Reid April Newsletter 2022

Grateful for You

Spring – it’s a time of hope, freshness and cheer. As the sun shines and flowers bloom in our communities, we want to thank you and your staff for all you do for our members. Like the season itself, you bring hope and renewal to so many people. Thank you for your hard work. For your knowledge, talent and expertise. For the kindness and cheer you bring our members. This spring and beyond, our hearts bloom with gratitude for you.

As It Relates to You

Key information for you and your staff.

Important Information About
Our New Claims Platform, Epic Tapestry

We’re excited to announce that we’ve slowly started moving our plan members and groups to our new claims platform, Epic Tapestry, while also continuing to utilize our legacy platform. The full transition will take about a year to complete.

During the transition period, claims will be processed on both platforms depending on the date of service and the plan renewal date of the group or individual member. Over the next couple of years, providers may see remittance advices from both platforms, as we look to wind down operations in our legacy platform. We simply want you to be aware of this as you post payments on your outstanding receivables. Please reach out to your provider relations specialist if you have any questions.

Keep Your Provider Information Up to Date

The information in our provider directories is key to making sure patients – both existing and new – can easily reach you. Our members use the directories to search for new providers, get directions to clinics and find contact information to schedule appointments. CMS and departments of insurance require that providers review and update their information in a timely manner or whenever there are significant changes.

Please remember to use our new forms to update your provider information or to add a provider to your practice. You’ll find the forms in the Provider Resources section on Provider.HealthAlliance.org. If you’re adding providers to a currently contracted practice, please use the Provider Addition form – along with attaching the appropriate provider application and supporting documentation – not the Prospective Provider form.

Please send all provider updates to [email protected]. Your provider relations specialist will continue to be your contact for all other inquiries. Thank you so much for your help in keeping your information up to date.

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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.

Remind Your Patients About
Scheduling Their School and Sports Physicals

As this school year comes to a close, make sure you and your staff talk with your young patients – and their parents and guardians – and help them schedule their school and sports physicals for the upcoming school year.

Your patients might think it’s too soon to schedule these, but now is in fact the best time to think ahead and get the appointments made. As you know all too well, summer is a busy time for your office – and this is why we always recommend patients schedule their physicals as early as possible. We want them to experience the least delays in getting an appointment, which becomes harder as the summer progresses.

As you know, regular physical exams for children and teenagers are a great way to detect any health problems in their earliest stages when they’re easiest to treat. These exams also give you a chance to talk to your young patients (and their parents and guardians) about body mass index (BMI), nutrition and maintaining a healthy weight.

It’s also important to ask – and check the medical records to see – if your young patients are up to date on their needed vaccines, including Gardasil^®, which helps prevent HPV (a virus that can lead to cancer).

If your young patients take any medications, make sure their prescriptions are up to date and they have enough supply for the beginning of the school year. Also make sure their parents or guardians know the school’s medication policies.

Finally, for your young patients who participate in sports, remember that specific sports physicals are often required by schools – and without one, they might not be able to participate. The new school year will be here before you know it – thank you for helping your patients and their families during this important time.

Learn More About Asthma Care

If you or your staff want to learn more about asthma care, the American Lung Association^® (ALA) has a great resource for you. The ALA’s Basics program is offered as both a self-paced online learning module and an in-person workshop – your choice, perfect for busy providers. The program is ideal for frontline healthcare professionals – doctors, school nurses, community health workers and beyond – as well as for individuals with asthma and their family members, friends and others who simply want to learn more about the condition. To reach the widest audience, the ALA offers the online learning module in both English and Spanish.

The Basics program teaches participants to:

• Recognize and manage asthma triggers.
• Understand the value of an asthma action plan.
• Recognize – and respond to – a breathing emergency.
• And much more.

One of the highlights of the program is a short (less than two-minute) animation that shows the three main changes in a person’s airway during an asthma episode. Other helpful videos demonstrate how to use different types of inhalers and peak flow meters. Take a moment to discover the many resources, downloads and educational tools the Basics program has to offer – and share the links with others.

To register for the online course, click here – and if you have any questions about registering you can visit this page to request help. Finally, to learn more about hosting an in-person workshop, contact your local ALA office.

