June 2024 Newsletter

Our Warmest Thanks

With the official start to summer just a couple days away, we’re entering into the warmest months of the year – the perfect time to express our warm thanks for all you do for our members. Every day, you bring your knowledge, talent and hard work to improve their health and well-being, and we hope you know how truly grateful we are. Your partnership makes everything we do so much better – like bright sunshine on a long summer’s day.

Network Change

Note: This article only applies to our Health Alliance^TM network (the plans we refer to as Midwest and Carle in the Pharmacy Updates section below). It does not apply to the Health Alliance Northwest^TM network.

Carlinville Area Hospital & Clinics, including Carlinville Family Health Care and Girard Family Health Care, will cease participation in Health Alliance networks after 07/31/24. If one of your patients asks you about this change, please refer them to the Customer Service phone number that’s on the back of their ID card. The Customer Service team can answer any questions patients may have as it relates to this change in the Health Alliance network.

Thank you for all you do for our members on a daily basis to provide the best care and service.

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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.

Capturing Nutrition, Physical Activity and BMI in the EMR

Help us improve our HEDIS^®* performance for counseling our young members on nutrition, physical activity and their BMI percentile by capturing it in the EMR when you perform these important services.

Background:

• The HEDIS measure looks at patients age 3 to 17 years old.
• Documentation for BMI must include: height, weight and BMI percentile (either as a value or on a plotted age-growth chart).
  • Since BMI varies with age and gender, we’re more focused on whether or not the BMI was documented – and less worried about what the value is.
• Documentation for nutrition should include one of these: notes on discussion of current nutrition habits; counseling or referral to nutrition education; guidelines for nutrition; and more.
• Documentation for physical activity should include one of these: notes on discussion of current physical activity behaviors; counseling or referral for physical activity; educational materials; and more

We appreciate your efforts and help with not only improving our HEDIS performance, but – even more so – with making sure our young members are well educated about healthy habits. You have such a life-changing impact on them, and we are thankful beyond words.

Visit our provider resources page for our full Well-Child Visit tip sheet.

*The Healthcare Effectiveness Data and Information Set (HEDIS^®) is a set of quality standards that helps us together measure and assess the care and treatments patients receive. HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Well-Baby Visits and Infant Immunizations

As you know, the American Academy of Pediatrics recommends children have 11 well-care visits – and a number of specific immunizations – before they turn 2½ years old.

Our HEDIS performance is broken down into the first 15 months of a child’s life and then, subsequently, into months 15 through 30 of life. In total, the goal is for those young members to have eight or more visits within that time frame.

For this same age group, our HEDIS performance is also based on their completion of the following vaccines before they turn 2 years old:

• Four diphtheria, tetanus and acellular pertussis (DTaP).
• Three polio (IPV).
• One measles, mumps and rubella (MMR).
• Three Haemophilus influenzae type b (Hib).
• Three hepatitis B (HepB).
• One chickenpox (VZV).
• Four pneumococcal conjugate (PCV).
• One hepatitis A (HepA).
• Two or three rotavirus (RV).
• Two influenza (flu) vaccines.

For our members who are new parents, we have a campaign sharing a “Healthy Baby Guide” when their new baby is between 1 and 2 months old. The hope of the campaign is to encourage the completion of all 11 visits and all recommended immunizations.

Although this campaign is active, we’re finding parents have more trust in the words of their providers – and we need your help getting these members in for their appointments and vaccinations. Thank you for such important work.

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

Men’s Health Highlight: Colorectal Cancer

June is Men’s Health Month – the perfect time to educate your male patients about colorectal cancer. According to the American Cancer Society^®, the risk of developing colorectal cancer is 1 in 23 for men. Plus, colorectal cancer is the third-leading cause of cancer-related death for men.

That’s why screening is so important. The United States Preventive Services Task Force recommends people age 45 to 75 be screened for colorectal cancer regularly.

