October 2023 Newsletter

As the leaves change, our gratitude never does.

Autumn is a time of change. The weather’s getting colder, daylight is fading quicker into evening dusk and the trees are showcasing brilliant colors in the weeks before losing their leaves for another winter ahead. While nature is in a constant state of change, our gratitude for you never is. Across the seasons, you and your staff never rest as you provide our members the best in compassionate, world-class care. And that’s why – all year round – we’re simply beyond thankful for all that you do. As you enjoy the beauty of nature this autumn, please know how deeply grateful we are for your partnership.

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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.

Breast Cancer Awareness Month

October is Breast Cancer Awareness Month – help us spread information about the disease and the importance of regular screenings. As the trusted health expert for your patients and their families, you have more influence than you might realize. Your voice is key – use this month and beyond to encourage your patients to get their breast cancer screenings completed.

Some helpful background:

• Your patients become eligible for mammograms starting at age 40.
• Those 45 to 54 should be screening every year.
• Patients 55 and older could start getting screened biyearly.
• Earlier detection is the best way to be able to treat breast cancer.

Thank you for being our partner – we so dearly value the encouragement you give our members to get their screenings to help them stay healthy!

World COPD Day

Every year, World COPD Day is observed on the third Wednesday of November. Organized by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in collaboration with healthcare professionals and COPD patient groups across the world, this year’s observance takes place on November 15.

COPD (chronic obstructive pulmonary disease) is a preventable and treatable progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. People with COPD often experience shortness of breath and a cough, and possible chronic sputum production. COPD worsens over time, making everyday activities like walking or getting dressed increasingly difficult. The most common cause of COPD is tobacco smoking and other inhaled toxic particles or gasses. Other factors are alpha-1 antitrypsin deficiency, older age and genetics.

This World COPD Day, and throughout the year, make an effort to raise awareness about the disease – and how to prevent and treat it. This year’s theme is “Breathing is Life – Act Earlier,” and it focuses on the importance of lung health from an early age, and early diagnosis and treatment of COPD. To learn more, and to find great resources and tools, visit here.

Are you addressing your patients’ social needs?

We need your help. As you know, healthcare goes beyond the walls of the doctor’s office and hospital. Your patients’ health depends not only on your expert care, but also on many other social factors like their access to nutritious food, stable housing, transportation and more. Help us identify your patients’ social-determinants-of-health (SDoH) needs so we can together discover opportunities and close gaps.

How can you help us? Make sure you capture and document these SDoH needs in your patients’ EMRs.

• Our health plan tracks whether or not food, housing and transportation needs are discussed with patients.
• For food needs, discuss: food insecurity.
• For housing needs, discuss: housing stability, homelessness or housing inadequacy.
• For transportation needs, discuss: transportation inadequacy.
• Yearly wellness visits are a great opportunity to touch on these areas with your patients.

Thank you for the hard work you and your staff do to help keep our members healthy – well beyond the walls of the clinic.

Quick Tips – Best Practices for Taking Blood Pressure

Taking accurate blood pressure readings are key to patient checkups. Follow these few short tips and share them with your staff:

• Train your staff to use proper technique. And retrain as needed to keep your staff at top skill level.
• Make sure all your blood pressure monitors are validated models – and get them all checked annually for proper functioning.
• Ensure you have a full range of cuff sizes on hand.
• Whenever you or your staff retakes a patient’s blood pressure – for example, when a first reading is elevated and it’s taken again later – make sure you update the blood pressure field in the patient’s chart.

Thank you for your skill and attention to detail.

Reference Used for this Article:

“Office BP Measurement: Current Challenges and Best Practices.” Heart Health Now! The North Carolina Cooperative for AHRQ’s EvidenceNOW Advancing Heart Health in Primary Care. The Cecil G. Sheps Center for Health Services Research at the University of North Carolina, North Carolina Healthcare Quality Alliance, North Carolina Area Health Education Centers and Community Care of North Carolina. 2015.

Key Facts: Antidepressant Medication Practices for Adult Patients

Here’s key information to know about antidepressant medication practices for your adult patients.

