Washington October Newsletter

As It Relates to You

New Provider Forms

We have new forms to update provider information or add a provider to your practice. Please discontinue using the old forms and use these new ones instead. If you have any questions, contact your provider relations specialist.

New Phone Numbers

With our recent move to Carle at The Fields, our phone numbers have changed. Please use the new phone numbers below.

*Note: The phone number for the Pharmacy Department for Medicare members remains the same: 1-800-851-3379, ext. 6010.

If you have any questions, contact your provider relations specialist.

Flu Season Is Coming

Please remind your patients about the importance of getting vaccinated each flu season. Explain that flu viruses change each year, so a yearly shot is necessary for the best protection. Our members can get their shot for free at in-network pharmacies, clinics or doctor’s offices but may have an office visit copay if they get their shot in a doctor’s office.

Medication Therapy

OptumRx Medication Therapy Management (MTM) is a service for members that reviews all of their medications to make sure they are receiving the best care. It’s free for members, and eligible members are automatically enrolled. However, many members do not use the service to its fullest.

Through the service, a pharmacist calls members to talk about their medications. This pharmacist makes sure members receive the safest medications, educates them on low-cost alternative medications (generics), and answers any questions they may have. After the phone call, members also receive a package of information about their personal medication therapy. OptumRx MTM may also communicate member interactions with prescribing doctors to ensure coordination of care.

This is a great service that tends to be underutilized because many members don’t engage in the calls. If our members ask you about this service, please encourage them to use OptumRx MTM to ensure the safest care.

Preauthorization Reminder

Please remember that if you’ve received preauthorization for a certain CPT code and during the procedure you have to perform something other than what was preauthorized, you need to call eviCore within 24 hours of the procedure to update the CPT code. This helps ensure the claim is paid correctly.

Coding Reminders

Both the Medicare Advantage and commercial Marketplace adjustment models are dependent on us receiving diagnosis codes through claims submission. All claims submitted to us must have associated diagnosis codes. There are 2 areas of opportunity related to provider business processes that could improve:

1. Code truncation, or limiting the number of diagnosis codes per claim submission
2. Claims that are not submitted at all (e.g., claims for capitated, custodial care, etc.)

These scenarios lead to inaccurate reporting of the overall risk of our population. Please assess your billing practices at an organizational and provider level to ensure these situations don’t apply to you.

If you identify these issues in your provider system, contact us at CodingCounts@healthalliance.org, and we’ll reach out to help with a solution.

For useful information on documentation and code reporting, subscribe to our coding e-newsletter.

Appropriate Use of GY Modifier

If you’re submitting a preauthorization request you know will be denied (for example, for patient non-compliance), please submit it as you would any other preauthorization request. Do not apply the GY modifier, which tells our claims system the service is not covered.

When we deny preauthorization requests that don’t have the GY modifier, it automatically sends a letter to the member telling them they’ll be responsible for the full cost of the service if they choose to get it. We want to make sure members receive this important notice, so please refrain from applying the GY modifier unless the service is actually not covered.

New eviCore Enhancements

EviCore has recently added the following features to its website.

1. Urgent Case on the Web-You can now process urgent cases online, without having to call.
2. Expanded Document Upload-You can now upload up to 5 documents online, in .doc, .docs, or .pdf formats.
3. Provider at a Glance-You’ll see a Certification Summary tab in your online account that shows details for recent cases you’ve created.

These changes were implemented based on provider feedback and with the support of various compliance, operations, and clinical departments.

When Insulin is Indicated in Type 2 Diabetes, Consider NPH

Last year, the American Diabetes Association developed a work group to review the marked increase in the cost of insulin, which tripled from 2002 to 2013. These high prices have interfered with patient compliance and the provider’s ability to improve diabetes control. The basal insulin analogs (Lantus and Levemir) and bolus forms (Novolog and Humalog) are extremely expensive. With coupons, Lantus is $278 per vial and Humalog is $178 per vial, according to GoodRx. Prices for pens and cartridges increase these costs to $540 and $550, respectively. The current patient charge for NPH and regular insulin is $24.

