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December Newsletter

Help Patients Break Tobacco’s Hold

Many people make New Year’s resolutions to quit smoking, but they might not know where to start or are afraid they won’t succeed. We partner with Quit for Life®, the nation’s leading smoking cessation program, to help our members break tobacco’s hold for good.

Please encourage your patients/our members to take advantage of this program, which is free with their coverage.

With Quit For Life, participants are 8 times more likely to quit than going cold turkey.

The program includes:

  • One-on-one coaching
  • A customized quit plan
  • Helpful tools, like Text2Quit
  • Web Coach®, an online learning and support community

Quit for Life participants may also be able to use nicotine replacement therapy, like patches, gum, or medicines at reduced copays.

Members can call 1-866-QUIT-4-LIFE (1-866-784-8454) or visit QuitNow.net to get started.

Pharmacy Updates

Medicare

New and Revised Policies

New Medicare Policies

  • Cyclobenzaprine: New policy created in response to CMS requirement to cover this drug

Commercial

Formulary Additions

  • Beleodaq (belinostat)
    • Tier 5 with Preauthorization (PA)
  • Cerdelga (eliglustat tartrate)
    • Tier 6 with PA
  • Jardiance (empagliflozin)
    • Tier 3 with Step Therapy
  • Jublia (siluximab)
    • Tier 3 with PA
  • Kerydin (tavaborole)
    • Tier 3 with PA
  • Orbactiv (oritavancin)
    • Tier 4
  • Striverdi Respimat (olodaterol)
    • Tier 2
  • Triumeq (dolutegravir/abacavir/lamivudine)
    • Tier 5
  • Zydelig (idelalisib)
    • Tier 5 with PA

Criteria Changes

  • Synagis – Coverage criteria updated to follow the American Academy of Pediatrics 2014 guidance for Palivizumab (Synagis) prophylaxis
  • Hormone Replacement Therapy (HRT) in Gender Reassignment – Requires that approval be placed on file by Medical Management for gender reassignment intended treatment plan
  • Erectile Dysfunction – Updated criteria for Affordable Care Act

HEDIS® MEASURE – Drug-Disease Interaction

Potentially Harmful Drug-Disease Interactions in the elderly is a HEDIS measure that addresses medication and safety in the Medicare Advantage population. This measure reports the percentage of members with underlying diseases or health conditions who were given an ambulatory prescription for a contraindicated medication. There are 3 separate measures and a total rate:

  • A history of falls and a prescription for anticonvulsants, nonbenzodiazepine hypnotics, selective serotonin reuptake inhibitors, anitemetics, antipsychotics, benzodiazepines, or tricyclic antidepressants.
  • Dementia and a prescription for antiemetics, antipsychotics, benzodiazepines, tricyclic antidepressants, H2 receptor antagonists, nonbenzodiazepine hypnotics, or anticholinergic agents.
  • Chronic kidney disease and prescription for Cox-2 Selective non-steroidal anti-inflammatory drug (NSAID) or nonaspirin NSAID.
  • The total rate is the sum of the 3 numerators divided by the sum of the 3 denominators.

Note: With this HEDIS measure, lower rates mean fewer prescriptions for potentially harmful medication.

 

Results from 2014 Quality Compass® Report and HEDIS®

Results from 2014 Quality Compass Report and HEDIS

As you review medications for at risk patients, please consider using a safer alternative for the contraindicated medications. If you have questions about alternative medications, call us at 1-800-851-3379, option 4.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Quality Compass® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Medicaid Updates & Reminders

Medicaid prescriptions for eyeglasses can be sent directly to JAK Lab or Dixon Lab. JAK Lab is able to produce the eyeglasses within 30 days. You do not need to go through Health Alliance Connect for approval before sending to either of these optical labs.

Coming Soon: New Facility Editor Software

We use a physician’s claim editor software called iCES by Ingenix. By the end of the first quarter in 2015, we plan to start using the Ingenix facility editor software as well. As we near the start date, we’ll share more information about when to expect changes to the remit identifying any coding issues.

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