Help Us Improve Medication Adherence

We know there’s a correlation between medication adherence and reductions in complications and hospitalization rates among people with diabetes, hypertension and hypercholesterolemia. Unfortunately, only about half of the patients in the U.S., on average, take their medicines as directed by their doctor. Here’s how you can help move the needle:

• Do 90-day prescriptions and encourage mail order (a.k.a. fill by mail). Kaiser Permanente found that individuals filling 90-day supplies of oral diabetes medication via the mail had higher adherence rates than those filling 90-day supplies at on-site retail pharmacies.
• Synchronize refills of chronic medications so your patients can pick up multiple refills at the same time.
• Make sure your patients understand why they are taking the medication and the importance of taking it consistently (and correctly).
• Also make sure your patients know what to do if they miss a dose.
• Help your patients learn how to avoid possible side effects – for example, by taking a medication with food or at a different time of the day.

Your patients, rightly, trust you. All you can do to help them get, take – and keep taking – their medications can have a large impact on their health. Thank you for your constant advocacy for better adherence.

Up-to-Date Screening Guidelines
for Chlamydia

Here are the most up-to-date screening recommendations and guidelines for chlamydia, directly from the CDC. Talk with your patients and make sure they’re getting these important screenings as needed.

Women

• Sexually active women under 25 years of age.
• Sexually active women 25 years of age and older, if at increased risk (those with a new sex partner, more than one sex partner, a sex partner with concurrent partners or a sex partner who has an STI).
• Retest approximately three months after treatment.
• Rectal chlamydial testing can be considered in females based on reported sexual behaviors and exposure, through shared clinical decision between the patient and the provider.

Pregnant Women

• All pregnant women under 25 years of age.
• Pregnant women 25 years of age and older, if at increased risk (those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners or a sex partner who has an STI).
• Retest during the third trimester for women under 25 years of age or at risk.
• Pregnant women with chlamydial infection should have a test of cure four weeks after treatment and be retested within three months.

Men Who Have Sex With Women

• There is insufficient evidence for screening among heterosexual men who are at low risk for infection. However, screening young men can be considered in high-prevalence clinical settings (g., adolescent clinics, correctional facilities, STI/sexual health clinics).

Men Who Have Sex With Men (MSM)

• At least annually for sexually active MSM at sites of contact (urethra, rectum), regardless of condom use.
• Every three to six months if at increased risk (i.e., MSM on PrEP, with HIV infection, or if they or their sex partners have multiple partners).

Transgender and Gender Diverse Persons

• Screening recommendations should be adapted based on anatomy, (i.e., annual, routine screening in cis-gender women younger than 25 years-old should be extended to all transgender men and gender diverse people with a cervix. If age 25 or older, persons with a cervix should be screened if at increased risk.)
• Consider screening at the rectal site based on reported sexual behaviors and exposure.

Persons With HIV

• For sexually active individuals, screen at first HIV evaluation, and at least annually thereafter.
• More frequent screening might be appropriate depending on individual risk behaviors and the local epidemiology.

Take Steps To Fight Hypertension

Hypertension is one of the most common and problematic health conditions in the U.S. According to the CDC, nearly half of American adults – a full 116 million – have high blood pressure, and only a quarter of those with the condition have it under control. Tragically, over half a million deaths a year in the U.S. have hypertension as a primary or contributing cause. This is because high blood pressure puts people at risk of heart disease, stroke, kidney disease and more. You can help your patients dealing with hypertension, and also those who are at risk of developing it. Here are some actions you can take:

• Provide both initial and ongoing training to your staff to ensure that blood pressure readings are taken correctly during patient visits.
• Follow best practices for taking patients’ blood pressure. These include:
  • Have the patient sit in a chair with their feet on the floor and their arm supported so that their elbow is at about heart level. The inflatable part of the cuff should completely cover at least 80% of the upper arm. The cuff should be placed on bare skin, not over a shirt. Remove any tight-sleeved clothing.
  • Assess whether the patient has used nicotine or caffeine, has exercised in the last 30 minutes or has a full bladder.
  • Repeat elevated blood pressure readings after giving the patient a chance to rest quietly.
• Encourage your patients to monitor their blood pressure at home – and share this instructional video we made to help them do so. Also have your patients bring their home blood pressure cuff into your office for calibration – and let them know when to report their at-home readings to you.
• Create blood pressure goals with your patients, and educate them on how to reach them (g. lifestyle modifications).
• Stress the importance of medication adherence. And consider prescribing a statin medication as well.
• Consider non-pharmacological treatments in addition to medications. Encourage patients to lead a healthier lifestyle including weight loss, reducing sodium intake and increasing physical activity.
• Finally, encourage patients to engage in health coaching or care coordination. This is a free, built-in feature for most members of our health plans – all they need to do is call the number on the back of their member ID card and sign up.

