Carle October Newsletter 2021

As the Seasons Turn

It’s hard to believe it’s already autumn. Throughout our communities, the leaves are changing colors, temperatures are cooling and days are getting shorter. Autumn in particular reminds us how things change, whether we like it or not. Two things that don’t change – your steadfast and outstanding care for our members’ health, and our commitment to helping you every way we can. Thanks for all that you do. And know that we’re always here for you – now, throughout autumn and across all four seasons.

Beyond Pink

October is Breast Cancer Awareness Month. You’ll probably see a lot of beautiful pink ribbons and artwork raising awareness. We’re always so heartened and encouraged by everyone doing all they can to bring attention to the disease. But what else can we – as healthcare providers – also be doing to further aid the cause?

Most importantly, we should remind our patients to get their regular mammograms. These screenings detect issues early, when they’re easiest to treat. In fact, according to the CDC, mammograms can even detect cancer up to three years before it would be physically felt.

Following guidance from the American Cancer Society, women age 45 to 54 should get mammograms every year, while those 55 and older can switch to every 2 years or continue yearly screenings. Women at higher risk of breast cancer should start getting mammograms before age 45. Many health plans cover these screenings at no cost to the patient. Please advise your patients to call the number on the back of their health plan ID cards for questions about coverage.

You should also remind your patients about the importance of breast self-exams. A monthly self-examination is easy to do and only takes a few minutes.

Also important – encourage your patients to make healthy lifestyle changes to help lower their risk of breast cancer. Promote physical activity, maintaining a healthy weight and limiting how much alcohol they drink.

Finally, share helpful information and resources with your patients. We have many at hally.com, including a wonderful podcast with Dr. Maria Grosse Perdekamp of the Mills Breast Cancer Institute at Carle. All they have to do is visit hally.com and search “breast cancer.” We add more health and wellness resources every month.

As It Relates to You

Key information for you and your staff from your Provider Relations Specialists.

Reminder: Provider Satisfaction Survey Coming Soon

We depend on you to take care of our members’ health, and we deeply value your opinion. Each year, we send provider satisfaction surveys to a random sample of our providers. We use the feedback from these surveys to make changes to our processes as part of our effort of constant improvement. If you receive a survey, please take the time to give us your honest feedback. It’s how we’re best able to adapt and meet your current and future needs.

We thank you in advance for your help with the survey and – as always – for the excellent care you give our members.

We Need Your Help – Please Keep Your Provider Information Up to Date

Federal and state governments require you to review and update your provider information in a timely manner or whenever there are significant changes.

Please send all provider updates to Provider.Updates@HealthAlliance.org. Note that this is a new email address. Your provider relations specialist will continue to be your contact for all other inquiries. Thanks for all that you do.

Important Reminder – Complete Your Annual Attestation Form

We’re committed to making sure our contracted providers are compliant with the Centers for Medicare & Medicaid Services (CMS) guidelines – outlined in the Medicare Managed Care Manual and/or the Prescription Drug Benefit Manual – for the services provided on our behalf.

We require First Tier, Downstream and Related Entities (FDRs) under our Medicare Advantage plans, Part D plans and Qualified Health Plans to complete an attestation form annually to show you’ve met the CMS requirement. This form must be completed by your organization’s CEO, COO or compliance officer.

If you haven’t already, please complete your attestation form and send it to Provider.Relations@HealthAlliance.org. As always, feel free to contact your provider relations specialist with any questions. Thank you.

The ABCDs of Medicare – Understanding the Different Types of Plans

It’s time once again for the Medicare Annual Enrollment Period, which takes place October 15 through December 7. As your patients look at their options and try to decide what’s best for them, they might come to you with questions. Here’s a quick review of some of the different types of Medicare coverage they can choose:

• Original Medicare is offered through the federal government and includes Part A (hospital coverage) and Part B (medical coverage). Like the other types of Medicare, it’s available for those who are 65 or older or have certain disabilities. Beneficiaries with Original Medicare can see any provider who accepts Medicare, but they won’t have extra perks or pharmacy coverage.
• Medicare Advantage (Part C) plans are private health plans that replace Original Medicare. They often include pharmacy coverage and extra perks, like dental, hearing and vision benefits. These plans typically have a provider network and can offer more care coordination than Original Medicare.
• Medicare Supplement (also known as Medigap) plans are sold through private insurance companies. They don’t replace Original Medicare but work as an add-on alongside it to help pay for what Original Medicare doesn’t. In general, they don’t cover additional services or offer extra benefits or perks – they simply pay (part of) the remainder of the bill since Original Medicare doesn’t pay the full 100% of many of the services it covers. Beneficiaries can generally see any provider who accepts Medicare.
• Finally, many people who have Original Medicare – whether they have Medicare Supplement or not – also purchase standalone Part D plans to cover their prescription drugs. As mentioned above, many Medicare Advantage plans already have prescription coverage built in.