Talk with your patients – both men and women – about which screening option might be the best kind of test for them:

• Fecal occult blood test or fecal immunochemical test, annually.
• Cologuard^®, every three years.
• Flexible sigmoidoscopy, every five years.
• Colonoscopy, every 10 years.

Your recommendations to your patients are key – you’re their trusted provider, and your advice can literally save their lives by helping them prevent cancer or catch it early. Thank you for your valued partnership.

Check out our Tip Sheets – for colorectal cancer screening and much more – on our provider resources page.

Diabetes Care, Treatment and Management

You play a vital role in helping your patients prevent, delay or manage diabetes. Here’s some key information – and resources – from the Centers for Disease Control and Prevention (CDC).

• Having prediabetes increases the risk of developing type 2 diabetes. And in the U.S., about 1 in 3 adults have prediabetes – but over 80% of these people don’t know they have it.
• You can help – make sure your patients get screened for prediabetes.
• For those who have prediabetes, you can then refer them to the National Diabetes Prevention Program (National DPP), a CDC-recognized lifestyle-change program. It’s proven to lower the risk of diabetes by more than half.
• The program teaches your patients how to get more exercise, eat healthier, manage stress levels and stay motivated.
• Click here to learn more about how you can refer your patients to the National DPP, and find resources and support here.
• For your patients already with diabetes, make sure you refer them to Diabetes Self-Management Education and Support (DSMES) services.
• DSMES improves your patients’ diabetes management skills, teaching them strategies for controlling their diabetes in their daily lives. It gives your patients structured support to help them make lasting lifestyle changes. Most importantly, it boosts their health outcomes – those who participate in DSMES are more likely, among other benefits, to have lower A1C levels and fewer complications from their diabetes.
• Despite these benefits, less than 7% of people with diabetes participate in DSMES within the first year following their diagnosis. Your referrals, encouragement and follow ups can help change this.
• Also make sure you’re staying up to date on the latest Standards of Diabetes Care. You’ll then be able to ensure your patients are getting the most timely, equitable and high-quality care (for their diabetes and for any related comorbidities).
• Also, at every visit, make sure you’re encouraging your patients to keep taking their medications as prescribed, and check in to ensure they’re staying up to date with the needed care for their ears, eyes, feet and teeth:
  • How to promote medication management.
  • How to promote ear health.
  • How to promote eye health.
  • How to promote foot health.
  • How to promote oral health.

Thank you for your constant dedication to all your patients, including those with prediabetes and diabetes. Your guidance, encouragement, care and referrals are improving so many lives.

Help your patients quit tobacco.

You can help your patients quit tobacco – even if they’re dealing with constant, difficult urges. Print out and share these “Five D’s of Coping with Tobacco Urges,” from our partners at Quit For Life^®. (Note: The “Five D’s” are written for your patient(s) as the audience.)

Five D’s of Coping with Tobacco Urges

1. Distract yourself. If you’re feeling an urge to smoke (or chew, dip, vape, etc.), do something else. Call a friend. Grab a book or crossword puzzle. Turn on a movie or TV show. Or just take a walk. The urge will eventually pass.
2. Deep breaths. When you get an urge, relax your body and mind by taking deep breaths. Inhale through your nose, exhale through your mouth and repeat 10 times. You’ll find yourself feeling calmer and better able to cope.
3. Drink water. During times when you’re used to having tobacco – for example, first thing in the morning or during a usual break from work – instead have a glass of water. It’ll help you feel full and keep your hands busy.
4. Say out loud, “I’m not going to smoke/vape/chew/etc. for the next five minutes.” If you get through this time period without giving into the urge, it’ll likely disappear.
5. Talk to others – friends, family, trusted loved ones – about your urges, your feelings, your hopes to quit, your confidence, your pride, your shortcomings, your successes, etc. Talking with others helps you stay motivated, keeps you accountable and aids you in overcoming hurdles.

Remember, cravings usually only last a few minutes – but it’s crucial to have coping techniques, like these Five D’s, ready. You have the power to quit and lead your healthiest life.

