August 2023 Newsletter

A Word of Thanks

The weeks of late summer always seem to fly by far too quickly. There’s so much to do and so little time. It’s a time of last-minute vacations, stressed parents and guardians setting up their children’s back-to-school physicals, and the start of new sports seasons for our communities’ youth. All of this makes your job much busier, as you provide the expert care needed for checkups, preventive services, vacation-acquired illnesses or injuries, and the bumps and bruises that come along with children’s sports. We simply can’t say it enough – or with large enough emphasis – thank you. The dedicated, tireless, expert care you give our members and their families means so much to us. We’re honored to call you our valued partner.

Health Alliance ranked #1 in member satisfaction in Illinois/Indiana region by J.D. Power.

Health Alliance™ received top honors in member satisfaction for Commercial Health Plans in the Illinois/Indiana region based on the results of the J.D. Power 2023 U.S. Commercial Member Health Plan Study^SM. With a continued focus on bringing innovative solutions, comprehensive coverage and supportive customer service experiences, Health Alliance is the #1 Commercial Member Health Plan for Customer Satisfaction in the region. The honor marks the fifth time Health Alliance has received the award, having received it in 2014, 2017, 2018, 2019 and 2023.

Additionally, the newly released study shows Health Alliance was also recognized as best in the region, receiving the highest score in:

• Billing and payment.
• Coverage and benefits.
• Customer Service.
• Information and communication.
• Provider choice.

“We are committed to bringing our members innovative products, services and education which empowers them to enhance their lives and achieve their goals,” Sinéad Rice Madigan, president and chief executive officer, Health Alliance, said. “Our priority includes focusing on offering the best experience for members in every touch point with our health plan.”

The J.D. Power 2023 U.S. Commercial Member Health Plan Study measures satisfaction among members of 150 health plans in 22 regions throughout the United States and looks at six factors. The J.D. Power study also measures several other key aspects of the experience and member engagement. The study was fielded from January through April 2023.

Health Alliance is committed to bringing award-winning, high-quality support and solutions to help individuals and families thrive. More information about the study and its methodology can be found at http://www.jdpower.com/pr-id/2023053.

About J.D. Power

J.D. Power is a global leader in consumer insights, advisory services, and data and analytics. A pioneer in the use of big data, artificial intelligence (AI) and algorithmic modeling capabilities to understand consumer behavior, J.D. Power has been delivering incisive industry intelligence on customer interactions with brands and products for more than 50 years. The world’s leading businesses across major industries rely on J.D. Power to guide their customer-facing strategies.

J.D. Power has offices in North America, Europe and Asia Pacific. To learn more about the company’s business offerings, visit JDPower.com/Business. The J.D. Power auto shopping tool can be found at JDPower.com.

A Note About Awards

At Health Alliance and Health Alliance Northwest^TM, our teams are very proud of our awards – but we’re even more proud of the partnerships that make these honors possible. It is you – our valued provider partners – who make the care we cover so exceptional and the support we offer your patients so seamless. Our achievements are your achievements. Thank you.

***

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.

We need your help this flu season.

This year – like all since the beginning of the COVID-19 pandemic – it’s of increased importance that people in our communities get their yearly flu shot. According to the CDC, recommendations – and even simple reminders – from their trusted providers are a critical factor in whether many adults get vaccines for themselves and their families.

With this in mind, the CDC is continuing its vital SHARE campaign – meant to help providers do all they can to encourage their patients to get their yearly flu shot. Here are the basics, quoted from their campaign:

• S – Share the reasons why the influenza vaccine is right for the patient given their age, health status, lifestyle, occupation or other risk factors.
• H – Highlight positive experiences with flu vaccines (personal or in your practice), as appropriate, to reinforce the benefits and strengthen confidence in vaccination.
• A – Address patient questions and any concerns about the flu vaccine – including side effects, safety and vaccine effectiveness – in plain and understandable language.
• R – Remind patients that vaccines protect them and their loved ones from serious influenza illness and influenza-related complications.
• E – Explain the potential costs of getting the flu, including serious health effects, time lost (such as missing work or family obligations) and financial costs.

