Carle April Newsletter 2020

As It Relates to You

Expressing Our Thanks

The past month has been a difficult time in America and throughout the world. As COVID-19 has infected over one million people and ground much of daily life to a halt, our frontline healthcare providers have once again shown their tireless talents, courage and humanity to a world in need of inspiration. Health Alliance expresses our most heartfelt thanks for your care, concern and selfless service for our members during these difficult and trying times.

We also thank you for your partnership in working with us to make healthcare accessible and affordable for our members during this public health emergency. Together we have lessened burdens and eliminated barriers for those seeking care. Thank you.

We aren’t out of the woods yet. But knowing the strength, courage and talents of our providers, we feel confident that better days are ahead. From Health Alliance, thanks for all that you do.

Reminder: Please Use In-Network Providers

Remember to use contracted, in-network providers before referring a patient outside our network. You can search a member’s network on Your Health Alliance for providers by attaching to that member.

When our members need services that aren’t available from an in-network provider, they might be able to get those services from a provider in their secondary or tertiary network. You can also access this while attached to a member.

Reminder: Please Use Your Health Alliance to Update Provider Information

Please remember to use our new forms to update provider information or add a provider to your practice. You’ll find the forms in the Forms & Resources section of Your Health Alliance for providers. If adding providers to a currently contracted practice, please use the Provider Addition form, along with attaching the appropriate provider application and supporting documentation, not the Prospective Provider form. If you have any questions, contact your provider relations specialist.

Altruista/Guiding Care Tip

Here are some helpful tips for when submitting Prior Authorizations through Altruista/Guiding Care:

• When submitting a pharmacy request via the Provider Portal, backdating and future requests are not allowed. The date/time received field should be when the request was received, not when the patient should receive the medication. We’ve changed the field name to “Request Received on Date/Time” to help providers navigate more efficiently.
• To add documents to an authorization, click on the three dots next to the authorization you just submitted and select “Add Documents.” Save the “Notes” section for general information. Cutting and pasting information from Epic is not clear to read and unidentifiable to the member.

Provider Directory Updates

As you know, it’s vital your patients have access to accurate, up-to-date information in the provider directory. To ensure this accuracy, the Illinois Department of Human Services, the Illinois Department of Insurance and the Centers for Medicare and Medicaid Services all require that providers review and update their information quarterly or whenever there’s a significant change.

As a reminder, here’s the directory information that must be reviewed and updated:

• Ability to accept new patients
• Street address
• Phone number
• Office hours
• Hospital privileges
• Any other information that affects availability to the patient

Members must be able to call the phone number listed in our provider directory and make an appointment with that specific provider at that location.

If you have any questions or have trouble with your updates, please contact your provider relations specialist. 

Thank you for your cooperation in this important initiative.

Provider Portal Resources and Feedback

The Provider Portal is a great tool for you to use. It provides forms and resources to help better work with us as you care for your patients. It can be accessed at Provider.HealthAlliance.org.

To make sure the portal is as beneficial as possible, we need your help. Please let us know if there’s something you would like to see that isn’t there and/or additional resources that would help you find information via our portal, etc. You can submit feedback to us or discuss with your provider relations specialist. 

Hypertension is the Most Common Reason for Visiting a Doctor

Hypertension affects almost one-third of American adults aged 18 or older (72 million people) and is uncontrolled in nearly half of those (35 million people). Those with uncontrolled hypertension represent a large pool of patients for whom clinicians could consider further clinical intervention. Hypertension is a major risk factor for heart disease, stroke and kidney disease. In individuals between 40 to 89 years of age, the risk of death from ischemic heart disease and stroke doubles for every 20 mm Hg.

Provide both initial and ongoing training to staff to ensure that blood pressure readings are taken correctly.

Repeat elevated blood pressures after patient has rested quietly. 

• Encourage staff to assess whether patients have used nicotine or caffeine, have exercised in the last 30 minutes or have a full bladder. Have patient sit in a chair with feet on the floor and arm supported so that the elbow is at about heart level. The inflatable part of the cuff should completely cover at least 80% of the upper arm. The cuff should be placed on bare skin, not over a shirt. Remove any tight-sleeved clothing.
• Encourage patients to monitor their blood pressure at home. Remember to ask patients to bring in their home blood pressure cuff into your office for calibration. Educate them on their blood pressure goals as well as when to report their readings.
• Consider non-pharmacological treatments in addition to medications. Encourage patients to lead a healthier lifestyle including weight loss, reducing sodium intake and increasing physical activity.
• Stress the importance of medication adherence to your patients. Consider prescribing a statin medication as well.
• Encourage patients to engage in health coaching/care coordination. Health Alliance members may also call the phone number on the back of their ID card.

https://www.cdc.gov/dhdsp/pubs/guides/best-practices/smbp.htm

Colorectal Cancer is the Second Leading Cause of Cancer-Related Death in the U.S.

