InforMED

Midwest December Newsletter

December 14, 2017

Help Your Patients Save Money on Meds

When prescribing medications to our Medicare Advantage members, remember that they have no copay or deductible for Tier 1 preferred generics.

Statins – High Intensity

  • Prescribe Atorvastatin
  • Avoid Rosuvastatin
  • Average savings of $70 per prescription

Statins – Low-to-Moderate Intensity

  • Prescribe Simvastatin
  • Avoid Livalo and Fluvastatin
  • Average savings of $260 per prescription

Beta Blockers

  • Prescribe Metoprolol Tartrate
  • Avoid Bystolic
  • Average savings of $200 per prescription

ACE Inhibitors

  • Prescribe Lisinopril
  • Avoid Moexipril and Enalapril
  • Average savings of $75 per prescription

Calcium Channel Blockers

  • Prescribe Amlodipine, Verapamil or Cartia XT
  • Avoid Nisoldipine ER and Verapamil SR
  • Average savings of $134 per prescription

Proton Pump Inhibitors*

  • Prescribe Omeprazole
  • Avoid Dexilant
  • Also avoid Esomeprazole, and Omeprazole-Sodium Bicarbonate, which are both non-formulary for 2018
  • Average savings of $318 per prescription

*Should be limited to 8 weeks of therapy for most patients. Recent addition to Beers List due to C. diff and bone-loss risk.

Thyroid Hormones

  • Prescribe Levothyroxine
  • Avoid Armour Thyroid (high-risk medication) and Synthroid
  • Average savings of $27 per prescription

Our members can also call the number on the back of their ID cards to have a pharmacist review their medications to see if there are lower-cost options available.

View this as information as a PDF

Morphine Equivalent Dose (MED) and Opioid Prescribing

Q: What is the Morphine Milligram Equivalent (MME) conversion factor?

A: The MME conversion factor is a constant value which allows practitioners to convert different types of opioid products to an equivalent dose of oral morphine.

Q: What is each opioid product’s MME conversion factor?

A:Use the most recent version of the Centers for Medicare and Medicaid Services (CMS) Opioid Oral Morphine Milligram Equivalent (MME) Conversion Factors for these.

Q: What is the Morphine Equivalent Dose (MED)?

A: The MED represents a patient’s total intake of all drugs in the opioid class over a 24-hour period.

Q: How is the MED calculated?

A: This is the equation for calculating MED:

  • Strength per Unit x (Number of Units / Days Supply) x MME Conversion Factor = MED

Example:

Fentanyl patches (microgram) have a MME conversion factor of 7.2.

Hydrocodone (milligram) has a MME conversion factor of 1.

A patient receives:

  • A 30-day supply of 5 patches of fentanyl, 25mcg, with directions to change the patch every 72 hours

and

  • A 30-day supply of 120 tablets of hydrocodone/APAP, 5/325mg, with directions to take 1 tablet every 6 hours

Fentanyl patch: 25mcg/patch X (5 patches/30 days) X 7.2 = 30mg/day

Hydrocodone tablet: 5mg/tablet X (120 tablets/30 days) X 1 = 20mg/day

The patient’s MED is 50mg.

Q: How does the way I write a prescription affect the MED?

A: Pharmacies will process the number of days the medication should last based on the directions written. In most cases, if a supply for a specific number of days or a note saying, “Must last X days,” is not written on the prescription, they will process the prescription assuming the member will take the highest quantity at the highest frequency allowed by the directions.

Example:

A pharmacy receives:

  • A prescription for 60 tablets of hydrocodone/APAP, 10/325mg, with directions to take 1 to 2 tablets every 4 to 6 hours

Though the provider may believe the patient will only need to take 4 to 6 tablets per day, the directions will cause the pharmacy to process the prescription as though the member will be taking 12 tablets a day, which equals a MED of 120mg.

Suggestion: Place directions for the pharmacy staff on your opioid prescriptions. Adding “Must last 7 days,” (or 10 days, 14 days, etc.) is a great way to ensure that both the pharmacy and patient understand how long it should last.

  • Calculation based on directions as written (maximum daily amount is 12): MED is 120mg
  • With note saying it must last 7 days: MED is 85mg
    • Since it’s less than 100 mg, this can also help you avoid the preauthorization requirement.

Additional Info

  • The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain advises that opioids being used for acute pain should be prescribed at the lowest effective dose and quantity needed in order to decrease the likelihood of physical dependence, withdrawal symptoms, and intentional or unintentional diversion.
  • 3 days of therapy is often all that is needed. More than 7 days of therapy is rarely necessary.

Note: This is for educational or analytical purposes only and should not be used as medical guidance. Refer to the drug-specific package insert for instructions regarding dose titration and conversion from one opioid to another.

Colorectal Cancer Screening Updates

Colorectal cancer screening is an important part of preventive care for adults starting at age 50. In the June 2017 publication of the American Journal of Gastroenterology, the U.S. Multi-Society Task Force of Colorectal Cancer updated their recommendations for colorectal cancer screenings.

In an office-based practice setting, they recommend offering colorectal screenings in a tiered, sequential approach.

  • Tier 1 screening tests are a colonoscopy every 10 years or an annual fecal immunochemical test (FIT) for those who decline colonoscopies
  • Tier 2 tests are a FIT-fecal DNA (Cologuard) every 3 years, a flexible sigmoidoscopy every 5 to 10 years, or a CT colonography every 5 years

Multi-Society Task Force Ranking of Current Colorectal Cancer Screening Tests

Tier 1
 Colonoscopy every 10 years
Annual fecal immunochemical test
Tier 2
CT colonography every 5 years
FIT-fecal DNA every 3 years
Flexible sigmoidoscopy every 10 years (or every 5 years)
Tier 3
Capsule colonoscopy every 5 years
Available Tests Not Currently Recommended
Septin 9

The HEDIS® Colorectal Cancer Screening measure evaluates the percentage of commercial and Medicare members 50 to 75 years old who have had appropriate screenings for colorectal cancer. Colorectal cancer screenings include:

  • Fecal occult blood tests during the measurement year
  • Flexible sigmoidoscopies during the measurement year or the 4 years before the measurement year
  • Colonoscopies during the measurement year or the 9 years before the measurement year
  • CT colonographies during the measurement year or the 4 years before the measurement year
  • FIT-DNA tests during the measurement year or the 2 years before the measurement year

We strive to meet or exceed the Quality Compass 90th percentile for Colorectal Cancer Screening for our members. Our most recent HEDIS results for this were in the 75th percentile of Quality Compass for Commercial HMO-POS and within the national average for Medicare Advantage HMOs.

We cover colorectal cancer screening tests, except for CT colonography, under our wellness benefits. Check the Forms & Resources section of Your Health Alliance for providers for wellness guides, or attach to a specific member for their wellness benefits. If you have questions or need more information about specific codes and coverage, call us at 1-800-851-3379, option 3.

Thank-you for your efforts to prevent colorectal cancer in your patients and our members. Looking forward to working toward a healthier 2018!

Sleep Studies Best Practices

Sleep apnea is a serious condition, and it should not be ignored. It can lead to many serious conditions, including high blood pressure, stroke, and heart disease. Sleep studies can help you diagnose sleep apnea.