Commonly prescribed types of antidepressants include:

• SSRIs: Selective serotonin reuptake inhibitors.
• SNRIs: Serotonin-norepinephrine reuptake inhibitors.
• NDRIs: Norepinephrine-dopamine reuptake inhibitors.

As a provider, you know that medications may need adjusted for your patients’ specific needs, and this remains true for antidepressants. Most of the time, a change is needed because your patient is experiencing intolerable side effects or they report that they feel the drug’s no longer working.

For providers, there are three important things to remember about antidepressants:

1. Drug interactions.
2. Symptoms from discontinuing a specific medication.
3. Depression relapse.

As you’re probably aware, cross-tapering is the most common technique used when switching antidepressant medications, and there are many combinations that could affect patients. Here are some things to remember when switching up antidepressant drugs:

• Switching between SSRI medications is the simplest change to negate side effects, because the new SSRI would stop any discontinuation symptoms that occur with an SSRI.
• When switching from an SSRI to an SNRI, usually the change involves using an equivalent dose.
• When converting to or from an atypical antidepressant, serotonin modulator or tricyclic antidepressant, cross-tapering is the preferred method.
• When interchanging an SNRI to anything other than an MAOI (monoamine oxidase inhibitor), the cross-taper must take place over a two-to-three-week period.

Lastly, combining antidepressants with medications or supplements that also act on the serotonin system – such as “triptan” medications (often used to treat migraine headaches) and St. John’s wort (a dietary supplement) – can cause a rare but life-threatening illness called serotonin syndrome. Symptoms of serotonin syndrome include agitation, muscle twitches, hallucinations (seeing or hearing things others do not see or hear), high temperature and unusual blood pressure changes.

References Used for this Article:

Michael Hirsch, MD, and Robert J. Birnbaum, MD, PhD. “Switching antidepressant medications in adults.” UpToDate^®. 20 October 2022.

“Mental Health Medications.” National Institute of Mental Health. June 2022.

Annual Great American Smokeout

Help your patients quit smoking. On Thursday, November 16, thousands across the country will take part in the annual Great American Smokeout^®, challenging themselves to go a full 24 hours without cigarettes. The hope is that they find strength and motivation in being able to go an entire day without smoking, and perhaps decide to quit for good. The day is an initiative of the American Cancer Society^® (ACS) and has brought health, hope and inspiration for nearly half a century. Between now and November 16, encourage your patients to take part, and point them to cancer.org/smokeout for more information about the day, along with tools and resources.

Also, for your patients who are members of our health plans, remind them that we offer access to Quit For Life^® at no additional cost on many plans. It’s a built-in part of their plan – just waiting for them to use – where they can get personalized help to quit smoking. They should visit hally.com/care for more information, and call the number on the back of their member ID card to see if their plan includes Quit For Life.

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Coding Counts:
Using M.E.A.T. for Your Documentation

Supporting documentation and accurate coding are key to making sure your patients receive the care they need. During outpatient encounters, it’s essential you use adequate support for any chronic condition that’s been addressed during the patient’s office visit. ICD-10-CM codes that are unsupported with clinical documentation are subject to failing audits, takebacks or repayments.

We’re here to help – to ensure that your documentation is always sufficient and provides enough information, remember the acronym M.E.A.T.

Document in the medical record – every time – you address any aspect of M.E.A.T.:

• Monitor: Includes disease progression or regression, and/or associated signs, symptoms or status.
• Evaluate: Includes reviewing test results, lab results, responses to treatment and/or effectiveness of medication.
• Assess: Includes ordering tests, discussions of condition, reviewing medical records and/or counseling.
• Treat: Includes therapies, medications and/or referrals.

Documentation of the medical record in your own words is vitally important, as this determines code selection. A simple list of diagnoses is not acceptable, since it doesn’t prove that each condition has been addressed during the visit.

Also, remember to include support for the condition in the assessment and plan portions of the note, as well as ensuring that there’s no conflicting documentation in any section of the note. Following this principle will ensure that chronic conditions are supported and validated, which results in better care for the patient.