Each patient is different, and you know them best. Consider the best approach that’ll let them know just how important the flu vaccine is and why they and their families should get it. With your help, our communities can stay safer – and breathe easier – this flu season. Thanks for your assistance in this vital endeavor.

It varies according to health plan, but flu shots are covered at no cost to our members in most cases. Your patients can call the number on the back of their health plan member ID card to learn more about costs and where they can go to get their shots.

Treatment Tips and Recommendations:
ADHD in Children and Adolescents

Here are recommendations and tips for providing consistent and continuing top-level care to your young patients (children and adolescents) with ADHD (attention-deficit/hyperactivity disorder).

Before beginning any treatment or prescribing any medication:

• Do risk-factor screenings for major depression, bipolar disorder and substance abuse.
• Include a baseline for common side effects of medications.

When choosing which medication to prescribe, take this into consideration:

• Possible adverse effects.
• Coexisting behavioral or emotional issues. Or coexisting tic disorder.
• How long the patient might need to be on the drug.
• The preferences of the parent(s)/guardian(s), as well as the preferences of the child/adolescent.
• The time of day symptoms occur.
• The desire to avoid medication administration at school, if possible.
• The patient’s ability to swallow pills or capsules.
• Cost of the drug.
• Any history of substance abuse for the patient or a member of their household. Avoid stimulants – or use stimulants with less potential for abuse – if needed.

Finally, once you prescribe a medication, start – and keep – monitoring for adverse effects. The most common side effects of stimulant ADHD drugs are:

• Dizziness.
• Insomnia.
• Mood lability.
• Decreased appetite.
• Poor growth.

References Used for This Article

Kevin R. Krull, PhD, and Eugenia Chan, MD, MPH, Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications, UpToDate^®

Diabetes Care: Help promote better eye health.

Your patients trust your expertise, knowledge and advice – help those with diabetes by giving them the information they need to keep their eyes healthy and cared for. Here’s actions you can take, according to the CDC:

• Make sure they get a comprehensive vision exam, including a dilated retinal exam, every year. Provide extra encouragement – and extra reminders – for those with a history of skipping these exams.
• Ask your patients questions about their eye health – at every visit.
• Share key information with your patients:
  • Explain how diabetes can lead to eye diseases and vision problems – like retinopathy, glaucoma and cataracts.
  • Tell them how important early detection and treatment is for these eye diseases and conditions.
  • Explain how these diseases/conditions can often be avoided or delayed by getting their regular annual eye exams.
  • Remind them that – otherwise – many of these eye problems don’t have obvious symptoms or warning signs, which is why the yearly exams are so important.
  • Encourage them to keep control of their blood sugar and overall health, since this can help lower their risk for these eye issues. And also help them keep their blood pressure and cholesterol at healthy levels.
  • Share this great CDC fact sheet with your patients. Print it out or give them the URL.
• Encourage your patients to always monitor their vision for any changes or concerning issues.
• Refer your patients to diabetes self-management education and support (DSMES) services.

Thank you for all the help and encouragement you give to your patients with diabetes. We’re so thankful for your expertise.

HEDIS Tip Sheet – Low Back Pain and Imaging Studies

By working together, we can get patients the best and most appropriate care for low back pain. Our Quality Improvement (QI) program checks up on provider performance for clinical care and services – such as imaging for patients with low back pain (LBP) – through various initiatives, including using the Healthcare Effectiveness Data and Information Set (HEDIS^®) measures as developed and maintained by the National Committee for Quality Assurance (NCQA). This tip sheet is designed to help us together increase the number of patients who meet these HEDIS quality measures – and it includes best practices and suggested approaches for patients with LBP.

What is HEDIS?

HEDIS is a set of standardized performance measures that evaluates a health plan’s performance on important dimensions of care and service. NCQA develops HEDIS measures through a committee represented by purchasers, consumers, health plans, healthcare providers and policymakers. HEDIS allows for standardized measurement and reporting – and accurate, objective, side-by-side comparisons of quality across health plans and against benchmarks.