We invite you to visit the Understand Medicare page on our website for additional information, and as always, feel free to reach out to your provider relations specialist with any questions. And perhaps most helpful, we encourage you to visit our Providers Resources page to find presentations we’ve developed specifically for you during this year’s Annual Enrollment. Under “Medicare Information” you’ll find Medicare Provider Education links based on region and product, and you’ll also find a short video describing Medicare Advantage.

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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.

Closing Gaps in Care – End-of-Year Screening Reminders

With autumn now in full swing and winter around the corner, 2021 is fast coming to an end. Before we ring in the new year, make sure your patients get the appropriate preventive services they need to identify any issues and close any gaps in their care. As appropriate, please remind your patients about the following end-of-year screenings:

All patients:

• Colorectal cancer screening.
• Blood pressure reading.
• Medication review.

Women:

• Breast cancer screening.
• Cervical cancer screening.

Patients with diabetes:

• A1C test.
• Nephropathy screening.
• Diabetic retinal eye exams.

Also, please remember we have health coaching and care coordination services that can help our members manage their conditions at no extra cost to them. We know you worry about your patients’ health between visits, and these services can help improve their health outcomes throughout the entire year. What a perfect way for your patients to finish 2021 – and open 2022 – on a strong and healthy note!

World COPD Day

Each year, the Global Initiative for Chronic Obstructive Lung Disease hosts World COPD Day. Mark your calendars for Wednesday, November 17, as this year’s theme is “Healthy Lungs – Never More Important.” Part of this year’s goal is to remind people that the burden of COPD (chronic obstructive pulmonary disease) remains, even as so much attention is focused on the ongoing COVID-19 pandemic. COPD is a leading cause of death worldwide – and we can’t let up on our efforts to raise awareness about the disease. Please continue to educate your patients and families on keeping their lungs healthy – by avoiding cigarettes, air pollution and occupational exposures. Make sure they stay active through regular physical activity or pulmonary rehab. And remind them that getting their vaccines, keeping their medical appointments and taking their medications correctly can also help keep their lungs healthy.

Shingles

Risk increases with age, and those with certain long-term health conditions like COPD are more likely to get the disease.  Shingles isn’t life threatening, but it can be incredibly painful.  The CDC recommends that most healthy adults 50 and older should receive the vaccine.  Talk to your doctor about scheduling your shingles vaccine.

Find more resources – to both use and share with others – here.

45^th Annual Great American Smokeout

Help your patients quit smoking. On November 18, thousands across the country will take part in the yearly Great American Smokeout®, challenging themselves to go a full 24 hours without cigarettes. The hope is that they find strength and motivation in being able to go an entire day without smoking, and perhaps decide to quit for good. The day is an initiative of the American Cancer Society® (ACS) and has brought health, hope and inspiration for nearly half a century. Between now and November 18, encourage your patients to take part, and point them to cancer.org/smokeout for more information about the day, along with tools and resources.

Also, for your patients who are members of our health plans, remind them that we offer access to Quit For Life® at no additional cost. It’s a built in part of their plan – just waiting for them to use – where they can get personalized help to quit smoking. They should visit hally.com/care for more information, and call the number on the back of their health plan ID card to see if their plan includes Quit For Life.

Antidepressant Medication Management – Make Sure Your Patients Stick to Their Medication Regimen

Unfortunately, many patients don’t stick to their antidepressant medication regimens. Some don’t accept their disease or think they’re feeling “better,” while others are disturbed by the drugs’ side effects. Please make sure your patients know that they should never discontinue their medications abruptly without speaking to you.

Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressants. These are considered first-line antidepressants due to their efficacy, tolerability and safety in overdose. Side effects can include serotonin syndrome, sexual dysfunction, drowsiness, weight gain, insomnia, anxiety, headache, dry mouth, dizziness, nausea, blurred vision, constipation and rash. More serious side effects include emotional blunting, suicidal ideation, prolonged QT interval, movement disorders and decreased mental energy. SSRIs are contraindicated in patients with hypersensitivity and those who’ve received monoamine oxidase inhibitor (MAOI) in the previous two weeks. Have caution when prescribing SSRIs with other serotonergic medications like lithium or SNRIs (serotonin-norepinephrine reuptake inhibitors).

