February Newsletter

Pharmacy

Formulary Additions

• Potiga – Indicated as adjunctive treatment of partial-onset seizures.
  • Tier 3
• Picato gel – For the topical treatment of actinic keratosis.
  • Tier 3 with a preauthorization (PA)
• Korlym – For patients with endogenous Cushing’s syndrome who have type 2 diabetes and have failed surgery or are not candidates for surgery.
  • Tier 5 non-preferred specialty pharmacy with PA
• Kalydeco – For the treatment of cystic fibrosis in patients who have a G551D mutation in the CFTR gene.
  • Tier 5 non-preferred specialty pharmacy with PA

Formulary Changes

• Removed Intermezzo and Edluar, brand-name formulations of the sleep agent zolpidem
  • Claims will process at 100% coinsurance

Preauthorization Criteria Updates

• Acthar HP gel – Exacerbation of multiple sclerosis is now an excluded indication due to the lack of evidence to support greater efficacy compared to high-potency corticosteroids and the $35,000 cost for Acthar
• Synagis treatment in Respiratory Syncytial Virus (RSV)
  • Coverage is limited to a maximum of 5 doses per season
  • Seasonality will be reviewed and exceptions may be made as medically necessary
• Added Managed Dose Limits (MDL) that follow the label indications and recommended doses
  • Remicade
  • Enbrel
  • Humira
  • Cimzia
  • Tysabri
  • Actemra
  • Kineret
  • Orencia
  • Aredia
  • Simponi
  • Stelara
  • Soliris

Preauthorization and MDL information for specific drugs are available by looking at the Policies and Procedures page of Your Health Alliance for provider or office personnel.

Preauthorization Requirement Changes for Procedures

Effective March 1, 2013, Endothelial Keratoplasty and Transfemoral Aortic Valve Replacement will require preauthorization for all plans.

Skilled Nursing Facility & Home Health Submission

Medicare Advantage organizations and other entities are required to submit Health Insurance Prospective Payment System (HIPPS) codes to the Centers for Medicare and Medicaid Services for all Skilled Nursing Facility/Home Health (SNF/HH) encounter submissions that have a July 2013 or later date of submission. Therefore, all providers submitting SNF/HH encounters to us must use these codes on all encounters starting no later than July 1, 2013.

High-Risk Medications in the Elderly

In 2012, the Centers for Medicare and Medicaid Services (CMS) updated its list of high-risk medications (HRMs) that should be avoided or used with caution in the elderly population. Several widely prescribed drugs were added to the list, including amitriptyline and glyburide.

An updated version of the complete High-Risk Medication chart will soon be available on Your Health Alliance for providers and office personnel.

*Tiers (Open Formulary)

• T1: Tier 1/Preferred Generic
• T2: Tier 2/Non-preferred Generic
• T3: Tier 3/Preferred Brand
• T4: Tier 4/Non-preferred Brand
• NA: Not applicable
• PA: Preauthorization
• ST: Step Therapy
• OTC: Over-the-Counter

Tiers in this table are based on Medicare part D formulary.

Medicare Health Outcomes Survey

One of the ways CMS measures quality of care provided by Medicare Advantage plans is through the Health Outcomes Survey (HOS). In collaboration with the National Committee for Quality Assurance (NCQA), a random sample of our Medicare Advantage members are surveyed to measure and assess physical and mental functioning over time. From August through October 2012, a random sample of 603 of our Medicare Advantage members responded to an off-season mock survey to compare against the results of the 2011 HOS survey.

Although the survey results were very good, there were still some opportunities for improvement on the provider side. These included advising members to start, increase, or maintain their level of physical activity, discussing possible treatment options for members indicating a problem with bladder control and falls, and talking to members about the prescription medications they are taking.

We are proud to say we’re one of the top-ranking Medicare Advantage health plans in the nation. By working together on quality improvement initiatives, we will continue to meet or exceed quality measures in the future.

HEDIS^® Chart Reviews are Coming

Each spring, we collect data to determine how we compare to national averages for the Healthcare Effectiveness Data and Information Set (HEDIS). This data collection and analysis indicates where we need to focus our quality efforts and is required to obtain NCQA accreditation. Successfully completing our HEDIS report depends largely on the cooperation we receive from provider office staff. In other words, we need your help.

Gathering data for the HEDIS audit requires access to medical records. Random samples are generated for each HEDIS measure. If your office is identified in one or more sample, you may receive a request by mail or fax to copy and send specific medical records to us, or a representative may visit your office to review and obtain copies of specific medical records relating to HEDIS.

The HEDIS audit is overseen by an external audit group to ensure rigorous compliance to standards and specifications. Our reviewers are professionals who understand the importance of protecting personal health information. All individually identifiable information concerning patients will be kept strictly confidential in compliance with HIPAA regulations.

More information about HEDIS is available in your provider manual, and HEDIS results are posted at HealthAlliance.org.

You can review the provider manual on the Forms and Resources page of  Your Health Alliance for providers and office personnel.

If you have any questions about HEDIS, contact the Quality Management department at 1-800-851-3379, extension 8112.

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

Provider Satisfaction Survey Coming Soon

Each year, we send provider satisfaction surveys to a random sample of our providers. We take the feedback from these surveys seriously and value your input as we continue to improve our processes. If you receive a survey, please take the time to give us your honest feedback and send it back. Thanks in advance for the time you take to complete the survey and for the excellent care you provide our members.

2013 Provider Manuals

The 2013 Provider Manual will soon be available on Your Health Alliance for providers and office personnel. If your office does not have internet access, you may request a CD copy of the manual by contacting your provider relations specialist.