We thank you for your attention to detail and professionalism, and we’re always here to help. To find more coding resources, visit our Coding Counts page. Thank you for your continued care and dedication to our members’ health.

Questions?

Please contact us at CodingCounts@HealthAlliance.org.

Midwest – Pharmacy Updates

All Plans

Neurology

Formulary Additions

• Briumvi (ublituximab)—Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults
  • Formulary placement recommendations
    • Commercial— Non-Preferred Specialty Medical with PA
    • Medicare—Medicare Part B with PA
  • Rystiggo (rozanolixizumab)— Treatment of generalized myasthenia gravis in adults who are anti-acetylcholine receptor (AChR) or anti-muscle-specific tyrosine kinase (MuSK) antibody positive
    • Formulary placement recommendations
      • Commercial— Non-Preferred Specialty Medical with PA
      • Medicare—Medicare Part B with PA
    • Skyclarys (omaveloxolone)— Treatment of Friedreich’s ataxia in adults and adolescents aged 16 years and older
      • Formulary placement recommendations
        • Commercial— Non-Preferred Specialty Pharmacy with PA and MDL
        • Medicare—Non-Formulary
      • Zavzpret (zavegepant)— Acute treatment of migraine with or without aura in adults
        • Formulary placement recommendations
          • Commercial— Non-Preferred Brand with PA and MDL
          • Medicare—Non-Formulary
        • Qalsody (tofersen)—Treatment of amyotrophic lateral sclerosis (ALS) in adults who have a mutation in the superoxide dismutase 1 (SOD1) gene
        • Elevidys (delandistrogene moxeparvovec)—Treatment of Duchenne muscular dystrophy (DMD) in ambulatory pediatric patients 4 through 5 years of age with a confirmed mutation in the DMD gene
          • Formulary placement recommendations for Elevidys and Qalsody
            • Commercial—Non-Formulary
            • Medicare—Non-Formulary

Miscellaneous New Drug Reviews

• Veozah (fezolinetant)—Indicated for treatment of moderate to severe vasomotor symptoms (VMS) due to menopause
  • Beverly London: This will be a game-changer for many patients
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with ST and MDL
    • Medicare—Non-Formulary

Commercial

Neurology

Criteria Changes

• Immune Globulin Products
  • Removed Asceniv, reorganized policy by diagnosis
• Nuplazid (pimavanserin)
  • Expanded diagnosis criteria, added specialist requirement, added exclusion criteria
• Vyvgart (efgartigimod alfa)
  • Added Vyvgart Hytrulo, expanded diagnostic criteria, added exclusion criteria

Psychiatry/Behavioral Health

Criteria Changes

• Behavioral Health
  • Added Auvelity, added criteria for antipsychotics for agitation with Alzheimer disease

Miscellaneous Policy Updates

• Testosterone – Implantable, Topical, Oral and Nasal
  • Updated symptom and testing requirements, updated exclusions

Formulary Changes—Commercial

Positive Changes

• Adalimumab Biosimilar Additions
  • Hadlima (40mg/0.8mL and 40mg/0.4mL)
  • Adalimumab-adaz (40mg/0.4mL)
• MDL Updates

Negative Changes (effective 1/1/24)

• Asceniv—Move to non-formulary (minimal member impact)
• Sodium phenylbutyrate products—Move to Specialty tiers (Avg cost/30d: $27,000, no utilization)
  • Sodium Phenylbutyrate oral tablet and powder
  • Buphenyl oral tablet and powder
  • Pheburane oral pellets

Please Note: The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, 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 2023 and changes may be made:

• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Northwest – Pharmacy Updates

