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August Newsletter

August 2, 2013

Medicaid Update

Our Seniors and Persons with Disabilities (SPD) plan goes into effect on September 1. You can see SPD patients as of that date. These members will have Health Alliance Connect ID cards.

Our anticipated enrollment for the SPD plans is about 5,500 members in the next year.

The Medicare-Medicaid Alignment Initiative (MMAI) has been pushed back to January 1, 2014. We will share more information about our MMAI plan as we get closer to that date.

We recently launched our new Medicaid website, HealthAllianceConnect.org. It’s still in the works, but it will soon have important information for you, like a provider manual, preauthorization requirements, and training tools. We’ll let you know when that information becomes available.

Secret Shopper Survey

Every year, we contract with Sigma Group to conduct a Secret Shopper survey to assess appointment access for primary and behavioral health care. We share the results of the survey with providers. If you were surveyed, a letter will be sent to you in August with the results.

Primary care access is reviewed at 4 levels, preventive care, routine appointments, urgent care appointments, and after-hours care. Preventive care appointments should be available within 8 weeks. Routine appointments should be available within 2 weeks. Urgent care should be available within one business day. After-hours care is assessed by reviewing after-hours messaging for adequate instructions on how to obtain care.

Behavioral health access is reviewed at 3 levels, routine office, urgent care, and non-life threatening emergency. National Committee for Quality Assurance (NCQA) defines the standards for behavioral health access to include routine visits available within 10 business days, urgent care available within 48 hours, and non-life threatening emergency available within 6 hours.

Committee Completes Annual Clinical Guidelines Review

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

We’ve adopted evidence-based, nationally recognized sources for clinical guidelines, which are summarized below, complete with links to additional information. If you prefer a paper copy of this information, contact our Quality & Medical Management Department at 1-800-851-3379, extension 8112.

Index of Clinical Guidelines Associated with Health Alliance Disease and Population Management

Alcohol Misuse

Asthma

Attention Deficit Hyperactivity Disorder

Cholesterol Control

Chronic Obstructive Pulmonary Disease (COPD)

Depression in Adults

Diabetes

Hypertension

Migraines and Headaches

Osteoporosis

Potentially Inappropriate Medication (PIM) Usage in Older Adults

Tobacco Use

Weight Management

Index of Useful Clinical Guidelines

Asthma Medication Adherence

Please remember to schedule regular medication reviews for members with asthma.

You will get a report from us when one of our members is seen in the emergency room for an asthma-related issue. The report will show active respiratory medications for the member.

This allows you to assess if what you prescribed is appropriate for the member, if it was ordered or if it’s being used correctly. Then you can make adjustments as necessary.

For more information, visit the American Lung Association website to see videos about how to correctly use an inhaler, which might help your patients with asthma

Coding Updates

  • The Fluzone Quadrivalent influenza vaccine CPT Codes are 90685 for pediatric and 90686 for adult. For fully insured members, the vaccine is covered under their wellness benefits. For self-funded members, coverage varies depending on the group’s plan.
  • We’re now covering colonoscopy codes 45378-PT and 45380-PT for members 50 and over once every 10 years under the wellness benefit. The PT modifier is required for coverage under the wellness benefit.
  • Colonoscopy codes 45383-PT, 45384-PT, and 45385-PT continue to be covered under the wellness benefit once every 10 years for members 50 and over.

Processing Secondary Claims

We can now accept secondary claims electronically. Make sure the primary insurance information (paid amount, member responsibility, and adjusted amount) are noted on the 837 (electronic form). This will save your office time, and it will help speed up claims processing.

Pharmacy

Non-Medicare

Formulary Additions

  • Zioptan (tafluprost) – Added to Tier 3, no restrictions
  • Jetrea (ocriplasmin) – Added to non-preferred specialty medical with preauthorization (PA)
  • Stribild (elvitegravir/cobicistat/emtricitabine/tenofovir) – Added to Tier 5
  • Liptruzet (ezetimibe/atorvastatin) – Tier 3, PA (same as Vytorin)
  • Quillivant XR (methylphenidate HCL susp) – Tier 3, edit for age 12 and under, with managed dose limit

Formulary Changes – Effective August 1

  • Lumigan – Added to Tier 3
  • Victrelis
    • Moved from Tier 5 to Tier 4
    • New starts to Incivek will require relative contraindication to Victrelis
  • These HIV meds moved to specialty Tier 5 based on monthly ingredient cost
    • Trizivir
    • Atripla
    • Strbild
    • Complera
    • Truvada
    • Fuzeon injection
    • Selzentry

Formulary Change – Effective October 1

  • Starting October 1, 2013, we will only cover diabetic meters and test strips from Abbott Diabetes Care. We will no longer cover other brands after that date. Abbott offers these preferred test strips:
    • Freestyle Lite
    • Freestyle InsuLinx
    • Precision Xtra

Preauthorization Criteria Updates

  • Hepatitis C policy – Require relative contraindication to Victrelis for new starts to Incivek
  • Subxone policy – Added Subutex to follow same opioid reverse step edit
  • Botox policy
    • Coverage for the treatment of migraines
    • Added a required psychiatric evaluation
    • Updated continuation of therapy coverage requirements
  • Intravitreal Avastin
    • Removed PA for for ophthalmologic conditions
    • Still requires PA for all other indications
  • Humira – Reduced initial authorization time period for Ulcerative Colitis indication to 8 weeks

Preauthorization Criteria Updates on Oncology Agents

  • Stivarga – Added indication to existing PA for metastatic colorectal cancer
  • XGeva – Added a step through generic zoledronic acid (Zometa)
  • Gleevec – Added quantity limits of 30/30 day supply
  • Bosulif – Added quantity limits 30/30 day supply
  • Sprycel – Treatment naïve members will require step through Gleevec as part of PA
  • Tasigna – Treatment naïve members will require step through Gleevec as part of PA
  • Inclusig
    • Modified criteria to include testing for mutation
    • Added quantity limits of 30/30 day supply
  • Revlimid – Treatment naïve members have an added step through Velcade prior to Revlimid as part of PA
  • Tykerb – Treatment naïve members have an added step through Xeloda in HER2 positive breast cancer as part of PA.
  • Yervoy – Added PA criteria
  • Xtandi – Treatment naïve member will require step through Zytiga as part of PA
  • Zytiga – Moved to preferred specialty pharmacy (Tier 4)

Enrollment forms for CVS Caremark Specialty Pharmacy are now available at HealthAlliance.org.

Medicare

Formulary Additions

  • Gattex – Indicated for treatment of Short Bowel Syndrome who are on parental support.
    • Added to Tier 5 specialty with PA criteria
  • Juxtapid – An oral agent to reduce cholesterol in the orphan disease state of homozygous familial hypercholesterolemia (HoFH).
    • Added to Tier 5 specialty with PA criteria
  • New DPP4 agents Nesina (alogliptin), Oseni (alogliptin and pioglitazone), and Kazano (alogliptin and metformin) – Added to Tier 4 (non-preferred brand) with similar step edit to other DPP4 (Januvia, Onglyza, and Tradjenta)