It may be possible to reduce the dose to help alleviate SSRI side effects. However, it’s worth warning patients against stopping antidepressants because of the possible discontinuation symptoms they may get. These could include headaches, fatigue, dizziness, nausea, anxiety, diaphoresis, agitation, chills, tremor, myalgia, insomnia, dysphoria, irritability, paresthesia or rhinorrhea. They may occur when patients abruptly stop antidepressants or taper them rapidly. The risk for developing these discontinuation symptoms increases after a person has taken the SSRIs for six-plus weeks. Although these discontinuation symptoms usually last for only a week or two, they sometimes continue for a month and can lead to hospitalization.

Blood Pressure Health – Reminders and Tips

Did you know that hypertension is the most common reason people with any chronic condition visit the doctor? It’s a major risk factor for heart disease, stroke and kidney disease. Even small increases in blood pressure raise the risk for cardiovascular disease and mortality. Here are some tips to help your patients stay healthy.

• Provide both initial and ongoing training to your staff to make sure they’re taking blood pressure readings correctly. They should have the patient sit in a chair with their feet on the floor and their arm supported so their elbow is at heart level. Tight-sleeved clothing should be removed. They need to place the cuff on the patient’s bare skin, and the inflatable part should completely cover at least 80% of the upper arm. Make sure they communicate the readings and reassess all elevated blood pressure results.
• Share this short video with your patients, to help them take their own blood pressure readings at home.
• Stress the importance of medication adherence to your patients.
• Consider prescribing statin medications.
• Encourage your patients and staff to become familiar with Life’s Simple 7®, from the American Heart Association. These are the risk factors people can improve through lifestyle changes, helping them achieve better cardiovascular health. Have them visit here for information and resources about how to:

1. 1. Manage blood pressure.
   2. Control cholesterol.
   3. Reduce blood sugar.
   4. Get active.
   5. Eat better.
   6. Lose weight.
   7. Stop smoking.

• If your patients are members of our health plans, encourage them to sign up for health coaching or care coordination for help managing their blood pressure (and much more) at no extra cost. They can call the number on the back of their health plan ID cards to sign up.

HEDIS Quality Measure – Statin Therapy for Patients with Cardiovascular Disease (SPC)

Like 90% of America’s health plans, we use the Healthcare Effectiveness Data and Information Set (HEDIS®) standards to measure performance related to care and service. The HEDIS Statin Therapy for Patients with Cardiovascular Disease (SPC) measure assesses care for our members with clinical atherosclerotic cardiovascular disease (ASCVD).

Both the American College of Cardiology and the American Heart Association recommend that people with a history of ASCVD take a statin medication to reduce risk for future heart attack or stroke. The HEDIS measure tracks how many of our members with ASCVD (among men age 21 – 75 and women 40 – 75) received statin therapy from their providers, as well as how many remained on the medication for at least 80% of the treatment period. HEDIS defines receiving medication as being dispensed at least one high- or moderate-intensity statin during the year.

Here are some tips to help your patients stick to their statin medications:

• Develop a medication adherence plan with them.
• Recommend that they set medication reminders for themselves.
• Encourage the use of pillboxes or medication organizers.
• Identify and resolve patient-specific adherence barriers or concerns – such as costs, worries about side effects, pharmacy/refill access and knowledge gaps.
• Consider low-cost generic statins to reduce your patients’ financial burden.
• Encourage patients to obtain 90-day supplies at their pharmacy.

Thank you for your help. Finally, but importantly, know that – because statins shouldn’t be prescribed for everyone – the HEDIS measure excludes from counting those who meet certain criteria. See the list under the “Measure Exclusions” headline on this webpage from Johns Hopkins.

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The “Big Six” – Chronic Obstructive Pulmonary Disease

Supporting documentation and accurate coding are key to making sure your patients receive the care they need. Failure to document chronic conditions on an annual basis impacts your patients, fellow providers and our organization. Here are some helpful documentation and coding tips for Chronic Obstructive Pulmonary Disease (COPD), one of the “Big Six” diagnosis categories frequently miscoded or unsupported in documentation.

COPD is an umbrella term for multiple pulmonary conditions that include:

• COPD.
• Emphysema.
• Chronic obstructive bronchitis.
• Chronic obstructive asthma.

Specificity when documenting a patient’s condition and the selection of an ICD-10-CM code are key to accurately reporting their medical status.

Many times, providers incorrectly report COPD for patients who have emphysema. Per ICD-10-CM Official Coding Guidelines, COPD with emphysema should be reported as emphysema.

