ADAMTS13 Recombinant)—Prophylactic or on demand enzyme replacement therapy (ERT) in adult and pediatric patients with congenital thrombotic thrombocytopenic purpura (cTTP)
        • Formulary placement recommendations
          • Commercial—Non-Preferred Specialty Medical with PA
          • Medicare—Non-Formulary
        • Aphexda (motixafortide)—Mobilization of hematopoietic stem cells to the peripheral blood (in combination with filgrastim) for collection and subsequent autologous transplantation in patients with multiple myeloma
          • Formulary placement recommendations
            • Commercial—Non-Preferred Specialty Medical with PA
            • Medicare—Non-Formulary
          • Roctavian (valoctocogene roxaparvovec)—Treatment of severe hemophilia A (congenital factor VIII deficiency with factor VIII activity <1 IU/dL) without antibodies to adeno-associated virus serotype 5 (AAV5) in adults
            • Formulary placement recommendations
              • Commercial—Non-Formulary
              • Medicare—Non-Formulary
            • Lyfgenia (lovotibeglogene autotemcel)—Treatment of sickle cell disease in patients 12 years of age or older with a history of vaso-occlusive events
              • Formulary placement recommendations
                • Commercial—Non-Formulary
                • Medicare—Non-Formulary
              • Casgevy (exagamglogene autotemcel)—Treatment of patients age 12 years or older with either sickle cell disease (SCD) with recurrent vaso-occlusive events OR transfusion dependent beta thalassemia (TBT)
                • Formulary placement recommendations
                  • Commercial—Non-Preferred Specialty Medical with PA
                  • Medicare—Non-Formulary

Oncology NDTM Chart

Infectious Disease

New Drug Reviews

• Rezzayo (rezafungin)—Treatment of candidemia and invasive candidiasis in adults who have limited or no alternative options
  • Formulary placement recommendations
    • Commercial—Non-Formulary
    • Medicare—Non-Formulary
  • Vowst (fecal microbiota, live-brpk)—Prevention of recurrence of difficile infection (CDI) in adults following antibiotic treatment of recurrent CDI
    • Sader: Do the two other options in this treatment class have comparable clinical efficacy and hospital readmissions rate?
      • Debra: Yes. While there haven’t been direct comparison clinical trials, Rebyota has similar efficacy and Zinplava is included in current IDSA recommendations
    • Formulary placement recommendations
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary

Commercial

Oncology/Hematology 

New Policy

• Cosela (trilaciclib)
  • Drug was previously reviewed by eviCore; policy was needed to support switch to internal HA review

Infectious Disease

Criteria Changes

• Prevymis (letermovir)
  • Added coverage criteria for new indication of CMV prevention in kidney transplants
• Preventive Vaccines
  • Added Abrysvo for pregnant women and Penbraya; removed Prevnar 13, Menactra and DT (discontinued)

Miscellaneous New Policies

• Non-Formulary Medications
  • Provides further clinical reasoning to support keeping these drugs off formulary

Formulary Changes—Commercial

Negative Changes (effective 7/1/2024)

• BRAND removals from formulary: Gleevec, Zytiga, Afinitor
  • Products have generic equivalents, removing brand only
• Move brand Alphagan from Preferred to Non-Preferred Brand tier
  • All strengths of Alphagan now have generic equivalents

The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers. Upcoming negative formulary and criteria changes can be found online at the following website: HealthAlliance.org/Documents/960/2022. Drug coverage and policies in the following categories will be reviewed during the remainder of 2024 and changes may be made:

• April Meeting: Rheumatology, Gastroenterology, Dermatology.
• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Northwest – Pharmacy Updates