Low Back Pain Measure

For LBP, HEDIS measures the percentage of patients with a primary diagnosis of LBP who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of diagnosis. A better rating is achieved by having fewer of these patients receive imaging. Read on to learn why.

LBP Facts

• More than 80% of Americans will experience LBP in their lifetime.
• Currently, many providers order imaging tests – such as plain X-rays, MRIs and CT scans – to diagnose the severity of the condition. But there’s a need to reduce the use of imaging studies for LBP since imaging tests:
  • Do not provide useful information in cases of strained muscles and ligaments.
  • Can expose patients to unnecessary radiation.
  • Are often costly.
• Unnecessary imaging studies can also lead to the need for additional (and more invasive) testing, which increases the risk for complications, such as infections.
• Evidence-based studies do not recommend imaging for LBP during this time unless red flags are present, such as severe or progressive neurological signs, or symptoms that suggest a serious or specific underlying condition.
• Patients with LBP usually feel better within a month, and pain can often be managed through self-help techniques.

Recommended Treatment Plan for LBP

• Educate the patient about the reason imaging tests are not warranted.
• Self-care home treatment:
  • Use heat/ice.
  • Use non-narcotic pain relievers.
  • Remain active, stretch and avoid bedrest.

Thank you for your help getting our members the most appropriate, evidence-based care.

References Used for This Article

NCQA’s HEDIS 2018 Technical Specifications for Health Plans, Volume 2, Washington, D.C., 2017.

Integrated Healthcare Association – Smart Care California. LBP information retrieved from www.iha.org/our-work/insights/smart-carecalifornia/focus-area-low-back-pain, accessed 31 October 2017.

Screening for Unhealthy Drug and Alcohol Use in Primary Care

Oftentimes in primary care, alcohol and drug misuse are missed or overlooked. But recent stats should be a wake-up call for all of us to take greater action. Nearly 28% of adults use alcohol in a way that’s considered unhealthy. Of those, 1 in 4 confirm binge-drinking within the past year. And illicit drug use was reported by 18% of adults.

For men younger than 65, unhealthy alcohol use means more than 14 drinks per week or more than four drinks on any single day. For women and older adults, unhealthy use is more than seven drinks per week or more than three drinks in one day.

Let’s commit to take action. The United States Preventive Services Task Force (USPSTF) recommends that all adults be screened for unhealthy alcohol and drug use during their primary care visits. For those who screen positive, a counseling intervention should be set up.

Common screening methods for use by primary care providers include AUDIT, CAGE questions and the CRAFFT instrument:

• The CRAFFT instrument is the most validated tool to use for adolescents.
• CAGE questions lead patients through self-reflection by asking the following questions:
  • Have you ever felt you should Cut down on your drinking?
  • Have people Annoyed you by criticizing your drinking?
  • Have you ever felt bad or Guilty about your drinking?
  • Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?
• Finally, AUDIT is the most validated method, and it only takes a few minutes to complete. However, it’s scored electronically, which takes a much longer time to finish – so it’s more effective when the patient has a longer visit. A score of eight or higher indicates an unhealthy use of alcohol.

Perhaps most importantly, when you determine through screening or other indications that a patient is using drugs or alcohol in an unhealthy manner, the most highly recommended intervention is reduction in substance use or complete abstinence. Counseling as an intervention is also recommended. With your help, your patients can get the support and treatment they need to live their healthiest, most fulfilling lives.

References Used for This Article

Andrew J. Saxon, MD, Screening for unhealthy use of alcohol and other drugs in primary care, UpToDate®

Help your patients at risk of osteoporosis:
Use the FRAX test.

Osteoporosis is often called the “silent disease” because it has few warning signs or symptoms – until you break a bone. And the stats are alarming: an osteoporosis-related fracture happens about every three seconds worldwide, and half of all women over age 50 will have one sometime in their life. Early action to detect osteoporosis is key – and there’s a free, simple online test you can encourage your patients to take that’ll calculate their risk of fracture. You can even lead them through the test during their next visit. Here’s the key information.