HEDIS Measure Adherence:
Toolkit for Providers for Two Important HEDIS Measures

By working together, we can improve health outcomes for your patients. The Healthcare Effectiveness Data and Information Set (HEDIS®) is a performance measurement tool used by health plans to evaluate performance by analyzing clinical quality and customer service. HEDIS includes standardized performance measures used to compare healthcare quality. Every year, data is collected by the health plan regarding all of the HEDIS measures, so that we can evaluate and improve our performance levels. This month, we’ll discuss two behavioral health HEDIS measures: Antidepressant Medication Management and Adherence to Antipsychotic Medications for Individuals with Schizophrenia. Read on to learn about each measure – including key best practice tips.

Antidepressant Medication Management (AMM)

This measure looks at those patients 18 years of age and older with a diagnosis of major depression who were treated with antidepressant medication, and who remained on an antidepressant medication treatment. This measure begins May 1 of the year prior to the measurement year, and ends on April 30 of the measurement year.

Antidepressants can be prescribed by a primary care provider (PCP) or mental health practitioner.

Two components are reported:

1. Effective Acute Phase Treatment: Patients who remained on an antidepressant medication for at least 84 days (12 weeks).
2. Effective Continuation Phase Treatment: Patients who remained on an antidepressant medication for at least 180 days (6 months).

Best Practice Tips:

• Medication prescribed by the patient’s PCP or a mental health practitioner.
• Patients should be educated regarding side effects, time period for medication to become therapeutic and how important it is to remain on the medication.
• Awareness that the following types of visits fall under this measure: outpatient, inpatient, observation/emergency department, intensive outpatient, partial hospitalization, community mental health center, telehealth, e-visits and virtual check-ins.

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)

This measure looks at patients 18 years of age and older during the measurement year, who have schizophrenia and who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period. The treatment period starts with the earliest prescription dispensing date and continues through the last day of the measurement year.

Best Practice Tips:

• Patients should be educated about remaining adherent with their medication.
• Medication reconciliations and reviews should be undertaken when the patient is in the provider’s office.
• Patients should follow up with their providers.

Thank you for all you do every day to give your patients the best care. We are deeply grateful for all your efforts.

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Coding Counts:
A New Resource for Coding Major Depressive Disorders

We’re excited to announce our new flier to help you document and code major depressive disorders (MDDs). This flier can be used as a quick and comprehensive reference for staging the level of reoccurrence, severity and complications of MDDs. It gives code descriptions and helpful references for documentation, along with diagnostic tools and documentation best practices for MDDs – including information on what you need to document and specify when coding. Click here to easily view and print the flier.

Thank you for your help with accurate coding and documentation. We’re grateful for how hard you work and all you do for our members’ health. For even more coding tips, watch these short videos we made just for you and your staff. And visit our Coding Counts page for even more helpful resources.

Pharmacy Note: Prior Authorizations Will Be Added to These Medicare Part B Drugs

Our Pharmacy and Therapeutics Committee has placed prior authorization requirements on a number of infusions covered on the Medicare Part B benefit, in an effort to ensure clinical guidelines and best practices are followed. Effective July 1, 2022, the following medications will require prior authorization for Medicare members who are new to therapy:

Insulin Savings Through Medicare’s
Part D Senior Savings Model

We all know how expensive medications can be for your patients, so we’d like to share some information about potential savings on insulin through Medicare’s Part D Senior Savings Model. If a patient’s drug plan has this benefit, they’ll pay the capped insulin copay of Tier 2 or Tier 3 for these select products – including during their coverage gap. The medications included will be reflected on the formulary as “Select Insulin.” You can reach out to us for more information or if you have any questions.

