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Northwest June Newsletter 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
          • WA Individual—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
          • WA Individual—Excluded
          • Medicare—Non-Formulary
      • Zelnorm (tegaserod)—Treatment of irritable bowel syndrome with constipation in women (<65 years of age)
        • Formulary placement recommendations
          • WA Individual—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

    WA Individual

    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—WA Individual

    • 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

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