Midwest August Newsletter 2022

During a Busy Month – We Thank You

August – it’s a busy time of year. For families, summer trips are wrapping up and new school years are beginning. At many workplaces, late summer deadlines are giving way to fall planning sessions. We know that for healthcare providers, August is particularly busy. We thank you for your hard work this month keeping our members healthy. Your knowledge, expertise and talents never go unnoticed by us. Thank you for all that you do, now and year-round, for so many individuals and families.

As It Relates to You

Key information for you and your staff.

The ABCDs of Medicare –
Understanding the Different Types of Plans

It’s almost time again for the Medicare Annual Enrollment Period, which takes place October 15 through December 7. As your patients look at their options and try to decide what’s best for them, they might come to you with questions. Here’s a quick review of some of the different types of Medicare coverage they can choose:

• Original Medicare is offered through the federal government and includes Part A (hospital coverage) and Part B (medical coverage). Like the other types of Medicare, it’s available for those who are 65 or older or have certain disabilities. Beneficiaries with Original Medicare can see any provider who accepts Medicare, but they won’t have extra perks or pharmacy coverage.
• Medicare Advantage (Part C) plans are private health plans that replace Original Medicare. They often include pharmacy coverage and extra perks, like dental, hearing and vision benefits. These plans typically have a provider network and can offer more care coordination than Original Medicare.
• Medicare Supplement (also known as Medigap) plans are sold through private insurance companies. They don’t replace Original Medicare but work as an add-on alongside it to help pay for what Original Medicare doesn’t. In general, they don’t cover additional services or offer extra benefits or perks – they simply pay (part of) the remainder of the bill since Original Medicare doesn’t pay the full 100% of many of the services it covers. Beneficiaries can generally see any provider who accepts Medicare.
• Finally, many people who have Original Medicare – whether they have a Medicare Supplement plan or not – also purchase standalone Part D plans to cover their prescription drugs. As mentioned above, many Medicare Advantage plans already have prescription coverage built in.

We invite you to visit the Understand Medicare page on our website for additional information, and as always, feel free to reach out to your provider relations specialist with any questions.

We Need Your Help –
Please Keep Your Provider Information Up to Date

Federal and state governments require you to review and update your provider information in a timely manner or whenever there are significant changes. Please send all your provider updates to us via email at Provider.Updates@HealthAlliance.org. Note that this is a new email address. Your provider relations specialist will continue to be your contact for all other inquiries. Thanks for all that you do.

Appealing on Behalf of Your Patients –
Important Information

If you’re appealing a decision we’ve made on behalf of one of your patients (who’s a member of our plans) – for example, if you’re appealing a claims denial – please submit the appeal to Member/Provider Resolutions via email at Member.Relations@HealthAlliance.org, fax at (217) 902-9708 or by mail. If these types of appeals are sent via the Provider Portal, they’ll be denied. Thank you for understanding.

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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.

Take Action This Flu Season

This year – like the last two – it’s of increased importance that people in our communities get their yearly flu shot. With the COVID-19 pandemic still among us, we need to be doing all we can to recommend both the flu and COVID-19 vaccines (and boosters, as appropriate). According to the CDC, recommendations – and even simple reminders – from their trusted providers are a critical factor in whether many adults get vaccines for themselves and their families.

With this in mind, the CDC is again leading a SHARE campaign to urge providers to do all they can to encourage their patients to get their yearly flu shot. Here are the basics, directly quoted from their campaign:

• S – Share the reasons why the influenza vaccine is right for the patient given his or her age, health status, lifestyle, occupation or other risk factors.
• H – Highlight positive experiences with influenza vaccines (personal or in your practice), as appropriate, to reinforce the benefits and strengthen confidence in influenza vaccination.
• A – Address patient questions and any concerns about the influenza vaccine, including side effects, safety and vaccine effectiveness in plain and understandable language.
• R – Remind patients that influenza vaccines protect them and their loved ones from serious influenza illness and influenza-related complications.
• E – Explain the potential costs of getting influenza, including serious health effects, time lost (such as missing work or family obligations) and financial costs.

Each patient is different, and you know them best. Consider the best approach that’ll let them know just how important the flu vaccine is and why they and their families should get it. With your help, our communities can stay safer – and breathe easier – this flu season. Thanks for your help in this vital endeavor.

It varies according to health plan, but flu shots are covered at no cost to our members in most cases. Your patients can call the number on the back of their health plan member ID card to learn more about costs and where they can go to get their shots.

