Pay BillSCOPE | Provider Update
August 2025
Clinical Matters
Statin therapy recommendations for patients with cardiovascular disease or diabetes
Adherence to statin medications can aid in risk reduction of clinical atherosclerotic cardiovascular disease (ASCVD) for patients living with CVD and/or diabetes.
The American Diabetes Association recommends the following types of individuals be treated with a statin, regardless of their baseline LDL cholesterol concentration:
- individuals living with diabetes or a history of CVD.
- individuals older than 40 years of age without CVD but with CVD risk factors.
For patients living with CVD and/or diabetes, adherence to statin medications can aid in risk reduction of clinical atherosclerotic cardiovascular disease (ASCVD). As such, there are three unique quality metrics focused on statin therapy, which are included in the Independent Health HEDIS provider manual on the provider portal.
1. Statin Therapy for Patients with Cardiovascular Disease (SPC): Assesses males 21 to 75 years of age and females 40 to 75 years of age during the measurement year, who are identified as having ASCVD and meet the following criteria:
- Received Statin Therapy: members who have received at least one high or moderate intensity statin medication during the measurement year. [Note: SPC - Statin received is a Primary Value measure.]
- Applies to all lines of business - Commercial, Medicaid, and Medicare.
2. Statin Therapy for Patients with Diabetes (SPD): Assesses individuals 40 to 75 years of age with a diagnosis of diabetes and no diagnosis of ASCVD, and who meet the following criteria:
- Received Statin Therapy: members who have received at least one statin medication of any intensity during the measurement year. [Note: SPD - Statin received is Primary Value measure.]
- Statin Adherence 80%: members who remained adherent to their statin medication for at least 80% of the treatment period.
- Applies to the Commercial and Medicaid line of business.
- Note there is a separate Medicare STAR measure that focuses on statin therapy received. See below.
3. Statin Use in Persons with Diabetes (SUPD) assess members 40-75 years of age during the measurement period who were dispensed at least two diabetes medication fills during the measurement period and are receiving statin therapy.
- Applies to the Medicare only line of business.
Did you know?
Certain adverse reactions to a statin medication may exclude the patient from the measure denominator if properly documented.
- Diagnosis of active muscle pain and disease, including myalgia, myositis, myopathy, or rhabdomyolysis during calendar year 2025.
- Please refer to the HEDIS manual for a full list of exclusion diagnoses.
- These exclusionary diagnoses may come from claims or chart review data.
NEW in 2025 for the HEDIS SPC and SPD measures:
We are now able to accept a historical diagnosis of myalgia or rhabdomyolysis caused by a statin any time during the member’s history for measure exclusion. Diagnoses for these conditions must be documented in the medical record progress note. You may upload the diagnoses into the portal through the Gaps in Care Correction process.
Note: We will accept these corrections through the portal; however, they will not fall off your gap reporting until November 2025, when the new historical exclusions officially go into effect.
Historical diagnoses do not currently apply to the STAR SUPD measure.
If there are any questions, please reach out to your dedicated Physician Engagement Specialist or email engagement@independenthealth.com.
National Immunization Awareness Month: Immunizations are safe, effective, and necessary
With vaccine hesitancy on the rise, healthcare providers are in an optimal position to educate and vaccinate patients of all ages.
August is National Immunization Month, shining a light on the importance of immunizations in providing protection from serious diseases – advancing both individual and public health. Individuals who understand the personal and community-wide benefits of immunizations are more likely to vaccinate versus patients who do not understand the value.
All healthcare professionals play an important role in slowing down the spread of vaccine hesitancy. We want to support this important work by sharing information about population trends and attitudes, and how to talk with patients about their individual concerns.
Understanding vaccine hesitancy by populations
The World Health Organization (WHO) defines vaccine hesitancy as “delay in acceptance or refusal of vaccination despite availability of vaccination services.” The populations most likely to be vaccine hesitant include racial/ethnic minorities, low economic status, and less education. However, it is vital to understand every patient's baseline comfort level with vaccines and not make sweeping assumptions.