Indications for Sleep Studies

  • Daytime drowsiness
  • Falling asleep during daytime activities, like meetings and driving
  • Changes in memory or having trouble paying attention
  • Loud snoring
  • Other people describing apneic spells
  • Waking up frequently during the night
  • Sleepwalking
  • Morning headaches

Most sleep studies can be done at home, which lets patients sleep in the comfort of their own bed. This also allows for a more timely study since patient and facility availability won’t be an issue.

However, there are certain criteria that might indicate a patient needs to visit a facility for their sleep study:

  • Congestive heart failure or a history of heart problems
  • COPD or active asthma
  • History of stroke
  • History of seizures
  • Obesity – BMI >45
  • Low oxygen levels
  • Neuromuscular diseases, like Parkinson’s disease
  • Someone who can properly set up the equipment

Fall Assessments and Intervention in Medicare Members

The Health Outcomes Survey (HOS) from the Centers for Medicare and Medicaid (CMS) collects member-reported health data to improve managed care and increase accountability. You can help improve these measures for Medicare members by talking to them about balance problems, falls, difficulty walking, and other risk factors for falling during their annual exams.

Talk to them about:

  • The danger and risk of falls
  • Factors that cause falls
  • Using a cane or a walker
  • Getting a vision or hearing test
  • The importance of exercise and physical therapy, how to start increasing or maintaining activity, or exercise or physical therapy programs that might be right for them

You should also:

  • Check blood pressure with them standing, sitting, and reclining
  • Perform bone density screenings, especially for high risk members

You can also learn more about HOS and the survey questions on CMS.gov.

Talking Exercise with Patients

Exercise has been a part of daily life for John Kim, a Carle family nurse practitioner, from an early age, but he realizes that’s not the case for everyone.

Kim, who started at Carle in 2015, stresses the importance of exercise with all of his patients.

“I talk about exercise consistently to every patient because not only can it treat comorbidities, but it can also prevent future illness and disease,” Kim said. “I believe exercise along with diet is the foundation of health, and so I make it a priority to talk about exercise with each patient.”

He treats exercise like a vital sign, having his certified medical assistant ask all patients if they exercise and how much.

“Asking about exercise as a vital sign has made it extremely easy to bring up the topic of exercise to each patient,” he said.

Kim offers his patients advice about how to get started if they’re new to exercise and offers ways to increase physical activity if they aren’t active enough. He caters each plan to each patient’s individual interests and lifestyle and tries to help them take one small step at a time.

“If I have a patient that is completely sedentary, I will find out what his or her interests are and try to tailor some kind of physical activity from that,” Kim said. “I try to shoot for my patients to start off with a number they know they can do, whether it’s 5 minutes or 20 minutes a day.”

He also has patients fill out exercise logs to help hold them accountable and initially follows up with them every 2 weeks or once a month until exercise becomes more routine.

Through it all, he’s learned that being patient and nonjudgmental is key.

“New habits take time to build,” he said. “So I make sure patients know that I am not here to ridicule them, but to encourage and support them as they try to build the new habit of exercising. I have found that when patients know that their provider genuinely cares about their health, it gets to the point where it motivates the patients to push themselves a little more, and I believe this is why I have many success stories of patients going from a sedentary lifestyle to a more active lifestyle.”

Key Takeaways

  • Discuss exercise along with vital signs for every patient.
  • Be patient about results, and don’t ridicule.
  • Set attainable goals with small steps.
  • Follow up frequently until exercise becomes a habit.
  • Have patients use exercise logs and bring them to each appointment.

Meet with a Coding Specialist

The risk adjustment coding consultants are continuing to request meetings with participating, high-volume provider offices. These meetings are designed to share member-specific examples of coding and quality measure needs and to update providers on the latest efforts to educate on risk adjustment. Along with member specific examples, there is information on yearly risk adjustment data validation (RADV) audits and how provider practice participation is essential in this process.

A member of the coding consultant team is willing to meet with you to discuss any coding or quality questions you may have, or to provide member-specific examples from your panel of members. If interested, contact us at CodingCounts@healthalliance.org.

Reid December InforMED

December 14, 2017

Help Your Patients Save Money on Meds

When prescribing medications to our Medicare Advantage members, remember that they have no copay or deductible for Tier 1 preferred generics.

Statins – High Intensity

  • Prescribe Atorvastatin
  • Avoid Rosuvastatin
  • Average savings of $70 per prescription

Statins – Low-to-Moderate Intensity

  • Prescribe Simvastatin
  • Avoid Livalo and Fluvastatin
  • Average savings of $260 per prescription

Beta Blockers

  • Prescribe Metoprolol Tartrate
  • Avoid Bystolic
  • Average savings of $200 per prescription

ACE Inhibitors

  • Prescribe Lisinopril
  • Avoid Moexipril and Enalapril
  • Average savings of $75 per prescription

Calcium Channel Blockers

  • Prescribe Amlodipine, Verapamil or Cartia XT
  • Avoid Nisoldipine ER and Verapamil SR
  • Average savings of $134 per prescription

Proton Pump Inhibitors*

  • Prescribe Omeprazole
  • Avoid Dexilant
  • Also avoid Esomeprazole, and Omeprazole-Sodium Bicarbonate, which are both non-formulary for 2018
  • Average savings of $318 per prescription

*Should be limited to 8 weeks of therapy for most patients. Recent addition to Beers List due to C. diff and bone-loss risk.

Thyroid Hormones

  • Prescribe Levothyroxine
  • Avoid Armour Thyroid (high-risk medication) and Synthroid
  • Average savings of $27 per prescription

Our members can also call the number on the back of their ID cards to have a pharmacist review their medications to see if there are lower-cost options available.

View this as information as a PDF

Morphine Equivalent Dose (MED) and Opioid Prescribing

Q: What is the Morphine Milligram Equivalent (MME) conversion factor?

A: The MME conversion factor is a constant value which allows practitioners to convert different types of opioid products to an equivalent dose of oral morphine.

Q: What is each opioid product’s MME conversion factor?

A:Use the most recent version of the Centers for Medicare and Medicaid Services (CMS) Opioid Oral Morphine Milligram Equivalent (MME) Conversion Factors for these.

Q: What is the Morphine Equivalent Dose (MED)?

A: The MED represents a patient’s total intake of all drugs in the opioid class over a 24-hour period.

Q: How is the MED calculated?

A: This is the equation for calculating MED:

  • Strength per Unit x (Number of Units / Days Supply) x MME Conversion Factor = MED

Example:

Fentanyl patches (microgram) have a MME conversion factor of 7.2.

Hydrocodone (milligram) has a MME conversion factor of 1.

A patient receives:

  • A 30-day supply of 5 patches of fentanyl, 25mcg, with directions to change the patch every 72 hours

and

  • A 30-day supply of 120 tablets of hydrocodone/APAP, 5/325mg, with directions to take 1 tablet every 6 hours

Fentanyl patch: 25mcg/patch X (5 patches/30 days) X 7.2 = 30mg/day

Hydrocodone tablet: 5mg/tablet X (120 tablets/30 days) X 1 = 20mg/day

The patient’s MED is 50mg.

