November 2025

There is often a misconception about who is most affected by Chronic Obstructive Pulmonary Disease (COPD). Often people think COPD is most likely to affect older adults; however, anyone can develop COPD. While cigarette smoking is the leading risk factor for COPD, one in four people who develop COPD have never smoked cigarettes.

Risk factors for COPD include:

• Adults aged 40 or older
• Those who currently or previously smoked
• Exposure to indoor and outdoor air pollution
• Occupational exposures like dust, chemicals, and fumes
• Changes to lung growth and/or development
• History of childhood respiratory infections
• Alpha 1 antitrypsin deficiency, a genetic form of COPD

COPD is diagnosed after reviewing the results of the patient’s medical and family history including symptoms and exposure to risk factors, a physical examination and the results from spirometry lung function testing. There are many treatment options to consider, including reducing COPD triggers that may worsen a person’s COPD. 

A COPD Action and Management Plan should include opportunities to reduce or eliminate exposure to COPD triggers. Examples include:

• Tobacco smoke - Smoking causes lung function to worsen at a faster rate. Tobacco cessation is the single most important thing that can be done and should be stressed at every opportunity with resources to assist.
• Air quality - exposure to strong odors, chemicals, dust, fumes, smoke from wood burning stoves or fireplaces, and poor outdoor air quality.
• Weather - Changes in temperature, high humidity, pollen, and wind may affect a person’s COPD.

COPD Medications

• Bronchodilators are used to treat breathlessness by relaxing the muscles around the airways, with severity of symptoms determining if short or long-term therapy is predicted to be most effective.
• Inhaled corticosteroids or a muscarinic antagonist may be prescribed if the patient experiences frequent exacerbations.
• Combination medicines include two or three types of medications working together to relieve symptoms.
• Antibiotics may be prescribed during exacerbations, or flare-ups
• The article in this edition, "Appropriate Use of Antibiotics and Corticosteroids in COPD" discusses in detail the types of appropriate medications to treat the condition.

Pulmonary Rehabilitation

• Supplemental Oxygen
• Supportive care options such as palliative care and hospice can help address physical and emotional concerns. Palliative care is a type of treatment that can be started at any stage of COPD and may improve the condition, help manage symptoms and make a patient’s treatment goals known.
• Hospice is support provided at the end stage of COPD that is not intended to improve the condition.

Source: National Indicator Report COPD, March 2024

To view COPD Clinical Practice Guidelines, please visit the 2025 GOLD Report - Global Initiative for Chronic Obstructive Lung Disease

Each November, the Great American Smokeout, led by the American Cancer Society, offers a powerful opportunity for primary care providers to initiate or reinforce smoking cessation conversations with their patients. Held on the third Thursday of November, this national event encourages individuals who smoke to commit to quitting—even if just for one day—with the goal of building toward long-term cessation.

Why It Matters

Despite decades of progress, tobacco use remains the leading cause of preventable death in the U.S., contributing to over 480,000 deaths annually. Smoking is a primary risk factor for chronic obstructive pulmonary disease (COPD), and cessation is the most effective intervention to slow disease progression, reduce exacerbations, and improve quality of life.

The Role of Primary Care Providers

Primary care providers are uniquely positioned to influence smoking cessation. According to CDC, over 40% of adults who smoke do not receive advice to quit from a healthcare professional, and fewer than 10% successfully quit each year. The Great American Smokeout serves as a timely prompt to engage patients in meaningful conversations about quitting.

The 5 A’s Model: A Brief, Evidence-Based Intervention

The 5 A’s framework offers a structured, efficient approach for providers to support smoking cessation during routine visits:

• Ask – Identify and document tobacco use status at every visit.
• Advise – Strongly urge every tobacco user to quit in a clear, personalized manner.
• Assess – Determine the patient’s readiness to quit.
• Assist – Provide counseling, recommend pharmacotherapy, and refer to quit lines or behavioral support.
• Arrange – Schedule follow-up contact to reinforce the quit attempt and address challenges.

Integrating Smoking Cessation into COPD Management

For patients with COPD, smoking cessation is not optional, it’s essential. The 2024 GOLD Report emphasizes that quitting smoking can significantly reduce symptoms, slow decline in lung function, and improve survival. Providers should:

• Incorporate tobacco use screening as a vital sign.
• Use the 5 A’s model during COPD visits to reinforce cessation.
• Prescribe appropriate cessation medications (e.g., varenicline, nicotine replacement therapy).
• Refer to pulmonary rehabilitation and quit lines for additional support.
• Educate patients on inhaler technique and adherence, which can be compromised by ongoing smoking.

Conclusion

The Great American Smokeout is more than a symbolic event—it’s a strategic opportunity for providers to initiate change. By combining this national momentum with the proven 5 A’s model, primary care teams can make a measurable impact on smoking cessation and COPD outcomes. Let’s use this moment to empower our patients toward a smoke-free future.

For more information, visit:

NY Smoke Free

Treating Tobacco Use and Dependence  - Five Major Steps to Intervention

Great American Smokeout and CDC: Make Today your Quit Day!

NYS Quit Help 

As part of our ongoing efforts to ensure consistency and compliance, Independent Health aligns our policies with applicable National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and New York State (NYS) guidelines wherever possible.

