Midwest February Newsletter

HEDIS^® Chart Reviews Coming Soon

Each spring, Health Alliance collects data to determine how we measure up against 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 for National Committee for Quality Assurance (NCQA) accreditation. Successfully generating our HEDIS report depends largely on the cooperation we receive from provider office staff.

In other words, we need your help. Representatives may visit your office this spring to review specific medical records or ask you to copy, fax ,or mail records. All individually identifiable information concerning patients will be kept strictly confidential in compliance with HIPAA regulations. If you have any questions about HEDIS, contact the Quality & Medical Management Department at 1-800-851-3379, ext. 8656.

Results of the HEDIS audit will be available on the Health Alliance website in the fall of 2016.

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

Medicaid Coverage for Immunization Administration Charges

Health Alliance Connect follows traditional Medicaid payment guidelines (as outlined in our Medicaid provider agreements) and does not reimburse for the immunization administration charges for our Medicaid members.

If you have questions, contact your provider relations specialist.

Meet with a Coding Specialist

The Risk Adjustment coding consultants are visiting participating provider offices to share member-specific examples of coding and quality measure needs. A coding consultant is happy to meet with you to discuss any coding or quality questions you may have or to provide specific examples from your panel of members. If you’re interested, email us at CodingCounts@healthalliance.org.

New CMS Training Requirements

Starting in 2016, all Medicare Advantage organizations and Prescription Drug Plan sponsors, like Health Alliance Medicare, will be required to provide general compliance and fraud, waste, and abuse (FWA) training for all employees of their organization and for the first-tier, downstream, and related entities (FDRs) they partner or contract with to provide benefits or services.

If you have a contractual relationship with Health Alliance Medicare, you are considered an FDR, and you and all your employees are required to complete this training.

If you are an FDR, please make sure that you and your employees complete the general compliance and/or FWA training modules located on the Centers for Medicare & Medicaid Service’s (CMS) Medicare Learning Network (MLN). Choose “Web-Based Training Courses” under “Related Links” to get to the training modules. The MLN system-generated certificates of completion will serve as evidence of compliance.

You must maintain certificates or documentation of training completion (certificates of completion, training logs, system-generated reports, spreadsheets, etc.), containing at least employee names, dates of employment, dates of completion, and passing scores (if captured), for 10 years.

Pharmacy Updates

All Plans

Formulary Additions

• Lonsurf (trifluridine/tipiracil) – An oral cytotoxic agent that combines 2 drugs (trifluridine and tipiracil) to treat patients with recurrent colorectal cancer despite previous chemotherapy treatments.
  • Commercial – Tier 5 with preauthorization (PA)
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA
• Odomzo (sonidegib) – Joins Erivedge (vismodegib) as the second drug approved for the treatment of locally advanced basal cell carcinoma (BCC). Belongs to the hedgehog pathway inhibitor drug class.
  • Commercial – Tier 5 with PA
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA

Formulary Exclusions

• Addyi (flibanserin) – The first and only FDA-approved agent to treat female sexual disorder.
  • Commercial – Excluded
  • Medicare, Duals, and Medicaid – Non-Formulary
• Zecuity (sumatriptan) – Novel iontophoretic transdermal patch delivery route for sumatriptan in the treatment of migraines in adults.
  • Commercial – Excluded
  • Medicare, Duals, and Medicaid – Non-Formulary

Medicaid

Tier Changes – Effective 2/1/16

Contraceptives moved from Covered to Not Covered:

• Depo-SubQ 104
• Ortho Tri Cyclen Lo
• Safyral
• Beyaz
• Lo Loestrin FE
• Natazia

Criteria Change

Lansoprazole Step-Edit – Added coverage of first lansoprazole suspension.

Medicaid & Commercial

Criteria Additions and Changes

• Behavioral Health – Separated Brand Name Atypical Antipsychotic criteria based on indication and removed psychiatrist gold card on atypical antipsychotics
• Humira – Added coverage criteria for Hidradenitis Suppurativa and specified approval time
• Kalydeco – Edited age criteria to 2 years or older
• Excluded Drug List – Changed language regarding Excluded Formulations to include both brand name and generic, added exclusion of compounding kits, and removed nasal corticosteroid exclusion
• Phenoxybenzamine – Established coverage criteria
• Naloxone Injection – Established coverage criteria

Commercial

Formulary Additions

• Envarsus XR (tacrolimus) – An oral, once-daily, extended-release tacrolimus tablet formulation.
  • Commercial – Tier 3
  • Medicare, Duals, and Medicaid – Non-Formulary
• Varubi (rolapitant) – A selective and competitive antagonist that acts centrally to block the NK1 receptor from substance P, which in turn prevents activation of the vomiting center in the brain.
  • Commercial – Tier 3 with quantity limit of 2 tablets in 28 days
  • Medicare, Duals, and Medicaid – Non-Formulary

Criteria Additions and Changes

• Soolantra – Added PA
• Medical Exception for Tier 2 Copayment – Excluded DAW exception approvals from eligibility for Tier 2 copayment
• Eurax – Added step through permethrin
• Sklice – Added step through permethrin

Tier Changes – Effective 1/1/16

• First lansoprazole suspension – Moved from Excluded to Tier 1
• Multiple Sclerosis agents – Moved from Tier 5 to Tier 4
  • Avonex
  • Aubagio
  • Plegridy
  • Tecfidera
• Multiple Sclerosis agents – PA removed*
  • Avonex
  • Aubagio
  • Plegridy
  • Tecfidera
  • Betaseron
  • Copaxone
  • Extavia
  • Gilenya
  • Glatopa
  • Rebif

*Note: PA remains on Tysabri and Lemtrada.