Note to providers: Many of our health plans include Quit For Life, a personalized program to help our members quit tobacco. If your patient is a member of our health plan and is interested, have them call the number on the back of their ID card and ask if their plan includes Quit For Life.

***

 Coding Counts:
Coding Tips for COPD and Asthma

Supporting documentation and accurate coding are key to making sure your patients receive the care they need. Here are this issue’s tips for you and your staff, focused on coding for chronic obstructive pulmonary disease (COPD) and asthma.

COPD

COPD is a condition characterized by chronic airway obstruction and breathing difficulty. There’s no cure for COPD, but it can be managed. Some symptoms include dyspnea upon exertion, reduced exercise tolerance, decreased intensity of breath sounds and prolonged exhalation of breath.

Patients with COPD with asthma have continuous obstruction to breathing, which is different from nonobstructive asthma where you return to normal breathing after an asthma attack.

Please specify if COPD is:

• With acute lower respiratory infection.
• With exacerbation.
• Or unspecified.

Asthma

Asthma is a chronic respiratory condition that causes airways to swell, narrow and produce mucus – which causes difficulty breathing. As with COPD, it cannot be cured, but symptoms can be managed or controlled.

It’s important for documentation to be clear and detailed, using specific terms to allow for accurate ICD-10-CM code selection. When documenting asthma, be sure to specify the following:

• Mild Intermittent: Patient experiences symptoms up to two days a week and up to two nights a month.
• Mild Persistent: Patient experiences symptoms more than twice a week, but no more than once a day.
• Moderate Persistent: Patient experiences symptoms once a day and more than one night a week.
• Severe Persistent: Patient experiences symptoms throughout the day on most days and frequently at night.
• Uncomplicated: status asthmaticus or acute exacerbation.

Please also remember to specify if asthma is allergic, atopic, intrinsic, extrinsic, etc.

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

Questions?

Please contact us at [email protected].

 References Used for this Article:

 “Asthma.” Mayo Clinic. 6 April 2024.

“COPD.” Mayo Clinic. 15 April 2020.

“Documentation and Coding: COPD and Asthma.” BlueCross BlueShield of North Carolina. 19 October 2022.

“EncoderPro.com for Payers.” Optum. Accessed 29 April 2024.

New Weight-Loss Benefit for State of Illinois Employees (Only)

Note: This article/benefit only applies to our members who are State of Illinois employees on a Health Alliance State of Illinois employee health plan. It does not apply to members of any of our other health plans.

The Illinois state government has enacted a legislative mandate covering weight-loss medications for state employees, effective July 1, 2024. The law requires patients be diagnosed with obesity, prediabetes or gestational diabetes, and patients must actively participate in a health plan-sponsored lifestyle-management program to maintain medication coverage. Beginning July 1, 2024, Health Alliance will automatically cover a State of Illinois employee plan member’s first 30-day supply, without prior authorization.

The first fill will trigger a notice that’ll be sent to the member informing them:

• How to enroll online in our lifestyle-management program, Virta Health.
• About the prior authorization requirement for ongoing prescription coverage.

Per the legislation, continued participation in the Virta Health program or a Health Alliance-sponsored equivalent is required, and any patient who ceases participation in the program will lose medication coverage. Medications that may be covered through this mandate include phentermine, Qsymia^®, Saxenda^®, Wegovy^® and Zepbound^®. Coverage of Qsymia^® will require previous trial and failure with Saxenda^®, Wegovy^® or Zepbound^®.

GLP-1 agonists only indicated for diabetes (such as Ozempic^®, RYBELSUS^®, etc.) will not be covered for weight-loss indications, to avoid shortages of these medications for patients with type 2 diabetes.