An article in the Journal of the American Medical Association (JAMA) from June 23, 2018, indicates that in people with Type 2 diabetes requiring insulin, there is no significant difference in outcomes between basal insulin analogs and NPH insulin. Current literature does support the use of basal/bolus insulin with analogs in persons with Type 1 diabetes, but that recommendation has not been supported by medical literature for Type 2 diabetes.

The JAMA study reviewed more than 25,489 people with diabetes (with an average age of 60) over a 10-year period. There was no difference in hypoglycemia, and diabetic control was actually a little better with NPH and regular insulins. Plus, for a person taking Lantus (60 U daily) and Humalog (20 U TID) at the lowest cost with coupons, the annual cost would be $10,944, compared to $1,152 for an NPH and regular insulin regimen.

In short, higher-priced analog insulins have not been demonstrated to have long-term clinical benefits over human insulin regimens in Type 2 diabetes. NPH insulin can lead to better patient compliance, as it requires fewer daily injections and costs 90 percent less than basal/bolus insulin. Please consider prescribing NPH insulin for people with Type 2 diabetes who require insulin therapy.

Pharmacy Updates

All Plans

Formulary Additions

• Aimovig (erenumab-aooe)
• WA Individual-Tier 3 with preauthorization (PA) and quantity limit (QL) of 1 dose per 30 days; Medicare- Tier 4 with QL of 1 dose per 30 days
• Olumiant (baricitinib)
• New Janus-associated kinase inhibitor indicated for the treatment of moderate to severe active rheumatoid arthritis who have had an inadequate response to one or more tumor necrosis factor antagonist therapies
• Same category as Xeljanz
• Formulary placement recommendations
• WA Individual-Tier 5 with PA
• Medicare-Non-Formulary
• Xeljanz
• Added to Medicare formulary at Tier 5 with PA
• Siliq (brodalumab)
• Interleukin-17 inhibitor indicated for treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy and have failed to respond or have lost response to other systemic therapies
• WA Individual—Tier 5 with PA
• Medicare—Non-Formulary
• Symproic (naldemedine)
• Indicated for treatment of opioid-induced constipation in adults with chronic noncancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation
• WA Individual—Tier 3 with QL (#30/30 days)
• Medicare—Tier 4 with QL (#30/30 days)

WA Individual

Tier Changes

• Droxia—moved from Tier 2 to Tier 3
• Generic hydroxyurea available at Tier 1
• Nuedexta—moved from Tier 3 to Excluded
• Branded dextromethorphan/quinidine product
• Banzel—moved from Tier 2 to Tier 3
• Not a preferred product
• Inflectra and Renflexis—moved from Tier 5 to Tier 4
• Remicade is covered at Tier 5
• Moved biosimilars into preferred tier position
• ZolpiMist—moved from Tier 3 to Excluded
• Zolpidem is covered at Tier 1

Managed Drug Limitation (MDL) Changes

• Duloxetine—removed MDL
• Movantik—added MDL (#30/30 days)
• Aripiprazole—added MDL (#30/30 days)
• Paliperidone ER—added MDL (#30/30 days)
• Quetiapine ER—added MDL (#30/30 days)

