April Newsletter
April 1, 2013Meet With a Coding Specialist
The Medicare Advantage Coding Consultant has been making rounds to high-volume participating provider offices sharing member-specific examples of coding and Medicare quality measure needs. She is willing to meet with you to discuss any coding or quality questions you may have, or to provide member-specific examples from your panel of members. If interested, contact Dawn Peterson, CPC 217-722-0869 or via e-mail Dawn.Peterson@healthalliance.org.
Help with HEDIS® Reviews
Each spring, we collect data to determine how we compare to national averages for the Healthcare Effectiveness Data and Information Set (HEDIS). This data collection is required to maintain National Committee for Quality Assurance (NCQA) accreditation. Successfully completing our HEDIS report depends largely on the cooperation we receive from provider office staff.
We ask that you please work with us as quickly as possible if your office receives a fax request for records or if an onsite record review is needed. We are on a much tighter time frame this year due to new software challenges and revised NCQA medical record validation requirements.
More information about HEDIS is available in your provider manual, and HEDIS results are posted at HealthAlliance.org.
To review the provider manual, log in to Your Health Alliance for providers and visit the Forms and Resources page.
If you have any questions about HEDIS, contact the Quality Management department at 1-800-851-3379, extension 8112.
Home Health Submission Update
- CMS is currently accepting institutional and professional home health encounters
- Effective for July 2013 DOS and beyond, only institutional home health encounters will be accepted
Pharmacy
Formulary Additions
- Tudorza Pressair – Indicated for treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema.
- Tier 2
- Myrbetriq – For the treatment of overactive bladder (OAB) with the symptoms of urinary frequency, urgency, or urge incontinence.
- Tier 2
- Elelyso -For the treatment of Gaucher disease.
- Tier 6 (Non-Formulary Specialty Medical) with preauthorization (PA)
- Onmel – For the treatment of nail fungus.
- Tier 3 with PA
Formulary Changes
- Provigil – Tier 3 to Tier 5 (specialty non-preferred)
- Modafinil – Tier 1 to Tier 4 (specialty preferred)
Preauthorization Criteria Updates
- Sildenafil, Adcirca (tadalafil), and Revatio (sildenafil) in Pulmonary Arterial Hypertension (PAH)
- Revised policy to include step therapy through generic sildenafil prior to coverage of Adcirca and Revatio
- Epoprostenol, Flolan (epoprostenol), and Veletri (epoprostenol) in PAH
- Revised policy to include step therapy through generic epoprostenol prior to coverage of Flolan and Veletri
- Coverage of brand name statins (Crestor, Livalo, etc.)
- Revised policy to include LDL reporting and inability to achieve goal on maximum tolerated dose of atorvastatin, or intolerance to 2 statins
Preauthorization Added to IV Oncology Agents – Effective May 1 2013
- IV injectable oncology drugs and oncology-related drugs require PA for new starts
- Avastin (bevacizumab)
- Erbitux (cetuximab)
- Perjeta (pertuzumab)
- Vectibix (panitumumab)
- Herceptin (trastuzumab)
- Rituxan (rituximab)
- Neulasta (pegfilgrastim)
- Neupogen (filgrastim)
- Neumega (oprelvekin)
- Leukine (sargramostim)
- All current users are grandfathered
There will be a specific oncology PA fax form that will be required when requesting these drugs. These will soon be posted to our website. Stay tuned for an upcoming InforMED Flash announcement.
Zolpidem/Ambien Now High Risk Medications
Zolpidem, a sleep medication marketed as Ambien® and other brand names, is one of the most widely used medications of its kind, and is now considered by the Centers for Medicare and Medicaid Services (CMS) to be a High Risk Medication (HRM) that should be avoided or used only short-term (< 90 days) in the elderly.
Zolpidem, and others in this class including zaleplon (Sonata) and eszopiclone (Lunesta), are considered nonbenzodiazepine hypnotics but have adverse events similar to those of benzodiazepines in older adults. Those events include morning drowsiness, cognitive impairment, delirium, falls ,and fractures. There is also minimal improvement in sleep latency and duration in the elderly.
Zolpidem is one of the top prescribed HRMs for us. As with any HRM, use of zolpidem (or zaleplon or eszopiclone) has a negative impact on our Medicare Part D Star Ratings.
A possible alternative to zolpidem is Rozerem (ramelteon). It is the first of a new class of insomnia drugs and works as a melatonin receptor agonist. These are similar to the naturally-produced sleep hormone melatonin, which your body needs for healthy sleep cycles. There are no contraindications in prescribing this new class of drugs in the elderly.
New Partnership with CVS Caremark Specialty Pharmacy
Effective May 1, 2013, we have a new specialty pharmacy vendor, CVS Caremark. Specialty medicines must be filled at a CVS Caremark Specialty Pharmacy. Those filled at any other pharmacy after this date will be rejected as not covered.
CVS Caremark Specialty Pharmacy provides medications and personalized pharmacy care management, including:
- Access to an on-call pharmacist 24/7
- Coordination of care with members and their doctors
- Convenient delivery directly to members or their doctors’ offices
- Medicine and disease education and counseling
- Online support through CVSCaremarkSpecialtyRx.com, including disease-specific information and interactive areas to submit questions to pharmacists and nurses
Enrollment forms are available on our website.
Note: Medicare members can still use any in-network specialty pharmacy vendor.
If you have any questions, contact your provider relations specialist or call Specialty Customer Care at 1-800-237-2767, Monday through Friday, 6:30 a.m. to 8 p.m.
Statin Chart
This statins chart will help you easily switch your patients with high cholesterol to more affordable generic options when appropriate.