Q: How does the way I write a prescription affect the MED?

A: Pharmacies will process the number of days the medication should last based on the directions written. In most cases, if a supply for a specific number of days or a note saying, “Must last X days,” is not written on the prescription, they will process the prescription assuming the member will take the highest quantity at the highest frequency allowed by the directions.

Example:

A pharmacy receives:

  • A prescription for 60 tablets of hydrocodone/APAP, 10/325mg, with directions to take 1 to 2 tablets every 4 to 6 hours

Though the provider may believe the patient will only need to take 4 to 6 tablets per day, the directions will cause the pharmacy to process the prescription as though the member will be taking 12 tablets a day, which equals a MED of 120mg.

Suggestion: Place directions for the pharmacy staff on your opioid prescriptions. Adding “Must last 7 days,” (or 10 days, 14 days, etc.) is a great way to ensure that both the pharmacy and patient understand how long it should last.

  • Calculation based on directions as written (maximum daily amount is 12): MED is 120mg
  • With note saying it must last 7 days: MED is 85mg
    • Since it’s less than 100 mg, this can also help you avoid the preauthorization requirement.

Additional Info

  • The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain advises that opioids being used for acute pain should be prescribed at the lowest effective dose and quantity needed in order to decrease the likelihood of physical dependence, withdrawal symptoms, and intentional or unintentional diversion.
  • 3 days of therapy is often all that is needed. More than 7 days of therapy is rarely necessary.

Note: This is for educational or analytical purposes only and should not be used as medical guidance. Refer to the drug-specific package insert for instructions regarding dose titration and conversion from one opioid to another.

Colorectal Cancer Screening Updates

Colorectal cancer screening is an important part of preventive care for adults starting at age 50. In the June 2017 publication of the American Journal of Gastroenterology, the U.S. Multi-Society Task Force of Colorectal Cancer updated their recommendations for colorectal cancer screenings.

In an office-based practice setting, they recommend offering colorectal screenings in a tiered, sequential approach.

  • Tier 1 screening tests are a colonoscopy every 10 years or an annual fecal immunochemical test (FIT) for those who decline colonoscopies
  • Tier 2 tests are a FIT-fecal DNA (Cologuard) every 3 years, a flexible sigmoidoscopy every 5 to 10 years, or a CT colonography every 5 years

Multi-Society Task Force Ranking of Current Colorectal Cancer Screening Tests

Tier 1
 Colonoscopy every 10 years
Annual fecal immunochemical test
Tier 2
CT colonography every 5 years
FIT-fecal DNA every 3 years
Flexible sigmoidoscopy every 10 years (or every 5 years)
Tier 3
Capsule colonoscopy every 5 years
Available Tests Not Currently Recommended
Septin 9

The HEDIS® Colorectal Cancer Screening measure evaluates the percentage of commercial and Medicare members 50 to 75 years old who have had appropriate screenings for colorectal cancer. Colorectal cancer screenings include:

  • Fecal occult blood tests during the measurement year
  • Flexible sigmoidoscopies during the measurement year or the 4 years before the measurement year
  • Colonoscopies during the measurement year or the 9 years before the measurement year
  • CT colonographies during the measurement year or the 4 years before the measurement year
  • FIT-DNA tests during the measurement year or the 2 years before the measurement year

We strive to meet or exceed the Quality Compass 90th percentile for Colorectal Cancer Screening for our members. Our most recent HEDIS results for this were in the 75th percentile of Quality Compass for Commercial HMO-POS and within the national average for Medicare Advantage HMOs.

We cover colorectal cancer screening tests, except for CT colonography, under our wellness benefits. Check the Forms & Resources section of Your Health Alliance for providers for wellness guides, or attach to a specific member for their wellness benefits. If you have questions or need more information about specific codes and coverage, call us at 1-800-851-3379, option 3.

Thank-you for your efforts to prevent colorectal cancer in your patients and our members. Looking forward to working toward a healthier 2018!

Sleep Studies Best Practices

Sleep apnea is a serious condition, and it should not be ignored. It can lead to many serious conditions, including high blood pressure, stroke, and heart disease. Sleep studies can help you diagnose sleep apnea.

Indications for Sleep Studies

  • Daytime drowsiness
  • Falling asleep during daytime activities, like meetings and driving
  • Changes in memory or having trouble paying attention
  • Loud snoring
  • Other people describing apneic spells
  • Waking up frequently during the night
  • Sleepwalking
  • Morning headaches

Most sleep studies can be done at home, which lets patients sleep in the comfort of their own bed. This also allows for a more timely study since patient and facility availability won’t be an issue.

However, there are certain criteria that might indicate a patient needs to visit a facility for their sleep study:

  • Congestive heart failure or a history of heart problems
  • COPD or active asthma
  • History of stroke
  • History of seizures
  • Obesity – BMI >45
  • Low oxygen levels
  • Neuromuscular diseases, like Parkinson’s disease
  • Someone who can properly set up the equipment

Fall Assessments and Intervention in Medicare Members

The Health Outcomes Survey (HOS) from the Centers for Medicare and Medicaid (CMS) collects member-reported health data to improve managed care and increase accountability. You can help improve these measures for Medicare members by talking to them about balance problems, falls, difficulty walking, and other risk factors for falling during their annual exams.

Talk to them about:

  • The danger and risk of falls
  • Factors that cause falls
  • Using a cane or a walker
  • Getting a vision or hearing test
  • The importance of exercise and physical therapy, how to start increasing or maintaining activity, or exercise or physical therapy programs that might be right for them

You should also:

  • Check blood pressure with them standing, sitting, and reclining
  • Perform bone density screenings, especially for high risk members

You can also learn more about HOS and the survey questions on CMS.gov.

Talking Exercise with Patients

Exercise has been a part of daily life for John Kim, a Carle family nurse practitioner, from an early age, but he realizes that’s not the case for everyone.

Kim, who started at Carle in 2015, stresses the importance of exercise with all of his patients.

“I talk about exercise consistently to every patient because not only can it treat comorbidities, but it can also prevent future illness and disease,” Kim said. “I believe exercise along with diet is the foundation of health, and so I make it a priority to talk about exercise with each patient.”

He treats exercise like a vital sign, having his certified medical assistant ask all patients if they exercise and how much.

“Asking about exercise as a vital sign has made it extremely easy to bring up the topic of exercise to each patient,” he said.

Kim offers his patients advice about how to get started if they’re new to exercise and offers ways to increase physical activity if they aren’t active enough. He caters each plan to each patient’s individual interests and lifestyle and tries to help them take one small step at a time.

“If I have a patient that is completely sedentary, I will find out what his or her interests are and try to tailor some kind of physical activity from that,” Kim said. “I try to shoot for my patients to start off with a number they know they can do, whether it’s 5 minutes or 20 minutes a day.”

He also has patients fill out exercise logs to help hold them accountable and initially follows up with them every 2 weeks or once a month until exercise becomes more routine.

Through it all, he’s learned that being patient and nonjudgmental is key.