- Many racial minorities report a lack of trust in the medical system due to systemic inequalities over time. Another common concern involves the lack of minority representation in vaccine clinical trials. Antiracist and culturally competent healthcare is imperative to mitigate vaccine hesitancy.
- Those of a lower economic status and less educated are more likely to fall prey to vaccine misinformation. This may be due to lack of understanding of where to find reliable information. Healthcare providers can assist in providing reliable sources of information on vaccines, taking advantage of their status as one of the country’s most trusted professions.
Common vaccination myths vs. facts
Myth: Vaccines contain several harmful ingredients.
- Fact: Different ingredients are included to assist with stability, preserving and more at much lower doses than what the average person is exposed to in the environment. No evidence exists that vaccine ingredients cause health risks.
Myth: Vaccines will cause autism and SIDS.
- Fact: There is currently no clear understanding on the etiology of autism and SIDS, but there is no evidence that actually links those conditions with vaccinations. A significantly flawed 1998 study raised concerns between the MMR vaccine and autism. That study has since been retracted from the journal it was published in to due to bad design and bad science.
Myth: It is possible to get the disease from the vaccine.
- Fact: Most vaccines are inactivated (killed), meaning contracting the disease is impossible. Out of the live vaccines, a mild case of the disease can take place that can actually be a positive sign the vaccine is working.
The 5C model of vaccine hesitancy
This helpful model was developed as a person-specific method to understand an individual’s vaccine hesitancy.
- Confidence: the individual’s trust in the safety and efficacy of vaccines. Solution: respect, understand, and debunk their concerns in an easy-to-understand language.
- Complacency: lack of perception of personal risk and/or disease severity. Solution: educate on the risk of contracting a vaccine-preventable disease as well as the benefits to the population (herd immunity for those who legitimately cannot get vaccinated).
- Constraints: having access to affordable vaccines in areas where communities gather. Solution: hold a mass vaccination event (ex: at a place of work or school) and work to assist with external factors that can impact access.
- Calculation: the ‘infodemic’ of vaccine misinformation. Solution: understand the emotionally charged nature of this content and why people believe it. Create space for open dialogue to provide education.
- Collective responsibility: understanding the importance of herd immunity (and who it intends to protect). Solution: educate the individual on the immunocompromised who rely on herd immunity to stay healthy and the public health benefits that come from getting vaccinated.
Conclusion
Vaccinations have been heavily studied over the years and shown to be incredibly safe and effective at preventing several diseases. The benefits of vaccination far outweigh the risks. When encountering a vaccine-hesitant individual, empathize and patiently work to debunk false or harmful information.
Helpful resources
Office Matters
Upcoming change in coverage for blood glucose meters and supplies
FreeStyle to become preferred brand; OneTouch will no longer be covered
We have an upcoming change in coverage for blood glucose meters, lancets and test strips.
Preferred products
The following FreeStyle products will be our preferred products:
- FreeStyle Lite Meter
- FreeStyle Freedom Lite Meter
- FreeStyle Precision Neo Meter Kit
- FreeStyle Xtra Meter
- FreeStyle Test Strips and Lancets
Timing of the change
On August 1, 2025, we are adding coverage of the FreeStyle products for all members. OneTouch products will still be covered to ease the transition.
FreeStyle products will become the preferred products, and OneTouch blood glucose meters and supplies become non-preferred and no longer covered on the following dates:
- September 1, 2025, for self-funded members
- October 1, 2025, for commercial and state members
- January 1, 2026, for Medicare members
Free meters for members
To help with the switch, members are eligible to receive a FreeStyle Lite Meter or FreeStyle Freedom Lite Meter at no cost. Members affected by this change will receive a letter with all this information, including how to obtain the new meter.
If you are a provider who has prescribed OneTouch products in the last six months, you should receive a detailed communication from Independent Health. Abbott, the manufacturer of FreeStyle products, will also be conducting provider outreach.
As always, if you have any questions, please contact Provider Relations. Thank you for your continued partnership.
New prior authorization requirements begin Oct. 1 – cardiology, vascular procedures, physical medicine
Independent Health has partnered with Evolent to conduct the prior authorization processes.
