June 2023 Newsletter

Welcoming Summer with Gratitude

Tomorrow is the official start to summer – a time we know is particularly busy for you and all your fellow providers with whom we’re so honored to partner. All year round we’re incredibly grateful for you, but in the summer we’re especially aware of how full your schedules are and how much you do every day for our members and their families. We simply can’t thank you enough. As the first weeks of summer bring (hopefully!) added sunshine, we extend rays of warmth your way, through heartfelt gratitude for your compassionate and dedicated care.

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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.

National Men’s Health Month

June is National Men’s Health Month – an excellent time to remind all your male patients to stay healthy by eating right, exercising and seeking regular annual checkups.

Encourage your male patients to:

• Eat healthy by including more fruits and vegetables in their diet, and by limiting foods that are high in calories, sugar, salt and fat.
• Get moving. Have them make a personal goal to reach 2.5 hours of physical activity per week. They can pick activities they enjoy – this’ll help them stay motivated.
• Quit tobacco. Smoking is the number one preventable cause of death in the U.S. and the primary cause of COPD and lung cancer.
• Make prevention a priority. Help them schedule their yearly checkups and regular health screenings, including:
  • Annual physical exams, where their overall health status is reviewed, a thorough physical exam is performed, and health-related topics like blood pressure and cholesterol checkups are discussed.
  • The shingles vaccine for those 50 and older. Note: if they have COPD or diabetes, they’re at an even higher risk for shingles.
  • Osteoporosis prevention for those 45 and older who are at higher risk for osteoporosis because they: have low body weight, smoke, consume alcohol regularly, or are of older age and have a family history of osteoporosis or hip fractures.
  • Colorectal cancer screening for those 45 and older. Great at-home options include an annual FIT testing kit or a Cologuard® kit every three years.

Thank you, as always, for your dedication – together we can help men live their healthiest lives this month and beyond.

Your Voice Is Key – How to Talk Vaccines with Your Patients

As healthcare providers, you know how important vaccines are. But sometimes it’s hard to talk to patients about the specifics – for example, why they’re so important, how they work, when they should schedule them and more. Here are some tips to help you talk with your patients and their families when it comes to vaccines.

Childhood and Adolescent Vaccines

• Have confidence and remember the influence you have. According to the CDC, your recommendation is the number one reason parents and guardians vaccinate their children on time.
• Make sure your staff shares the same consistent message with parents and guardians about the importance of childhood vaccines.
• When talking about vaccines with parents and guardians, use presumptive language that assumes they’ll choose vaccination, like “Your child needs these vaccines this summer,” rather than statements like “What do you want to do about vaccines?”
• Be persistent. Bring up missed vaccines, upcoming vaccines and the child’s vaccination status at every visit.
• Share the CDC’s vaccine schedule with parents and guardians – and take the time to explain it to them.
• Recommend the HPV vaccine the same way and at the same time that you’re mentioning other vaccines.

Adult Vaccines

• Once again, have confidence and remember your influence. YOU are the most trusted and valued source of health information for adults, according to the CDC.
• Make sure your staff shares the same consistent message about the importance of vaccines.
• Be persistent. At every visit, bring up your patient’s missed vaccines, upcoming shots and vaccination status.
• Share the CDC’s adult vaccine schedule with your patients – and take the time to explain it to them.
• Remind patients who have health conditions that increase their risks (of getting certain diseases or developing more serious complications from certain diseases) how vaccines are even more important for them.

Finally – for both your adult patients and the parents and guardians of your young patients – remember that people are often just looking for reassurance that vaccines are safe and effective. Always take the time to listen and understand their concerns. Know beforehand, and be prepared to talk about, the benefits and side effects of every vaccine you administer. And if someone refuses a vaccine, always revisit the subject at their next appointment. You’re the trusted expert, and your voice can help more children and adults get the preventive care they need to stay healthy.

References Used for This Article

CDC, “Key Messages to Help Healthcare Providers Make Strong Vaccine Recommendations,” https://www.cdc.gov/vaccines/events/niam/hcp/key-messages.html#print.

Lung Cancer Screening Recommendations

Here are the lung cancer screening recommendations from the United States Preventive Services Task Force (USPSTF).

Recommendations

Those age 50 to 80 who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years should:

• Screen for lung cancer with low-dose computed tomography (CT) every year.
• Stop screening once they have not smoked for 15 years or have a health problem that limits life expectancy or the ability to have lung surgery.