About Osteoporosis

Osteoporosis is a disease that makes bones weak and thin, and therefore more likely to fracture or break. Often fractures occur in the wrist, pelvis, hip, spine and upper arm. Postmenopausal osteoporosis is common in women as they undergo rapid bone loss due to hormonal changes during menopause. Even after menopause ends, bone loss continues (although at a slower pace). Both women and men can get osteoporosis.

About the Free Online Test

• It’s called the FRAX^® (Fracture Risk Assessment) test, found at sheffield.ac.uk/FRAX (or search “Sheffield FRAX test” on Google).
• On the website, hover over the “Calculation Tool” tab, then hover over “North America” and then “US,” and then click on one of the four choices. You’ll be taken to the questionnaire. Fill out your patient’s information and hit “Calculate.”
• You’ll be given the percent chance your patient will have a major bone fracture in the next 10 years. The higher the percentage, the more likely they are to have a fracture.
• Note: If you don’t know your patient’s BMD (bone mineral density), you can leave it blank and still hit “Calculate.”
• Please note that the test is not for those younger than 40 or for people currently taking a prescription medication for osteoporosis.

The FRAX test takes into account age, sex, family history, smoking, arthritis, use of certain steroids, bone mineral density and other risk factors. This allows it to calculate a better estimate of fracture risk than other assessment tools. Help encourage your patients at risk of osteoporosis to take the FRAX test. Together we can take action against fractures and limit the potential harms of osteoporosis.

***

Coding Counts:
Documenting and Reporting Drug Use

Supporting documentation and accurate coding are key to making sure your patients receive the care they need. Screening, prevention and coordination of care help provide opportunities for early intervention and improved patient outcomes. Here are some key tips for documenting, reporting and coding drug use.

Be specific.

Per ICD-10-CM guidelines, coding for drug use is based on provider documentation, making it key to distinguish use from dependence and abuse. Provider documentation of drug use should include specifics such as mild, moderate or severe drug use (or mild, moderate or severe drug abuse, if that’s the case). Signs and symptoms indicating drug use include:

• Using or drinking larger amounts of drugs or alcohol, or over longer periods of time, than planned.
• Continually wanting, or unsuccessfully trying, to cut down or control use of drugs and alcohol.
• Spending a lot of time getting, using or recovering from use of drugs or alcohol.
• Craving (having a strong desire to use) drugs or alcohol.
• Ongoing drug or alcohol use that interferes with work, school or home duties.
• Using drugs or alcohol even with continued relationship problems caused by use.

Medical Conditions Due to Drug Use

Report drug use when there’s a relationship between the drug use and an associated disorder. Incidental or recreational drug use is only reported when the use affects the treatment or care of the patient.

In Remission

New ICD-10-CM diagnosis codes have been created to identify drug use when it’s “in remission.”

Reporting Hierarchy for Use, Abuse and Dependence

• If both use and abuse are documented, assign only the code for abuse.
• If both use and dependence are documented, assign only the code for dependence.
• If both abuse and dependence are documented, assign only the code for dependence.
• If use, abuse and dependence are all documented, assign only the code for dependence.

Use and abuse are not interchangeable terms in ICD-10-CM. Report drug use when there’s irregular use of a substance that’s not habitual.

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.

References Used for This Article

ICD-10-CM Official Guidelines for Coding and Reporting

Optum EncoderPro

Johns Hopkins Medicine, HopkinsMedicine.org

Sheri Poe Bernard, Risk Adjustment Documentation & Coding

Our Remote Patient Monitoring benefit improves care and quality of life for your patients.

There’s a relatively new, high-impact benefit you should know about – Remote Patient Monitoring. It’s available to most of your patients who have one of our health plans, and who are dealing with certain chronic health issues or have recently visited the emergency department or had an inpatient hospital stay. We’re excited to tell you about how this benefit works, and how it can help improve their care and quality of life.