Independent Health will make the following changes to our claims editing processes for the following, beginning with dates of service of February 1, 2026 and on:

NCD - Lipid Testing (190.23)

• Deny Lipid panel/testing when billed without a covered diagnosis.
• This applies to all lines of business

NCD - Prostate Specific Antigen (190.31)

• Deny Gonadotropin, chorionic; quantitative when billed without a covered diagnosis.
• This applies to all lines of business

New York State Department of Health Medicaid (NYS) guidelines- Laboratory-Pathology: Microbiology

• Apply a 50% reduction to the subsequent Hepatitis B tests when two or more Hepatitis B tests are billed in combination.
• This applies to State Programs only.

As a reminder, please regularly check the Coding & Documentation Resources section under the Coding tab in the provider portal for updates. 

As the market leader for Medicare Advantage in Western New York and the area’s consistent top-rated plan, Independent Health is committed to offering a choice of Medicare Advantage plans with comprehensive coverage and benefits.  

We are making our members aware that Roswell Park Comprehensive Cancer Center and its community network practices will not participate with Independent Health’s individual Medicare Advantage plans starting January 1, 2026, which are:  

• Encompass 65 Red 042 HMO
• Encompass 65 Red 043 HMO
• Encompass 65 Red 044 HMO
• Encompass 65 HMO without prescription coverage
• Medicare Passport Connect PPO
• Medicare Family Choice HMO I-SNP plan
• Assure Advantage HMO C-SNP plan 

While Roswell Park and its community network practices will not be in-network participating providers for the above plans, they will remain participating with all other lines of business. This includes our Group Medicare plans, as well as Commercial (large group, small group, non-Medicare individual products), State Programs (e.g., MediSource) and Self-funded plans. 

To assure our members they will continue to have access to in-network oncology services, we are advising our members that our in-network oncology providers include Buffalo Medical Group, Catholic Health, Great Lakes Cancer Care Collaborative (which covers ECMC, Kaleida/General Physicians Practice Plan, UBMD, WNY Urology, and Windsong), and Wilmot Cancer Institute (at Strong Memorial Hospital).

Other updates: Medicare Annual Enrollment Period

The 2026 Medicare Annual Enrollment Period occurs Oct. 15 through Dec. 7, which is the time for Medicare beneficiaries to consider their plan options for the coming year.  Our 2026 plan options for individuals are available on our website. Your patients may have questions about the following:

• Formularies: For 2026, our individual Medicare Advantage plans will include either a standard or enhanced formulary. The formularies are posted online for your reference.
• Tiered Network: While all of our 2026 individual Medicare Advantage plans include a tiered provider network cost share for some medical services, participating hospitals and providers with our individual Medicare plans will be in Tier A for 2026, at the lower cost share. There are no providers or hospitals in Tier B at this time.

We have informed relevant providers directly by secure message about upcoming prior authorization requirements and policy changes that will go into effect in the upcoming months. For reference, these changes are summarized below:

• Prior authorization for radiation oncology: Effective November 1, for services on or after that date, Evolent will provide management services for the following radiation oncology therapy treatments on our commercial and Medicare lines of business for members aged 18 and older for primary and metastatic cancers being treated with:  Low-dose-rate (LDR) Brachytherapy, High-dose-rate (HDR) Brachytherapy, Image Guided Radiation Therapy (IGRT), Intensity Modulated Radiation Therapy (IMRT), Proton Beam Radiation Therapy (PBT), Three-dimensional Conformal Radiation Therapy (3D-CRT), Two-dimensional Conventional Radiation Therapy (2D), Stereotactic Radiosurgery (SRS), Stereotactic Body Radiation Therapy (SBRT). This prior authorization program does not include our State Programs or Self-funded products. More information is available here.  

Flu Shot Campaign

This campaign will encourage adult members to receive a flu vaccine this season.  Practices are also encouraged to further reinforce the importance of the flu vaccine with their patients.

• Target Population: Adult members in Commercial, State Programs, and Medicare lines of business
• Outreach method: Email and digital correspondence
• Timeframe: September 2025 to January 2026

Metabolic Monitoring for Children and Adolescents on Antipsychotics

The Independent Health Behavioral Health and Pediatric Case Management departments will outreach to parents or guardians of members under the age of 13 who have been prescribed an antipsychotic medication but have not received metabolic monitoring (glucose and cholesterol testing). The Case Manager will provide the parent/guardian with education on the importance of metabolic screening for the child and encourage follow-up conversation with the provider regarding testing.

• Outreach method: Outbound telephone call campaign
• Target members: Commercial and Medicaid managed care members under the age of 13 who are prescribed antipsychotics and have not received metabolic monitoring (glucose and cholesterol testing).
• Timeframe: September to November 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 campaign will encourage Essential Plan members to complete a health-related social needs screening as well as provide referral information for community resources 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 Member Success Team will outreach telephonically to Medicare members who fall into the Osteoporosis Management in Women Who Had a Fracture (OMW) measure. The Member Success Team will contact members to provide education on the importance of getting screened for osteoporosis following a fracture and discuss options for gap closure. The option of an in-home heel ultrasound with Stall Senior Medical (SSM) will be discussed. If the member is interested, The Member Success Team 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 Member Success Team 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 prescription 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. 

Drug Formulary Changes

View the formulary deletions, effective November 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. Log in to 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.

Independent Health Medicare HMO plans rated 5 out of 5 Stars  - October 21, 2025

All of Independent Health’s Medicare HMO plans have received the highest possible rating – 5-Stars –  by the Centers for Medicare and Medicaid Services (CMS) for 2026. The Williamsville-based company is the only insurer in Western New York, and one of only 18 plans nationally, to offer a 5-Star Medicare Advantage plan in 2026.