How to Implement the Recommendations

• Assess patient risk based on age and pack-year smoking history: Is the patient age 50 to 80, and have they accumulated 20 pack-years or more of smoking?
  • A “pack-year” is a way of calculating how much someone has smoked in their lifetime. One pack-year is the equivalent of smoking an average of 20 cigarettes (one pack) a day for a year.
• Screen: If your patient is age 50 to 80 and has a 20 pack-year or more smoking history, engage in shared decision-making about screening.
  • Make sure to discuss the potential benefits, limitations and harms of screening.
  • If your patient decides to get screened, refer them for lung cancer screening with low-dose CT, ideally to a healthcare center that has experience and expertise in lung cancer screening.
  • If the patient currently smokes, help them receive smoking cessation help. See the next article for one great option our members have access to.

Note: Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Help your patients quit smoking.

Did you know that most of our health plans cover smoking cessation medications and coaching for our members?

Our smoking and vaping cessation program, Quit For Life^®, is a great first step. Quit For Life is the nation’s leading tobacco cessation program, complete with one-on-one support from a Quit Coach^®. Here are some more details:

• Members can enroll once every 12 months (equals two quit attempts).
• They can use a combination of nicotine replacement therapy (NRT) and Zyban^®, or Chantix^®. There’s no pharmaceutical copay if accompanied by a prescription.
• They can get patches, gum and lozenges through our own pharmacy without a prescription, when we mail directly to them.

And they also can get:

• Behavioral support that lasts six months.
• Help understanding their medication.
• One-on-one coaching by phone.
• A personal quit plan made just for them.

Tobacco harms far too many lives. We ask for your help in encouraging your patients to get the support they need. Let them know about this covered program, and point them to this webpage to learn more. Together we can help them Quit For Life.

What to Know About Benzodiazepine and Opioid Use Disorders

Benzodiazepines and opioids should always be prescribed with caution (and always monitored closely if prescribed), since these medications can often cause patient harm. They carry a risk of dependence and major withdrawal symptoms. Here’s key information from UpToDate^®.

Benzodiazepines

If your patient is on benzodiazepines, potential harms (and signs of harm) can include:

• Intoxication: unsteady gait, slurred speech, cognitive impairment.
• Overdose: nystagmus, stupor comas or respiratory depression.
• Withdrawal: hyperactivity, anxiety, seizures and death.

Watch for the signs of benzodiazepine use disorder, which can include:

• Taking the drugs in larger amounts, or for longer periods, than intended.
• Cravings to use benzodiazepines.
• Persistent desire to control their benzodiazepine use, and/or unsuccessful efforts to control it.
• Evidence of tolerance or withdrawal.
• Large amounts of time spent obtaining and/or using the drugs.
• Continued/repeated benzodiazepine use:
  • Despite the failure to fulfill major obligations.
  • In dangerous situations.
  • Despite persistent social problems.
  • To the point of giving up or greatly reducing time spent on other important activities in their life.

Opioids

If your patient is on opioids, here’s what to know:

• Opioid dependence: defined as when abrupt cessation or rapid reduction of opioid use results in physical and affective withdrawal.
• Opioid misuse: any use of opioids outside the specific prescribed use.
• Opioid use disorder is a psychiatric disorder. Its risk factors include when patients:
  • Undergo a surgery that causes high levels of pain.
  • Use other substances like alcohol and tobacco.
  • Are prescribed subsequently larger doses by their providers.
  • Are prescribed doses for longer durations.

References Used for This Article

Jennifer Hah, MD, MS, James Khan, MSc, MD, FRCPC, and Chinwe Nwaneshiudu, MD, PhD, “Risk of long term opioid use and misuse after prescription of opioids for pain,” UpToDate^®, https://www.uptodate.com/contents/risk-of-long-term-opioid-use-and-misuse-after-prescription-of-opioids-for-pain.

Tae Woo Park, MD, MSc, “Benzodiazepine use disorder,” UpToDate^®, https://www.uptodate.com/contents/benzodiazepine-use-disorder.

Help us increase shingles vaccine uptake for high-risk patients.

The shingles vaccine is especially important for your high-risk patients, like those with diabetes or COPD. Here’s key information from the CDC and the National Library of Medicine.

The Basics

Herpes zoster (also known as HZ or shingles) is a viral disease characterized by a painful rash. It’s due to the reactivation of the varicella zoster virus (VZV). Despite treatment, the most common complication of HZ is chronic pain in the affected area (postherpetic neuralgia, or PHN). HZ incidence increases sharply with age, being higher after age 50 and affecting up to 50% of people age 85 and older. Along with age, underlying diseases such as diabetes and chronic obstructive pulmonary disease (COPD) also increase the risk, severity and impact of HZ episodes among this population.