With so many patients now comfortable using telehealth options, Remote Patient Monitoring offers a new pathway to improve their care. Most impactfully, it can help patients with chronic health conditions identify potential problems early, before they reach crisis stage.

We partner with CareSignal to bring this Remote Patient Monitoring program to your patients. When a patient signs up, they receive a text or call twice a week with short questions about their specific health issue. Currently, our program can help your patients who have hypertension, congestive heart failure, asthma or chronic obstructive pulmonary disease (COPD) – and those who’ve recently visited the emergency department or have been discharged from the hospital. Future expansion of the program may include conditions such as depression, diabetes and gaps in care.

To make it most convenient for your patients, the calls or texts occur at the time they request. Examples of questions they’re asked include things like, “What is your blood pressure reading today?” and “When did you last take your medication?” When your patient responds in a manner showing that they’re doing well, no intervention is needed. But if the response indicates your patient needs help, their CareSignal virtual care navigator (VCN), a licensed register nurse, will engage with them. The VCN will ask questions and advise your patient on steps they should take, including connecting with you or setting up an appointment with your office.

VCNs also work directly with our health plan’s care coordinators when escalation is needed or your patient can’t be reached after an alert. Together, they make sure your patient gets the right care at the right time for their specific issue. ​​​​​​​

The CareSignal team has seen great feedback from patients and providers. Patients love how the program is effective, simple and easy to engage with – meeting them where they’re at, in a way that’s convenient and comfortable for them. Some people like the simplicity of texts, while others enjoy being talked to over the phone. And Michael Smith, MD, our senior vice president and chief medical officer, explains why providers love it:

“Providers often feel frustrated by the fact that we seem to spend more time interacting with electronic devices than we do clinically evaluating our patients. Remote Patient Monitoring (RPM) has unique potential to shift that trend. Instead of digital systems pulling you away from patient care, the RPM model works directly to enhance your ability to care for your patient. By collecting timely and actionable self-reported data when your chronic disease patients begin to decompensate, we expect that better health outcomes will result.”

Best of all, the program does not replace providers. It supports you and provides another eye on your patient’s health to help reduce risks and improve their awareness of the issues they’re facing – and it improves communication and coordination with you and your team.

Here’s just one example of an instance where – working together with the CareSignal team and a patient’s provider – our Remote Patient Monitoring program helped one of our members:

During a call with our member, the CareSignal VCN learned that the member had been experiencing lengthy blackouts that he’d been hesitant to tell anyone about. The member said his pulse would drop and he’d become dizzy, fall and wake up on the floor. His Eliquis levels had not been evaluated for over six months. The VCN reviewed for signs of stroke and reasoned the member may be experiencing transient ischemic attacks and instructed him to call his primary care provider right away, when he might be advised to go to the emergency department. The VCN also contacted our care coordinator, who helped the member get a priority appointment to see his PCP that day. The member was ultimately admitted to the hospital, where he had surgery to address cervical stenosis with cord myelomalacia.

This is just one story of many. You too can help get your patients this high-impact support.

If your patients are members of one of our health plans, they simply need to call us at (855) 519-2190 to ask to join the Remote Patient Monitoring program.

You – and they – can also find more information on this flier. And please also watch these short videos featuring Dr. Smith, and share them with your patients and fellow providers:

• General Introduction – Remote Patient Monitoring
• For Providers and Staff
• For Patients

Click here to read more intervention stories from the CareSignal team. 

Did you know? In addition to Remote Patient Monitoring, we also have a robust care coordination program and can provide more forms of support to your patients for a wide variety of other complex care journeys – including transplant/end-stage renal disease, prenatal and postpartum care, high-risk pediatrics/NICU, oncology, and behavioral health. And our health coaches are available to work with patients to make health and lifestyle behavior changes. Click here to learn more.