Finally, please know that coverage of these medications for weight loss for members of all our other plans – including all our Medicare plans and our other Commercial plans – is not changing. Please encourage your patients to call the number on the back of their ID card if they 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^TM 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^TM 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

New Drug Reviews/Policies

• Bimzelx (bimekizumab)—Treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy
  • Formulary placements
    • Commercial—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary
  • Filsuvez (birch triterpenes)—Treatment of wounds associated with dystrophic epidermolysis bullosa (DEB) and junctional epidermolysis bullosa (JEB) in adult and pediatric patients 6 months of age and older
    • Formulary placements
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary
    • Ycanth (cantharidin)—Treatment of molluscum contagiosum in adult and pediatric patients’ ≥2 years of age
      • Formulary placements
        • Commercial—Non-Formulary
        • Medicare—Non-Formulary
      • Litfulo (ritlecitinib)—Treatment of severe alopecia areata in adults and pediatric patients’ ≥12 years of age
        • Formulary placements
          • Commercial— Non-Preferred Specialty Pharmacy with PA and MDL
          • Medicare—Tier 5 Specialty Pharmacy

Gastroenterology

New Drug Reviews/Policies

• Omvoh (mirikizumab)—Treatment of moderately to severely active ulcerative colitis in adults
  • Formulary placements
    • Commercial—Non-Preferred Specialty Medical (IV)/Pharmacy (subQ) with PA
    • Medicare—Non-Formulary
  • Velsipity (etrasimod)—Treatment of moderately to severely active ulcerative colitis in adults
    • Formulary placements
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary
    • Rivfloza (nedosiran)—Lower urinary oxalate levels in pediatric patients ≥9 years of age and adults with primary hyperoxaluria type 1 and relatively preserved kidney function
      • Formulary placements
        • Commercial—Non-Formulary
        • Medicare—Non-Formulary

Commercial

Dermatology

Criteria Changes

• Bylvay Policy
  • Added coverage criteria for pruritus due to Alagille Syndrome (ALGS)
• Livmarli Policy
  • Added coverage criteria for pruritus due to Familial Intrahepatic Cholestasis (PFIC)
• Zoryve Policy
  • Added coverage criteria for Seborrheic Dermatitis

Gastroenterology

New Drug Reviews/Policies

• Chenodal Policy
  • Outlines PA criteria and QL of #90 tablets per 30 days

Criteria Changes

• Oral Budesonide Policy
  • Added Tarpeyo coverage criteria for Primary Immunoglobulin A Nephropathy
• Tepanor Products Policy
  • Added Xphozah coverage criteria for Hyperphosphatemia
• Voquezna Policy
  • Added coverage criteria for erosive esophagitis
  • Added QL of #30 tablets per 30 days

Rheumatology

Criteria Changes

• Ilaris Policy
  • Added coverage criteria for gout flares
• Psoriatic Arthritis Immunomodulator Policy
  • Specified age 2 minimum for Enbrel
  • Specified age 2 minimum for Orencia

Formulary Changes—Commercial

Negative Changes (effective 7/1/2024)

Humira Brand Removal

• Numerous biosimilar products available in varying strengths and formulations
• Covered biosimilars include: Amjevita (LW), Hadlima and Adalimumab-adaz
• Policies Impacted:
• Ankylosing Spondylitis Immunomodulator Policy
• Cosentyx Policy
• Crohn’s Disease Immunomodulator Policy
• Entyvio Policy
• Adalimumab Products Policy
• Plaque Psoriasis Immunomodulator Policy
• Polyarticular Juvenile Idiopathic Arthritis Immunomodulator Policy
• Psoriatic Arthritis Immunomodulator Policy
• Remicade and Infliximab Biosimilars Policy
• Rheumatoid Arthritis Immunomodulator Policy
• Rituxan and Rituximab Biosimilars Policy
• Tysabri Policy
• Ulcerative Colitis Immunomodulator Policy

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. Upcoming negative formulary and criteria changes can be found online at the following website: HealthAlliance.org/Documents/960/2022. Drug coverage and policies in the following categories will be reviewed during the remainder of 2024 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