All Plans

Neurology

Formulary Additions

• Briumvi (ublituximab)—Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults
  • Formulary placement recommendations
    • Commercial— Non-Preferred Specialty Medical with PA
    • Medicare—Medicare Part B with PA
  • Rystiggo (rozanolixizumab)— Treatment of generalized myasthenia gravis in adults who are anti-acetylcholine receptor (AChR) or anti-muscle-specific tyrosine kinase (MuSK) antibody positive
    • Formulary placement recommendations
      • Commercial— Non-Preferred Specialty Medical with PA
      • Medicare—Medicare Part B with PA
    • Skyclarys (omaveloxolone)— Treatment of Friedreich’s ataxia in adults and adolescents aged 16 years and older
      • Formulary placement recommendations
        • Commercial— Non-Preferred Specialty Pharmacy with PA and MDL
        • Medicare—Non-Formulary
      • Zavzpret (zavegepant)— Acute treatment of migraine with or without aura in adults
        • Formulary placement recommendations
          • Commercial— Non-Preferred Brand with PA and MDL
          • Medicare—Non-Formulary
        • Qalsody (tofersen)—Treatment of amyotrophic lateral sclerosis (ALS) in adults who have a mutation in the superoxide dismutase 1 (SOD1) gene
        • Elevidys (delandistrogene moxeparvovec)—Treatment of Duchenne muscular dystrophy (DMD) in ambulatory pediatric patients 4 through 5 years of age with a confirmed mutation in the DMD gene
          • Formulary placement recommendations for Elevidys and Qalsody
            • Commercial—Non-Formulary
            • Medicare—Non-Formulary

Miscellaneous New Drug Reviews

• Veozah (fezolinetant)—Indicated for treatment of moderate to severe vasomotor symptoms (VMS) due to menopause
  • Beverly London: This will be a game-changer for many patients
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with ST and MDL
    • Medicare—Non-Formulary

Commercial

Neurology

Criteria Changes

• Immune Globulin Products
  • Removed Asceniv, reorganized policy by diagnosis
• Nuplazid (pimavanserin)
  • Expanded diagnosis criteria, added specialist requirement, added exclusion criteria
• Vyvgart (efgartigimod alfa)
  • Added Vyvgart Hytrulo, expanded diagnostic criteria, added exclusion criteria

Psychiatry/Behavioral Health

Criteria Changes

• Behavioral Health
  • Added Auvelity, added criteria for antipsychotics for agitation with Alzheimer disease

Miscellaneous Policy Updates

• Testosterone – Implantable, Topical, Oral and Nasal
  • Updated symptom and testing requirements, updated exclusions

Formulary Changes—Commercial

Positive Changes

• Adalimumab Biosimilar Additions
  • Hadlima (40mg/0.8mL and 40mg/0.4mL)
  • Adalimumab-adaz (40mg/0.4mL)
• MDL Updates

Negative Changes (effective 1/1/24)

• Asceniv—Move to non-formulary (minimal member impact)
• Sodium phenylbutyrate products—Move to Specialty tiers (Avg cost/30d: $27,000, no utilization)
  • Sodium Phenylbutyrate oral tablet and powder
  • Buphenyl oral tablet and powder
  • Pheburane oral pellets

Please Note: The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, 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 2023 and changes may be made:

• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Carle – Pharmacy Updates

All Plans

Neurology

Formulary Additions

• Briumvi (ublituximab)—Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults
  • Formulary placement recommendations
    • Commercial— Non-Preferred Specialty Medical with PA
    • Medicare—Medicare Part B with PA
  • Rystiggo (rozanolixizumab)— Treatment of generalized myasthenia gravis in adults who are anti-acetylcholine receptor (AChR) or anti-muscle-specific tyrosine kinase (MuSK) antibody positive
    • Formulary placement recommendations
      • Commercial— Non-Preferred Specialty Medical with PA
      • Medicare—Medicare Part B with PA
    • Skyclarys (omaveloxolone)— Treatment of Friedreich’s ataxia in adults and adolescents aged 16 years and older
      • Formulary placement recommendations
        • Commercial— Non-Preferred Specialty Pharmacy with PA and MDL
        • Medicare—Non-Formulary
      • Zavzpret (zavegepant)— Acute treatment of migraine with or without aura in adults
        • Formulary placement recommendations
          • Commercial— Non-Preferred Brand with PA and MDL
          • Medicare—Non-Formulary
        • Qalsody (tofersen)—Treatment of amyotrophic lateral sclerosis (ALS) in adults who have a mutation in the superoxide dismutase 1 (SOD1) gene
        • Elevidys (delandistrogene moxeparvovec)—Treatment of Duchenne muscular dystrophy (DMD) in ambulatory pediatric patients 4 through 5 years of age with a confirmed mutation in the DMD gene
          • Formulary placement recommendations for Elevidys and Qalsody
            • Commercial—Non-Formulary
            • Medicare—Non-Formulary

