Midwest February Newsletter 2020

As It Relates to You

Provider Relations Team Improvements

We’re excited to announce the Provider Relations Team will be transitioning into external facing and internal facing roles.

Your current provider relations specialist will be transitioning into more of a provider engagement role by providing education and training, and developing strategy around provider satisfaction results while improving and maintaining provider relationships.

Internal provider relations specialists will now be your source for administrative issues or concerns, which include claims issue resolution, fee schedule requests, and provider credentialing/contract status, to name a few. They can be contacted by emailing [email protected].

If you have any questions regarding this exciting improvement, please don’t hesitate to reach out to your provider relations specialist.

New Provider Relations Specialists

Provider Network Management would like to welcome several new provider relations specialists.

First, we welcome Chrissy Uden. Chrissy joined the Health Alliance team in December and will service Kankakee, Iroquois, Livingston, Woodford, McLean, Ford, DeWitt, Moultrie, Shelby, Fayette and Effingham counties, which includes Gibson City PHO, Riverside Medical Center, Regional Dialysis, Home Infusion, PT/OT/ST and hospital-based network of providers.

Also, we’d like to welcome Cass Dockrill. Cass joined the Health Alliance team in October and will service the Peoria/Macomb network of providers. 

Finally, we welcome Mongkon Cida. Mongkon joined the Health Alliance team in December and will service the Southern Illinois/Missouri, Reid Health Care and Indiana/Ohio network of providers.

Please join us in welcoming Chrissy, Cass and Mongkon to Health Alliance. Chrissy can be reached at (217) 902-8254 or by emailing [email protected]. Cass can be reached at (217) 902-8256 or by emailing [email protected]. Mongkon can be reached at (217) 902-8253 or by emailing [email protected].

HOS/CAHPS Surveys Start with You

As survey season quickly approaches, do your part in improving patient satisfaction:

• Ask patients if they’ve seen another provider. If you know they received specialty care, mention this and discuss as needed.
• Ask if they’re taking medications prescribed by other providers. Let patients know you have a record of their complete medical history and always ask if there’ve been changes since you last saw them.
• Regularly assess patients’ physical activity levels and discuss any changes they could make to improve their health.
• Conduct an annual wellness visit and review health assessment results with patients.
• Encourage patients to take advantage of wellness perks offered by their health plan, like health coaching, Be Fit fitness reimbursement and wellness rewards.
• Conduct medication reconciliation with patients for appropriate usage and modify prescriptions as needed.
• Be proactive and help avoid gaps in care by calling patients months in advance to schedule needed screenings, tests or physicals.

Reduce Readmissions for Health Alliance Medicare Advantage Members with Congestive Heart Failure

The benefits below are offered to our Medicare Advantages (MA) members diagnosed with congestive heart failure (CHF).

Meal Benefit:

• Post-discharge from an inpatient facility is required.
• Members are eligible for two frozen meals a day for 14 days, delivered directly to the members’ homes. The meals are delicious low fat, low sodium, low sugar and low cholesterol, as well as microwave and oven friendly.

Care Kits:

• Member must be currently participating in care coordination or health coaching.
• Once the member with CHF is enrolled in one of the programs, they may request to receive the Care Kit. The kit includes a blood pressure monitor, digital scale, 28-dose pill organizer and other useful educational materials.

For questions, members can call the number on the back of their ID card.  

Osteoporosis Management in Women Who’ve Had Fractures

The Healthcare Effectiveness Data and Information Set (HEDIS®) recommends that woman between 67 and 85 years of age have either a bone mineral density test (DEXA) or a prescription for a drug to treat osteoporosis within six months after a fracture. Please consider ordering a DEXA or prescribing an osteoporosis medication at the time of the fracture, as this is a time sensitive measure. 

Health Alliance Medicare Advantage plans cover low-cost osteoporosis medications such as:

• Alendronate: Tier 1
• Ibandronate: Tier 2
• Risedronate: Tier 2

Health Alliance Medicare Advantage plans also cover some osteoporosis medications under Medicare Part B such as:

• Zoledronic acid
• Prolia

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

Rheumatoid Arthritis Management

The Healthcare Effectiveness Data and Information Set (HEDIS®) recommends that patients age 18 and older who have a diagnosis of rheumatoid arthritis have a prescription for a disease-modifying antirheumatic drug (DMARD). Please consider ordering a DMARD medication for patients with rheumatoid arthritis. Medications that are routinely used to treat rheumatoid arthritis but don’t qualify include long-term use of NSAIDs (such as meloxicam or naproxen) and steroids (such as low dose prednisone).

