You can find the updated Medicare provider manual on the Forms & Resources page of Your Health Alliance.

If your office does not have internet access, you can request a printed copy of the manual by contacting your provider relations specialist.

Meet with a Coding Specialist

The Risk Adjustment coding consultants are making their rounds to high-volume participating provider offices sharing member-specific examples of coding and quality measure needs. A member of the team is happy to meet with you to discuss any coding or quality questions you may have, or to provide member-specific examples from your panel of members. If interested, contact us at CodingCounts@healthalliance.org.

Give Patients Your Full Attention

Handheld devices help you be more connected and efficient, but it’s important that your patients feel like you are listening to them and are not solely focused on your device. When meeting with patients, remember to make eye contact to show patients they have your attention. This simple gesture can go a long way toward building open provider-patient relationships.

Learn About Our Case Management Program

Health Alliance offers members with chronic or complex health conditions access to a case manager who can answer questions and provide resources and support. The program doesn’t cost members anything extra. Learn more at HealthAlliance.org or in the provider manual, which is posted on Your Health Alliance.

A Carle Doctor’s Take on Properly Screening for Acute Pharyngitis

Health Alliance: Today we are here with Dr. Charles Liang, who has been with the Carle physician group for more than 22 years. He worked 16 years in family medicine at the Carle Bloomington-Normal branch. Recently he has been the associate medical director of convenient care. Dr. Liang is also a medical director at Health Alliance and serves on the recruitment committee, physician council, and medical executive committee.

Dr. Liang, I see you wear several hats at Carle and Health Alliance.

Dr. Liang: Yes, I find it very beneficial to have different roles. It allows me to retain my prospective as a clinician and is a reminder that taking care of patients is why we’re all here.

HA: Today we’re going to talk about doing a rapid strep test before treating acute pharyngitis.

Some providers say they are able to diagnose strep pharyngitis based solely on a physical exam and that doing a rapid strep test only adds cost.

Dr. Liang: Although it seems reasonable, a physical exam alone is only accurate approximately half the time, based on the Modified Centor Criteria. It is difficult to distinguish between viral and bacterial causes of physical findings. For example, mono can present with a sore throat, swollen tonsils, and exudate.

It is best to follow the Infectious Disease Society of America’s evidence-based and best-practice guidelines from 2012. The recommendation is: “Swabbing the throat and testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture should be performed because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis except when overt viral features like rhinorrhea, cough, oral ulcers, and/or hoarseness are present.”

HA: Why is it important to avoid always treating pharyngitis with antibiotics? Wouldn’t it be better just to be safe?

Dr. Liang: Well, there are a number of reasons why a rapid strep test should be done before treating pharyngitis:

The Development of Antibiotic-Resistant Bacteria

With repeated overuse of antibiotics, we are increasing the rate of developing antibiotic-resistant bacteria. For example, the Department of Defense recently announced finding the first MCR-1 gene in E.coli bacteria in a human in the United States. The MCR-1 gene makes bacteria resistant to the antibiotic colistin, which is used as a last-resort drug to treat patients with multi-drug-resistant infections.

Adverse Drug Reactions

Every year, thousands of patients develop drug reactions. A classic example is when a patient with mono is given amoxicillin and develops a rash. There is also a relatively infrequent risk of developing clostridium difficile colitis. Clostridium difficile is a colonic bacterial infection that that can develop after just one course of antibiotics. It was initially associated with clindamycin but now can occur with other antibiotics including penicillin, cephalosporins and quinolones.

Lack of Documentation

If a patient develops recurrent episodes of streptococcal pharyngitis requiring tonsillectomy, there would be no documentation if the patient is in fact developing streptococcal pharyngitis, which would make it more difficult for an ear, nose and throat provider to decide whether to do a tonsillectomy.
In conclusion, evidence-based best practices support doing a strep screen before the  treatment of pharyngitis. This provides the best care for our patients.

Pharmacy Updates

All Plans

Formulary Additions

10 new oncology medications were added to the Commercial and Medicaid policy Oncology Agents and to Medicare D Drug Policy for Oncology Agents:

