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Carle August Newsletter 2019

As It Relates to You

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.

BMI Status and Morbid Obesity

There was a change in the 2019 coding guidelines for documenting and reporting a patient’s body mass index (BMI).

BMI status can be recorded by ancillary medical staff, even if they’re not the main provider. The BMI status can’t be reported as the primary diagnosis and can only be reported when linked by the provider in the documentation to an associated condition, such as morbid obesity.

Per coding guidelines, morbid obesity only applies to patients 21 years or older with a BMI of 40 or greater and should not be reported during pregnancy.

ICD-10 code range for (morbidly obese) BMI status:

Code Description
Z68.41 Body Mass Index (BMI) 40.0 – 44.9 Adult
Z68.42 Body Mass Index (BMI) 45.0 – 49.9 Adult
Z68.43 Body Mass Index (BMI) 50.0 – 59.9 Adult
Z68.44 Body Mass Index (BMI) 60.0 – 69.9 Adult
Z68.45 Body Mass Index (BMI) 70 or greater, Adult

ICD-10 codes for morbid obesity:

Code Description
E66.01 Morbid (severe) obesity due to excess calories
E66.2 Morbid (severe) obesity with alveolar hypoventilation

People who are overweight, obese, or morbidly obese can have an increased risk for certain medical conditions. These related conditions are always clinically significant and should be documented and reported annually.

If you have any questions or would like more information, contact us at, and we’ll reach out to help with a solution.

For useful information on documentation and code reporting, subscribe to our coding e-newsletter.

Submit Claims Inquiries and Appeals Online

Please remember to submit claims inquiries and appeals online. Use the New Inquiry form under the Claims tab of Your Health Alliance for providers. Search for a specific claim and submit a Claim Reprocessing Inquiry.

Pharmacy Updates

Formulary Additions


  • Qbrexza (glycopyrronium)
    • Indicated for the topical treatment of primary axillary hyperhidrosis in adult and pediatric patients age 9 years or older
    • Formulary placement
      • Commercial—Non-Preferred Brand with PA
      • Medicare—Non-Formulary
  • Seysara (sarecycline)
    • Indicated for the treatment of moderate to severe acne vulgaris in patients 9 years or older
    • Formulary placement
      • Commercial—Excluded
      • Medicare—Non-Formulary
  • Xepi (ozenoxacin)
    • Indicated for the treatment of impetigo due to Staphylococcus aureus or Streptococcus pyogenes in adult and pediatric patients ≥ 2 months of age
    • Formulary placement
      • Commercial—Non-Preferred Brand with Step Edit
      • Medicare—Non-Formulary
  • Ilumya (tildrakizumab-asmn) and Skyrizi (risankizumab)
    • Both drugs are indicated for the treatment of moderate-to-severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy
    • Formulary placement
      • Commercial—Non-Preferred Specialty with PA
      • Medicare—Non-Formulary


  • Arikayce (amikacin liposomal)
    • Aminoglycoside antibiotic indicated for treatment of Mycobacterium avium complex (MAC)
    • Formulary placement
      • Commercial—Non-Preferred/Non-Formulary Specialty (Tier 6) with PA
      • Medicare—Tier 5 with PA
  • Yupelri (revefenacin)
    • Long-acting muscarinic antagonist agent indicated for the treatment of COPD
      • The first once-daily nebulized bronchodilator approved for COPD
    • Formulary placement
      • Commercial—Non-Preferred Specialty Pharmacy with PA
      • Medicare—Tier 4 with PA and B vs. D determination

Criteria Changes—Commercial


  • PCSK9 Inhibitors
    • Updated policy to reflect new American College of Cardiology (ACC) guidelines for secondary prevention of ASCVD
  • Weight-Loss Medications
    • Policy only applies to Federal Employee Health Benefit (FEHB) plan members
    • Updated policy to align with obesity guidelines by allowing coverage in members with a BMI of greater than 27 with one risk factor (hypertension, diabetes mellitus, dyslipidemia, etc.) or a BMI of greater than 30


  • Azelaic Acid
    • Updated coverage criteria of Azelex for acne to require documented trial and failure of two generic agents, including topicals or oral tetracyclines or contraindication to all topical and oral tetracycline agents
    • Also added smallest package size managed dose limit language; MDL has been in place since April 2015
  • Diclofenac Sodium
    • Updated criteria to require failure, intolerance, or contraindication to fluorouracil and imiquimod
      • These are considered first-line therapies and should be used prior to diclofenac sodium 3%
  • Eurax (crotamiton)
    • Divided policy into separate criteria for scabies and pruritus/urticaria
    • Also added smallest package size managed dose limit language; MDL has been in place since April 2015
  • Isotretinoin Oral
    • Updated the policy to allow for #60 capsules per 30 days for a maximum of 8 months
  • Mirvaso (brimonidine tartrate) Gel and Rhofade (oxymetazoline)
    • Updated criteria to require failure, intolerance, or contraindication to metronidazole and doxycycline so that patients who are not good candidates for these drugs can bypass the requirements
    • Also added smallest package size managed dose limit language; MDL has been in place since April 2015
  • Dapsone Gel
    • Removed PA
    • Excluding Aczone 7.5% (brand-name dapsone)
  • Siliq, Taltz, and Tremfya
    • Updated systemic therapy requirement to 3-month trial
  • Altabax Step-Edit
    • Added step through mupirocin ointment
  • All drugs with plaque psoriasis indication that have phototherapy requirement
    • Updated to allow waiving of phototherapy requirement with documented barriers to phototherapy access that impede treatment (e.g., unmanageable distance from phototherapy treatment location or inability to schedule treatments)


  • Dupixent (dupilumab)
  • Addition of coverage criteria for eosinophilic phenotype severe asthma and glucocorticoid-dependent asthma
  • Adcirca (tadalafil)
  • Updated policy to indicate that Adcirca has gone generic and generic is required prior to brand
  • Adempas (riociguat)
  • Updated policy to indicate that Adempas is also used to treat WHO Group 4

Additional Criteria Change

  • Promacta (eltrombopag)
  • Added criteria for coverage of aplastic anemia

Tier Changes

Commercial/ Exchange

Altabax 1% Ointment—Moved from Preferred Brand to Non-Preferred Brand

  • Mupirocin ointment is less expensive first-line treatment option

Aczone 7.5% Gel—Moved from Tier 3 with PA to Excluded

  • Generic dapsone 5% gel is now covered on the generic tier with no PA

Incruse Ellipta—Moved from Non-Preferred Brand to Preferred Brand

  • GOLD Guidelines do not prefer one LAMA over another; adding third Preferred option

Seebri Neohaler—Moved from Non-Preferred Brand to Excluded

  • Currently have three formulary LAMAs; zero utilization of this product

Xopenex HFA—Moved from Non-Preferred Brand to Excluded

  • Enantiomer of albuterol that offers no additional clinical benefit beyond that of albuterol

Adcirca—Moved to Non-Formulary/Non-Preferred Specialty

  • Generic is covered on the Preferred Specialty tier

Commercial/Exchange – Two Generic Tier Formulary

Warfarin: Moved from Non-Preferred Generic to Preferred Generic

  • Offers $0 option for those patients who cannot afford novel anticoagulants Simvastatin: Moved from Non-Preferred Generic to Preferred Generic
  • Adding lowest cost statin option to the Preferred Generic tier so members have a $0 statin option


Mupirocin 2% Cream: Moved from Tier 1 to Non-Formulary

  • Mupirocin 2% ointment covered at Tier 1


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