Health Alliance Medicare Advantage plans cover low-cost rheumatoid arthritis medications such as:

• Sulfasalazine-tier 1
• Hydroxychloroquine-tier 1
• Methotrexate-tier 1
• Leflunomide-tier 2

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

Pharmacy Updates

All Plans

Long-Term Antibiotic Use for Tick-Borne Diseases

• P&T Committee was presented text from section of IL mandate (HB0889) pertaining to long-term antibiotic use for tick-borne diseases
• Committee reviewed policy long-term antibiotic use for tick-borne diseases to ensure compliance
  • Committee approved policy

Formulary Additions

Ophthalmology

• Beovu (brolucizumab)—Treatment of neovascular (wet) age-related macular degeneration
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty with No PA
    • Medicare—Covered under Part B only

Approved strategy for this drug class: No PA

• Oxervate (cenegermin)—Treatment of neurotrophic keratitis
  • Formulary placement recommendations
    • Commercial—Non-Formulary Specialty with PA
    • Medicare—Non-Formulary

Other

• Firdapse (amifampridine)—Treatment of Lambert-Eaton myasthenic syndrome (LEMS) in adults
  • Formulary placement recommendations
    • Commercial—Excluded
    • Medicare—Non-Formulary

• Ruzurgi (amifampridine)—Treatment of Lambert-Eaton myasthenic syndrome (LEMS) in pediatric patients 6 to < 17 years
  • Aimée—Ruzurgi is approved for pediatric patients, but study was in adults ages 23-83
  • Cranston supports treating adults with Ruzurgi
  • Formulary placement recommendations
    • Commercial—Non-Preferred/Non-Formulary Specialty (Tier 6) with PA
    • Medicare—Non-Formulary

• Vyndaqel, Vyndamax (tafamidis meglumine)—Treatment of amyloid cardiomyopathy to reduce cardiovascular mortality and cardiovascular-related hospitalization
  • Formulary placement recommendations
    • Commercial—Non-Preferred/Non-Formulary Specialty (Tier 6) with PA
    • Medicare—Tier 5 with PA

Commercial

Criteria Changes

• Crysvita (burosumab)
  • Updated age requirement from 1 year to 6 months due to change in FDA label
• Relistor (methylnaltrexone bromide)
  • Removed exclusions due to injection formulation getting OIC due to cancer pain indication

• Symdeko (tezacaftor-ivacaftor)
  • Updated age requirement from 12 years to 6 years
• Spravato (esketamine)
  • Added REMS requirement, specified unipolar depression

Tier Changes

• Zostavax: Move to Excluded
  • Shingrix is the Preferred product
  • This change was approved in 2018 to be effective 1/1/19, but update was delayed due to Shingrix shortage
  • Shortage is resolved, so Zostavax is Excluded as of 1/1/20
  • Note: It’s recommended that Zostavax recipients be re-vaccinated with Shingrix

Medicare

Medicare D Policies

• CMS has requested that B-vs.-D PA be re-added for 2020 (removed for 2019):
  • Medicare D Aranesp
  • Medicare D Epoetin

Medicare Policy Changes

• Amitriptyline
  • No longer covering for insomnia or migraine
  • Added coverage for IBS (requires trial of laxatives, loperamide, or anti-spasmodic agents)
  • Added coverage for post herpetic neuralgia (requires trial with gabapentin or Lyrica)
  • Added coverage for headache (requires trial with NSAID)
• Cimzia
  • Had to remove requirements of phototherapy, systemic therapy, and topical therapy for Plaque
  • Psoriasis; Policy still requires failure on Humira and Enbrel
•  Duodote
  • Removed B versus D determination

• Emgality
  • Updated approval periods
•  Enbrel
  • Updated age restrictions
• HRM-Antihistamines
  • Added hydroxyzine pamoate to policy
• Humira
  • Had to remove requirement of phototherapy for Plaque Psoriasis
• Jakafi
  • Added coverage for Polycythemia Vera (requires failure on hydroxyurea)
  • Added coverage for Steroid-Refractory Acute Graft Versus Host Disease
• Kalydeco
  • Updated age requirement to 6 months or older for oral granules
• Nucala
  • Age 6 years or older
• Nuvigil
  • Added coverage of shift work sleep disorder
• Oncology Agents Policy
  • Added the following drugs to policy: Asparlas, Balversa, Belrapzo, Cisplatin, Copiktra, Daurismo, Elzonris, Inrebic, Kanjinti, Libtayo, Lobrena, Lumoxiti, Mvasi, Nubeqa, Piqray, Polivy, Talzenna, Turalio, Vitrakvi, Vizimpro, Xospata, Xpovio

• Sub-Q IG
  • Removed B versus D determination (always covered under Part D)
• Symdeko
  • Updated age requirement from 12 years to 6 years
•  Xifaxan
  • Had to remove criteria for SIBO

View As PDF