The CDC estimates that one-quarter to one-third of adults will develop shingles at some point in their life. One-third of these will develop complications, most commonly long-lasting nerve pain that can go on for months or even years after the rash has healed. The CDC recommends SHINGRIX (recombinant zoster vaccine) for the prevention of HZ and related complications, including the chance of drug addiction from opioids and other pain management medication.

The CDC recommends two doses of SHINGRIX, separated by two to six months, for immunocompetent adults age 50 and older:

• Whether or not they report a prior episode of HZ.
• Whether or not they report a prior dose of Zostavax, a shingles vaccine no longer available in the U.S.
• Who have chronic medical conditions (like chronic renal failure, diabetes mellitus, rheumatoid arthritis or COPD), unless a contraindication or precaution exists.
• Who are getting other adult vaccines in the same doctor’s visit, including those routinely recommended for adults 50 and older, such as influenza and pneumococcal vaccines.

It’s not necessary to screen, either verbally or by laboratory serology, for evidence of prior varicella infection. And SHINGRIX may still be used for adults who are taking low-dose immunosuppressive therapy; those who are anticipating immunosuppression; and those who have recovered from an immunocompromising illness.

Contraindications and Precautions for HZ Vaccination

• A person with a history of severe allergic reaction, such as anaphylaxis, to any component of a vaccine or after a previous dose of SHINGRIX.
• A person who is known to be seronegative for varicella.
  • It’s not necessary to screen (either verbally or via laboratory serology) for a history of varicella. However, if a person is known to be varicella negative via serologic testing, providers should follow ACIP guidelines for varicella vaccination.
  • A person experiencing an acute episode of HZ. SHINGRIX is not a treatment for HZ or postherpetic neuralgia.
• Providers should consider delaying SHINGRIX vaccination for pregnant women and women who are breastfeeding.
• Adults with a minor acute illness, such as a cold, still can receive SHINGRIX. Adults with a moderate or severe acute illness should usually wait until they recover before getting the vaccine. This includes anyone with a temperature of 101.3°F or higher.

To learn more, see Contraindications and Precautions, General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP).

Coverage Information

SHINGRIX is covered as preventive on our Commercial plans for ages 50 years and older. For Medicare plans, it’s covered on the Part D benefit and is covered on Tier 3 on the Medicare Part D benefit.

Other References Used for This Article

“Shingrix Recommendations,” CDC, https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/recommendations.html.

Marianthi Papagianni, Symeon Metallidis and Konstantinos Tziomalos, “Herpes Zoster and Diabetes Mellitus: A Review,” National Library of Medicine, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6104256/.

Cintia Muñoz-Quiles, Mónica López-Lacort and Javier Díez-Domingo, “Risk and impact of herpes zoster among COPD patients: a population-based study, 2009–2014,” National Library of Medicine, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5934818/.

Connect your patients to diabetes care and education specialists.

For your patients with diabetes, help from a large and knowledgeable team makes a world of difference. Diabetes care and education specialists can help your patients manage their condition and live their healthiest life. Here’s what you need to know, from the CDC.

Who They Are and What They Do

Diabetes care and education specialists give your patients evidence-based diabetes self-management education and support (DSMES) services. They’re an essential part of the diabetes care team, extending the help you yourself provide your patients. These specialists can also help people, for example those with prediabetes, prevent type 2 diabetes.

CDC Toolkit for DSMES Services

The CDC has developed a toolkit and training just for providers. It’ll help you implement DSMES services and resources for your patients. Among other benefits, DSMES will teach your patients practical skills and personalized strategies to help them manage their diabetes and improve their health outcomes. Check out this webpage for more information, and utilize these helpful links:

• DSMES Toolkit: a comprehensive collection of resources, tools and more.
• DSMES Website for Healthcare Providers: Learn all about how people with diabetes benefit from DSMES.
• Looking for proven and reliable DSMES services to refer your patients to? Discover DSMES services recognized by the American Diabetes Association or accredited by the Association of Diabetes Care and Education Specialists (ADCES).

Help prevent type 2 diabetes.

Diabetes care and education specialists can also help your patients reverse prediabetes or slow down the onset of type 2 diabetes, including through the evidence-based National Diabetes Prevention Program:

• Learn about this proven lifestyle-change program.
• Find out how you can offer this program to your patients.
• Already implementing a program? Find support, resources and more here.

Antipsychotics for Schizophrenia – Links to Metabolic Syndrome and More

Antipsychotic medications prescribed for schizophrenia are often linked to certain health problems. Here’s key information from UpToDate^®.

