Washington October Newsletter

Medicare Advantage vs. Medicare Supplement Plans

The Medicare Annual Enrollment Period (AEP) is October 15-December 7. During this time, beneficiaries can choose a private Medicare plan to supplement or pay in place of Original Medicare.

Health Alliance offers 2 kinds of Medicare plans:

• Medicare Advantage (MA) – These plans offer another way to get your Medicare coverage. MA plans pay in place of Original Medicare and cover expenses beyond what Original Medicare covers. Members must continue to pay their Part B premium.
• Medicare Supplement (Med Supp) – Works with Original Medicare. Only covers expenses that Original Medicare covers, which is about 80% of members’ medical costs after they meet their yearly deductible

A few of the differences between Med Supp and MA plans:

• MA plans can include drug coverage. Med Supp plans do not. Med Supp members have to purchase a stand-alone prescription drug plan if they want drug coverage.
• MA plan premiums do not increase because of age. Med Supp plans can get more expensive as a member gets older.
• Health Alliance MA plans have just one Customer Service number for members to call with questions about any aspect of their plan, and all the bills come from one company. With Med Supp, members still have Original Medicare and often have a separate drug plan, so they’re dealing with multiple call centers and sets of bills.
• MA plans include lots of extras for no additional cost to the member, like a fitness membership, disease management programs, health coaching, access to our Anytime Nurse Line, and travel coverage through Assist America. Med Supp plans don’t include these extras.

Why MA plans are good for our members, Health Alliance, and our providers:

• Members get lower premiums and more benefits than a Med Supp plan or Original Medicare.
• MA plans attract new members and keep our current members happy.
• MA plans help both Health Alliance and our provider networks grow.

Pharmacy Updates

All Plans

Formulary Additions

• Unituxin (dinutuximab) – A GD2-binding monoclonal antibody indicated, in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2 (IL-2), and 13-cis-retinoic acid (RA), for the treatment of pediatric patients with high-risk neuroblastoma who achieve at least a partial response to prior first-line multi-agent, multimodality therapy.
  • Self-Funded – Requires preauthorization (PA)
  • Medicare – Tier 5 with PA
• Hysingla ER (hydrocodone bitartrate extended-release) – The second extended-release formulation of hydrocodone available on the market; part of the extended-release (ER) and long-acting (LA) opioid medication risk evaluation and mitigation strategy (REMS) program.
  • Medicare – Non-Formulary
• Lemtrada (alemtuzumab) – The first CD52-directed cytolytic monoclonal antibody approved for the treatment of relapsing forms of MS.
  • Self-Funded – Requires PA
  • Medicare – Non-Formulary
• Plegridy (peginterferon beta-1a)—The first pegylated formulation of interferon beta-1a indicated for the treatment of patients with relapsing forms of multiple sclerosis.
  • Self-Funded – Requires PA
• Glatopa (glatiramer acetate) – Branded generic of Copaxone.
  • Self-Funded – Requires PA

Criteria Changes

• Xifaxan – Added coverage for IBS-D indication
• Xolair – Added daily dose specification and removed immunosuppressant requirement for chronic idiopathic urticaria

Multiple Modifiers on Claims

When submitting electronic or paper claims, please indicate the pricing modifiers in the first two positions and processing or informational modifiers in the third and fourth positions.

Supplemental Medicare Benefit

Health Alliance Medicare Advantage members now get $100 per plan year to spend on their choice of supplemental dental, vision, or hearing care. They have the freedom to use it on the services they need, so they can get the most from their coverage.