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August Newsletter

Committee Completes Annual Clinical Guidelines Review

To support National Committee for Quality Assurance (NCQA) goals and help providers make proactive decisions about appropriate health care in specific clinical circumstances, the Health Alliance Quality Improvement Committee annually reviews and updates adopted clinical guidelines.

Health Alliance adopted the following evidence-based, nationally recognized sources for clinical guidelines. Click the links for more information.

Index of Clinical Guidelines Associated with Health Alliance Disease and Population

We’ve posted links to all of these guidelines and other helpful resources on Your Health Alliance for providers and office managers. If you prefer a paper copy of a guideline, call our Quality & Medical Management Department at 1-800-851-3379, extension 8112.

*2015 HEDIS® measures were just released and align with the updated hypertension guidelines. NCQA has retired the HEDIS measure for cholesterol management for 2015, but it remains in place for 2014. We will release more information on HEDIS soon.

Your Health Alliance Password Reset

As mentioned in the recent InforMED flash, we’re increasing the security of Your Health Alliance by requiring all users to reset their passwords every 6 months as of August 1, 2014. You will receive a prompt to reset your password 14 days before it expires.

If you have any questions about Your Health Alliance, contact your provider relations specialist.

Pharmacy Updates

Medicare

New and Revised Policies

New Medicare Policies

Medicare Part D Tier Changes

  • Simbrinza – Moved from Non-Formulary to Non-Preferred Brand on all formularies
  • Xarelto – Moved to Preferred Brand with no PA on all formularies
  • Aerospan – Moved from Non-Formulary to Non-Preferred Brand on all formularies

Medicaid

Formulary Additions

  • Anoro Ellipta (umeclidinium/vilanterol)
    • MMAI – Tier 2
    • SPD – Covered with step therapy
  • Aptiom (eslicarbazepine acetate)
    • MMAI – Tier 2 with step therapy
    • SPD – Covered with step therapy
  • Vimizim (elosulfase alfa)
    • MMAI – Tier 2 with PA
    • SPD – Covered with PA
  • Aerospan (flunisolide hemihydrate)
    • MMAI – Tier 2
    • SPD – Covered with no PA

SPD Formulary Changes

  • Specialty – Autoimmune Inflammatory Disorders
    • Remicade – Moved to Non-Preferred Specialty
    • Enbrel – Moved to Preferred Specialty

Revised Policy

  • Hepatitis C – The purpose of this policy is to define the criteria for coverage of peginterferon (PEG), ribavirin (RBV), and direct-acting antiviral (DAA) agents in the treatment of Hepatitis C. These criteria were developed with guidelines from the American Association for the Study of Liver Diseases/Infectious Diseases Society of America and the Treatment Considerations for Chronic Hepatitis C published by the Veterans Association.

Commercial

Formulary Additions

  • Corifact (Factor XIII) – Tier 5 with PA
  • Tretten [Coagulation Factor XIII A-Subunit (Recombinant)] – Tier 5 with PA
  • Cyramza (ramucirumab) – Tier 5 with PA
  • Gattex [teduglutide (rDNA origin)] – Tier 6 with PA
  • Grastek (Timothy grass pollen allergen extract) – Tier 3
  • Oralair (Sweet Vernal, Orchard, Perennial Rye, Timothy and Kentucky Bluegrass mixed pollen allergen extracts) – Tier 3
  • Ragwitek (short ragweed pollen allergen extract) – Tier 3
  • Hetlioz (tasimelteon) – Tier 6 with PA
  • Myalept (metreleptin) – Tier 6 with PA
  • Otezla (apremilast) – Tier 5 with PA
  • Zykadia (ceritinib) – Tier 5 with PA
  • Nexium 24HR – Tier 1

Formulary Changes

  • Xarelto – Moved to Tier 2 with no PA

Helping Members Keep Up on Diabetes

Please tell your patients with diabetes about our upcoming Health Alliance/Carle event, Keeping up on Diabetes.

When: September 9, 6-7:30 p.m. (Doors open at 5:30)

Where: Carle Foundation Forum – Pollard Auditorium, Urbana

What:

  • Helpful diabetes info
  • Q&A with speakers
  • Info booths

Guests will enjoy free parking and free snacks. Those interested should RSVP by September 5 to Danielle Daly at 1-800-851-3379, ext. 4643.