• Antipsychotics prescribed for schizophrenia have been shown to cause hepatic insulin resistance in patients.
• They’re also proven to cause weight gain.
• For patients with schizophrenia, antipsychotics are also associated with a higher risk for diabetes, cardiovascular disease, hyperlipidemia and metabolic syndrome.
• Metabolic syndrome is linked with other health issues, including chronic liver disease, fatty liver, polycystic ovarian syndrome, sleep apnea and cancer.
• Patients with schizophrenia are also more likely to develop side effects from their antipsychotics.

Because of these links, you should always monitor your patients (who are taking antipsychotics) for cardiovascular disease. Do this through regular lab checks for fasting cholesterol, glucose, triglycerides and waist circumference.

Diagnosis for metabolic syndrome can be made with the following findings:

• High-density lipoprotein cholesterol: <40 mg/dL in men or <50 mg/dL in women (or receiving drug therapy for reduced high-density lipoprotein cholesterol).
• Fasting glucose: ≥100 mg/dL (or receiving drug therapy for hyperglycemia).
• Triglycerides: ≥150 mg/dL (or receiving drug therapy for hypertriglyceridemia).
• Blood pressure: ≥130/85 mmHg (or receiving drug therapy for hypertension).
• Waist circumference: ≥102 cm (40 inches) in men or ≥88 cm (35 inches) in women; if Asian American, ≥90 cm (35 inches) in men or ≥80 cm (32 inches) in women.

Thank you for your dedicated care of your patients.

References Used for This Article

Brenda Vincenzi, MD, and David C Henderson, MD, “Metabolic syndrome in patients with severe mental illness: Epidemiology, contributing factors, pathogenesis, and clinical implications,” UpToDate^®, https://www.uptodate.com/contents/metabolic-syndrome-in-patients-with-severe-mental-illness-epidemiology-contributing-factors-pathogenesis-and-clinical-implications.

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Coding Counts:
Documenting and Coding Drug Abuse

Supporting documentation and accurate coding are key to making sure your patients receive the care they need. Screening, prevention and coordination of care help provide opportunities for early intervention and improved outcomes for patients dealing with drug abuse. Mental and behavioral disorders due to drug abuse require the provider’s clinical judgment and are assigned only on the basis of provider documentation. Here are some more key tips for documenting and coding drug abuse.

Be specific.

Provider documentation of drug abuse should include specifics such as mild, moderate or severe drug abuse. Document and code if the patient is in early or sustained remission.

Per ICD-10-CM guidelines, coding for drug abuse is based on provider documentation, making it key to distinguish abuse from use and dependence. According to Johns Hopkins, “drug abuse is defined as habitual use of a substance that negatively impacts a patient’s health or social functioning but has not arrived at the point of physical and/or mental dependency.”

Signs and symptoms indicating drug abuse may include:

• Missing work or school in an effort to get, use and recover from effects.
• Using the substance in dangerous situations, such as driving a car.
• Withdrawal from social activities and relationships.

Medical Conditions Due to Drug Abuse

ICD-10-CM includes codes for disorders related to drug abuse and these codes should be reported when complications associated with the drug abuse are documented. Complications can include:

Refer to the acronym M.E.A.T. when adding supporting documentation for your diagnosis:

• M – Monitor
• E – Evaluate
• A – Assess
• T – Treat

What to Report When Use, Abuse and Dependence Are Documented

• If both abuse and dependence are documented, assign only the code for dependence.
• If use, abuse and dependence are all documented, assign only the code for dependence.
• If both use and dependence are documented, assign only the code for dependence.

We thank you for your attention to detail and exceptional professionalism, and we’re always here to help. To find more coding resources, visit our Coding Counts page. Thank you for your continued care and dedication to our members’ health.

Questions?

Please contact us at CodingCounts@HealthAlliance.org.

References Used for This Article

ICD-10-CM Official Guidelines for Coding and Reporting

Optum EncoderPro

Johns Hopkins Medicine, HopkinsMedicine.org

Elective Outpatient Dental:

Referral Type and HCPCS Code

We know it’s often challenging for you when you need to submit authorizations for benefit exceptions for:

• Coverage of dental services under medical benefits; and
• Coverage of anesthesia and facility fees for oral or dental surgery.

To streamline this process for you, we’ve added a specific referral type in Epic Tapestry for these requests. This change will allow providers to clearly tell us what services they’re requesting coverage for – and it’ll allow you to receive a clear answer back from our Utilization Management (UM) team.

