Midwest June Newsletter 2020

June 23, 2020

Passing the Torch

Enjoy this farewell video from Robert Good, DO, retiring chief medical officer at Health Alliance, as he welcomes Chester Ho, MD as the new chief medical officer. Get to know Dr. Ho and his vision for Health Alliance – continuing the important work Dr. Good has done since 2013 in population health and medical management, and providing exceptional experiences and outcomes for partners and members.

View video here.

Important Notice: Timely Filing Requirements

We will return back to the timely filing requirements as stated in the provider’s contract effective 7/1/2020 based on an outpatient claim through date or inpatient claim discharge date.

In March, we temporarily extended the claims timely filing requirement to 180 days to provide relief during the early weeks and months of the COVID-19 public health emergency. This temporary extension will now come to an end.

Diabetes Preventive Screenings

Preventive healthcare screenings are essential for people with diabetes. National guidelines lay out a number of screenings that need to be completed to help prevent complications of the disease.

Unfortunately, a recent study found that fewer than 60% of patients with diabetes received recommended screenings – 58% for HbA1C tests and 57% for lipid profile tests (Dai, M., Peabody, M. R., Peterson, L. E., and Mainous, A. G., 2018).

Pre-visit screenings can help increase the likelihood that patients with diabetes receive the appropriate preventive tests. Using a template, like the one linked here, can further improve the chances that patients complete all recommended screenings. This template can be printed and started by the medical office assistant prior to a patient’s visit, and then given to the patient as a take-home reminder to complete the labs, screenings and/or vaccines that were ordered during the visit.

Please share this template with your office assistants and encourage its regular use.

Yearly Nephropathy Screenings for Patients with Diabetes

Did you know that 20-40% of people diagnosed with diabetes also develop kidney disease? Or that 40-50% of all diagnosed cases of end-stage renal disease (ESRD) are related to diabetes? Despite these statistics, many people with diabetes do not get their recommended yearly nephropathy urine screenings. Providers should make sure their patients stay up to date with this screening so kidney damage can be detected early and interventions can be started if needed. Providers should educate their patients on the importance of these yearly diabetic nephropathy screenings and order the tests when due. Please remember to:

Review your patient’s health record and order a nephropathy screening if it’s due. If it’s not due yet, give your patient a reminder or when it will be due.
Educate your patients about how symptoms of kidney failure don’t typically occur until nearly all function is lost, which is why yearly nephropathy screenings are so important.
Stress the importance of staying within their target blood sugar ranges and keeping their blood pressure controlled.
Encourage your patients to lead a healthier lifestyle. This includes engaging in physical activity, maintaining a healthy weight, limiting salt intake and eating enough fruits and vegetables.
Encourage your patients to engage in health coaching or care coordination. Our members can call the number on the back of their insurance ID card or visit the webpage linked above to find out more about these helpful services.

Reminder: Please Use Claim Frequency Code 7 for Corrected or Replacement Claims

To ensure accurate and timely processing, we remind you to use frequency code 7 when submitting any corrected or replacement claims. When submitting a corrected or replacement claim, also make sure that the new claim lists all of the services that were on the original claim (where appropriate). Your new claim should not only mention the services denied and/or needing correction.

Using GuidingCare’s Prior Authorization Tool: Helpful Tips

When using the Prior Authorization Tool in Altruista Health’s GuidingCare® platform, here are some helpful tips:

Use the Down Arrow key for Diagnosis and Procedure Code to populate the verification section.
Select Radio Button under Member Eligibility before moving forward.
Use N0-PROV when referring OON provider feature.
Use the NPI1 for the Provider Search to narrow your search.

Pharmacy Updates

All Plans

New Drug Reviews

- Rinvoq (upadacitinib)—Treatment of moderately to severely active rheumatoid arthritis in adults who have had an inadequate response or intolerance to methotrexate
  - Formulary placement recommendations
    - Commercial—Preferred Specialty with PA
    - Medicare—Tier 5 with PA
- Aklief (trifarotene)—Topical treatment of acne vulgaris in patients 9 years of age and older
  - Formulary placement recommendations
    - Commercial—Excluded
    - Medicare—Non-Formulary
- Zelnorm (tegaserod)—Treatment of irritable bowel syndrome with constipation in women (<65 years of age)
  - Formulary placement recommendations
    - Commercial—Excluded
    - Medicare—Non-Formulary

Hydroxychloroquine and Chloroquine Coverage

- No official HAMP PA policy is in place; general policy is to cover when rx is written for appropriate indication
- Will monitor on month-by-month basis as COVID-19 situation evolves
- Communication has been sent to members warning about self-medication

Commercial

Immunomodulators Across Rheumatology, Gastroenterology, and Dermatology

New Immunomodulator Policies

For all: Auths will be for 12 months to decrease PA burden for specialists
- Ankylosing Spondylitis Immunomodulator Therapies
- Polyarticular Juvenile Idiopathic Arthritis Immunomodulator Therapies
- Rheumatoid Arthritis Immunomodulator Therapies
- Psoriatic Arthritis Immunomodulator Therapies
- Psoriasis Immunomodulator Therapies
- Crohn’s Disease Immunomodulator Therapies
- Ulcerative Colitis Immunomodulator Therapies

Immunomodulator Criteria Changes

For all: Auths will be for 12 months
- Humira
  - Replaced criteria for each of the disease states in the above agenda section with referral to appropriate policy
  - Stated that uveitis specialist is permissible prescriber for uveitis indication (added to ophthalmologist)
  - Motion to approve changes. Committee agreed; motion approved.
- Remicade (infliximab), Inflectra (infliximab), and Renflexis (infliximab) Updated
  - Updated to reflect above disease state recommendations
  - Updated prerequisite trial of one preferred product before use (previously required both Enbrel and Humira for a number of indications)
- Tysabri (natalizumab)
  - Updated to reflect above disease state recommendations
  - Added Cimzia and Stelara as preferred products for Crohn’s

