Midwest August Newsletter 2020

Does the type of mask matter for COVID-19 prevention?

Robert G Good, DO, MACOI
Associate Chief Medical Officer for Carle Population Health

Everywhere in the news these days, we hear about the importance of wearing masks to help prevent the spread of COVID-19. But we rarely hear what types of masks are best to wear. Please visit the website of the Centers for Disease Control and Prevention for the most up-to-date recommendations on masks and face coverings, but here’s some information we’ve found helpful, from a recent study published by scholars at Northeastern University in Boston.

Their study used properly-fitted N95 masks as the standard of comparison methodology and 3M surgical masks as the baseline to compare other options. Please note that N95 masks are not recommended for the general public, as they remain critical supplies that should be reserved for healthcare providers and first responders.

The findings showed that N95 masks had an average particle removal efficiency of >99%, while 3M surgical masks removed 75% on average. Below are the particle removal efficiencies of some other common masks and face coverings:

• Charcoal Air Pollution facemask: 73%
• Sewn 2-ply cotton muslin pocket mask without filter: 70%
• Staples brand surgical mask: 59%
• Sewn 2-ply cotton mask with Pellon interfacing: 59%
• Sewn 2-ply cotton mask with organic cotton batting filter: 35%
• Sewn 2-ply cotton mask with nose wire and ear loops: 34%
• Sewn 2-layer cotton mask with Halyard H600 filter: 33%

Additionally, the researchers found that using a nylon stocking over-layer improved the particle removal efficiency of all loose-fitting masks by 15-50%.

So, what are the main conclusions and recommendations? All facemasks have some benefit, and tight-fitting masks are significantly better. Choose one of the above masks with a particle removal efficiency of 59% or higher. Perhaps add a nylon stocking over-layer to improve the mask’s efficiency. Remember that masks with ventilation aren’t recommended, as they don’t protect others from what you exhale. Avoid using vacuum cleaner bags as masks as they are potentially carcinogenic. And always continue – even while wearing your mask – to practice social distancing, hand washing and other precautionary practices.

Health Coaching and Care Coordination

Did you know we provide free Health Coaching and Care Coordination services for our members? Our coaches and coordinators partner with members to help them achieve their health and wellness goals, working closely with their doctors and care specialists.

Our Health Coaches are available to support and encourage your patients on their journey to better health. They help your patients understand and manage their health challenges, assist them in locating tools and resources, provide education on nutrition and exercise, and much more. Most importantly, they motivate your patients to stick to their goals.

For your patients who need a little more support, Care Coordination services are available. Our Care Coordinators can help your patients manage their illness or condition, assist them in coordinating care, help them locate tools and resources, and provide education on how to best prevent illness and future hospital stays. They can also help your patients know how to make the most of their health plan’s benefits.

If you think your patient would benefit from our Health Coaching or Care Coordination services, have them call (800) 851-3379, ext. 28947. They can also call the number on the back of their insurance ID card.

Make Sure Patients Get their Diabetic Eye Exams

Researchers have found that nearly 60% of Americans with diabetes don’t get their annual diabetic eye exam. How can you help change this discouraging stat? Sometimes your best medical tools are simple reminders and encouragement. Whenever your patients with diabetes come in for their annual wellness visit or physical:

• Remind them to schedule their annual diabetic eye exam.
• Offer encouragement, and remind them that 90% of the blindness caused by diabetes is preventable.
• Let them know that common eye diseases caused by diabetes often have no warning signs, and that a dilated/retinal eye exam is the best way to detect these diseases in their early stages.
• Remind them to have the ophthalmologist/optometrist send their eye exam results to their primary care provider if they get the exam at a different facility. You can even give your patients their PCP’s business card, for them to give to their ophthalmologist/optometrist.
• Ensure that they schedule their other diabetic preventive screenings they’re due for as well.

Coding Fragility

There’s an abundance of peer-reviewed academic literature showing the relationship between frailty and poor health outcomes. Doctors who perform better assessments of their patients’ frailty can help identify individuals who are at risk, which helps us provide focused care coordination and support.

Consider using the following “fragility” codes when seeing patients with a history of falls or altered gait. For example, any of your patients using canes, walkers or requiring assistance with walking would qualify.

• Unspecified abnormalities of gait and mobility – R26.9
• History of falling – Z91.81
• Muscle weakness (generalized)

New Provider Addition Form (CAQH)

If you use CAQH, please use this form when adding a new provider to your contract. If you don’t use CAQH or aren’t an Illinois MD/DO/DC, please make sure you’re submitting all of the required documents noted here. Thank you.

Updates to High Cost Medical Drugs List

See the table below for upcoming 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.