To submit an authorization request, you should sign into your EpicCare Link account and choose the Authorization Type: Elective Outpatient Dental from the drop-down list. Another way to start this type of request, specifically for anesthesia and facility fee coverage, is to enter code G0330 in the Service Search: Procedure field.

HCPCS code G0330 is a new code created specifically by the Centers for Medicare & Medicaid Services (CMS) to allow oral surgeons and dentists to accurately bill health insurance payors for anesthesia and facility charges. Code G0330 is described in Encoder as: Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care)) and use of an operating room.

We hope you’re as excited as we are about these changes, which will hopefully save you time and hassle. We’re committed to continue optimizing authorizations to deliver the best outcomes for your patients.

In Summary:

What is it?

• A new process for submitting requests for coverage exceptions for dental or oral surgery procedures, and anesthesia and facility fee coverage, if those procedures are to be performed at a surgical facility.

Why do we need it?

• To provide clear communication of coverage when benefit exceptions are requested for dental or oral surgery procedures or coverage of anesthesia/facility fees.

What is in scope?

• Requests for coverage of anesthesia and facility fees using new code G0330: “Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (g., general, intravenous sedation (monitored anesthesia care)) and use of an operating room.”
• Requests for American Dental Association (ADA) CPT codes that may or may not be covered under the member’s medical benefits.

What You Need to Include:

• Clinical documentation outlining why this member’s dental or oral surgical procedure should be covered under their medical benefit.
• Clinical documentation outlining why this member needs to have their dental or oral surgery procedure in a surgical facility rather than in an office setting.

If you have questions, please contact your provider relations specialist. We’re always happy to help.

Sources:

Below is the verbiage from the CMS Fact Sheet, titled “CY 2023 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule with Comment Period (CMS 1772-FC).”

First, we are creating a new code, HCPCS code G0330, to describe facility services for dental rehabilitation procedure(s) furnished to patients who require monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care)) and use of an operating room. We are adopting this code based on extensive public comments expressing the need for a coding and payment mechanism to improve access to covered dental procedures under anesthesia, especially dental rehabilitation procedures, an issue that commenters explained is caused by barriers to securing sufficient operating room time to furnish these services. HCPCS code G0330 will be assigned to APC 5871 (Dental Procedures), the APC to which we proposed to assign CPT code 41899. Due to public comments detailing the lack of access to appropriate facilities to receive dental services under anesthesia, we are creating this code to enable HOPDs to bill the technical, facility-fee component of Medicare-covered dental rehabilitation services only. We further note that HCPCS G0330 is only billable under the OPPS and must only be used to describe facility fees for dental rehabilitation services that meet Medicare coverage requirements as interpreted in the CY 2023 PFS final rule. Therefore, G0330 cannot be used to describe or bill the facility fee for non-covered dental professional services.

…That is why we are creating HCPCS code G0330 for providers to use to bill for facility services for dental rehabilitation procedures performed on patients who require monitored anesthesia in an operating room. We believe this new code is more clinically appropriate and would more accurately pay facility fees for covered dental rehabilitation services furnished to patients who require monitored anesthesia in an operating room rather than unlisted CPT code 41899, which is non-specific. Therefore, we are clarifying that unlisted CPT code 41899 may be used more broadly to describe other dental or dental-related procedures on the teeth and gums, not otherwise described by other HCPCS codes currently assigned to APCs, such as those performed in the clinical dental scenarios as described in the CY 2023 PFS final rule, as well as covered non-surgical dental services and surgical dental services provided to patients who do not require monitored anesthesia and the use of an operating room. In accordance with existing billing practices, providers will continue to use existing, specific CDT codes already assigned to APCs when available.

OPPS Payment for Dental Services

CMS is finalizing coding changes for billing of covered dental services in the CY 2023 OPPS/ASC final rule with comment period. First, CMS is creating a new G-code to describe dental rehabilitation services that require monitored anesthesia and the use of an operating room (OR). CMS is assigning this new G-code to APC 5871 (Dental Procedures), effectively increasing the payment for these dental rehabilitation services from about $200 to about $2000. This code can be used to bill for covered services furnished to patients with special health needs that require general anesthesia in an OR to receive dental care. Second, CMS is clarifying that existing unlisted CPT code 41899 should be used to bill for covered, non-surgical dental services, or surgical dental services not performed under monitored anesthesia in an OR, not otherwise described by existing dental codes already assigned to an APC. We are further clarifying that for Medicare payment to be made for dental services, including services that may be described by G0330, Medicare coverage requirements for dental services as finalized in the CY 2023 PFS final rule, must be met. 

Important Information About the DAW Penalty

Note: This article does not apply to Medicare plans.

