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Midwest April Newsletter

May 2, 2016

New Partnership with Cotiviti Healthcare

We would like to inform you of our partnership with Cotiviti Healthcare, beginning June 2016, for periodic post-payment reviews of paid medical claims.

Cotiviti Healthcare’s staff includes registered nurses and medical and claims experts with varying areas of expertise, including but not limited to coding, claims operations, and quality. They work collaboratively with their clients and medical providers to create effective strategies, plans and activities to both prevent future payment errors and improve the reimbursement process. You may already be familiar with Cotiviti Healthcare as an industry leader with health plans throughout Illinois and beyond.

Cotiviti Healthcare is a business associate of Health Alliance as defined in 45 CFR, Section 160.103 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and will perform its responsibilities on behalf of Health Alliance in full compliance with HIPAA requirements.

We ask for your help in providing Cotiviti Healthcare staff access to medical and/or financial information necessary to complete these reviews to the same extent Health Alliance staff would be authorized to access such records.

Thank you for your cooperation, and please share this information with staff as you see fit. If you have questions, please call us at 1-800-851-3379, option 3.

Wellness Code Clarification

In previous versions of the Be Healthy wellness brochures, two of the diagnosis code criteria were switched. Below is the correct information on which diagnoses codes are covered as a wellness benefit.

  • Medical Nutritional Therapy is covered as a wellness benefit with diagnosis codes E08.00-E13.9, E71.30–E75.6, E77.0–E88.9, I10, I25.10–I25.9, I50.20–I50.9, J41.0–J44.9, N18.1–N18.9, O24.410–O24.439, O99.810, O99.815, Z48.22, Z94.0
  • Face-to-face behavioral counseling for obesity (15 minutes, 26 every 12 months) is covered as a wellness benefit with diagnosis codes Z68.30–Z68.45

New HEDIS® Measure for Medicare Advantage

Medication Reconciliation is a HEDIS measure introduced in 2016 that applies to Medicare Advantage members. This measure evaluates if members discharged from acute and non-acute settings from January 1 to December 1 of the measurement year had a medication reconciliation completed within 30 days after discharge. The medication review can be completed by a registered nurse, physician, or pharmacist and must be completed in the outpatient setting. Home visits and telephone encounters are approved settings for the medication review if documentation is included in the medical record.

Medication reconciliation is an important part of continuity of care and improves the safety of patients. Documentation within the medical record is vital to show that medication review has been done. The National Committee of Quality Assurance will also recognize these codes as meeting compliance for this measure: 99495, 99496, and 1111F.

Thank you for your efforts in helping patients understand their medications and how to take them safely.

Active Listening Shows Respect for Patients

In today’s busy healthcare environment, it can be hard for providers to balance packed schedules with giving each patient enough time and attention. But good provider-patient relationships depend in part on patients feeling like their providers listen to them and respect what they say and how they feel.

Patients’ time spent with their providers should feel like a conversation, not a lecture. Here are some tips to help with active listening:

  • Make eye contact when patients are talking.
  • Have open body language and nod to show you’re listening.
  • Don’t interrupt or rush patients through an explanation or question.
  • Ask follow-up questions when appropriate.
  • Try to make sure patients leave feeling all their questions are answered.

Keeping these simple tips in mind can help you make your patients feel like they are being heard and respected, which goes a long way toward building open provider-patient relationships.