Miscellaneous New Drug Reviews

• Veozah (fezolinetant)—Indicated for treatment of moderate to severe vasomotor symptoms (VMS) due to menopause
  • Beverly London: This will be a game-changer for many patients
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with ST and MDL
    • Medicare—Non-Formulary

Commercial

Neurology

Criteria Changes

• Immune Globulin Products
  • Removed Asceniv, reorganized policy by diagnosis
• Nuplazid (pimavanserin)
  • Expanded diagnosis criteria, added specialist requirement, added exclusion criteria
• Vyvgart (efgartigimod alfa)
  • Added Vyvgart Hytrulo, expanded diagnostic criteria, added exclusion criteria

Psychiatry/Behavioral Health

Criteria Changes

• Behavioral Health
  • Added Auvelity, added criteria for antipsychotics for agitation with Alzheimer disease

Miscellaneous Policy Updates

• Testosterone – Implantable, Topical, Oral and Nasal
  • Updated symptom and testing requirements, updated exclusions

Formulary Changes—Commercial

Positive Changes

• Adalimumab Biosimilar Additions
  • Hadlima (40mg/0.8mL and 40mg/0.4mL)
  • Adalimumab-adaz (40mg/0.4mL)
• MDL Updates

Negative Changes (effective 1/1/24)

• Asceniv—Move to non-formulary (minimal member impact)
• Sodium phenylbutyrate products—Move to Specialty tiers (Avg cost/30d: $27,000, no utilization)
  • Sodium Phenylbutyrate oral tablet and powder
  • Buphenyl oral tablet and powder
  • Pheburane oral pellets

Please Note: The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, 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 2023 and changes may be made:

• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Reid – Pharmacy Updates

Medicare

Neurology

Formulary Additions

• Briumvi (ublituximab)—Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults
  • Formulary placement recommendations
    • Medicare—Medicare Part B with PA
  • Rystiggo (rozanolixizumab)— Treatment of generalized myasthenia gravis in adults who are anti-acetylcholine receptor (AChR) or anti-muscle-specific tyrosine kinase (MuSK) antibody positive
    • Formulary placement recommendations
      • Medicare—Medicare Part B with PA
    • Skyclarys (omaveloxolone)— Treatment of Friedreich’s ataxia in adults and adolescents aged 16 years and older
      • Formulary placement recommendations
        • Medicare—Non-Formulary
      • Zavzpret (zavegepant)— Acute treatment of migraine with or without aura in adults
        • Formulary placement recommendations
          • Medicare—Non-Formulary
        • Qalsody (tofersen)—Treatment of amyotrophic lateral sclerosis (ALS) in adults who have a mutation in the superoxide dismutase 1 (SOD1) gene
        • Elevidys (delandistrogene moxeparvovec)—Treatment of Duchenne muscular dystrophy (DMD) in ambulatory pediatric patients 4 through 5 years of age with a confirmed mutation in the DMD gene
          • Formulary placement recommendations for Elevidys and Qalsody
            • Medicare—Non-Formulary

Miscellaneous New Drug Reviews

• Veozah (fezolinetant)—Indicated for treatment of moderate to severe vasomotor symptoms (VMS) due to menopause
  • Beverly London: This will be a game-changer for many patients
  • Formulary placement recommendations
    • Medicare—Non-Formulary

Please Note: The P&T Committee meets bimonthly, and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, 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 2023 and changes may be made:

• October Meeting: Ophthalmology, Urology, Rare Diseases.
• December Meeting: Specialty and Medicare.

Contact Us

(800) 851-3379, option 3

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