• For unspecified COPD (without emphysema), ICD-10-CM includes codes to differentiate between COPD with acute exacerbation and COPD with lower respiratory infection. Document if the exacerbation of COPD is due to infection and also document the infective agent, if known.
• When reporting chronic obstructive bronchitis, supporting documentation should have definitive statements as to the chronic and obstructive nature of the patient’s condition.
• For cases of chronic obstructive asthma, report COPD and asthma if the severity and type of asthma are known (for example, mild intermittent asthma). If the severity and type of asthma aren‘t known, report only

Supporting documentation for chronic obstructive pulmonary disease should include:

• Any hypoxia, hypercapnia, hypoxemia or polycythemia.
• Dependence on supplemental oxygen, ventilator or presence of tracheostomy.
• Smoking status.
• Tobacco counseling, treatment or intervention.
• Treatments such as bronchodilator inhalers, corticosteroids and antibiotic treatments for infection.
• The severity – mild, moderate, severe or end-stage.

Chronic obstructive pulmonary disease can occur with or without respiratory failure and should be separately reported. Acute respiratory failure, when present, should be reported even if intubation is not required.

Thank you for your help with accurate coding and documentation. We’re grateful for how hard you work and all you do for our members’ health. For short videos with coding tips for all of the “Big Six” conditions, click here. Visit our Coding Counts page for even more helpful tips and resources.

Pharmacy 101: What happens when a medication is denied?

We work hard to make sure our members get the proper medication for each health situation, to keep them safe and control costs. That’s why certain covered drugs require special requests for approval. When our Pharmacy department receives requests for coverage of a medication that requires prior authorization (PA) or step therapy (ST) – or for quantities that exceed the quantity limits (QL) – one of our clinical pharmacists reviews the request and makes a decision whether or not to approve it.

Once their decision is made, we send a letter regarding this decision to both the member and provider. If we deny the request for coverage, we provide the reason in member-friendly language, stating the policy we used to review the request and the specific criteria that wasn’t met. When appropriate, we’ll list alternative medications for consideration.

Reasons for a denial include, among others:

• The diagnosis is not an FDA-approved indication.
• The FDA-approved age limit wasn’t met.
• Proper documentation of the required lab values wasn’t submitted, or the lab values were not met.
• A lack of documentation of trial, or a failure or contraindication of preferred products as set by best practices.
• The FDA-approved dosing was exceeded (in the case of QL).
• A lack of medical necessity.

We’re always open about the reason for denial, and the member or provider can appeal our decision to the next level of review. As always, if you have any questions about this process or would like to learn more, simply reach out to your provider relations specialist.

Pharmacy 101: Why are Medicare requirements stricter?

We’re often asked why our Medicare plans have stricter pharmacy requirements than many of our commercial plans. Most simply, it’s because Medicare plans must meet a number of government requirements.

We create our Medicare Part D formularies under the guidance of our Pharmacy and Therapeutics (P&T) Committee. To determine formulary choices, we evaluate the needs of our patients, the products’ use(s) and cost-effectiveness. In contrast to commercial formularies, Medicare Part D formularies are subject to review and approval by the Centers for Medicare & Medicaid Services (CMS). Each Medicare Part D formulary must give at least a standard level of coverage set by CMS – which checks each formulary to make sure it includes of a range of drugs in a broad distribution of therapeutic categories and classes. CMS will consider the specific drugs, our tiering levels and the utilization management strategies we use in each formulary. They’ll also look to existing best practices to make sure our use of prior authorization, step therapy and quantity limits are consistent.

In general, all Medicare Part D formularies must cover at least two drugs per drug category and almost all medications within these protected classes: antipsychotics, antidepressants, anticonvulsants, immunosuppressants, cancer drugs and HIV/AIDS drugs. If a certain drug isn’t on the formulary, providers may submit for a formulary exception, showing medical necessity.

In general, CMS does not allow Medicare Part D formularies to include:

• Over-the-counter (OTC) medications or their equivalents.
• Any drug product used for cosmetic purposes.
• Experimental drug products or any drug product used in an experimental manner.
• Foreign drugs or drugs not approved by the FDA.
• Anorexics or drugs for weight loss or gain.
• Fertility agents.
• Agents for hair growth.
• Agents for the symptomatic relief from cough and colds.
• Prescription vitamins and minerals (except prenatal vitamins and fluoride preparations).
• Outpatient drugs for which the manufacturer seeks to require – as a condition of sale – that associated tests be purchased exclusively from the manufacturer or its designee.
• Medical supplies and items not considered drugs.
• Erectile dysfunction drugs.