Health Alliance Upgraded Our Secure Email System

On January 30, we upgraded our system for sending secure emails. The first time you received an email from a Health Alliance address with *secure* in the subject line, you had to set up an account to view the message. Now that we’ve upgraded, the next time you receive a secure email from a Health Alliance address, you’ll have to register for a new account again.

In the past, you might have had issues opening secure emails from Health Alliance in browsers other than Internet Explorer, like Chrome, Firefox, or Safari. With this upgrade, you shouldn’t have problems opening secure emails in those browsers anymore.

You can no longer access emails stored on the old secure system. If you can’t find a message you need, email your Health Alliance contact and ask if he or she can resend the original message.

If you have any questions, contact your provider relations specialist.

Annual Monitoring of Patients on Persistent Medications

Annual Monitoring of Patients on Persistent Medications is a HEDIS^® measure that reports the percentage of members 18 years and older who received at least 180 treatment days of ambulatory medication therapy for a selected agent during the measurement year and at least one therapeutic monitoring event for that agent.

This table shows the 3 medication categories and the required lab tests measured during the 2015 HEDIS audit.

For the past 2 years, Health Alliance Commercial HMO/POS and Medicare Advantage HMO plans have reported rates above the Quality Compass^® 75^th percentile in this measure. The Medicare Advantage PPO plan rates are at the Quality Compass National Average for the ACE/ARB and Diuretics and are above the 90^th percentile for the Digoxin measure.

As you order medication refills for your patients, please check to be sure they have had lab tests to monitor the effects of these medications.

Potentially Harmful Drug-Disease Interactions in the Elderly

Potentially Harmful Drug-Disease Interactions in the Elderly is a HEDIS^® measure that shows the percentage of Medicare Advantage members who have a documented history of falls, dementia, or chronic renal failure and are taking a medication contraindicated for the specific diagnosis.

These are the medications to avoid for these conditions.

• History of falls – Anticonvulsants, nonbenzodiazepine hypnotics, SSRIs, antiemetics, antipsychotics, benzodiazepines, or tricyclic antidepressant
• Dementia – Antiemetics, antipsychotics, benzodiazepines, tricyclic antidepressants, H² receptor antagonists, nonbenzopdiazepine hypnotics, or anticholinergic agents.
• Chronic renal failure – Cox-2 selective NSAIDs or nonaspirin NSAIDS

The goal of this measure is to promote patient safety and decrease adverse drug events in a population that is at increased risk.

For the past 2 years, Health Alliance Medicare Advantage plans have performed below the national average for this measure. The 2015 HEDIS audit shows that 56% of the Medicare HMO (MAHMO) and 52% of Medicare PPO (MAPPO) members with history of falls were on at least one of these medications. The report also showed 53% of members with dementia in the MAHMO and 56% of members with dementia in the MAPPO were on one of these medications. The chronic kidney disease measure performs better with the MAHMO at 4%, which is the 75th percentile and MAPPO at 6%, which is at the national average.

For members with a history of falls, the most frequently prescribed medications to avoid are amitriptyline and zolpidem. Review this high-risk medication chart for suggested alternatives.

Please consider these recommendations when prescribing medication.

Smoking Cessation Support for Members

The Affordable Care Act mandates that insurers cover a 90-day supply of tobacco cessation drugs without a copayment every 6 months. However, physicians should also stress the importance of behavioral support to the success of quitting tobacco. People are far more likely to quit if a physician encourages quitting and discusses not only drugs, but also behaviors that may help or hurt their success.

Health Alliance offers free counseling for our members through Quit For Life^® at 1-866-784-8454. The American Lung Association Tobacco QuitLine at 1-800-LUNGUSA also offers free support.

New Clear Coverage Usage Requirements

Clear Coverage, the program used to request preauthorization, has new minimum usage requirements. Please ensure your computer and software meet these requirements so you can continue using Clear Coverage without issues.

Browser Support

Use any of these recommended Web browsers:

• Internet Explorer 11 or higher
• Google Chrome version 47 or higher
• Mozilla Firefox version 42 or higher

You will also need Adobe® Flash® Player 17 or higher installed. Most browsers have the Flash Player installed, but you can check which version you have installed.

If you do not have Flash Player installed or have an older version, please upgrade to Flash Player 17 or higher.

Adobe Reader

Clear Coverage generates PDF files. In order to view and print PDFs, Adobe Reader^® is required. Please download Adobe Reader if you don’t already have it.

Screen Resolution

Clear Coverage requires a screen resolution of 1024 x 768 pixels. It will function with smaller screen resolutions, but you will have difficulty scrolling to all the buttons. For optimal viewing, use a monitor that supports a screen size of 1024 x 768, and change your screen resolution to 1024 x 768 or greater.