All Plans

Oncology/Hematology

 New Drug Reviews/ Policies

• Jesduvroq (daprodustat)—Treatment of anemia due to chronic kidney disease (CKD) in adults who have been receiving dialysis for at least 4 months
• • Formulary placement recommendations
    • Commercial—Non-Formulary
    • Medicare—Non-Formulary
  • Veopoz (pozelimab)—Treatment of adult and pediatric patients 1 year of age and older with CD55-deficient protein-losing enteropathy (PLE), also known as CHAPLE disease
    • Formulary placement recommendations
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary
    • Fabhalta (iptacopan)—Treatment of adults with paroxysmal nocturnal hemoglobinuria (PNH)
      • Formulary placement recommendations
        • Commercial— Non-Preferred Specialty Pharmacy with PA and MDL (#60/30)
        • Medicare—Non-Formulary
      • Adzynma (ADAMTS13 Recombinant)—Prophylactic or on demand enzyme replacement therapy (ERT) in adult and pediatric patients with congenital thrombotic thrombocytopenic purpura (cTTP)
        • Formulary placement recommendations
          • Commercial—Non-Preferred Specialty Medical with PA
          • Medicare—Non-Formulary
        • Aphexda (motixafortide)—Mobilization of hematopoietic stem cells to the peripheral blood (in combination with filgrastim) for collection and subsequent autologous transplantation in patients with multiple myeloma
          • Formulary placement recommendations
            • Commercial—Non-Preferred Specialty Medical with PA
            • Medicare—Non-Formulary
          • Roctavian (valoctocogene roxaparvovec)—Treatment of severe hemophilia A (congenital factor VIII deficiency with factor VIII activity <1 IU/dL) without antibodies to adeno-associated virus serotype 5 (AAV5) in adults
            • Formulary placement recommendations
              • Commercial—Non-Formulary
              • Medicare—Non-Formulary
            • Lyfgenia (lovotibeglogene autotemcel)—Treatment of sickle cell disease in patients 12 years of age or older with a history of vaso-occlusive events
              • Formulary placement recommendations
                • Commercial—Non-Formulary
                • Medicare—Non-Formulary
              • Casgevy (exagamglogene autotemcel)—Treatment of patients age 12 years or older with either sickle cell disease (SCD) with recurrent vaso-occlusive events OR transfusion dependent beta thalassemia (TBT)
                • Formulary placement recommendations
                  • Commercial—Non-Preferred Specialty Medical with PA
                  • Medicare—Non-Formulary

 Oncology NDTM Chart

Infectious Disease

New Drug Reviews

• Rezzayo (rezafungin)—Treatment of candidemia and invasive candidiasis in adults who have limited or no alternative options
  • Formulary placement recommendations
    • Commercial—Non-Formulary
    • Medicare—Non-Formulary
  • Vowst (fecal microbiota, live-brpk)—Prevention of recurrence of difficile infection (CDI) in adults following antibiotic treatment of recurrent CDI
    • Sader: Do the two other options in this treatment class have comparable clinical efficacy and hospital readmissions rate?
      • Debra: Yes. While there haven’t been direct comparison clinical trials, Rebyota has similar efficacy and Zinplava is included in current IDSA recommendations
    • Formulary placement recommendations
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary

Commercial

Oncology/Hematology

New Policy

• Cosela (trilaciclib)
  • Drug was previously reviewed by eviCore; policy was needed to support switch to internal HA review

Infectious Disease

Criteria Changes

• Prevymis (letermovir)
  • Added coverage criteria for new indication of CMV prevention in kidney transplants
• Preventive Vaccines
  • Added Abrysvo for pregnant women and Penbraya; removed Prevnar 13, Menactra and DT (discontinued)

Miscellaneous New Policies

• Non-Formulary Medications
  • Provides further clinical reasoning to support keeping these drugs off formulary

Formulary Changes—Commercial

Negative Changes (effective 7/1/2024)

• BRAND removals from formulary: Gleevec, Zytiga, Afinitor
  • Products have generic equivalents, removing brand only
• Move brand Alphagan from Preferred to Non-Preferred Brand tier
  • All strengths of Alphagan now have generic equivalents

The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers. Upcoming negative formulary and criteria changes can be found online at the following website: HealthAlliance.org/Documents/960/2022. Drug coverage and policies in the following categories will be reviewed during the remainder of 2024 and changes may be made:

• April Meeting: Rheumatology, Gastroenterology, Dermatology.
• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Carle – Pharmacy Updates