Note: This article does not apply to Reid Health Alliance Medicare branded plans.

Please note this important information about the DAW (Dispense As Written) penalty, which applies to the cost-share your patients pay for a medication when you request a brand-name drug that has a generic alternative available. Effective July 1, 2023, the DAW penalty will apply to specialty products that have a generic alternative. Drugs with a narrow therapeutic index, such as transplant drugs and seizure drugs, will be exempt. The penalty will be assessed as the Non-Preferred Specialty copay plus the cost difference between the brand-name and generic versions. Patients who’ve experienced an allergic reaction to the generic can request an exception to the DAW penalty through the medical exception process. Please let us know if you have any questions.

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 High Cost Medical Drugs List may still require prior authorization.

Note: This article/table only applies to our Health Alliance branded Commercial plans (the plans we refer to as Midwest and Carle in the Pharmacy Updates section below). It does not apply to Health Alliance Northwest or Reid Health Alliance Medicare branded plans.

Note: This article/table does not apply to any of our Medicare plans (no matter what their brand/name).

Midwest – Pharmacy Updates

All Plans

Dermatology

Formulary Additions

• Hyftor (sirolimus)— Treatment of facial angiofibroma associated with tuberous sclerosis in adults and pediatric patients ≥6 years of age
  • Formulary placement recommendations
    • Commercial— Non-Preferred Brand with PA
    • Medicare—Non-Formulary
• Spevigo (spesolimab)— Treatment of generalized pustular psoriasis flares in adults
  • Formulary placement recommendations
    • Commercial— Non-Preferred Specialty Medical with PA
    • Medicare—Medicare Part B with PA

Gastroenterology

Formulary Additions

• Bylvay (odevixibat)—Treatment of pruritus in patients’ ≥ 3 months of age with progressive familial intrahepatic cholestasis (PFIC). May not be effective in PFIC type 2 patients with ABCB11 variants resulting in non-functional or complete absence of bile salt export pump protein (BSEP-3)
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy with PA and MDL
    • Medicare—Non-Formulary
  • Voquezna (vonoprazan)—Treatment of H. pylori infection in adults
    • Formulary placement recommendations
      • Commercial—Non-Preferred Brand with PA and MDL
      • Medicare—Non-Formulary

Commercial

Dermatology

New Policy

• Condylox (podofilox gel) Step-Edit
  • Defines step-edit and clarifies how prescribers can bypass step for perianal warts diagnosis

Criteria Changes*

• Denavir (penciclovir cream) Step-Edit
  • Updated to specify topical step
• Opzelura (ruxolitinib)
  • Added coverage criteria for nonsegmental vitiligo, updated exclusion criteria
• Qbrexza (glycopyrronium)
  • Specified axillary hyperhidrosis, added age criteria, added exclusion criteria

Gastroenterology

New Policies

• Xermelo (telotristat ethyl)
  • Health Alliance policy needed since eviCore no longer completes review of supportive therapies
• Ravicti (glycerol phenylbutyrate)
  • Criteria for coverage of Ravicti for urea cycle disorders (specialty pharmacy benefit)
• Irritable Bowel Syndrome – Constipation Step Edit
  • Criteria for coverage of Amitiza, Trulance and Motegrity
  • Coverage requires previous paid claim of Linzess

Criteria Changes*

• Mulpleta (lusutrombopag)
  • Updating exclusion criteria to match other policies within same drug class

Rheumatology

New Policies

• Kevzara (sarilumab)
  • Reinstated Commercial policy to address new polymyalgia rheumatic indication for Kevzara; policy had been retired with creation of immunomodulator policies

Criteria Changes*

• Arcalyst (ilonacept)
  • Updated clinical criteria requirements for CAPs, added criteria for deficiency of IL-1 receptor antagonist and recurrent pericarditis
• Benlysta (belimumab)
  • Added age/specialist criteria to SLE, added lupus nephritis coverage criteria
• Krystexxa (pegloticase)
  • Added requirement for concurrent use with methotrexate
• Saphnelo (anifrolumab)
  • Added age and specialist criteria

Miscellaneous Policy Changes

• Behavioral Health Medications
  • Added generic lurasidone, added Vraylar to antipsychotics used in depression section
• Excluded Drug List
  • Added exclusion for hormone compounds
• Weight Loss Medications [covered for members on plans with a weight loss benefit ONLY (3 Self-Funded plans: FEHB, Paris Hospital, FirstHealth)]
  • Added clinical updates to ensure criteria is applied to specific drugs these plans have elected to cover

Formulary Changes—Commercial (Members have been notified of negative changes)

Positive Changes

Negative Changes

*Members currently utilizing these therapies will not experience a disruption.