Pharmacy Updates

All Plans

Cardiology

New Drug Reviews

• Nexletol (bempedoic acid)—Treatment of established atherosclerotic cardiovascular disease and heterozygous familial hypercholesterolemia, as an adjunct to diet and maximally tolerated statin therapy, in adult patients who require additional lowering of low-density lipoprotein cholesterol (LDL-C)
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with PA
    • Medicare—Tier 3 with PA

Endocrinology

New Drug Reviews

• Evenity (romosozumab)—Treatment of osteoporosis in postmenopausal females at high risk for fracture (defined as a history of osteoporotic fracture or multiple risk factors for fracture), or patients who have failed or are intolerant to other available osteoporosis therapy
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Medicare Part B with PA
  • Tepezza (teprotumumab)—Treatment of thyroid eye disease (Graves’ ophthalmopathy)
    • Policy will have Medical Director and Pharmacist review jointly given cost and to ensure prescriber has maximized therapy
    • Formulary placement recommendations
      • Commercial—Tier 6 with PA
      • Medicare—Medicare Part B with PA

Pulmonology

New Drug Reviews

• Trikafta (elexacaftor-tezacaftor-ivacaftor)—Treatment of cystic fibrosis in patients age 12 years or older who have at least one F508del mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene
  • Involvement of medical directors brings benefits of interdisciplinary approach
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with PA
    • Medicare—Tier 5 with PA

Commercial

Cardiology

Criteria Changes—Commercial

• Fish Oil – Lovaza (omega-3 acid ethyl esters), Triklo (omega-3 acid ethyl esters), and Vascepa (icosapent ethyl)
  • Removed Triklo from policy, Added criteria for Cardiovascular Risk Reduction in patients with milder hypertriglyceridemia, Updated references, Updated approval period
• PCSK9 Inhibitors
  • Moving to Non-Preferred Brand tier
  • Removed specialist requirement
  • Update approval and re-approval periods to 12 months
• Statin (HMG CoA reductase inhibitor), Brand Name
  • Added Ezallor Sprinkle
  • Updated approval period

Retired Policies—Commercial

• ALL: These do not need to be ordered by cardiologist; pharmacists have been approving at 100%
  • Antiplatelet, Effient and Zontivity, Step-Edit
  • Entresto (sacubitril-valsartan)
  • Kynamro (mipomersen)

Endocrinology

Criteria Changes—Commercial

• Diabetes Drug Therapies
  • Added Rybelsus and Trijardy XR
  • Removed Tanzeum (discontinued product)
• Testosterone, Implantable, Topical, Oral and Nasal
  • Added specialist and lab requirements
  • Removed Preferred Products section
  • Updated approval period

Pulmonology

Criteria Changes—Commercial

• Dupixent (dupilumab)
  • Lowered age requirement for atopic dermatitis to age 6
  • Added age requirement for rhinosinusitis with nasal polyps
  • Added allergist and immunologist to dermatologist as qualifying prescribers
  • Updated ST criteria
  • Updated approval period
• Esbriet and Ofev
  • Name change from Idiopathic Pulmonary Fibrosis due to change in Esbriet indications
  • Added criteria for Systemic Sclerosis-associated interstitial lung disease and chronic fibrosing interstitial lung disease
  • Updated approval period
• Nucala (mepolizumab)
  • Updated ST requirement for asthma
  • Added criteria for Churg-Strauss
  • Updated initial approval period to 12 months

Tier Changes—Commercial

• Repatha: Move from Non-Preferred Specialty to Non-Preferred Brand
  • Costs have decreased
  • No longer available from specialty pharmacies
•  Praluent: Move from Non-Preferred Specialty to Non-Preferred Brand
  • Costs have decreased
  • No longer available from specialty pharmacies
•  Trelegy: Move from Non-Preferred brand to Preferred Brand
  • Almost half of all patients on a LABA/LAMA are on Trelegy compared to Anoro Ellipta, Stiolto and Bevespi
  • Moving to preferred brand makes Trelegy our least costly agent
• Anoro Ellipta: Move from Non-Preferred brand to Preferred brand
  • Preferred tier LABA/LAMA option
• Stiolto Respimat: Move from Non-Preferred brand to Preferred brand
  • Preferred tier LABA/LAMA option
• Dupixent: Move from Non-Preferred Specialty to Preferred Specialty
  • Majority of our usage is in Dupixent compared to Fasenra, Nucala, Cinqair and Xolair
  • Preferred specialty rebate opportunity that offers plan savings
• Tresiba: Move from Non-Preferred brand to Preferred Brand
  • Move allows for enhanced rebate savings
• Bevespi: Move from Non-Preferred brand to Excluded
  • Effective 10/1/20 for Commercial
• Duaklir Pressair: Move from NDTM to Excluded
  • Anoro Ellipta and Stiolto Respimat are covered as preferred
• Rybelsus: Move from NDTM to Preferred Brand
  • Sits at parity with Byetta, Bydureon, Ozempic, Trulicity and Victoza

Medicare

Pulmonology

New Medicare D Policies

• Medicare D Drug Policy for Dupixent
  • Adding back to formulary at Tier 5 to align coverage across all lines of business

Tier Changes—Medicare

• Dupixent: Move from NF to Tier 5
  • Adding to formulary to allow another option in the space; will align with Commercial coverage

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