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 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

Cardiology

Formulary Additions

• Lamzede (velmanase alfa)— Treatment of non-central nervous system manifestations of alpha-mannosidosis in adult and pediatric patients
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Medicare Part B with PA
  • Xenpozyme (olipudase alfa)—Treatment of non-CNS manifestations of acid sphingomyelinase deficiency (ASMD) in adult and pediatric patients
    • Formulary placement recommendations
      • Commercial—Non-Preferred Specialty Medical with PA
      • Medicare—Medicare Part B with PA

Endocrinology

Formulary Additions

• Tzield (teplizumab)—Intended to delay the onset of stage 3 type 1 diabetes mellitus in adults and pediatric patients ≥8 years of age with stage 2 type 1 diabetes mellitus
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Medicare Part B with PA

Miscellaneous New Drug Reviews

• Daybue (trofinetide)—Indicated for Treatment of Rett syndrome in adult and pediatric patients 2 years of age and older
  • Formulary placement recommendations
    • Commercial—Non-Formulary
    • Medicare—Non-Formulary

Commercial

Cardiology

Criteria Changes

• Corlanor
  • Updated diagnostic criteria
• Omega-3 acid ethyl esters and Vascepa
  • Removed niacin step

Endocrinology

Criteria Changes

• Diabetes Drug Therapies
  • Updated GLP-1/Mounjaro criteria language, updated all steps to be 180 days, updated SGLT-2 products (moved Farxiga to preferred and Invokana to non-preferred)
• Evenity (romosozumab)
  • Added section to bypass bisphosphonates/Prolia
• Forteo (teriparatide)
  • Added section to bypass bisphosphonates/Prolia
• Tymlos (abaloparatide)
  • Updated diagnosis to align with FDA label, added section to bypass bisphosphonates/Prolia
• Infertility Medications
  • Added guidance for infertility medications used for testicular preservation
• Myfembree (Relugolix, Estradiol, and Norethindrone)
  • Added criteria for endometriosis and added Orilissa in exclusions
• Orilissa (elagolix)
  • Added exclusion criteria
• Zoladex (goserelin)
  • Added age criteria and specialist

Pulmonary

Criteria Changes

• Synagis (palivizumab)
  • Updated clinical criteria related to airway abnormalities, updated age criteria for CLD
• Trikafta (elexacaftor-tezacaftor-ivacaftor)
  • Updated mutation chart, age criteria, and age limit for granules
• Xolair (omalizumab)
  • Updated step through two asthma products

Miscellaneous New Drug Reviews

• Excluded Drug List
  • Added exclusion for Cequr, Daybue and prescription drug therapeutics products
• Cablivi (caplacizumab)
  • eviCore no longer reviewing, so Commercial criteria is needed for HA reviews

Miscellaneous Policy Changes

• Crohn’s Disease Immunomodulator Therapies
  • Added Rinvoq criteria
• Weight Loss Medications
  • Added specialist prescriber criteria for FirstHealth and divided the policy into plan sections

Tier Changes—Commercial

Positive Changes

• Xolair, Fasenra and Nucala—Move from Non-Preferred Specialty to Preferred Specialty
• Farxiga—Move from Non-Preferred Brand to Preferred Brand

Negative Changes (effective 10/1/23)

• Invokana, Invokamet and Invokamet XR—Move from Preferred Brand to Non-Preferred Brand

Retired Policy

• Makena (hydroxyprogesterone caproate)
  • Drug withdrawn from the market following FDA revoking approval status

Please Note: 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. Drug coverage and policies in the following categories will be reviewed during the remainder of 2023 and changes may be made:

• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Northwest – Pharmacy Updates

All Plans

Cardiology

Formulary Additions

• Lamzede (velmanase alfa)— Treatment of non-central nervous system manifestations of alpha-mannosidosis in adult and pediatric patients
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Medicare Part B with PA
  • Xenpozyme (olipudase alfa)—Treatment of non-CNS manifestations of acid sphingomyelinase deficiency (ASMD) in adult and pediatric patients
    • Formulary placement recommendations
      • Commercial—Non-Preferred Specialty Medical with PA
      • Medicare—Medicare Part B with PA