We submit Medicare Part D formularies to CMS for approval annually. Once a formulary is approved, medications can’t be moved off the formulary or to a higher tier until the following plan year. We can make changes to add newly approved medications or to move drugs to a lower tier (to provide cost savings for our members).

As always, if you have any questions about this process – or the process we use to create our commercial formularies – you can contact your provider relations specialist for more information.

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 list may still require prior authorization.

Notable 2022 Medicare Formulary Tier Changes

Here are some notable tier changes to the Medicare formulary, for calendar year 2022. As always, contact your provider relations specialist if you have any questions.

Positive Changes

Negative Changes

Pharmacy Updates

All Plans

Neurology

Formulary Additions

• Ponvory (ponesimod)—Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary-progressive disease, in adults
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy
    • Medicare—Non-Formulary
• Koselugo (selumetinib)—Treatment of pediatric patients 2 years of age and older with neurofibromatosis type 1 (NF1) who have symptomatic, inoperable plexiform neurofibromas (PN)
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Tier 5, Specialty with PA
• Aduhelm (aducanumab)—Treatment of Alzheimer’s disease
  • Formulary placement recommendations
    • Commercial—Excluded
    • Medicare—Excluded
  • Severe side effects; patients would require ongoing imaging and monitoring
  • Clinical benefit has not been shown at this time
  • HA has verified that other plans intend to exclude from coverage pending more evidence of clinical benefit

Psychiatry/Behavioral Health

Formulary Additions

• Azstarys (serdexmethylphenidate and dexmethylphenidate)—Treatment of attention-deficit/hyperactivity disorder (ADHD) in patients 6 years of age and older
  • Formulary placement recommendations
    • Commercial— Non-Preferred Brand with QL #30 per 30 days
    • Medicare—Non-Formulary
• Qelbree (viloxazine)—Treatment of attention deficit hyperactivity disorder (ADHD) in pediatric patients 6 to 17 years of age
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with AL of 6-17 years old and QL #30 per 30 days
    • Medicare—Non-Formulary
• Lybalvi (olanzapine and samidorphan)—Treatment of schizophrenia and bipolar I disorder in adults
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with PA
    • Medicare—Non-Formulary

Commercial

Neurology

Formulary Additions

• Kesimpta (ofatumumab)—Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease in adults
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy

New Policies

• Nuedexta (dextromethorphan hydrobromide/quinidine sulfate)—Treatment of pseudobulbar affect with underlying neurological disorder
  • Combination of two drugs that are available as generic; Health Alliance has received about 20 requests for Nuedexta over the last two years and we are recommending adding the drug to formulary with PA

Criteria Changes

• Botox (onabotulinumtoxin A)
  • Added physical rehab prescribers
• Xeomin (incobotulinumtoxin A)
  • Added requirement of age 2 and older for sialorrhea
• Prophylactic Calcitonin Gene-Related Peptide (CGRP) Inhibitors
  • Added Nurtec to policy; removed “injectable” from title
• Wakix (pitolisant)
  • Expanded coverage to include criteria for treatment of cataplexy in patients with narcolepsy
• Hetlioz (tasimelteon)
  • Added Smith-Magenis Syndrome (SMS) criteria

Psychiatry/Behavioral Health

Policy Change

• Behavioral Health Medications policy
  • Added new behavioral health drugs presented above (under “All Plans”)
  • Listed medications for each section
  • Added link to Parity Act and MHPAEA language

Criteria Changes

• Leuprolide Acetate (Fensolvi, Lupron Depot, Lupron Depot-Ped, Leuprolide acetate, Lupaneta)
  • Added WA-specific language and updated gender affirmation language, updated references
• Supprelin LA (histrelin acetate)
  • Added WA-specific language and updated gender affirmation language, updated references
• Dynavel XR (amphetamine ER) Suspension
  • Added mental health parity language
• Quillichew (methylphenidate HCl chew tab) ER
  • Added mental health parity language
• Quillivant XR (methylphenidate HCl susp)
  • Added mental health parity language
• Vyvanse (lisdexamfetamine) Chewable
  • Added mental health parity language
• Spravato (esketamine)
  • Added mental health parity language, updated references

Pain

Criteria Changes

• Relistor (methylnaltrexone bromide)
  • Added tablets to criterion 2.3 for duration of treatment

Additional Criteria Changes

• Medical Exception for Non-Covered Glucose Strips
  • Updated criteria to allow use for those with pumps regardless of disability or impairment
• Ulcerative Colitis Immunomodulator Therapies
  • Added criteria for Zeposia
• Wellness Coverage for HIV Medications
  • Updated policy with language from US Preventive Services Task Force (USPSTF)

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