Diabetic Eye Exams –
Make Sure Your Patients Get These Key Exams

It’s not a good stat – researchers have found that nearly 60% of Americans with diabetes don’t get their annual diabetic eye exam. How can you help change this? Sometimes the 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.

As their trusted provider, you can urge more people to take care of their health by getting the exams they need. Thank you for your help.

Help Your Patients at Risk of Osteoporosis –
Use the FRAX Test

Osteoporosis is often called the “silent disease” because it has few warning signs or symptoms – until you break a bone. And the stats are alarming: an osteoporosis-related fracture happens about every three seconds worldwide, and half of all women over age 50 will have one sometime in their life. Early action to detect osteoporosis is key – and there’s a free, simple online test you can encourage your patients to take that’ll calculate their risk of fracture. You can even lead them through the test during their next visit. Here’s the key information:

• It’s called the FRAX^® (Fracture Risk Assessment) test, found at ac.uk/FRAX (or search “Sheffield FRAX test” on Google).
• On the website, hover over the “Calculation Tool” tab, then hover over “North America” and then “US,” and then click on one of the four choices. You’ll be taken to the questionnaire. Fill out your patient’s information and hit “Calculate.”
• You’ll be given the percent chance your patient will have a major bone fracture in the next 10 years. The higher the percentage, the more likely they are to have a fracture.
• Note: If you don’t know your patient’s BMD (bone mineral density), you can leave it blank and still hit “Calculate.”

We encourage all women age 45 to 64, as well as all other women and men at increased risk of osteoporosis, to take the FRAX test – and we’d love your help in this endeavor. Please note that the test is not for those younger than 40 or for people currently taking a prescription medication for osteoporosis.

Together we can take action against fractures. Have your patients take the FRAX test – and going over the results with them – create plans as needed to limit the potential harms of osteoporosis.

Evaluating Low Back Pain –
Key Screening Information

Back pain is the third leading cause of healthcare visits – and over 40 million people in the U.S. alone are living with chronic low back pain. However, before you start your patients on any treatment plans, it’s important you know the different types of back pain and what’s best for each. Here’s some key information to help you evaluate your patients’ conditions.

• There are two main types of low back pain: mechanical back pain and inflammatory back pain.
• Mechanical back pain is very common. It’s when something’s wrong with how the mechanics of the spine, discs, nerves and back muscles are working together. It’s often caused by an injury, pinched nerves, poor posture or simple aging. For many people with mechanical back pain, rest, physical therapy and similar treatments may largely take care of the problem.
• Inflammatory back pain is different – it’s a problem of the immune system. People with inflammatory back pain may have axial spondyloarthritis (axSpA) – a type of arthritis that causes pain and swelling in the spine and joints.
• Recognizing the type of back pain is key – before prescribing medications or ordering certain imaging, tests or procedures. Many of these may be unnecessary for many types of mechanical back pain.
• Use of unnecessary healthcare resources can raise costs and even, at times, cause patient harm.
• Opioids in particular should be prescribed only when completely necessary and weighed against all their potential harms.
• Recognizing the type of back pain is also key for diagnosing axSpA early – since its treatment plan should be much different from that of common mechanical back pain.

Here’s a simple screening tool to recognize back pain that’s inflammatory. Use this for your patients who’ve had back pain for more than three months. The criteria for inflammatory back pain are fulfilled if at least four of the five questions are answered “yes.”

Take action today. Before you prescribe medications or order potentially unnecessary imaging or testing, use this simple screening tool to determine the type of low back pain. You’ll then be able to get your patients connected to the right treatment plan for their exact needs.

Note: The information in this article comes from the resource “Importance of Evaluating Patients for Inflammatory Back Pain,” created by UCB.

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Coding Counts:
Specificity Matters

Accurate coding – paired with specific and accurate supporting documentation – is key to making sure your patients receive the care they need. Failure to document persisting chronic conditions on an annual basis impacts patients, fellow providers and our organization.

Documenting and coding to the highest level of specificity can:

• Result in fewer claim denials and audit findings.
• Impact research and treatment for diseases, when studied by the National Center for Health Statistics (NCHS).
• Determine whether certain conditions are a Hierarchical Condition Category (HCC).
• Influence a patient’s ability to receive all eligible benefits and services of their health plan, such as care coordination and health coaching.
• Allow providers to follow disease progression, severity and acuity.