Colorectal cancer is preventable and treatable when detected early enough. Cancer risk is reduced by 90 percent after colonoscopy and polyp removal, according to estimates from the American College of Gastroenterology. When colorectal cancer is found at an early stage, the five-year relative survival rate is about 90 percent.

One in three adults over the age of 50 is not up to date on their colorectal cancer screening. Talk with your patients about colorectal cancer screening options.

Available colorectal cancer screenings:

• FIT (fecal immunochemical test) annually.
• Cologuard every three years.
• Flexible sigmoidoscopy every five years.
• Colonoscopy every 10 years.

Whichever screening test your patient chooses, Health Alliance plans cover it at 100 percent. If additional testing or related services are needed, copay may apply. To check for exact coverage, members should call the customer service number on the back of their insurance card. 

Improving Medication Adherence

We know there is a correlation between medical adherence and reductions in complications and hospitalization rates among individuals with diabetes, hypertension and hypercholesterolemia. Unfortunately, only about half of the patients in the United States, on average, take their medicines as directed by their doctor.

Suggestions:

• Do Rx 90-day prescriptions and encourage fill by mail. Kaiser Permanente found individuals filling 90-day supplies of oral diabetes medication via the mail had higher adherence rates than individuals filling 90-day supplies at a retail pharmacy.
• Synchronize refills of chronic medications so patients can pick up refills at the same time.
• Make sure the patient understands why they are taking the medication and the importance of taking it consistently.
• Ensure patients understand what to do if they miss a dose.
• Avoid side effects when possible, by taking the medication with food or at a different time of day if needed.

New Hierarchical Condition Categories (HCCs) for 2020

Effective January 1, 2020, CMS has added two new HCC categories for dementia:

HCC 51 – Dementia with complication (F03.91)

HCC 52 – Dementia without complication (F03.90)

• Supporting documentation for dementia should include a specific description of the patient’s mental capabilities, symptoms or diagnosis.
• For dementia patients with behavioral disturbances, document any aggressive, violent or combative behavior, as well as agitation or excessive wandering.
• ICD-10 codes F03.90 and F03.91 don’t capture conditions often related to dementia. These conditions should be documented, separately reported and can include:
  • Cachexia
  • Sleep disorders
  • Depression

CMS has also added a new HCC for Pressure Ulcers (also effective January 1, 2020):

HCC 159 – Pressure ulcer of skin with partial thickness skin loss (L89.0X2 – L89.92)

• ICD-10 codes for pressure ulcers denote etiology, site, laterality and severity.
• Supporting documentation for stage 2 pressure ulcers should state the stage of the ulcer or by using the clinical terms, in parentheses following each stage, found in ICD-10-CM. For stage 2 those terms are:
  • Abrasion
  • Blister
  • Partial thickness skin loss involving epidermis and/or dermis.
• Document and report any underlying condition related to the cause of the pressure ulcer. Risk factors can include:
  • Immobility
  • Loss of pain and pressure sensation
  • Poor nutrition and hydration
  • Poor circulation

Pharmacy Updates

Infectious Disease Review

Formulary Additions

• Pretomanid—Treatment of pulmonary extensively drug resistant or treatment-intolerant or nonresponsive multidrug-resistant tuberculosis (TB), as part of a combination regimen with bedaquiline and linezolid, in adult patients
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with PA
    • Medicare—Tier 5 with PA

• Xenleta (lefamulin)—Treatment of adults with community-acquired bacterial pneumonia caused by the following susceptible microorganisms: Streptococcus pneumoniae, Staphylococcus aureus (methicillin-susceptible isolates), Haemophilus influenzae, Legionella pneumophila, Mycoplasma pneumoniae, and Chlamydophila pneumonia
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty (no PA)
    • Medicare—Tier 5 (no PA)

New Policies

• Wellness Coverage for HIV Medications for PrEP
  • Policy will be used to determine when member’s cost-share can be reduced to Wellness rate ($0 copay)
• Ribavirin Oral Inhalation (Commercial and Exchange)
  • Mirrors Medicare policy