Endocrinology

Formulary Additions

• Tzield (teplizumab)—Intended to delay the onset of stage 3 type 1 diabetes mellitus in adults and pediatric patients ≥8 years of age with stage 2 type 1 diabetes mellitus
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Medicare Part B with PA

Miscellaneous New Drug Reviews

• Daybue (trofinetide)—Indicated for Treatment of Rett syndrome in adult and pediatric patients 2 years of age and older
  • Formulary placement recommendations
    • Commercial—Non-Formulary
    • Medicare—Non-Formulary

Commercial

Cardiology

Criteria Changes

• Corlanor
  • Updated diagnostic criteria
• Omega-3 acid ethyl esters and Vascepa
  • Removed niacin step

Endocrinology

Criteria Changes

• Diabetes Drug Therapies
  • Updated GLP-1/Mounjaro criteria language, updated all steps to be 180 days, updated SGLT-2 products (moved Farxiga to preferred and Invokana to non-preferred)
• Evenity (romosozumab)
  • Added section to bypass bisphosphonates/Prolia
• Forteo (teriparatide)
  • Added section to bypass bisphosphonates/Prolia
• Tymlos (abaloparatide)
  • Updated diagnosis to align with FDA label, added section to bypass bisphosphonates/Prolia
• Infertility Medications
  • Added guidance for infertility medications used for testicular preservation
• Myfembree (Relugolix, Estradiol, and Norethindrone)
  • Added criteria for endometriosis and added Orilissa in exclusions
• Orilissa (elagolix)
  • Added exclusion criteria
• Zoladex (goserelin)
  • Added age criteria and specialist

Pulmonary

Criteria Changes

• Synagis (palivizumab)
  • Updated clinical criteria related to airway abnormalities, updated age criteria for CLD
• Trikafta (elexacaftor-tezacaftor-ivacaftor)
  • Updated mutation chart, age criteria, and age limit for granules
• Xolair (omalizumab)
  • Updated step through two asthma products

Miscellaneous New Drug Reviews

• Excluded Drug List
  • Added exclusion for Cequr, Daybue and prescription drug therapeutics products
• Cablivi (caplacizumab)
  • eviCore no longer reviewing, so Commercial criteria is needed for HA reviews

Miscellaneous Policy Changes

• Crohn’s Disease Immunomodulator Therapies
  • Added Rinvoq criteria
• Weight Loss Medications
  • Added specialist prescriber criteria for FirstHealth and divided the policy into plan sections

Tier Changes—Commercial

Positive Changes

• Xolair, Fasenra and Nucala—Move from Non-Preferred Specialty to Preferred Specialty
• Farxiga—Move from Non-Preferred Brand to Preferred Brand

Negative Changes (effective 10/1/23)

• Invokana, Invokamet and Invokamet XR—Move from Preferred Brand to Non-Preferred Brand

Retired Policy

• Makena (hydroxyprogesterone caproate)
  • Drug withdrawn from the market following FDA revoking approval status

Please Note: 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. Drug coverage and policies in the following categories will be reviewed during the remainder of 2023 and changes may be made:

• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Carle – Pharmacy Updates

All Plans

Cardiology

Formulary Additions

• Lamzede (velmanase alfa)— Treatment of non-central nervous system manifestations of alpha-mannosidosis in adult and pediatric patients
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Medicare Part B with PA
  • Xenpozyme (olipudase alfa)—Treatment of non-CNS manifestations of acid sphingomyelinase deficiency (ASMD) in adult and pediatric patients
    • Formulary placement recommendations
      • Commercial—Non-Preferred Specialty Medical with PA
      • Medicare—Medicare Part B with PA

Endocrinology

Formulary Additions

• Tzield (teplizumab)—Intended to delay the onset of stage 3 type 1 diabetes mellitus in adults and pediatric patients ≥8 years of age with stage 2 type 1 diabetes mellitus
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Medicare Part B with PA