• Alecensa (alectinib) 150 mg capsule – Indicated for the treatment of patients with anaplastic lymphoma kinase (ALK)-positive, metastatic non-small cell lung cancer (NSCLC) who have progressed on or are intolerant to Xalkori (crizotinib).
  • Commercial – Tier 5 with preauthorization (PA)
  • Medicaid- Covered with PA
  • Medicare – Tier 5 with PA
• Cotellic (cobimetinib) 20mg tablet – Indicated for the treatment of patients with unresectable or metastatic melanoma with a BRAF V600E or V600K mutation, in combination with Zelboraf (vemurafenib).
  • Commercial – Tier 5 with PA
  • Medicaid – Covered with PA
  • Medicare – Tier 5 with PA
• Darzalex (daratumumab) IV – Indicated for the treatment of patients with multiple myeloma who have received at least 3 prior lines of therapy, including a proteasome inhibitor (PI) and an immunomodulatory agent or who are double-refractory to a PI and an immunomodulatory agent.
  • Commercial – Tier 5 with PA
  • Medicaid – Covered with PA
  • Medicare – Tier 5 with PA
• Empliciti (elotuzumab) IV – Indicated in combination with lenalidomide and dexamethasone for the treatment of patients with multiple myeloma (MM) who have received one to three prior therapies.
  • Commercial- Tier 5 with PA
  • Medicaid – Covered with PA
  • Medicare – Tier 5 with PA
• Imlygic (talimogene laherparepvec) – Indicated for the local treatment of unresectable cutaneous, subcutaneous, and nodal lesions in patients with melanoma recurrent after initial surgery.
  • Commercial – Tier 5 with PA
  • Medicaid – Covered with PA
  • Medicare – Part B only
• Ninlaro (ixazomib) 2.3mg, 3mg, 4mg capsules – Indicated in combination with Revlimid (lenalidomide) and dexamethasone for the treatment of patients with multiple myeloma (MM) who have received at least one prior therapy.
  • Commercial – Tier 5 with PA
  • Medicaid – Covered with PA
  • Medicare – Tier 5 with PA
• Onivyde (irinotecan liposomal) IV – Indicated, in combination with fluorouracil and leucovorin for the treatment of patients with metastatic adenocarcinoma of the pancreas after disease progression following gemcitabine-based therapy.
  • Commercial – Tier 5 with PA
  • Medicaid – Covered with PA
  • Medicare – Part B only
• Portrazza (necitumumab) IV – Indicated, in combination with gemcitabine and cisplatin for first-line treatment of patients with metastatic squamous non-small cell lung cancer (NSCLC).
  • Commercial – Tier 5 with PA
  • Medicaid – Covered with PA
  • Medicare – Tier 5 with PA
• Tagrisso (osimertinib) 40mg, 80mg tablet –  Indicated for the treatment of patients with metastatic epidermal growth factor receptor (EGFR) T790M mutation-positive non-small cell lung cancer (NSCLC), as detected by an FDA-approved test, who have progressed on or after EGFR tyrosine kinase inhibitor (TKI) therapy.
  • Commercial – Tier 5 with PA
  • Medicaid – Covered with PA
  • Medicare – Tier 5 with PA
• Yondelis (trabectedin) IV – Indicated for the treatment of patients with unresectable or metastatic liposarcoma or leiomyosarcoma who received a prior anthracycline-containing regimen.
  • Commercial – Tier 5 with PA
  • Medicaid – Covered with PA
  • Medicare – Tier 5 with PA

2 new medications were added to the Commercial and Medicaid Behavioral Health policy:

• Rexulti (brexpiprazole) – An atypical antipsychotic indicated for (1) use as an adjunctive therapy to antidepressants for the treatment of major depressive disorder (MDD), and (2) treatment of schizophrenia.
  • Commercial – Tier 3 with PA;
  • Medicaid – Covered with PA;
  • Medicare – Tier 4 with Step Therapy (ST) through a generic atypical antipsychotic
• Vraylar (cariprazine) – Indicated for treatment of (1) acute manic or mixed episodes associated with bipolar I disorder, and (2) schizophrenia.
  • Commercial – Tier 3 with PA;
  • Medicaid – Covered with PA;
  • Medicare – Tier 4 with ST through a generic atypical antipsychotic

Nucala was added to all formularies, and PA policies were created for Commercial and Medicaid and Medicare Part D:

• Nucala (mepolizumab) – Indicated as an add-on maintenance treatment of patients with severe asthma aged 12 years and older, and with an eosinophilic phenotype.
  • Commercial – Tier 5 with PA
  • Medicaid – Covered with PA
  • Medicare – Tier 5 with PA

Medicaid

Tier Change

• Pexeva – Moved from Covered to Excluded
  • Paroxetine is covered on formulary
• Sarafem – Moved from Covered to Excluded
  • Fluoxetine is covered on formulary

OTC Coverage Change – Implementation Date TBD

• Our coverage of OTC products for Managed Medicaid has been reviewed, as HFS has provided their coverage list
• We’re covering significantly more products than the HFS list
• DECISION: Limit coverage of OTC products to only those covered on the HFS list

Medicaid and Commercial

Criteria Changes

• Cosentyx – Added coverage criteria for Ankylosing Spondylitis and Psoriatic Arthritis
• Quillivant XR (methylphenidate HCL susp) – Added Medicaid to policy

Commercial

New Policies

• Quillichew (methylphenidate HCl chew tab) ER – Specified criteria for coverage and MDL
• Dyanavel XR (amphetamine ER) Suspension – Specified criteria for coverage

Criteria Change

• PPI (Proton Pump Inhibitor) Coverage – Clarifed that Zegerid OTC will be covered at Tier 1, removed PA on rabeprazole

Tier Changes

• Hycamtin Oral – Move from Tier 5 to Tier 3
  • Hycamtin IV is covered under General Medical, and Hycamtin Oral cannot be covered at a higher copay tier than Hycamtin IV
• Temodar Oral – Move from Tier 6 to Tier 5
  • Temodar IV is covered at Tier 5, and Temodar Oral cannot be covered at a higher copay tier than Temodar IV
• Capecitabine Oral – Move from Tier 4 to Tier 3
  • Capecitabine IV is covered under General Medical, and capecitabine oral cannot be covered at a higher copay tier than capecitabine IV
• Pexeva – Move from Tier 3 to Excluded
  • Paroxetine is available at Tier 1
• Sarafem – Move from Tier 3 to Excluded
  • Fluoxetine is available at Tier 1