Pharmacy Updates

All Plans

Formulary Additions

  • Adynovate (antihemophilic factor [recombinant], pegylated) – Indicated for on-demand treatment and control of bleeding episodes, as well as routine prophylaxis to reduce the frequency of bleeding episodes. Not indicated for the treatment of von Willebrand Disease.
    • Commercial – Tier 5 with no preauthorization (PA)
    • Medicaid – Covered with no PA
    • Medicare – Part B only
  • Coagadex (coagulation Factor X [Human]) – For adults and children (aged 12 years and older) with hereditary Factor X deficiency for on-demand treatment and control of bleeding episodes, as well as perioperative management of bleeding in patients with mild hereditary Factor X deficiency.
    • Commercial – Tier 5 with no PA
    • Medicaid – Covered with no PA
    • Medicare – Part B only
  • Nuwiq (recombinant antihemophilic factor VII) – Indicated for adults and children with Hemophilia A for (1) on-demand treatment and control of bleeding episodes, (2) perioperative management of bleeding, and (3) routine prophylaxis to reduce the frequency of bleeding episodes. Not indicated for the treatment of von Willebrand Disease.
    • Commercial – Tier 5 with no PA
    • Medicaid – Covered with no PA
    • Medicare – Part B only
  • Genvoya (elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide) – A new single tablet once-daily regimen containing the 4-drug combination of elvitegravir, an HIV-1 integrase strand transfer inhibitor (INSTI), cobicistat, a CYP3A inhibitor, and emtricitabine and tenofovir alafenamide (TAF), both HIV-1 nucleoside analog reverse transcriptase inhibitors (NRTIs).
    • Commercial – Tier 5 with No PA
    • Medicaid – Covered with no PA
    • Medicare – Tier 5 with no PA
  • Kanuma (sebelipase alfa) – A human therapeutic biologic that is the first FDA-approved treatment for lysosomal acid lipase (LAL) deficiency.
    • Commercial – Tier 6 with PA
    • Medicaid – Covered with PA
    • Medicare – Tier 5 with PA
  • Strensiq (asfotase alfa) – The first therapy approved for the treatment of hypophosphatasia (HPP), a genetic, ultra-rare metabolic disorder.
    • Commercial – Tier 6 with PA
    • Medicaid – Covered with PA
    • Medicare – Tier 5 with PA
  • Keveyis (dichlorphenamide) – An oral carbonic anhydrase inhibitor indicated for the treatment of primary hyperkalemic periodic paralysis, primary hypokalemic periodic paralysis, and related variants.
    • Commercial – Tier 6 with PA
    • Medicaid – overed with PA
    • Medicare – Tier 5 with PA.
  • Uptravi (selexipag) – A prostacyclin receptor agonist approved for the treatment of pulmonary arterial hypertension (PAH).
    • Commercial – Tier 5 with PA
    • Medicaid – Covered with PA
    • Medicare – Tier 5 with PA
  • Veltassa (patiromer) – An electrolyte depleter indicated for the treatment of hyperkalemia.
    • Commercial – Tier 5 with PA
    • Medicaid – Not Covered
    • Medicare – Tier 5 with no PA
  • Viberzi (eluxadoline) – A mu-opioid receptor agonist, indicated in adults for the treatment of irritable bowel syndrome with diarrhea (IBS-D).
    • Commercial – Tier 4 with PA
    • Medicaid – Not Covered
    • Medicare – Tier 5 with No PA

Medicaid

Policy Review

Suboxone, Subutex, Bunavail, Zubsolv Reverse Step-Edit –  “Reverse” step edit in place for all generic and brand-name opioids consisting of 90-day look-backs for all Suboxone, Subutex, Bunavail, and Zubsolv products, any claim for which will cause opioid drug to reject for duplicate/inappropriate drug therapy.

Tier Change

First Omeprazole Suspension – Moved from Excluded to Covered (with step through ranitidine solution).

Medicaid & Commercial

Removed PA

  • Lotronex
  • Tretinoin

Criteria Changes

  • Excluded Drug List – Added Addyi to list
  • Gender Dysphoria Hormonal Reassignment Treatments – Added HST coverage criteria and Exclusion Criteria section
  • High-Dollar Medication Override – Reduced Medicaid compound threshold from $150/claim to $100/claim

Removed Managed Dose Limit

  • Sertraline (MDL had been #60 tablets per 30 days)
  • Citalopram (MDL had been #30 tablets per 30 days)

Commercial

Changed Step Therapy

  • Lemtrada – Removed step-therapy through Betaseron, Copaxone, and Rebif, and replaced with step through any 2 disease-modifying MS therapies

Removed Step-Therapy

  • Pioglitazone
  • Pioglitazone-glimepiride
  • Pioglitazone-metformin

Added MDL

  • Strattera
    • New MDL of #30 capsules per 30 days for 40mg, 60mg, 80mg, and 100mg strengths
    • New MDL of #60 capsules per 30 days for 10mg, 18mg, and 25mg strengths
  • Vyvanse
    • New MDL of #30 capsules per 30 days for all strengths

Tier Changes

  • Capital with Codeine Suspension
    • Moved from Tier 3 to Excluded
    • Acetaminophen with Codeine is a formulary alternative
  • Protopic 0.1% and 0.03% Ointment
    • Moved from Tier 3 to Excluded
    • Generic tacrolimus 0.1% and 0.03% ointment available at Tier 1
  • Zegerid Rx capsules and packet
    • Excluded both brand name and generic Rx formulations
    • Zegerid OTC now available at Tier 1
  • First Omeprazole Suspension
    • Moved from Excluded to Tier 1