Miscellaneous New Drug Reviews

• Daybue (trofinetide)—Indicated for Treatment of Rett syndrome in adult and pediatric patients 2 years of age and older
  • Formulary placement recommendations
    • Commercial—Non-Formulary
    • Medicare—Non-Formulary

Commercial

Cardiology

Criteria Changes

• Corlanor
  • Updated diagnostic criteria
• Omega-3 acid ethyl esters and Vascepa
  • Removed niacin step

Endocrinology

Criteria Changes

• Diabetes Drug Therapies
  • Updated GLP-1/Mounjaro criteria language, updated all steps to be 180 days, updated SGLT-2 products (moved Farxiga to preferred and Invokana to non-preferred)
• Evenity (romosozumab)
  • Added section to bypass bisphosphonates/Prolia
• Forteo (teriparatide)
  • Added section to bypass bisphosphonates/Prolia
• Tymlos (abaloparatide)
  • Updated diagnosis to align with FDA label, added section to bypass bisphosphonates/Prolia
• Infertility Medications
  • Added guidance for infertility medications used for testicular preservation
• Myfembree (Relugolix, Estradiol, and Norethindrone)
  • Added criteria for endometriosis and added Orilissa in exclusions
• Orilissa (elagolix)
  • Added exclusion criteria
• Zoladex (goserelin)
  • Added age criteria and specialist

Pulmonary

Criteria Changes

• Synagis (palivizumab)
  • Updated clinical criteria related to airway abnormalities, updated age criteria for CLD
• Trikafta (elexacaftor-tezacaftor-ivacaftor)
  • Updated mutation chart, age criteria, and age limit for granules
• Xolair (omalizumab)
  • Updated step through two asthma products

Miscellaneous New Drug Reviews

• Excluded Drug List
  • Added exclusion for Cequr, Daybue and prescription drug therapeutics products
• Cablivi (caplacizumab)
  • eviCore no longer reviewing, so Commercial criteria is needed for HA reviews

Miscellaneous Policy Changes

• Crohn’s Disease Immunomodulator Therapies
  • Added Rinvoq criteria
• Weight Loss Medications
  • Added specialist prescriber criteria for FirstHealth and divided the policy into plan sections

Tier Changes—Commercial

Positive Changes

• Xolair, Fasenra and Nucala—Move from Non-Preferred Specialty to Preferred Specialty
• Farxiga—Move from Non-Preferred Brand to Preferred Brand

Negative Changes (effective 10/1/23)

• Invokana, Invokamet and Invokamet XR—Move from Preferred Brand to Non-Preferred Brand

Retired Policy

• Makena (hydroxyprogesterone caproate)
  • Drug withdrawn from the market following FDA revoking approval status

Please Note: 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. Drug coverage and policies in the following categories will be reviewed during the remainder of 2023 and changes may be made:

• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Reid – Pharmacy Updates

Medicare

Cardiology

Formulary Additions

• Lamzede (velmanase alfa)— Treatment of non-central nervous system manifestations of alpha-mannosidosis in adult and pediatric patients
  • Formulary placement recommendations
    • Medicare—Medicare Part B with PA
  • Xenpozyme (olipudase alfa)—Treatment of non-CNS manifestations of acid sphingomyelinase deficiency (ASMD) in adult and pediatric patients
    • Formulary placement recommendations
      • Medicare—Medicare Part B with PA

Endocrinology

Formulary Additions

• Tzield (teplizumab)—Intended to delay the onset of stage 3 type 1 diabetes mellitus in adults and pediatric patients ≥8 years of age with stage 2 type 1 diabetes mellitus
  • Formulary placement recommendations
    • Medicare—Medicare Part B with PA

Miscellaneous New Drug Reviews

• Daybue (trofinetide)—Indicated for Treatment of Rett syndrome in adult and pediatric patients 2 years of age and older
  • Formulary placement recommendations
    • Medicare—Non-Formulary

Please Note: 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. Drug coverage and policies in the following categories will be reviewed during the remainder of 2023 and changes may be made:

• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Contact Us

(800) 851-3379, option 3

View as PDF