As part of Independent Health’s goal to promote clinically appropriate, evidence-based care while also mitigating variability in quality and cost, we are partnering with Evolent (formerly NIA) to implement prior authorizations for:
- Cardiology services, including interventional cardiology and vascular surgery – effective Oct. 1
- Physical, Speech and Occupational Therapy for Medicare plans – effective Oct. 1
These prior authorization programs are intended to help providers effectively deliver quality patient care using clinical criteria based on nationally recognized guidelines to promote evidence-based practices.
Interventional Cardiology and Vascular Services
For services beginning on October 1, 2025, select interventional cardiology and vascular services will require prior authorization through Evolent prior to being rendered in an outpatient or inpatient* (*professional component of elective services only) setting.
These requirements will apply to all specialties for the following non-emergent procedures for adult Independent Health commercial and Medicare lines of business:
- Cardiac catheterization and intervention
- Electrophysiology
- Vascular radiology and intervention
- Cardiac surgery
- Vascular surgery
These programs do not include our State Programs or Self-funded products.
Physical, Occupational, Speech Therapy – Medicare only
Beginning with services on and after October 1, 2025, select physical medicine services will require prior authorization through Evolent prior to being rendered in provider offices, outpatient hospitals, and comprehensive rehabilitation facilities.
The Evolent PM program will apply to the following specialties for Independent Health’s Medicare line of business only:
- Physical therapy
- Occupational therapy
- Speech therapy
This program does not include our commercial, State Programs or Self-funded products.
Evolent is a company that supports health plans, including Independent Health, with clinical technology and services to help improve patient outcomes while addressing variations in quality, service, and cost.
Independent Health informed providers via secure message on July 23 who will be required to request prior authorization for these services, and Evolent will conduct training sessions beginning in September.
Rite Aid stores closing: where to send patients' prescriptions
Rite Aid is transferring patients' prescriptions to CVS, but CVS is not in Independent Health's network.
As Rite Aid stores close, it has been transferring patients’ prescriptions to CVS Pharmacy.
However, CVS is not participating with Independent Health.
Our pharmacy network includes almost 275 local, chain, and independent pharmacies in Western New York, and 50,000 pharmacies across the country Local options include:
- Wegmans
- Tops
- Walgreens
- Walmart
- Many independent pharmacies
Independent Health also offers mail order pharmacy options for certain maintenance medications.
Our list of participating pharmacies is online under the Find-a-Doctor menu item on our website. In addition, if your Independent Health patients have questions about switching pharmacies, you may refer them to MyIH.com/SwitchRx for simple step-by-step instructions.
Upcoming member campaigns to encourage our members to take greater control of their health
Coming up: Essential Plan Non-utilizer campaign; State member incentive campaigns
Essential Plan Non-Utilizer Engagement Campaign
This campaign will engage Essential Plan members who are considered a non-utilizer (members with 7 or more months of continuous enrollment without any claim activity during that period) and who do not have an attributed PCP. The goal of the campaign is to assist the member with finding a PCP and scheduling a preventive visit.
- Target Population: Essential Plan non-utilizers without a PCP
- Outreach Method: Telephonic outreach
- Timeframe: August-September 2025
State Member Incentive Program Campaigns
Independent Health State members will have until December 31, 2025, to complete various preventive care visits and screenings to receive an incentive for the following programs:
- Gaps-in-Care Program - State members can earn gift cards for completing various preventive care tests and screenings included in the program.
- Non-Utilizer Program - State members with 7 or more months of continuous enrollment without a claim on file are eligible to earn a gift card for completing an annual well visit.
- Maternity Management Program - State members can earn gift cards for completing a prenatal visit during the first 12 weeks of pregnancy and postpartum visit within 11 weeks after delivery.
- Timeframe: July through December 31, 2025
Health-Related Social Needs Self Screening
This email campaign will encourage Essential Plan members to complete a self-administered health-related social needs screening as well as provide community resources for members to contact if an area of need is identified.