Think Twice Before Prescribing Antibiotics

A recent WebMD/Medscape survey showed troubling results about health care providers prescribing antibiotics when they are not needed.

According to the survey, 1 in 10 clinicians who prescribe antibiotics without clinical certainty say the drug won’t hurt if not needed. And when clinicians know an antibiotic is not needed, 1 in 10 write the script anyway if the patient demands the drug.

The idea of a harmless antibiotic is a myth. The Medscape article included an interview with Lauri Hicks, DO, medical director of the CDC’s program to promote smart antibiotic prescribing.

“It’s important for providers to know that prescribing antibiotics when they are not needed can cause patients harm,” she says. “They put them at harm for allergic reactions, antibiotic resistant infections and deadly diarrhea caused by the bacteria [Clostridium] difficile.”

We have two HEDIS® measures related to prescribing antibiotics that we hope to improve:

  • More than 25% of children with Health Alliance coverage who were diagnosed with pharyngitis and prescribed an antibiotic did not have a strep test. An in-office rapid strep test only takes 5-10 minutes, and we’ll pay for it.
  • 74 percent of adults with acute bronchitis were prescribed antibiotics, although the guidelines do not recommend that line of treatment.

You can read the full article and see survey results on Medscape.com (after logging in or signing up for a free account). We ask that you follow best practices and think twice before prescribing antibiotics to your patients.

Review Asthma Meds and Control

It’s back-to-school time, which means many kids will be coming in for yearly physicals. These visits are a great opportunity to review asthma medications and control with your young patients and their parents or guardians.

Health Alliance Growth Summary

With more than 30 years of experience in the health insurance industry, we continue to grow. We’ve moved far and beyond state lines, providing coverage for more than 300,000 members in Illinois, Iowa, Nebraska, and Washington. In addition to our approximately 2,500 employer groups and our expanding individual and Medicare Advantage membership, we are also welcoming members for Medicaid and Health Insurance Exchanges.

Health Alliance Connect

Medicaid is coverage for people with incomes below federal minimums, and it’s regulated by the Illinois Department of Health and Family Services and the Federal Centers for Medicare & Medicaid Services. Health Alliance Connect currently covers eligible residents in 15 counties in Illinois through 2 different offerings, Integrated Care Program (ICP) for Seniors and Persons with Disabilities (SPD) and Medicare-Medicaid Alignment Initiative (MMAI), a Medicare-Medicaid Program (MMP) for Dual Eligible members.

  • ICP brings together a member’s primary care physician, specialists, and other long-term services in the community to meet that member’s needs.
  • The MMAI demonstration is designed to test new ways to improve how members receive Medicare and Medicaid health care services.

Health Insurance Marketplaces

The Affordable Care Act allows these people to buy health insurance through the Health Insurance Marketplaces, also called exchanges:

  • Those without employer coverage
  • The self-employed
  • Those without coverage
  • Those who want to change their current coverage

This new way of buying health insurance makes getting coverage easier and more transparent for both businesses and individuals. We offer individual plans on the public and private, or direct, exchanges in Illinois, direct exchange plans in Nebraska, small group public and private plans in Illinois and small group private plans in Iowa. In 2015, we plan to offer individual public plans in Washington.

We’re developing 3 more growth opportunities for 2015:

  • Continue Medicaid expansion by adding members who are eligible for Temporary Assistance for Needy Families and adults as defined by the Affordable Care Act
  • Align with other health systems in Illinois to form an Accountable Care Entity called Illinois Partnership for Health
  • Offer Dual Eligible Special Needs (DSNP) plans for specific populations of Medicare beneficiaries

Please stay tuned for more information on these developments.

Save the Date: Risk Adjustment Coding Workshop

Mark your calendar for our fall risk adjustment coding workshop.

Enjoy an engaging evening of learning and discussion.

When: October 23, 2014, 6-8 p.m.

Where: Carle Foundation Forum – Pollard Auditorium, Urbana

What:

  • Risk Adjustment
  • Quality Management
  • EMR Hints and Tips
  • Q&A Sessions

More details coming soon. Email our Risk Adjustment Coding Team at CodingCounts@healthalliance.org to RSVP or with questions.

See you there!

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