“New habits take time to build,” he said. “So I make sure patients know that I am not here to ridicule them, but to encourage and support them as they try to build the new habit of exercising. I have found that when patients know that their provider genuinely cares about their health, it gets to the point where it motivates the patients to push themselves a little more, and I believe this is why I have many success stories of patients going from a sedentary lifestyle to a more active lifestyle.”

Key Takeaways

  • Discuss exercise along with vital signs for every patient.
  • Be patient about results, and don’t ridicule.
  • Set attainable goals with small steps.
  • Follow up frequently until exercise becomes a habit.
  • Have patients use exercise logs and bring them to each appointment.

Meet with a Coding Specialist

The risk adjustment coding consultants are continuing to request meetings with participating, high-volume provider offices. These meetings are designed to share member-specific examples of coding and quality measure needs and to update providers on the latest efforts to educate on risk adjustment. Along with member specific examples, there is information on yearly risk adjustment data validation (RADV) audits and how provider practice participation is essential in this process.

A member of the coding consultant team is willing to meet with you to discuss any coding or quality questions you may have, or to provide member-specific examples from your panel of members. If interested, contact us at CodingCounts@healthalliance.org.

Northwest December InforMED

December 14, 2017

Help Your Patients Save Money on Meds

When prescribing medications to our Medicare Advantage members, remember that they have no copay or deductible for Tier 1 preferred generics.

Statins – High Intensity

  • Prescribe Atorvastatin
  • Avoid Rosuvastatin
  • Average savings of $70 per prescription

Statins – Low-to-Moderate Intensity

  • Prescribe Simvastatin
  • Avoid Livalo and Fluvastatin
  • Average savings of $260 per prescription

Beta Blockers

  • Prescribe Metoprolol Tartrate
  • Avoid Bystolic
  • Average savings of $200 per prescription

ACE Inhibitors

  • Prescribe Lisinopril
  • Avoid Moexipril and Enalapril
  • Average savings of $75 per prescription

Calcium Channel Blockers

  • Prescribe Amlodipine, Verapamil or Cartia XT
  • Avoid Nisoldipine ER and Verapamil SR
  • Average savings of $134 per prescription

Proton Pump Inhibitors*

  • Prescribe Omeprazole
  • Avoid Dexilant
  • Also avoid Esomeprazole, and Omeprazole-Sodium Bicarbonate, which are both non-formulary for 2018
  • Average savings of $318 per prescription

*Should be limited to 8 weeks of therapy for most patients. Recent addition to Beers List due to C. diff and bone-loss risk.

Thyroid Hormones

  • Prescribe Levothyroxine
  • Avoid Armour Thyroid (high-risk medication) and Synthroid
  • Average savings of $27 per prescription

Our members can also call the number on the back of their ID cards to have a pharmacist review their medications to see if there are lower-cost options available.

View this as information as a PDF

Morphine Equivalent Dose (MED) and Opioid Prescribing

Q: What is the Morphine Milligram Equivalent (MME) conversion factor?

A: The MME conversion factor is a constant value which allows practitioners to convert different types of opioid products to an equivalent dose of oral morphine.

Q: What is each opioid product’s MME conversion factor?

A:Use the most recent version of the Centers for Medicare and Medicaid Services (CMS) Opioid Oral Morphine Milligram Equivalent (MME) Conversion Factors for these.

Q: What is the Morphine Equivalent Dose (MED)?

A: The MED represents a patient’s total intake of all drugs in the opioid class over a 24-hour period.

Q: How is the MED calculated?

A: This is the equation for calculating MED:

  • Strength per Unit x (Number of Units / Days Supply) x MME Conversion Factor = MED

Example:

Fentanyl patches (microgram) have a MME conversion factor of 7.2.

Hydrocodone (milligram) has a MME conversion factor of 1.

A patient receives:

  • A 30-day supply of 5 patches of fentanyl, 25mcg, with directions to change the patch every 72 hours

and

  • A 30-day supply of 120 tablets of hydrocodone/APAP, 5/325mg, with directions to take 1 tablet every 6 hours

Fentanyl patch: 25mcg/patch X (5 patches/30 days) X 7.2 = 30mg/day

Hydrocodone tablet: 5mg/tablet X (120 tablets/30 days) X 1 = 20mg/day

The patient’s MED is 50mg.

Q: How does the way I write a prescription affect the MED?

A: Pharmacies will process the number of days the medication should last based on the directions written. In most cases, if a supply for a specific number of days or a note saying, “Must last X days,” is not written on the prescription, they will process the prescription assuming the member will take the highest quantity at the highest frequency allowed by the directions.

Example:

A pharmacy receives:

  • A prescription for 60 tablets of hydrocodone/APAP, 10/325mg, with directions to take 1 to 2 tablets every 4 to 6 hours

Though the provider may believe the patient will only need to take 4 to 6 tablets per day, the directions will cause the pharmacy to process the prescription as though the member will be taking 12 tablets a day, which equals a MED of 120mg.

Suggestion: Place directions for the pharmacy staff on your opioid prescriptions. Adding “Must last 7 days,” (or 10 days, 14 days, etc.) is a great way to ensure that both the pharmacy and patient understand how long it should last.

  • Calculation based on directions as written (maximum daily amount is 12): MED is 120mg
  • With note saying it must last 7 days: MED is 85mg
    • Since it’s less than 100 mg, this can also help you avoid the preauthorization requirement.

Additional Info

  • The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain advises that opioids being used for acute pain should be prescribed at the lowest effective dose and quantity needed in order to decrease the likelihood of physical dependence, withdrawal symptoms, and intentional or unintentional diversion.
  • 3 days of therapy is often all that is needed. More than 7 days of therapy is rarely necessary.

Note: This is for educational or analytical purposes only and should not be used as medical guidance. Refer to the drug-specific package insert for instructions regarding dose titration and conversion from one opioid to another.

Colorectal Cancer Screening Updates

Colorectal cancer screening is an important part of preventive care for adults starting at age 50. In the June 2017 publication of the American Journal of Gastroenterology, the U.S. Multi-Society Task Force of Colorectal Cancer updated their recommendations for colorectal cancer screenings.

In an office-based practice setting, they recommend offering colorectal screenings in a tiered, sequential approach.

  • Tier 1 screening tests are a colonoscopy every 10 years or an annual fecal immunochemical test (FIT) for those who decline colonoscopies
  • Tier 2 tests are a FIT-fecal DNA (Cologuard) every 3 years, a flexible sigmoidoscopy every 5 to 10 years, or a CT colonography every 5 years

Multi-Society Task Force Ranking of Current Colorectal Cancer Screening Tests

Tier 1
 Colonoscopy every 10 years
Annual fecal immunochemical test
Tier 2
CT colonography every 5 years
FIT-fecal DNA every 3 years
Flexible sigmoidoscopy every 10 years (or every 5 years)
Tier 3
Capsule colonoscopy every 5 years
Available Tests Not Currently Recommended
Septin 9

The HEDIS® Colorectal Cancer Screening measure evaluates the percentage of commercial and Medicare members 50 to 75 years old who have had appropriate screenings for colorectal cancer. Colorectal cancer screenings include:

  • Fecal occult blood tests during the measurement year
  • Flexible sigmoidoscopies during the measurement year or the 4 years before the measurement year
  • Colonoscopies during the measurement year or the 9 years before the measurement year
  • CT colonographies during the measurement year or the 4 years before the measurement year
  • FIT-DNA tests during the measurement year or the 2 years before the measurement year

We strive to meet or exceed the Quality Compass 90th percentile for Colorectal Cancer Screening for our members. Our most recent HEDIS results for this were in the 75th percentile of Quality Compass for Commercial HMO-POS and within the national average for Medicare Advantage HMOs.