Tip: Make sure reported diagnoses codes are accurately reflected in documentation. For example, when reporting CKD III, documentation should state “CKD III” instead of “unspecified CKD.” For further understanding of the impact of specificity from an HCC perspective, please reference the CKD HCC hierarchy below.

Thank you for your help with accurate coding and documentation. We’re grateful for how hard you work and all you do for our members’ health. For even more coding tips, watch these short videos we made just for you and your staff. And visit our Coding Counts page for even more helpful resources.

Updates to High Cost Medical Drugs List

See the table 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 does not apply to Medicare plans.

Pharmacy Updates

All Plans

Cardiology

Formulary Additions

• Camzyos (mavacamten)—Treatment of adults with symptomatic New York Heart Association (NYHA) class II-III obstructive hypertrophic cardiomyopathy (HCM) to improve functional capacity and symptoms
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary
• Leqvio (inclisiran)—An adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (ASCVD) who require additional lowering of low-density lipoprotein cholesterol (LDL-C)
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Part B with PA

Endocrinology

Formulary Additions

• Kerendia (finerenone)—To reduce the risk of sustained eGFR decline, end-stage kidney disease, cardiovascular death, nonfatal myocardial infarction, and hospitalization for heart failure in adult patients with chronic kidney disease associated with type 2 diabetes
  • Formulary placement recommendations
    • Commercial— Non-Preferred Brand with PA
    • Medicare—Tier 4 Non-Preferred Brand with PA
• Korsuva (difelikefalin)—Treatment of moderate to severe pruritus associated with chronic kidney disease in adults undergoing hemodialysis
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Part B
• Skytrofa (lonapegsomatropin)—Treatment of pediatric patients 1 year of age and older who weigh at least 11.5 kg and have growth failure due to inadequate secretion of endogenous growth hormone
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary
• Mounjaro (tirzepatide)—Adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with PA
    • Medicare—Non-Formulary

Pulmonary

Formulary Additions

• Tezspire (tezepelumab)—Indicated for the add-on maintenance treatment of adult and pediatric patients 12 years of age and older with severe asthma
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Tier 5 Specialty Pharmacy

Commercial

Cardiology

Criteria Changes

• Juxtapid (lomitapide)
  • Updated approval period to align with IL law
• Weight Loss Medications
  • Added Wegovy since it’s intended for weight loss only

Endocrinology

Criteria Changes

• Diabetes Drug Therapies
  • Added Mounjaro, removed Bydureon (discontinued), updated criteria for GLP-1 and SGLT2, added ASCVD criteria, and updated references
• Erectile Dysfunction Medications
  • Removed brand Staxyn and Levitra, updated approval time for Raynaud Phenomenon
• QHP-Coverage of Erectile Dysfunction Medications
  • Updated approval time for Raynaud Phenomenon
• Signifor and Signifor LAR (pasireotide)
  • Updated references and approval time for Cushing’s
• Leuprolide acetate (Fensolvi, Lupron Depot, Lupron Depot-Ped, leuprolide acetate)
  • Updated references and language for gender inclusivity
• Supprelin LA (histrelin acetate)
  • Updated language for gender inclusivity
• Testosterone, Implantable, Topical, Oral, and Nasal
  • Updated language for gender inclusivity
• Lokelma (sodium zirconium cyclosilicate)
  • Updated approval time and references
• Veltassa (patiromer)
  • Updated approval time and references

Pulmonary

Criteria Changes

• Dupixent (dupilumab)
  • Transferred Atopic Dermatitis criteria to Atopic Dermatitis policy
  • Added criteria for Eosinophilic Esophagitis (EoE)
  • Updated age for asthma
• Nucala (mepolizumab)
  • Added nasal polyp indication

Pulmonary Arterial Hypertension

Criteria Changes

• Adempas (riociguat)
  • Added criteria for Chronic Thromboembolic Pulmonary Hypertension (CTEPH), updated references
• Tyvaso (treprostinil)
  • Added criteria for Pulmonary HTN Associated with Interstitial Lung Disease PH-ILD

Retired Policies

• Picato (ingenol)
  • Product discontinued

Please Note: The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during these meetings. Negative formulary changes are made effective on January 1 and July 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 2022, and potential changes may be made:

• August Meeting: Neurology, Psychiatry, Pain.
• October Meeting: Ophthalmology, Specialty.