SCOPE | Provider Update

January 2024

Clinical Matters

Update to preferred infliximab agents effective Feb. 1

As of Feb. 1, 2024, J1745 Remicade and infiximab will be the preferred biologics.

Effective February 1, 2024 the following drugs will be our preferred infliximab products:

J1745 Remicade and infliximab (unbranded biologic)

This switch will ensure we cover the most cost-effective agent as good stewards of our members’ premium dollars.

Impact & Action Items

Inflectra will no longer be covered as our preferred product.
J1745 Remicade and infliximab (unbranded biologic) will be covered for U.S. Food & Drug Administration (FDA) approved indications only.

Members Impacted

Commercial, Self-Funded and MediSource plans: those currently receiving therapy and those new to treatment.
Medicare Advantage: only those new to therapy.

Prescriber Action

An authorization for J1745 Remicade/infliximab (unbranded biologic) will be entered for members with an active Inflectra authorization.

Providers may switch patients to Remicade/infliximab (unbranded biologic) beginning February 1 or at the expiration of the patient’s current Inflectra authorization.
Note: you will need to request a new Remicade/infliximab authorization once the Inflectra authorization expires.

We look forward to our continued partnership in providing quality care for our members and your patients. For questions, please call our Provider Relations Department at (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 6 p.m.

Cervical Cancer Prevention – Screening works; make sure you know the guidelines

The number of deaths from cervical cancer continues to decline, thanks to regular screening and the HPV vaccine.

The number of deaths from cervical cancer in the United States have decreased substantially since the implementation of widespread cervical cancer screening and the rate continues to decline.

Most cases of cervical cancer occur among women who have not been adequately screened. Strategies that aim to ensure that all women are appropriately screened and receive adequate follow-up are most likely to succeed in further reducing cervical cancer incidence and mortality.

The United States Preventive Services Task Force (USPSTF) recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years.

For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting).

HPV vaccine is another important tool in cervical cancer prevention. Per the Centers for Disease Control, HPV vaccination prevents new HPV infections but does not treat existing HPV infections or diseases. HPV vaccine works best when given before any exposure to HPV.

Vaccine Recommendations:

HPV vaccine is recommended for routine vaccination at age 11 or 12 years. (Vaccination can be started at age 9.)
The Advisory Committee on Immunization Practices (ACIP) also recommends vaccination for everyone through age 26 years if not adequately vaccinated when younger. HPV vaccination is given as a series of either two or three doses, depending on age at initial vaccination.
Vaccination is not recommended for everyone older than age 26 years. Some adults ages 27 through 45 years might decide to get the HPV vaccine based on discussion with their clinician, if they did not get adequately vaccinated when they were younger. HPV vaccination of people in this age range provides less benefit, for several reasons, including that more people in this age range have already been exposed to HPV.
For adults ages 27 through 45 years, clinicians can consider discussing HPV vaccination with people who are most likely to benefit.

For more information, please view the following recommendations:

Tips for a smooth transition to members' new ID numbers in 2024

Self-funded and commercial members who renew their plans in 2024, along with new subscribers, will be assigned new ID numbers that begin with W.

Independent Health has begun issuing new ID numbers to commercial and self-funded members upon their plans’ renewal dates during 2024.

While this should have no effect on billing because the new ID number will track to the member’s current ID number, providers who submit authorizations through RadMD (NIA) or Magellan Rx will have to use the members’ new ID number.

Please keep the following information in mind and follow these tips for a smooth transition as commercial and self-funded members receive their ID cards during the year.

The new ID numbers for commercial and self-funded members will begin with “W.” (The ID numbers for Medicare and State program members will not change).
When requesting authorizations through NIA or Magellan Rx, use the new ID number immediately.
If NIA or Magellan Rx do not accept the member’s number that begins with “9” (the current format), please use a “W” in place of the 9.
If that does not work, please contact Provider Relations, or check WNYHealtheNet or search using the member’s name and date of birth.
All pre-authorization denial and approval letters will have the members’ new ID numbers.
Previously submitted orders and approved authorizations with current ID numbers will transition automatically.
Begin using the new ID numbers as members receive their new cards. It is important to ask patients if they have new ID cards and to use their new Member ID numbers.

Questions? Please call Provider Relations at 716-631-3282, Monday through Friday from 8 a.m. to 6 p.m.