New Drug Reviews/Policies

• Bimzelx (bimekizumab)—Treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy
  • Formulary placements
    • Commercial—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary
  • Filsuvez (birch triterpenes)—Treatment of wounds associated with dystrophic epidermolysis bullosa (DEB) and junctional epidermolysis bullosa (JEB) in adult and pediatric patients 6 months of age and older
    • Formulary placements
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary
    • Ycanth (cantharidin)—Treatment of molluscum contagiosum in adult and pediatric patients’ ≥2 years of age
      • Formulary placements
        • Commercial—Non-Formulary
        • Medicare—Non-Formulary
      • Litfulo (ritlecitinib)—Treatment of severe alopecia areata in adults and pediatric patients’ ≥12 years of age
        • Formulary placements
          • Commercial— Non-Preferred Specialty Pharmacy with PA and MDL
          • Medicare—Tier 5 Specialty Pharmacy

Gastroenterology

New Drug Reviews/Policies

• Omvoh (mirikizumab)—Treatment of moderately to severely active ulcerative colitis in adults
  • Formulary placements
    • Commercial—Non-Preferred Specialty Medical (IV)/Pharmacy (subQ) with PA
    • Medicare—Non-Formulary
  • Velsipity (etrasimod)—Treatment of moderately to severely active ulcerative colitis in adults
    • Formulary placements
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary
    • Rivfloza (nedosiran)—Lower urinary oxalate levels in pediatric patients ≥9 years of age and adults with primary hyperoxaluria type 1 and relatively preserved kidney function
      • Formulary placements
        • Commercial—Non-Formulary
        • Medicare—Non-Formulary

Commercial

 Dermatology

Criteria Changes

• Bylvay Policy
  • Added coverage criteria for pruritus due to Alagille Syndrome (ALGS)
• Livmarli Policy
  • Added coverage criteria for pruritus due to Familial Intrahepatic Cholestasis (PFIC)
• Zoryve Policy
  • Added coverage criteria for Seborrheic Dermatitis

Gastroenterology

New Drug Reviews/Policies

• Chenodal Policy
  • Outlines PA criteria and QL of #90 tablets per 30 days

Criteria Changes

• Oral Budesonide Policy
  • Added Tarpeyo coverage criteria for Primary Immunoglobulin A Nephropathy
• Tepanor Products Policy
  • Added Xphozah coverage criteria for Hyperphosphatemia
• Voquezna Policy
  • Added coverage criteria for erosive esophagitis
  • Added QL of #30 tablets per 30 days

Rheumatology

Criteria Changes

• Ilaris Policy
  • Added coverage criteria for gout flares
• Psoriatic Arthritis Immunomodulator Policy
  • Specified age 2 minimum for Enbrel
  • Specified age 2 minimum for Orencia

Formulary Changes—Commercial

Negative Changes (effective 7/1/2024)

Humira Brand Removal

• Numerous biosimilar products available in varying strengths and formulations
• Covered biosimilars include: Amjevita (LW), Hadlima and Adalimumab-adaz
• Policies Impacted:
• Ankylosing Spondylitis Immunomodulator Policy
• Cosentyx Policy
• Crohn’s Disease Immunomodulator Policy
• Entyvio Policy
• Adalimumab Products Policy
• Plaque Psoriasis Immunomodulator Policy
• Polyarticular Juvenile Idiopathic Arthritis Immunomodulator Policy
• Psoriatic Arthritis Immunomodulator Policy
• Remicade and Infliximab Biosimilars Policy
• Rheumatoid Arthritis Immunomodulator Policy
• Rituxan and Rituximab Biosimilars Policy
• Tysabri Policy
• Ulcerative Colitis Immunomodulator Policy

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. Upcoming negative formulary and criteria changes can be found online at the following website: HealthAlliance.org/Documents/960/2022. Drug coverage and policies in the following categories will be reviewed during the remainder of 2024 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