Criteria Changes

• Botox
• Exclusion section states that we will not cover concurrent use of Aimovig and Botox
• Migranal Nasal Spray
• Updated policy to include only prophylactic meds which are American Headache Society Level A or B
• Metoprolol, propranolol, timolol, atenolol, nadolol, amitriptyline, venlafaxine, divalproex, valproic acid, topiramate
• This makes the policy consistent with the prophylactic requirements of the Topiramate Extended Release and Botox for Migraine policies
• Austedo
• Updated policy to include criteria for new indication of tardive dyskinesia (TD). New criteria include:
• Ordered by neurologist
• Evaluation on Abnormal Involuntary Movedment Scale (AIMS)
• Failure on two prerequisite drugs (BZD, benztropine, 2nd generation antipsychotic, tetrabenazine)
• Xeomin
• Updated policy to include criteria for new indication of sialorrhea. New criteria include:
• Diagnosis of Parkinson disease, ALS, cerebral palsy, or stroke; and
• Failure on one of the following: glycopyrrolate, amitriptyline, hyoscyamine, sublingual ipratropium or atropine
• Savella
• Previous policy did not list a diagnosis requirement
• Added documented diagnosis of fibromyalgia to criteria
• Bunavail, Suboxone, Zubsolv
• Removed cost-effective step-edit through generic Suboxone SL tablets to align with other insurers
• Opioid reverse step-edit will remain in place
• Cimzia
• Recently received an indication for plaque psoriasis
• Added PA criteria that include failure of first-line treatment options as well as Humira and Enbrel
• Rituxan
• Added Rituxan Hycela to policy
• Updated to clarify that cancer-related indications are reviewed by eviCore
• Taltz
• Recently received an indication for psoriatic arthritis
• Added PA criteria that include failure of DMARDs as well as Humira and Enbrel
• Xeljanz
• Recently received an indication for psoriatic arthritis
• Added PA criteria that include failure of DMARDs as well as Humira and Enbrel
• Recently received an indication for ulcerative colitis
• Added PA criteria that include failure on corticosteroids and immunosuppressants and Humira
• Added to Medicare formulary with PA as noted above in Formulary Additions
• Behavioral Health
• Non-Preferred antidepressants
• Previous criteria included failure on two preferred SSRIs and two preferred SNRIs
• Updated criteria to include failure on one SSRI, one SNRI, and one other antidepressant from any drug class
• Generic Atypical Antipsychotics (aripiprazole, quetiapine ER, paliperidone ER)
• Removed PA
• Aripiprazole has additional indications of Tourette syndrome and irritability associated with autistic disorder that other generic atypicals do not carry
• Brand-Name Atypical Antipsychotics Indicated for Bipolar Disorder/Schizophrenia
• Previous criteria required previous trial of any two of the following: olanzapine, quetiapine, risperidone, ziprasidone
• Updated criteria to include aripiprazole, paliperidone ER, quetiapine ER as possible prerequisite options
• Brand-Name Atypical Antipsychotics Indicated as Adjunct Therapy for MDD
• Previous criteria required failure on two preferred SSRIs and two preferred SNRIs
• Updated criteria to include that the requested drug is FDA indicated as adjunct therapy for MDD (previously only Rexulti)
• Updated criteria to include documented failure of aripiprazole or quetiapine ER used in combination with an antidepressant for a period of at least 3 months
• Excluded Drug List
• Added exclusion of ketamine
• No other plans cover for off-label uses
• Male Erectile Dysfunction Medications
• Added exclusion of ketamine
• No other plans cover for off-label uses
• QHP Coverage of Erectile Dysfunction Drugs
• Added criteria for Raynaud’s phenomenon
• Diabetes Drug Therapies
• Added Admelog to non-preferred insulins
• Paricalcitol
• Created policy establishing step-edit criteria

Retired Policies

• Sedative Hypnotic Step-Edit, Belsomra and Silenor
• Removed ZolpiMist from policy and moved to Excluded
• For Belsomra and Silenor, removed double step through zolpidem AND zaleplon
• Decision based on Carle Neurology feedback of Belsomra’s preference over other hypnotics and the risks of the older drugs (abnormal sleep behavior, falls and fractures)
• Belsomra is currently at Tier 3, and Silenor at Tier 4, with no restrictions on Medicare
• Lyrica
• Policy previously had criteria for diabetic neuropathy, neuropathic pain, post-herpetic neuralgia, generalized anxiety disorder, partial onset seizure, and fibromyalgia
• Removed PA for all diagnoses
• PA removal will allow providers easier access to another non-opioid option for treating chronic pain
• Generic will be available next year

Medicare

Retired Policies

• Rytary—moved from Non-Formulary to Tier 4
• Proposed by Carle Neurology due to better tolerability, dosing flexibility, and reduced pill burden
• Movantik—moved from Non-Formulary to Tier 4 with QL (#30/30 days)
• Aligns with Commercial and Exchange formularies
• Xeljanz—moved from Non-Formulary to Tier 5
• Aligns with Commercial and Exchange formularies

MDL Changes

• Duloxetine—removed MDL
• Escitalopram—removed MDL

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