We cover colorectal cancer screening tests, except for CT colonography, under our wellness benefits. Check the Forms & Resources section of Your Health Alliance for providers for wellness guides, or attach to a specific member for their wellness benefits. If you have questions or need more information about specific codes and coverage, call us at 1-800-851-3379, option 3.

Thank-you for your efforts to prevent colorectal cancer in your patients and our members. Looking forward to working toward a healthier 2018!

Sleep Studies Best Practices

Sleep apnea is a serious condition, and it should not be ignored. It can lead to many serious conditions, including high blood pressure, stroke, and heart disease. Sleep studies can help you diagnose sleep apnea.

Indications for Sleep Studies

  • Daytime drowsiness
  • Falling asleep during daytime activities, like meetings and driving
  • Changes in memory or having trouble paying attention
  • Loud snoring
  • Other people describing apneic spells
  • Waking up frequently during the night
  • Sleepwalking
  • Morning headaches

Most sleep studies can be done at home, which lets patients sleep in the comfort of their own bed. This also allows for a more timely study since patient and facility availability won’t be an issue.

However, there are certain criteria that might indicate a patient needs to visit a facility for their sleep study:

  • Congestive heart failure or a history of heart problems
  • COPD or active asthma
  • History of stroke
  • History of seizures
  • Obesity – BMI >45
  • Low oxygen levels
  • Neuromuscular diseases, like Parkinson’s disease
  • Someone who can properly set up the equipment

Fall Assessments and Intervention in Medicare Members

The Health Outcomes Survey (HOS) from the Centers for Medicare and Medicaid (CMS) collects member-reported health data to improve managed care and increase accountability. You can help improve these measures for Medicare members by talking to them about balance problems, falls, difficulty walking, and other risk factors for falling during their annual exams.

Talk to them about:

  • The danger and risk of falls
  • Factors that cause falls
  • Using a cane or a walker
  • Getting a vision or hearing test
  • The importance of exercise and physical therapy, how to start increasing or maintaining activity, or exercise or physical therapy programs that might be right for them

You should also:

  • Check blood pressure with them standing, sitting, and reclining
  • Perform bone density screenings, especially for high risk members

You can also learn more about HOS and the survey questions on CMS.gov.

Talking Exercise with Patients

Exercise has been a part of daily life for John Kim, a Carle family nurse practitioner, from an early age, but he realizes that’s not the case for everyone.

Kim, who started at Carle in 2015, stresses the importance of exercise with all of his patients.

“I talk about exercise consistently to every patient because not only can it treat comorbidities, but it can also prevent future illness and disease,” Kim said. “I believe exercise along with diet is the foundation of health, and so I make it a priority to talk about exercise with each patient.”

He treats exercise like a vital sign, having his certified medical assistant ask all patients if they exercise and how much.

“Asking about exercise as a vital sign has made it extremely easy to bring up the topic of exercise to each patient,” he said.

Kim offers his patients advice about how to get started if they’re new to exercise and offers ways to increase physical activity if they aren’t active enough. He caters each plan to each patient’s individual interests and lifestyle and tries to help them take one small step at a time.

“If I have a patient that is completely sedentary, I will find out what his or her interests are and try to tailor some kind of physical activity from that,” Kim said. “I try to shoot for my patients to start off with a number they know they can do, whether it’s 5 minutes or 20 minutes a day.”

He also has patients fill out exercise logs to help hold them accountable and initially follows up with them every 2 weeks or once a month until exercise becomes more routine.

Through it all, he’s learned that being patient and nonjudgmental is key.

“New habits take time to build,” he said. “So I make sure patients know that I am not here to ridicule them, but to encourage and support them as they try to build the new habit of exercising. I have found that when patients know that their provider genuinely cares about their health, it gets to the point where it motivates the patients to push themselves a little more, and I believe this is why I have many success stories of patients going from a sedentary lifestyle to a more active lifestyle.”

Key Takeaways

  • Discuss exercise along with vital signs for every patient.
  • Be patient about results, and don’t ridicule.
  • Set attainable goals with small steps.
  • Follow up frequently until exercise becomes a habit.
  • Have patients use exercise logs and bring them to each appointment.

Meet with a Coding Specialist

The risk adjustment coding consultants are continuing to request meetings with participating, high-volume provider offices. These meetings are designed to share member-specific examples of coding and quality measure needs and to update providers on the latest efforts to educate on risk adjustment. Along with member specific examples, there is information on yearly risk adjustment data validation (RADV) audits and how provider practice participation is essential in this process.

A member of the coding consultant team is willing to meet with you to discuss any coding or quality questions you may have, or to provide member-specific examples from your panel of members. If interested, contact us at CodingCounts@healthalliance.org.

FLASH: Preauthorization on CPAPs and Supplies for Certain Self-Funded Plans

November 30, 2017

Certain self-funded group plans require preauthorization on CPAPs and supplies. These groups include:

  • Birkeys (BIR)
  • Crawford (CMH)
  • City of Vandalia (COV)
  • Illinois Feed Supply (IFS)
  • Kingery Printing (KPC)
  • Memorial (MHS)
  • Parkland (PRK)
  • PlastiPak (PLK)
  • Richland (RMH)

Visit Your Health Alliance for providers and the Durable Medical Equipment Services Preauthorization Form through Health Alliance to request these preauthorizations.

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

Midwest October Newsletter

October 19, 2017

2017 Provider and Risk Adjustment Workshop

We’re partnering with Carle to present a provider workshop on Thursday, October 26 at the Carle Forum. Doors open at 5:30 p.m., and the workshop starts at 6 p.m.

Our 3 speakers will include:

  • Dr. James Leonard, President and CEO of Carle, talking about the effects and advantages of risk adjustment for Carle and Health Alliance.
  • Dr. Robert Good, Chief Medical Officer, covering population health.
  • Dr. Jens Yambert, Medical Director Risk Adjustment Revenue Management, discussing the provider education module available for 2018.

CMS Education on Medicare Skilled Nursing and Therapy Services Coverage

The Centers for Medicare and Medicaid (CMS) want to remind you that the Jimmo v. Sebelius Settlement Agreement clarified that Medicare covers skilled nursing care and skilled therapy services under its skilled nursing facility, home health, and outpatient therapy benefits when a patient needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met). This may reflect a change in practice for those of you who thought that Medicare only covers nursing and therapy services under these benefits when a patient is expected to improve.

Specifically, this settlement required manual revisions to restate a maintenance coverage standard for both skilled nursing and therapy services under these benefits:

  • Skilled nursing services would be covered where such services are necessary to maintain the patient’s current condition or prevent or slow further deterioration, so long as the patient requires skilled care for the services to be safely and effectively provided.
  • Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of a safe and effective maintenance program. This type of maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the patient requires skilled care for the safe and effective performance of the program.