All Plans

Oncology/Hematology

New Drug Reviews/ Policies

• Jesduvroq (daprodustat)—Treatment of anemia due to chronic kidney disease (CKD) in adults who have been receiving dialysis for at least 4 months
  • Formulary placement recommendations
    • Commercial—Non-Formulary
    • Medicare—Non-Formulary
  • Veopoz (pozelimab)—Treatment of adult and pediatric patients 1 year of age and older with CD55-deficient protein-losing enteropathy (PLE), also known as CHAPLE disease
    • Formulary placement recommendations
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary
    • Fabhalta (iptacopan)—Treatment of adults with paroxysmal nocturnal hemoglobinuria (PNH)
      • Formulary placement recommendations
        • Commercial— Non-Preferred Specialty Pharmacy with PA and MDL (#60/30)
        • Medicare—Non-Formulary
      • Adzynma (ADAMTS13 Recombinant)—Prophylactic or on demand enzyme replacement therapy (ERT) in adult and pediatric patients with congenital thrombotic thrombocytopenic purpura (cTTP)
        • Formulary placement recommendations
          • Commercial—Non-Preferred Specialty Medical with PA
          • Medicare—Non-Formulary
        • Aphexda (motixafortide)—Mobilization of hematopoietic stem cells to the peripheral blood (in combination with filgrastim) for collection and subsequent autologous transplantation in patients with multiple myeloma
          • Formulary placement recommendations
            • Commercial—Non-Preferred Specialty Medical with PA
            • Medicare—Non-Formulary
          • Roctavian (valoctocogene roxaparvovec)—Treatment of severe hemophilia A (congenital factor VIII deficiency with factor VIII activity <1 IU/dL) without antibodies to adeno-associated virus serotype 5 (AAV5) in adults
            • Formulary placement recommendations
              • Commercial—Non-Formulary
              • Medicare—Non-Formulary
            • Lyfgenia (lovotibeglogene autotemcel)—Treatment of sickle cell disease in patients 12 years of age or older with a history of vaso-occlusive events
              • Formulary placement recommendations
                • Commercial—Non-Formulary
                • Medicare—Non-Formulary
              • Casgevy (exagamglogene autotemcel)—Treatment of patients age 12 years or older with either sickle cell disease (SCD) with recurrent vaso-occlusive events OR transfusion dependent beta thalassemia (TBT)
                • Formulary placement recommendations
                  • Commercial—Non-Preferred Specialty Medical with PA
                  • Medicare—Non-Formulary

 Oncology NDTM Chart

Infectious Disease

New Drug Reviews

• Rezzayo (rezafungin)—Treatment of candidemia and invasive candidiasis in adults who have limited or no alternative options
  • Formulary placement recommendations
    • Commercial—Non-Formulary
    • Medicare—Non-Formulary
  • Vowst (fecal microbiota, live-brpk)—Prevention of recurrence of difficile infection (CDI) in adults following antibiotic treatment of recurrent CDI
    • Sader: Do the two other options in this treatment class have comparable clinical efficacy and hospital readmissions rate?
      • Debra: Yes. While there haven’t been direct comparison clinical trials, Rebyota has similar efficacy and Zinplava is included in current IDSA recommendations
    • Formulary placement recommendations
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary

Commercial

Oncology/Hematology

New Policy

• Cosela (trilaciclib)
  • Drug was previously reviewed by eviCore; policy was needed to support switch to internal HA review

Infectious Disease

Criteria Changes

• Prevymis (letermovir)
  • Added coverage criteria for new indication of CMV prevention in kidney transplants
• Preventive Vaccines
  • Added Abrysvo for pregnant women and Penbraya; removed Prevnar 13, Menactra and DT (discontinued)

Miscellaneous New Policies

• Non-Formulary Medications
  • Provides further clinical reasoning to support keeping these drugs off formulary

Formulary Changes—Commercial

Negative Changes (effective 7/1/2024)

• BRAND removals from formulary: Gleevec, Zytiga, Afinitor
  • Products have generic equivalents, removing brand only
• Move brand Alphagan from Preferred to Non-Preferred Brand tier
  • All strengths of Alphagan now have generic equivalents

The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers. Upcoming negative formulary and criteria changes can be found online at the following website: HealthAlliance.org/Documents/960/2022. Drug coverage and policies in the following categories will be reviewed during the remainder of 2024 and changes may be made:

• April Meeting: Rheumatology, Gastroenterology, Dermatology.
• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Reid – Pharmacy Updates

IMPORTANT NOTE for Reid Health providers: For your patients with Health Alliance Medicare Advantage plans – previously referred to as “Reid Health Alliance Medicare” plans – please now refer to the above “Midwest – Pharmacy Updates.” The specific Medicare listings under the “All Plans” header are what’s relevant for your patients with Health Alliance Medicare Advantage plans.

Contact Us

 (800) 851-3379, option 3

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