- Target Population: Essential Plan members
- Outreach Method: Email and telephone
- Timeframe: July to December 2025
Osteoporosis Management in Women Who Had a Fracture (OMW) Member Outreach
Independent Health’s Case Manager will outreach telephonically to Medicare members that fall into the Osteoporosis Management in Women Who Had a Fracture (OMW) measure.
Independent Health’s Case Manager will contact members to discuss their fracture, provide education on fractures and falls prevention, and discuss options for gap closure.
The Case Manager will discuss the option of an in-home heel ultrasound with Stall Senior Medical (SSM). If the member is interested, the Case Manager will ask for consent for the member to be contacted by the SSM team and then SSM will call the member to schedule the appointment. All results will be sent to the member’s Primary Care Physician (PCP) for follow-up.
The Case Manager will also discuss other options for gap closure, depending on the member’s preference, and refer back to the member’s PCP. Each call will be individualized based on the member’s needs.
- Target population: The OMW measure focuses on females 67 to 85 years of age who had a fracture and have six months following the fracture to close the gap by having a bone density scan, filling a script for an osteoporosis medication, or receiving an injection for osteoporosis treatment.
- Timeframe: This outreach is on-going. Monthly, new members who fall into this measure are called.
Eye Exam for Patients with Diabetes (EED) Member Outreach
Independent Health will be facilitating outreach telephonically to Medicare members that have a gap in care for the Eye Exam for Patients with Diabetes (EED) measure. Independent Health will call members and discuss the option of an in-home eye exam with Stall Senior Medical (SSM). If the member is interested, Independent Health will ask for consent for the member to be contacted by the SSM team and then SSM will call the member to schedule the appointment. All results will be sent to the members’ Primary Care Physician (PCP) for follow-up.
- Target population: Medicare HMO members with a diagnosis of Diabetes (type 1 or 2) who have not had a retinal eye exam. An eye exam in the year prior must be negative for any type of retinopathy. If year prior eye exam is positive, then an eye exam in the current measurement year is needed.
- Outreach method: Outbound telephone call campaign.
- Timeframe: Campaign kicked off in mid-to-late March and runs through December 2025
Gaps in Care Reminder Calls
Independent Health’s Member Servicing team will perform telephonic outreach to provide education and encourage members with an open gap in care to reach out to their provider to schedule the appropriate appointments and/or get a vaccination to complete the gaps in care.
- Target populations: Medicaid Managed Care members who have open gaps for: breast cancer, colorectal, and/or cervical cancer screenings. Medicaid Managed Care and Child Health Plus members (ages 9-12) who have not started or who have started but not completed the series for HPV vaccinations. Medicare members who have open gaps for breast cancer and colorectal cancer screenings.
- Timeframe: Call campaign to run throughout 2025.
Pharmacy Updates
Formulary and Policy Changes
View our up-to-date formularies and policies online
Drug Formulary Changes
View the formulary deletions, effective August 1, 2025:
- Medicare Advantage formulary deletions for individual & group plan members
- Pharmacy Benefit Dimensions 3-Tier formulary deletions
- Pharmacy Benefit Dimensions 5-Tier formulary deletions
Access Independent Health's drug formularies here.
Drug Policy Changes
Search for and view the most current versions of all Independent Health’s drug policies when logged in to our provider portal.
Prime Therapeutics reviews prior authorizations for select oncology and specialty drugs on Independent Health's behalf. View Prime Therapeutics' policies for the drugs it reviews.
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 5 p.m.
Spotlight
Top Takeaways this Month
- September 2025 Policy Updates: New & revised policies will be posted to the secure portal on August 1, under the News tab on the menu bar. We post new and updated policies 30 days before their effective date. Please make sure to visit that page on the first of each month.
- Format changes coming to policies: As policies come up for annual review, we are moving the background and criteria to the beginning of the policy documents. Eventually all Independent Health policies will change to this format.
- State Program ID Cards: As a reminder, a group number is not required when billing for services for State Program members (MediSource, Child Health Plus, NY Essential). You may submit bills for this line of business without a group number.
- HEDIS Reference Manual: Remember to view this document posted under the Policies & Guidelines tab in the portal
- Participating Labs List: Review our updated list of participating laboratories.