This decision does not:

  • Mandate that you use daily services over intermittent skilled services for maintenance therapy.
  • Override benefit limits. Benefit limits are still in place for certain services, which may prevent indefinite treatment in some situations.
  • Require observation and assessment by a nurse for the treatment of the illness or injury when the characteristics are part of a longstanding pattern of a waxing and waning condition, which by themselves don’t require skilled services, and when there’s no attempt to change the treatment to resolve them. (A3-3132.1.C.2, SNF-214.1.C.2)

As part of our educational efforts to make sure services are provided and coverage determinations are adjudicated accurately and in accordance with existing Medicare policy, we ask that you review this educational information from CMS:

eviCore Online Clinical Consultation Scheduling

eviCore is excited to introduce their online clinical consultation scheduling system to help streamline the process for requesting peer-to-peer consultations.

You can schedule clinical consultations for our members’ cases faster on eviCore.com. You can also find this from the eviCore.com provider login page, beneath the log in button.

eviCore Peer-toPeer Tool

Note: You can’t access this feature from Your Health Alliance for providers, you must go to eviCore.com. You will have to continue to go to Your Health Alliance for providers to submit eviCore preauthorization request.

From there, choose Health Alliance Med Plan from the Select Health Plan dropdown and select your solution.

Choose Network and Specialty

Fill out the form with the required info, and submit. Then you’ll receive a confirmation email, and an agent will contact you before the time in your request to schedule your exact appointment time.

Oncology Preauthorizations on eviCore

For which oncology patients is preauthorization on eviCore through Your Health Alliance for providers required? We can help:

Patient Type When Is PA Required?
Patients on stand-alone medications who have approvals on file with us for medications that required PA before August 1, 2017 When the current authorization expires, or if treatment or medication changes.
Patients on standalone medications or regimens that did not require PA before August 1, 2017 Required as of August 1, 2017.
Patients on stand-alone medications or regimens who have an approval on file with us for only a part of the medications or regimens When the current authorization expires. We recommend these requests be placed through eviCore if the provider group would like an authorization verifying the full regimen.

Medicaid Claims

In our December 2016 Newsletter, we reminded all participating providers that we terminated our Medicaid contracts with Healthcare and Family Services, effective December 31, 2016. We asked all participating providers to submit all Medicaid claims with dates of service on or before December 31, 2016, no later than April 1, 2017.

We will not process claims received after that date. This is subject to your contract terms related to timely filing. We appreciate your understanding.

Reminder About In-Network Referrals

Remember to use contracted in-network providers before referring a patient outside our network. You can search a member’s network on Your Health Alliance for providers and office personnel by attaching to that member.

When our members need services that aren’t available from an in-network provider, they might also be able to get those services from a provider in their secondary or tertiary network. You can also access this while attached to a member. Note: All providers in secondary or tertiary networks require preauthorization.

Pharmacy Updates

All Plans

Formulary Additions

  • Kevzara (sarilumab) – Indicated for the treatment of adult patients with moderate to severe Rheumatoid Arthritis (RA) who have had an inadequate response or intolerance to one or more biologic or non-biologic Disease-Modifying Anti-Rheumatic Drugs (DMARDs).
    • Commercial – Tier 5 with preauthorization (PA)
    • Medicare – Non-formulary
  • Austedo (deutetrabenazine) – Indicated for the treatment of chorea associated with Huntington’s disease (HD).
    • Commercial – Tier 6 with PA
    • Medicare – Non-formulary
  • Ingrezza (valbenazine) – Indicated for the treatment of tardive dyskinesia (TD).
    • Commercial – Tier 5 with PA
    • Medicare – Tier 5 with PA
  • Ocrevus (ocrelizumab) – Indicated for the treatment of relapsing or primary progressive forms of multiple sclerosis (MS) in adult patients.
    • Commercial – Tier 5 with PA
    • Medicare – Tier 5 with PA
  • Radicava (edaravone) – Indicated for the treatment of Amyotrophic Lateral Sclerosis (ALS).
    • Commercial – Tier 6 with PA
    • Medicare – Non-formulary
  • Xadago (safinamide) – Indicated as adjunctive treatment to levodopa/carbidopa in patients with Parkinson’s disease experiencing “off” episodes.
    • Commercial – Tier 3
    • Medicare – Non-formulary

Formulary Additions – Effective October 4, 2017

  • Brineura (cerliponase alfa) – Indicated to slow the loss of ambulation in symptomatic pediatric patients 3 years of age and older with late infantile neuronal ceroid lipofuscinosis type 2 (CLN2), also known as tripeptidyl peptidase 1 (TPP1) deficiency.
    • Commercial – Tier 6 with PA
    • Medicare – Part B only
  • Emflaza (deflazacort) – Indicated for the treatment of Duchenne muscular dystrophy in patients 5 years of age and older.
    • Commercial – Tier 6 with PA
    • Medicare – Non-formulary
  • Spinraza (nusinersen) – Indicated for the treatment of spinal muscular atrophy (SMA).
    • Commercial – Tier 6 with PA
    • Medicare – Part B only
  • Tremfya (guselkumab) – Indicated for the treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy.
    • Commercial – Tier 5 with PA
    • Medicare – Non-formulary
  • Tymlos (abaloparatide) – Indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture defined as a history of osteoporotic fracture, multiple risk factors for fracture, or patients who have failed or are intolerant to other available osteoporosis therapy.
    • Commercial – Tier 5 with PA
    • Medicare – Non-formulary
  • Haegarda (C1 inhibitor [human]) – Indicated as routine prophylaxis against angioedema attacks in adults and adolescents with hereditary angioedema.
    • Commercial – Tier 6 with PA
    • Medicare – Tier 6 with PA
  • Nityr (nitisinone) – Indicated for the treatment of hereditary tyrosinemia type 1.
    • Commercial – Tier 6 with PA
    • Medicare – Non-formulary
  • Hepatitis C
    • Mavyret (glecaprevir and pibrentasvir) – Indicated for the treatment of chronic hepatitis C virus genotype 1, 2, 3, 4, 5, or 6 infection in adults without cirrhosis or with compensated cirrhosis, HCV genotype 1 infection in adults previously treated with a regimen containing an HCV NS5A inhibitor, or an NS3/4A protease inhibitor, but not both.
      • Commercial – Tier 4 with PA
      • Medicare – Tier 5 with PA
    • Vosevi (sofosbuvir, velpatasvir, and voxilaprevir) – Indicated for the treatment of adults with chronic hepatitis C virus (HCV) infection, without cirrhosis or with compensated cirrhosis (Child-Pugh class A), who have genotype 1, 2, 3, 4, 5, or 6 infection, and have previously been treated with an HCV regimen containing an NS5A inhibitor, or who have genotype 1a or 3 infection and have previously been treated with an HCV regimen containing sofosbuvir without an NS5A inhibitor.
      • Commercial – Tier 6 with PA
      • Medicare – Non-formulary
  • Oncology
    • Kisqali (ribociclib) 200mg tablet – Indicated for breast cancer, advanced or metastatic.
      • Commercial – Tier 5 with PA reviewed by eviCore
      • Medicare – Tier 5 with PA reviewed by Health Alliance
    • Nerlynx (neratinib) 40mg tablet – Indicated for breast cancer.
      • Commercial – Tier 5 with PA reviewed by eviCore
      • Medicare – Tier 5 with PA reviewed by Health Alliance
    • Bavencio (avelumab) 200mg/10mL IV – Indicated for Merkel cell carcinoma, metastatic, and urothelial carcinoma, locally advanced or metastatic.
      • Commercial – Tier 5 with PA reviewed by eviCore
      • Medicare – Tier 5 with PA, reviewed by Health Alliance if covered under Part D, reviewed by eviCore if covered under Part B
    • Rydapt (midostaurin) 25mg capsule – Indicated for acute myeloid leukemia, FLT3-positive, mast cell leukemia, and systemic mastocytosis.
      • Commercial – Tier 5 with PA reviewed by eviCore
      • Medicare – Tier 5 with PA reviewed by Health Alliance
    • Alunbrig (brigatinib) 30mg tablet – Indicated for non-small cell lung cancer, metastatic.
      • Commercial – Tier 5 with PA reviewed by eviCore
      • Medicare – Tier 5 with PA reviewed by Health Alliance
    • Imfinzi (durvalumab) 120mg/2.4mL, 500mg/10mL IV – Urothelial carcinoma, locally advanced or metastatic.
      • Commercial – Tier 5 with PA reviewed by eviCore
      • Medicare – Tier 5 with PA, reviewed by Health Alliance if covered under Part D, reviewed by eviCore if covered under Part B