Clinical Trials Policy: National Clinical Trial Identifier now required

When submitting claims, providers must submit the National Clinical Trial (NCT) identifier; other information will be required upon request..

At Independent Health, we acknowledge the importance of clinical trials in the treatment of serious conditions. As outlined in our Clinical Trials policy, Independent Health covers medically necessary routine patient costs of a Qualified Individual participating in an approved clinical trial, as well as the routine costs of treating any side effects and/or complications associated with the approved clinical trial.

In support of our Clinical Trials Policy, the National Clinical Trial (NCT) identifier must now be included on any claim submission in the Demonstration Project field for both institutional and professional claims. Independent Health will reject claims that do not include the NCT identifier in the Loop 2300 REF Demonstration Project Identifier (REF*P4) on the 837. This change is effective February 1, 2024.

As a reminder, providers will also need to continue submitting the following clinical trial information upon request:

Clinical trial protocol including Approved Clinical trial number, member information and medical history
Clinical trial sponsor budget
Protocol billing grid/treatment calendar

We recommend providers become familiar with the policy and its coverage exclusions. Log into your secure provider portal to view the Clinical Trials policy.

Ways to keep individuals active in winter

Despite the cold weather and short winter days, there are many ways patients can stay active and engaged for their own health.

Winter has arrived and with it comes decreased daylight, falling temperatures and fewer activities outside. Cold weather easily contributes to decreased motivation to exercise and the potential for increased isolation. Shorter days with less daylight reduce our exposure to vitamin D. This may lead to fatigue and disruption in sleep, ultimately contributing to low energy levels, anxiety, and depression.

“Staying connected with others may help boost your mood and improve your overall well-being. Stay in touch with family and friends in person or over the phone. Scheduling time each day to connect with others can help you maintain connections. Meet new people by taking a class to learn something new or hone a skill you already have.” (From "What do we know about healthy aging?" - National Institute on Aging, Feb. 23, 2023.

Research shows that physical activity has been proven to reduce fatigue, allow us to better manage stress and improve our overall wellbeing. While outdoor exercise offers opportunities for socialization and exposure to natural light, there are easy ways to stay active indoors to avoid prolonged sitting when inclement weather limits outdoor activity.

There are many ways to find exercise and activities – and Independent Health makes it easier through our community partnerships that providers may suggest to their patients.

Naturally, we encourage individuals to protect themselves during outdoor exercise and activity by dressing in layers, keeping skin dry and covered, staying hydrated and avoiding alcohol. We also encourage people to get their physician’s approval before doing any physical activity, be sure to get your physicians approval.

Exercises/Activities with friends

Outdoor

Hiking/Walking
Snowshoeing
Sledding
Skiing
Ice skating/Ice hockey
Curling

Indoor

Join a gym
Yoga
Walk at the mall
Zoom classes
Indoor equipment
Chores to music
Dancing

Social

Go to the movies
Game night
Cooking class
Dinner party
Book club
Go for coffee
Craft night
Bowling
Group tours
Send regular texts/emails
Volunteering
Scavenger hunt

Step therapy required for GLP-1 coverage for Medicare members

Requirement effective Jan. 1, 2024

Effective January 1, 2024, Independent Health will require Step Therapy through drugs that treat type 2 diabetes for all Medicare Advantage members.

Medicare members currently taking the medication will have the ability to continue treatment. New prescriptions will require the step or a confirmation of a diagnosis prior to the patient’s first fill.
As a reminder, Centers for Medicare & Medicaid Services (CMS) excludes all medications used exclusively for weight loss and does not allow coverage for drugs like Zepbound, Wegovy, and Saxenda. Glucagon-like peptide-1 (GLP-1) receptor agonists not indicated for weight loss, like Ozempic and Mounjaro, should not be prescribed for this purpose alone.

Note: Coverage for members with a Commercial Plan (individual/family or employer-sponsored), Essential Plan or Child Health Plus remains unchanged.

Formulary and Policy Changes

No updates for January, but view our up-to-date policies online.

View the most up to date versions of Independent Health’s policies when logged in to our provider portal

Magellan Rx, administered by Magellan Rx Management, reviews select specialty drug prior authorization requests on Independent Health’s behalf. To view Magellan Rx policies for the drugs that they review, click here.

Independent Health's drug formulary
Access Independent Health's drug formulary here.

To obtain a hard copy, please contact Independent Health Provider Relations by calling (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 6 p.m.