Please Note: The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers. Drug coverage and policies in the following categories will be reviewed during the remainder of 2023 and changes may be made:

• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Northwest – Pharmacy Updates

All Plans

Dermatology

Formulary Additions

• Hyftor (sirolimus)— Treatment of facial angiofibroma associated with tuberous sclerosis in adults and pediatric patients ≥6 years of age
  • Formulary placement recommendations
    • WA Individual—Non-Preferred Brand with PA
    • Medicare—Non-Formulary
  • Spevigo (spesolimab)— Treatment of generalized pustular psoriasis flares in adults
    • Formulary placement recommendations
      • WA Individual—Non-Preferred Specialty Medical with PA
      • Medicare—Medicare Part B with PA

Gastroenterology

Formulary Additions

• Bylvay (odevixibat)—Treatment of pruritus in patients’ ≥ 3 months of age with progressive familial intrahepatic cholestasis (PFIC). May not be effective in PFIC type 2 patients with ABCB11 variants resulting in non-functional or complete absence of bile salt export pump protein (BSEP-3)
  • Formulary placement recommendations
    • WA Individual—Non-Preferred Specialty Pharmacy with PA and MDL
    • Medicare—Non-Formulary
• Voquezna (vonoprazan)—Treatment of H. pylori infection in adults
  • Formulary placement recommendations
    • WA Individual—Non-Preferred Brand with PA and MDL
    • Medicare—Non-Formulary

WA Individual

Dermatology

New Policy

• Condylox (podofilox gel) Step-Edit
  • Defines step-edit and clarifies how prescribers can bypass step for perianal warts diagnosis

Criteria Changes*

• Denavir (penciclovir cream) Step-Edit
  • Updated to specify topical step
• Opzelura (ruxolitinib)
  • Added coverage criteria for nonsegmental vitiligo, updated exclusion criteria
• Qbrexza (glycopyrronium)
  • Specified axillary hyperhidrosis, added age criteria, added exclusion criteria

Gastroenterology

New Policies

• Xermelo (telotristat ethyl)
  • Health Alliance Northwest policy needed since eviCore no longer completes review of supportive therapies
• Ravicti (glycerol phenylbutyrate)
  • Criteria for coverage of Ravicti for urea cycle disorders (specialty pharmacy benefit)
• Irritable Bowel Syndrome – Constipation Step Edit
  • Criteria for coverage of Amitiza, Trulance and Motegrity
  • Coverage requires previous paid claim of Linzess

Criteria Changes*

• Mulpleta (lusutrombopag)
  • Updating exclusion criteria to match other policies within same drug class

Rheumatology

New Policies

• Kevzara (sarilumab)
  • Reinstated WA Individual (Commercial) policy to address new polymyalgia rheumatic indication for Kevzara; policy had been retired with creation of immunomodulator policies

Criteria Changes*

• Arcalyst (ilonacept)
  • Updated clinical criteria requirements for CAPs, added criteria for deficiency of IL-1 receptor antagonist and recurrent pericarditis
• Benlysta (belimumab)
  • Added age/specialist criteria to SLE, added lupus nephritis coverage criteria
• Krystexxa (pegloticase)
  • Added requirement for concurrent use with methotrexate
• Saphnelo (anifrolumab)
  • Added age and specialist criteria

Miscellaneous Policy Changes

• Behavioral Health Medications
  • Added generic lurasidone, added Vraylar to antipsychotics used in depression section
• Excluded Drug List
  • Added exclusion for hormone compounds
• Weight Loss Medications [covered for members on plans with a weight loss benefit ONLY (3 Self-Funded plans: FEHB, Paris Hospital, FirstHealth)]
  • Added clinical updates to ensure criteria is applied to specific drugs these plans have elected to cover

Formulary Changes—WA Individual (Members have been notified of negative changes)

Positive Changes

Negative Changes

*Members currently utilizing these therapies will not experience a disruption.