Commercial

Criteria Changes

  • Bunavail, Suboxone, and Zubsolv
    • Removed Subutex from policy (brand name is discontinued)
    • Added Bunavail and Zubsolv to policy
      • Tier 3 with PA
  • Pennsaid
    • Retired
    • Moving to Excluded
  • Rheumatology
    • Actemra
      • Added criteria for Giant Cell Arteritis/Temporal Arteritis – Newer indication
        • Documented diagnosis, ordered by a neuro-ophthalmologist, and failure to respond to glucocorticoids
        • Update: Dr. Rasheed requested broadening of provider requirement to include ophthalmologists and rheumatologists
    • Cosentyx
      • Updated criteria for Ankylosing Spondylitis
        • Removed step through intra articular steroids and through sulfasalazine to align our policy with ACR guidelines
        • ACR guidelines indicate that NSAIDs and TNFs are strong first- and second-line recommendations
    • Enbrel
      • Updated criteria for Plaque Psoriasis
        • Age restriction was changed from 18 years or older to 4 years or older, as the FDA label has recently changed
    • Humira
      • Added criteria for Uveitis – New indication
        • Documented diagnosis, ordered by an ophthalmologist, failure to respond to topical glucocorticoids, and failure to respond to systemic glucocorticoids or immunosuppressive agents
        • Update: Dr. Rasheed requested broadening of provider requirement to include ophthalmologists, rheumatologists, and providers experienced in the treatment of uveitis
      • Added criteria for Pyoderma Gangrenosum
        • Off-label indication, however we currently cover Remicade for this indication, so we would like to add coverage for our preferred product Humira
        • Documented diagnosis, ordered by a specialist, and documentation of not responding to standard therapy
    • Ilaris
      • Added criteria for Systemic Juvenile Idiopathic Arthritis
        • Documented diagnosis with moderate to severe disease, age 2 or older, ordered by a rheumatologist, failure of one NSAID
    • Orencia
      • Added criteria for Psoriatic Arthritis – New indication
        • Documented diagnosis, ordered by a rheumatologist, failure on a DMARD, failure on Humira or Enbrel
    • Remicade
      • Added biosimilar Renflexis to policy
      • Updated criteria for Ankylosing Spondylitis
        • Removed step through intra articular steroids and through sulfasalazine to align our policy with ACR guidelines
        • ACR guidelines indicate that NSAIDs and TNFs are strong first- and second-line recommendations
      • Updated criteria for Pyoderma Gangrenosum – Off-label
        • Added Humira step-therapy (ST) since Humira is now also used for Pyoderma Gangrenosum treatment and is a preferred product
    • Rituxan
      • Updated criteria for Autoimmune Hemolytic Anemia
        • Removed ST through azathioprine or cyclophosphamide
        • Removed ST through cyclosporine or mycophenolate
        • According to Uptodate, Rituxan is second-line treatment, following corticosteroids
      • Updated criteria for Immune Thrombocytopenic Purpura
        • Revised criteria to allow coverage if splenectomy is contraindicated
      • Updated criteria for Systemic Lupus Erythematosus
        • Updated ST through hydroxychloroquine or chloroquine to also check claims history for compliance
        • We do this for Benlysta as well
      • Updated criteria for Granulomatosis with Polyangitis
        • Revised terminology from Wegener’s Granulomatosis to Granulomatosis with Polyangitis
        • Removed ST through cyclophosphamide and azathioprine as cyclophosphamide and Rituxan are equally recommended as second-line, and azathioprine is not recommended for organ threatening disease
      • Added criteria for Multiple Sclerosis
        • This drug is pharmacologically similar to Ocrevus (new monoclonal antibody indicated for treatment of PPMS and RRMS)
        • Off label for MS, but is less costly than Ocrevus
    • All Policies
      • Updated exclusion criteria to indicate that we will not continue to cover if an inadequate response was achieved
      • Updated exclusion criteria to indicate that we will not cover concurrent therapy with multiple biologic DMARDS or other TNF blockers
  • Psychiatry
    • Behavioral Health
      • Updated Brand Name Antidepressants section to Non-Preferred Antidepressants
        • This allows generic desvenlafaxine to also follow this criteria, as we still PA this product
      • Add Khedezla to Non-Preferred Antidepressant section
        • This is also a desvenlafaxine product, and we want to PA it to be consistent with the PA we have on Pristiq
    • Dyanavel XR Suspension, Quillichew ER, Quillivant XR Policies
      • Updated age requirement from covered for ages 12 and under to covered for members ages 6 to 12 years, as these products are all indicated for children over age 6
  • Neurology
    • Provigil and Nuvigil policy
      • Retired policy
        • Both drugs have generics and prices no longer warrant PA
    • Xyrem
      • Updated to require a sleep lab evaluation confirming diagnosis of narcolepsy
        • Xyrem policy requires previous failure of modafinil or armodafinil, the use of which currently requires a sleep lab evaluation for PA
        • If PA is removed from modafinil and armodafinil, the sleep lab is no longer ensured and Xyrem could process without confirmed diagnosis of narcolepsy
      • Drug must be requested by a Xyrem certified REMS provider who is familiar with the risks and adverse effects of Xyrem
    • Xenazine
      • Edited to require a documented contraindication or allergic reaction to generic tetrabenazine before brand name Xenazine will be approved
        • Brand can cost up to ~$30,000 per month compared to generic cost of ~$18,840 per month
    • Lyrica
      • Added exclusion criteria to exclude coverage of Lyrica for trigeminal neuralgia due to lack of recommendation in the AAN and NICE guidelines
        • Recommendations for treatment of trigeminal neuralgia include carbamazepine, oxcarbazepine, baclofen, lamotrigine, and pimozide
    • Lemtrada and Tysabri policies
      • Current policies for both Lemtrada and Tysabri require a documented failure, intolerance, or contraindication to 2 or more unspecified disease modifying therapies for MS
      • Ocrevus was FDA approved in March 2017 for Relapsing forms of Multiple Sclerosis (RMS) and Primary Progressive Multiple Sclerosis (PPMS)
        • First drug approved for PPMS
        • At approximately $6,500 per month, Ocrevus is the least costly of the disease-modifying therapies for MS
      • Due to Ocrevus’ cost-saving opportunities, recommend updating Lemtrada and Tysabri policies to require documented failure, intolerance, or contraindication to Ocrevus and one additional unspecified disease modifying therapy
    • Trokendi XR and Qudexy XR policies
      • Established criteria for extended-release topiramate products since they received FDA approval for migraine prevention in April 2017
      • Criteria for seizure diagnosis remains the same – 90-day trial with topiramate immediate release
      • Diagnosis of migraine will require claims history illustrating 90-days use of immediate release topiramate in a 120-day period and 90-days use of a second migraine prophylactic in a 120-day period
        • Second preventive drug must have an evidence rating of Level A or Level B by the American Academy of Neurology (AAN)
    • Botox for Chronic Migraine Prevention
      • Removed psychiatric evaluation requirement
      • Removed abortive therapy requirement to better align with other insurers and to allow for use of over-the-counter treatments
      • Updated prophylactic requirement to require claims review showing 90-days use within 120-day periods of 2 preventive drugs
        • Preventive drugs must have evidence ratings of Level A or Level B by the AAN
    • Dysport
      • Dysport has received FDA indications for Adult Lower Limb Spasticity and Adult Upper Limb Spasticity
        • Added same criteria as for Botox
      • Recent new FDA indication for Pediatric Lower Limb Spasticity in children age 2 to 17 with Cerebral Palsy
    • H.P. Acthar
      • H.P. Acthar gel is FDA indicated for Infantile Spasms and Multiple Sclerosis, but we only cover the drug for Infantile Spams
      • We updated the exclusion criteria to specifically speak to the reasons why we don’t cover it for other uses