Pharmacy Updates

Medicare

Oncology/Hematology

Formulary Additions

• Abecma (idecabtagene vicleucel) 460 million cells IV suspension—Treatment of multiple myeloma, relapsed or refractory
  • Formulary placements­
    • Medicare—Part B; Reviewed by eviCore
• Besremi (ropeginterferon alfa-2b) 500mcg/mL subcutaneous solution—Treatment of polycythemia vera in adults
  • Formulary placements­
    • Medicare—Part B or Tier 5 with PA; Reviewed by Health Alliance
• Brukinsa (zanubrutinib) 80mg, 120mg oral capsule—Treatment of mantle cell lymphoma, marginal zone lymphoma, and Waldenström macroglobulinemia in adults
  • Formulary placements
    • Medicare—Tier 5 with PA; Reviewed by Health Alliance
• Cosela (trilaciclib) 300mg IV solution—Treatment of chemotherapy-induced myelosuppression
  • Formulary placements
    • Medicare—Part B; Reviewed by eviCore
• Exkivity (mobocertinib) 40mg capsule—Treatment of non-small cell lung cancer, locally advanced or metastatic
  • Formulary placements
    • Medicare—Tier 5 with PA; Reviewed by Health Alliance
• Fyarro (sirolimus protein bound) 100mg IV suspension—Treatment of perivascular epithelioid cell tumor, malignant, locally advanced or metastatic
  • Formulary placements
    • Medicare—Part B; Reviewed by eviCore
• Jemperli (dostarlimab) 500mg/10mL IV solution—Treatment of endometrial cancer (recurrent or advanced), treatment of solid tumors (recurrent or advanced)
  • Formulary placements
    • Medicare—Part B; Reviewed by eviCore
• Kimmtrak (tebentafusptebn) 100 mcg/0.5 mL—Treatment of uveal melanoma, unresectable or metastatic, HLA-A*02:01-positive
  • Formulary placements
    • Medicare—Part B; Reviewed by eviCore
• Lumakras (sotorasib) 120mg oral tablet—Treatment of Non–small cell lung cancer, locally advanced or metastatic, KRAS G12C-mutated
  • Formulary placements
    • Medicare—Tier 5 with PA; Reviewed by Health Alliance
• Pemfexy (pemetrexed) 500mg/20mL—Non-squamous, non-small cell lung cancer
  • Formulary placements
    • Medicare—Part B; Reviewed by eviCore
• Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) 10mg/0.5mL solution—Treatment of acute lymphoblastic leukemia and lymphoblastic lymphoma
  • Formulary placements
    • Medicare—Part B; Reviewed by eviCore
• Scemblix (asciminib) 20mg, 40 mg tablet—Treatment of Philadelphia chromosome-positive chronic myeloid leukemia (Ph+ CML)
  • Formulary placements
    • Medicare—Tier 5 with PA; Reviewed by Health Alliance
• Truseltiq (infigratinib) 25mg, 100mg oral capsule—Treatment of cholangiocarcinoma, unresectable locally advanced or metastatic
  • Formulary placements
    • Medicare—Tier 5 with PA; Reviewed by Health Alliance
• Welireg (belzutifan) 40mg oral tablet—Treatment of von Hippel-Lindau disease in adults
  • Formulary placements
    • Medicare—Tier 5 with PA; Reviewed by Health Alliance
• Zynlonta (loncastuximab tesirine) 10mg oral tablet—Large B-cell lymphoma, relapsed or refractory
  • Formulary placements­
    • Medicare—Tier 5 with PA; Reviewed by Health Alliance
• Empaveli (pegcetacoplan)—Treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH)
  • Formulary placements­
    • Medicare—Tier 5 Specialty Pharmacy with PA
• Rezurock (belumosudil)—Treatment of adult and pediatric patients ≥12 years of age with cGVHD after failure of at least 2 prior lines of systemic therapy
  • Formulary placements­
    • Medicare—Tier 5 Specialty Pharmacy with PA

Criteria Changes

• Soliris (eculizumab)
  • Added Medicare Part B and exclusion criteria

Infectious Disease

Formulary Additions

• Brexafemme (ibrexafungerp)—Treatment of adult and post-menarchal pediatric females with vulvovaginal candidiasis (VVC)
  • Formulary placements
    • Medicare—Non-Formulary
• Livtencity (maribavir)—Treatment of adults and pediatric patients (12 years of age and older and weighing at least 35 kg) with post-transplant CMV infection/disease that is refractory to treatment (with or without genotypic resistance) with ganciclovir, valganciclovir, cidofovir or foscarnet
  • Formulary placements
    • Medicare—Tier 5, Pharmacy Specialty
• Veklury (remdesivir)—Treatment of suspected or laboratory-confirmed COVID-19 in adult and pediatric patients (12 years of age and older and weighing at least 40 kg) who require hospitalization
  • Formulary placements
    • Medicare—Part B