Please Note: The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers. Drug coverage and policies in the following categories will be reviewed during the remainder of 2023 and changes may be made:

• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Carle – Pharmacy Updates

All Plans

Dermatology

Formulary Additions

• Hyftor (sirolimus)— Treatment of facial angiofibroma associated with tuberous sclerosis in adults and pediatric patients ≥6 years of age
  • Formulary placement recommendations
    • Commercial— Non-Preferred Brand with PA
    • Medicare—Non-Formulary
• Spevigo (spesolimab)— Treatment of generalized pustular psoriasis flares in adults
  • Formulary placement recommendations
    • Commercial— Non-Preferred Specialty Medical with PA
    • Medicare—Medicare Part B with PA

Gastroenterology

Formulary Additions

• Bylvay (odevixibat)—Treatment of pruritus in patients’ ≥ 3 months of age with progressive familial intrahepatic cholestasis (PFIC). May not be effective in PFIC type 2 patients with ABCB11 variants resulting in non-functional or complete absence of bile salt export pump protein (BSEP-3)
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy with PA and MDL
    • Medicare—Non-Formulary
• Voquezna (vonoprazan)—Treatment of H. pylori infection in adults
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with PA and MDL
    • Medicare—Non-Formulary

Commercial

Dermatology

New Policy

• Condylox (podofilox gel) Step-Edit
  • Defines step-edit and clarifies how prescribers can bypass step for perianal warts diagnosis

Criteria Changes*

• Denavir (penciclovir cream) Step-Edit
  • Updated to specify topical step
• Opzelura (ruxolitinib)
  • Added coverage criteria for nonsegmental vitiligo, updated exclusion criteria
• Qbrexza (glycopyrronium)
  • Specified axillary hyperhidrosis, added age criteria, added exclusion criteria

Gastroenterology

New Policies

• Xermelo (telotristat ethyl)
  • Health Alliance policy needed since eviCore no longer completes review of supportive therapies
• Ravicti (glycerol phenylbutyrate)
  • Criteria for coverage of Ravicti for urea cycle disorders (specialty pharmacy benefit)
• Irritable Bowel Syndrome – Constipation Step Edit
  • Criteria for coverage of Amitiza, Trulance and Motegrity
  • Coverage requires previous paid claim of Linzess

Criteria Changes*

• Mulpleta (lusutrombopag)
  • Updating exclusion criteria to match other policies within same drug class

Rheumatology

New Policies

• Kevzara (sarilumab)
  • Reinstated Commercial policy to address new polymyalgia rheumatic indication for Kevzara; policy had been retired with creation of immunomodulator policies

Criteria Changes*

• Arcalyst (ilonacept)
  • Updated clinical criteria requirements for CAPs, added criteria for deficiency of IL-1 receptor antagonist and recurrent pericarditis
• Benlysta (belimumab)
  • Added age/specialist criteria to SLE, added lupus nephritis coverage criteria
• Krystexxa (pegloticase)
  • Added requirement for concurrent use with methotrexate
• Saphnelo (anifrolumab)
  • Added age and specialist criteria

Miscellaneous Policy Changes

• Behavioral Health Medications
  • Added generic lurasidone, added Vraylar to antipsychotics used in depression section
• Excluded Drug List
  • Added exclusion for hormone compounds
• Weight Loss Medications [covered for members on plans with a weight loss benefit ONLY (3 Self-Funded plans: FEHB, Paris Hospital, FirstHealth)]
  • Added clinical updates to ensure criteria is applied to specific drugs these plans have elected to cover

Formulary Changes—Commercial (Members have been notified of negative changes)

Positive Changes

Negative Changes

*Members currently utilizing these therapies will not experience a disruption.

Please Note: The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers. Drug coverage and policies in the following categories will be reviewed during the remainder of 2023 and changes may be made:

• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Reid – Pharmacy Updates

Medicare

Dermatology

Formulary Additions

• Hyftor (sirolimus)— Treatment of facial angiofibroma associated with tuberous sclerosis in adults and pediatric patients ≥6 years of age
  • Formulary placement recommendations
    • Medicare—Non-Formulary
• Spevigo (spesolimab)— Treatment of generalized pustular psoriasis flares in adults
  • Formulary placement recommendations
    • Medicare—Medicare Part B with PA

Gastroenterology

Formulary Additions

• Bylvay (odevixibat)—Treatment of pruritus in patients’ ≥ 3 months of age with progressive familial intrahepatic cholestasis (PFIC). May not be effective in PFIC type 2 patients with ABCB11 variants resulting in non-functional or complete absence of bile salt export pump protein (BSEP-3)
  • Formulary placement recommendations
    • Medicare—Non-Formulary
• Voquezna (vonoprazan)—Treatment of H. pylori infection in adults
  • Formulary placement recommendations
    • Medicare—Non-Formulary

*Members currently utilizing these therapies will not experience a disruption.

Please Note: The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers. Drug coverage and policies in the following categories will be reviewed during the remainder of 2023 and changes may be made:

• June Meeting: Cardiology, Endocrinology, Pulmonology.
• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Contact Us

 (800) 851-3379, option 3

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