New Drug Reviews/Policies

• Bimzelx (bimekizumab)—Treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy
  • Formulary placements
    • Commercial—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary
  • Filsuvez (birch triterpenes)—Treatment of wounds associated with dystrophic epidermolysis bullosa (DEB) and junctional epidermolysis bullosa (JEB) in adult and pediatric patients 6 months of age and older
    • Formulary placements
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary
    • Ycanth (cantharidin)—Treatment of molluscum contagiosum in adult and pediatric patients’ ≥2 years of age
      • Formulary placements
        • Commercial—Non-Formulary
        • Medicare—Non-Formulary
      • Litfulo (ritlecitinib)—Treatment of severe alopecia areata in adults and pediatric patients’ ≥12 years of age
        • Formulary placements
          • Commercial— Non-Preferred Specialty Pharmacy with PA and MDL
          • Medicare—Tier 5 Specialty Pharmacy

Gastroenterology

New Drug Reviews/Policies

• Omvoh (mirikizumab)—Treatment of moderately to severely active ulcerative colitis in adults
  • Formulary placements
    • Commercial—Non-Preferred Specialty Medical (IV)/Pharmacy (subQ) with PA
    • Medicare—Non-Formulary
  • Velsipity (etrasimod)—Treatment of moderately to severely active ulcerative colitis in adults
    • Formulary placements
      • Commercial—Non-Formulary
      • Medicare—Non-Formulary
    • Rivfloza (nedosiran)—Lower urinary oxalate levels in pediatric patients ≥9 years of age and adults with primary hyperoxaluria type 1 and relatively preserved kidney function
      • Formulary placements
        • Commercial—Non-Formulary
        • Medicare—Non-Formulary

Commercial

Dermatology

Criteria Changes

• Bylvay Policy
  • Added coverage criteria for pruritus due to Alagille Syndrome (ALGS)
• Livmarli Policy
  • Added coverage criteria for pruritus due to Familial Intrahepatic Cholestasis (PFIC)
• Zoryve Policy
  • Added coverage criteria for Seborrheic Dermatitis

Gastroenterology

New Drug Reviews/Policies

• Chenodal Policy
  • Outlines PA criteria and QL of #90 tablets per 30 days

Criteria Changes

• Oral Budesonide Policy
  • Added Tarpeyo coverage criteria for Primary Immunoglobulin A Nephropathy
• Tepanor Products Policy
  • Added Xphozah coverage criteria for Hyperphosphatemia
• Voquezna Policy
  • Added coverage criteria for erosive esophagitis
  • Added QL of #30 tablets per 30 days

Rheumatology

Criteria Changes

• Ilaris Policy
  • Added coverage criteria for gout flares
• Psoriatic Arthritis Immunomodulator Policy
  • Specified age 2 minimum for Enbrel
  • Specified age 2 minimum for Orencia

Formulary Changes—Commercial

Negative Changes (effective 7/1/2024)

Humira Brand Removal

• Numerous biosimilar products available in varying strengths and formulations
• Covered biosimilars include: Amjevita (LW), Hadlima and Adalimumab-adaz
• Policies Impacted:
• Ankylosing Spondylitis Immunomodulator Policy
• Cosentyx Policy
• Crohn’s Disease Immunomodulator Policy
• Entyvio Policy
• Adalimumab Products Policy
• Plaque Psoriasis Immunomodulator Policy
• Polyarticular Juvenile Idiopathic Arthritis Immunomodulator Policy
• Psoriatic Arthritis Immunomodulator Policy
• Remicade and Infliximab Biosimilars Policy
• Rheumatoid Arthritis Immunomodulator Policy
• Rituxan and Rituximab Biosimilars Policy
• Tysabri Policy
• Ulcerative Colitis Immunomodulator Policy

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. Upcoming negative formulary and criteria changes can be found online at the following website: HealthAlliance.org/Documents/960/2022. Drug coverage and policies in the following categories will be reviewed during the remainder of 2024 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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