Criteria Changes—Commercial

Crotan (crotamiton)
- Updated policy title from Eurax to Crotan
- Added 6 month approval period
Doptelet (avatrombopag)
- Added separate criteria for Chronic Immune Thrombocytopenia
- Updated Exclusion Criteria and Approval Periods
Dupixent (dupilumab) Updated
- Added criteria for Rhinosinusitis with Nasal Polyposis
- Updated Approval Period
Gattex (teduglutide)
- Added requirement that patient must have received parenteral nutrition for past 12 months
- Added Exclusion Criteria
Otezla (apremilast)
- Added criteria for Behcet Disease
Rituxan (rituximab)
- Added criteria for Microscopic Polyangiitis (MPA) and Pemphigus Vulgaris
- Added Approval Period
Uceris (budesonide)
- Added exclusion for diagnosis of collagenous and lymphocytic colitis

Step Therapy and Tier Changes

Cyclobenzaprine 7.5mg
- Remove ST through cyclobenzaprine 5mg or 10mg
- Comparable cost of cyclobenzaprine 7.5mg to the step therapy prerequisites
Naloxone: Move from Tier 2 to Tier 1 on Enhanced Formulary
- Lowest cost reversal agent for opioid indication and wanting to remove any financial barrier
- Medications used for managing substance abuse disorders are required to be at preferred copay tiers
Procysbi: Move from Tier 6 to Excluded
- Cystagon is covered at non preferred brand tier (Tier 3 or Tier 4)
  - Brand medication provides limited clinical benefit vs the generics
From the pharmacy team’s review of Procysbi versus Cystagon
- Both Cystagon and Procysbi may be taken with a PPI to decrease GI effects
- Only benefit of Procysbi is convenience per available clinical evidence
- National Kidney Foundation, National Organization of Rare Diseases, 2014 International Consensus Document: all recommend early and long-term treatment with cysteamine, but do not make any recommendations regarding IR versus ER. Only that compliance can be an issue due to GI upset and foul odor

Immunomodulator Tier Changes
	Current Tier	New Recommended Tier
Cimzia	Non preferred Specialty	Preferred Specialty
Simponi	Non preferred Specialty	Preferred Specialty
Xeljanz/XR	Non preferred Specialty	Preferred Specialty
Rinvoq	Non preferred Specialty	Preferred Specialty
Stelara	Non preferred Specialty	Preferred Specialty
Otezla	Non preferred Specialty	Preferred Specialty
Tremfya	Non preferred Specialty	Preferred Specialty
Skyrizi	Non preferred Specialty	Preferred Specialty
Enbrel	Preferred Specialty	Non preferred Specialty
Immunomodulators with No Changes in Tier
Humira	Preferred Specialty	Preferred Specialty
Infliximab biosimilars	Preferred Specialty	Preferred Specialty
Remicade	Non preferred Specialty	Non preferred Specialty
Actemra	Non preferred Specialty	Non preferred Specialty
Orencia	Non preferred Specialty	Non preferred Specialty
Taltz	Non preferred Specialty	Non preferred Specialty
Kevzara	Non preferred Specialty	Non preferred Specialty
Kineret	Non preferred Specialty	Non preferred Specialty
Rituxan	Non preferred Specialty	Non preferred Specialty
Olumiant	Non preferred Specialty	Non preferred Specialty
Cosentyx	Non preferred Specialty	Non preferred Specialty
Siliq	Non preferred Specialty	Non preferred Specialty
Ilumya	Non preferred Specialty	Non preferred Specialty
Entyvio	Non preferred Specialty	Non preferred Specialty

Medicare

Step Therapy and Tier Changes

Move from Tier 1 to Tier 2—Effective 2021

Antacids
Cimetidine	Famotidine	Lansoprazole
Nizatidine	Omeprazole	Pantoprazole
Rabeprazole	Ranitidine
Antivirals/Anti-infectives/Antifungals
Acyclovir	Amphotericin B	Aztreonam
Griseofulvin	Meropenem	Piperacillin-Tazobactam
Terbinafine
Cardiovascular Agents
Alfuzosin	Bumetanide	Colestipol
Desmopressin	Diltiazem ER	Fenofibrate
Fenofibric Acid	Gemfibrozil	Methylclothiazide
Metolazone	Niacin	Nicardipine
Pindolol	Prazosin	Propafenone
Propranolol
Endocrinology
Liothyronine	Testosterone Cypionate	Testosterone Enanthate
Gastroenterology
Loperamide	Meclizine	Megestrol
Metoclopramide	Polyethylene Glycol	Prochlorperazine
Sucralfate
Neurology
Carbamazepine	Fluphenazine	Mitoxantrone
Nortriptyline	Oxcarbazepine	Phenobarbital
Phenytoin ER	Risperidone	Sumatriptan
Non-Steroidal Anti-Inflammatory Drugs
Diclofenac Potassium	Etodolac	Mefenamic Acid
Pain Medications
Acetaminopen with Codeine	Lidocaine	Tramadol
Prenatal Vitamins
Multiple medications
Respiratory
Acetylcysteine	Zafirlukast
Other
Baclofen	Betamethasone Valerate	Bethanechol
Bromocriptine	Calcium Acetate	Deferoxamine
Dexamethasone	Epinastine	Fluticasone
Glycopyrrolate	Oxybutynin	Potassium Chloride solution
Potassium Cl 20meQ packets	Sodium Fluoride	Tretinoin

Move from Tier 2 to Tier 1—Effective 2020
- Amiodarone 200mg
  - Recommendation informed by usage guidelines and specialist feedback

View As PDF