Criteria Changes

• Hepatitis B Treatment – Lamivudine, Hepsera, Baraclude, & Vemlidy
  • Added prophylaxis criteria
  • Changed age exclusion from children under 13 to children under 12
  • Specified 1 year initial approval

Oncology/Hematology Review

Formulary Additions

Oncology

• Piqray (alpelisib)—Treatment of Breast cancer, advanced or metastatic
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Tier 5 with PA; reviewed by Health Alliance

• Elzonris (tagraxofusp)—Treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN) in adults and in pediatric patients ≥2 years of age
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Part B; reviewed by eviCore

• Balversa (erdafitinib)—Treatment of Urothelial carcinoma, locally advanced or metastatic
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Tier 5 with PA; reviewed by Health Alliance

• Cablivi (caplacizumab)—Treatment of acquired thrombotic thrombocytopenic purpura (aTTP) in adults
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—IV dose covered under Part B; reviewed by eviCore. Sub-Q doses covered under Part D, Tier 5 with PA; reviewed by Health Alliance

• Nubeqa (darolutamide)—Treatment of nonmetastatic castration-resistant prostate cancer
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Tier 5 with PA; reviewed by Health Alliance

• Infugem (gemcitabine)—Treatment of metastatic breast cancer, non-small cell lung cancer, advanced ovarian cancer, pancreatic cancer
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Part B; reviewed by eviCore

• Turalio (pexidartinib)—Treatment of symptomatic tenosynovial giant cell tumor (TGCT)
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Tier 5 with PA; reviewed by Health Alliance

• Polivy (polatuzumab vedotin)—Treatment of Diffuse large B-cell lymphoma (relapsed or refractory)
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Part B; reviewed by eviCore

• Xpovio (selinexor)—Treatment of Multiple myeloma, relapsed or refractory
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Tier 5 with PA; reviewed by Health Alliance

• Inrebic (fedratinib)—Treatment of myelofibrosis
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Tier 5 with PA; reviewed by Health Alliance

• Rozlytrek (entrectinib)—Treatment of non-small cell lung cancer and solid tumors
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Tier 5 with PA; reviewed by Health Alliance

• Asparlas (calaspargase pegol)—Treatment of acute lymphoblastic leukemia (ALL)
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Part B; reviewed by eviCore

• Brukinsa (xanubrutinib)—Treatment of mantle cell lymphoma (relapsed or refractory)
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Tier 5 with PA; reviewed by Health Alliance

• Padcev (enfortumab vedotin)—Treatment of locally advanced or metastatic urothelial cancer in adults
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Part B; reviewed by eviCore

• Enhertu (fam-trastuzumab deruxtecan-nxki)—Treatment of unresectable or metastatic breast cancer
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
    • Medicare—Part B; reviewed by eviCore

Hematology

• Adakveo (crizanlizumab)—First targeted therapy approved for sickle cell disease and is approved to reduce the frequency of vaso-occlusive crises in adults and pediatric patients aged 16 years and older
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA
    • Medicare—Non-Formulary

• Oxbryta (voxelotor)—Treatment of sickle cell disease in adults and pediatric patients ≥ 12 years of age
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA
    • Medicare—Non-Formulary

• Reblozyl (luspatercept)—Treatment of anemia in adults with beta thalassemia who require regular RBC transfusions
  • Formulary placement recommendations
    • Commercial—Tier 6 (Non-Preferred Specialty/Non-Formulary Specialty) with PA
    • Medicare—Part B with PA

• Ultomiris (ravulizumab)—Treatment of paroxysmal nocturnal hemoglobinuria in adults
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA
    • Medicare—Tier 5 with PA

Criteria Changes

• Exjade (deferasirox) and Jadenu (deferasirox) (Commercial and Exchange)
  • Specified that requirements are for approval of generic deferasirox and that approval of brand names requires failure of, intolerance to, or allergy to generic

Additional New Policy

• Photrexa Viscous (riboflavin 5’-phosphate) (Commercial and Exchange)
  • Operational policy for coding update purposes; drug itself is covered under medical benefit

Tier Changes

Commercial and Exchange

• Herceptin biosimilars (Ontruzant, Herzuma, Ogivri, Trazimera, Kanjinti)—Move from Non-Preferred Specialty to Preferred Specialty
• Avastin biosimilars (Mvasi, Zirabev, bevacizumab)—Move from Non-Preferred Specialty to Preferred Specialty

Medicare

Praluent and Repatha: Move from Tier 4 to Tier 3

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