Criteria Changes – Effective October 4, 2017

  • Forteo
    • Updated policy with language for Tymlos
  • Orfadin and Nityr
    • Added Nityr to what had been Orfadin policy
    • Nityr is currently specialty pharmacy Tier 6 with PA
  • IVIG
    • Added Cuvitru, Hizentra, and Hyqvia to policy
    • Added criteria for treatment of PANS/PANDAS
  • Otezla
    • Removed Humira and Enbrel ST
  • Smoking Cessation
    • Specified 1 quit attempt covered under wellness benefit per 180 days
    • Edited bupropion criteria
    • Edited Chantix criteria
    • Defined medical necessity

Criteria Change – Effective January 1, 2018

  • Opioids, Long-Acting and Short-Acting
    • Added MED requirements
    • Changed from brand name LA Opioids to non-preferred LA Opioids
    • Added requirements to LA Opioid, Tramadol ER, and Nucynta sections

New Policies

  • Triptan Managed Dose Limit
    • Established the criteria for coverage of additional quantities of triptans above the established managed dose limit
  • Vyvanse Chewable
    • Tier 3 with PA
    • Covered for members ages 6 to 12 years
    • Quantity limit of #30 per 30 days
  • Oncology Regimen Review – eviCore
    • Offers guidance on the eviCore preauthorization review process for oncology agents and oncology supportive care agents
    • Update: Dr. Belgrave recommended adding stem cell procedures to eviCore review exclusions

New Policy – Effective October 4, 2017

  • Hereditary Angioedema (HAE)
    • Replaced individual drug policies for Cinryze, Berinert, Firazyr, Kalbitor, and Ruconest
    • Established criteria for coverage of formulary addition Haegarda

New Policy – Effective January 1, 2018

  • Wellness Coverage for Statin Medications
    • Establishes the criteria for coverage of atorvastatin, lovastatin, pravastatin, and simvastatin under the wellness benefit

Tier Changes

  • Zubsolv – Moved from Excluded to Tier 3 with PA
    • Pricing similar to Suboxone
    • Recommending coverage to give providers more options
  • Bunavail – Moved from Excluded to Tier 3 with PA
    • Pricing similar to Suboxone
    • Recommending coverage to give providers more options
  • Evekeo (amphetamine) – Moved from Tier 3 to Excluded
    • Multiple amphetamine products covered at Tier 1
  • Conzip (tramadol) – Moved from Tier 3 to Excluded
    • Tramadol is covered at Tier 1
  • Zipsor (diclofenac) – Moved from Tier 3 to Excluded
    • Multiple diclofenac products covered at Tier 1
  • Pennsaid – Moved from Tier 3 to Excluded
    • Diclofenac gel 1% covered at Tier 1
  • Ziagen tablets – Moved from Tier 2 to Tier 3
    • Abacavir covered at Tier 1
  • Epzicom – Moved from Tier 2 to Tier 3
    • Abacavir/lamivudine covered at Tier 1
  • Videx EC – Moved from Tier 2 to Tier 3
    • Didanosine covered at Tier 1
  • Viramune – Moved from Tier 2 to Tier 3
    • Nevirapine covered at Tier 1
  • Viramune XR – Moved from Tier 2 to Tier 3
    • Nevirapine ER covered at Tier 1
  • Antabuse – Moved from Tier 2 to Tier 3
    • Disulfiram covered at Tier 1
  • Namenda – Moved from Tier 2 to Tier 3
    • Memantine covered at Tier 1
  • Emend Oral – Moved from Tier 2 to Tier 3
    • Aprepitant is covered at Tier 1
  • Avodart – Move from Tier 2 to Tier 3
    • Dutasteride is covered at Tier 1
  • Jalyn – Moved from Tier 2 to Tier 3
    • Dutasteride/tamsulosin is covered at Tier 1
  • Uroxatrol – Moved from Tier 2 to Tier 3
    • Alfuzosin HCl ER is covered at Tier 1
  • Moved these seizure disorder medications from Tier 2 to Tier 3, as all have generics at Tier 1:
    • Carbatrol
    • Depakene
    • Depakote, Depakote Sprinkles
    • Dilantin
    • Gabitril
    • Klonopin
    • Lamictal, Lamictal XR
    • Mysoline
    • Neurontin
    • Tegretol, Tegretol XR
    • Topamax
    • Zarontin
    • Zonegran
    • Note: DAW penalty will not be assessed if member chooses to remain on brand name instead of switching to generic
  • Cafergot – Moved from Tier 2 to Tier 3
    • Ergotamine/caffeine is covered at Tier 1
  • Arixtra – Moved from Tier 2 to Tier 3
    • Fondaparinux is covered at Tier 1

Tier Change – Effective October 4, 2017

  • Sovaldi – Move from Tier 4 with PA to Tier 6 with PA
    • Preferred products are Harvoni, Epclusa, and Mavyret
    • Currently, there are no commercial members on Sovaldi

 

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