August 2023

As access and utilization to biologic drugs increase, there are opportunities to offer value and access through biosimilars. 

Innovation and technology in pharmaceuticals help to improve individuals’ health status and outcomes; however, the results come at a significant cost. Indeed, the cost of prescription drugs continue to surge, driven largely by the increase in unit costs and utilization of high-cost specialty drugs, along with annual drug price increases by pharmaceutical companies.

In fact, prescription drug costs consumed 28 percent of Independent Health’s premium dollar in 2022 and now accounts for the largest portion of our member’s premium. Nearly 45% of our total drug spend can be attributed to specialty drug utilization.

As part of our goal to maintain access, quality and safety in our pharmacy benefits, we ask prescribers to consider using biosimilar medications, which have the same expected benefits and risks as their reference products, when it is appropriate for the individual patient. In addition to biosimilars’ efficacy, they can provide several thousand dollars in savings per prescription.

Please see this reference document from the U.S. Food & Drug Administration regarding biosimilars, how they compare to their reference products, and other helpful information.  

Western New York Integrated Care Collaborative coordinates meal delivery for Independent Health's Medicare Advantage members.

In an effort to help patients maintain a healthy diet and support your long-term care plans, several of our Medicare Advantage plans cover  Home Meal Delivery of up to 14 consecutive days, up to 28 total meals, after an inpatient hospital or skilled nursing facility stay.

The plans are:

• Independent Health’s Assure Advantage HMO C-SNP
• Independent Health’s Encompass 65 Basic HMO
• Independent Health’s Encompass 65 Core HMO
• Independent Health’s Encompass 65 HMO without prescription coverage

Meal delivery may be coordinated through a discharge planner at the facility, through a healthcare provider referral, or via patient/family call to Independent Health’s Member Services. Meals must be delivered within the eight counties of Western New York.  

Together with your patient and through the referral process you can choose delivery options (fresh/frozen), days of the week, and dietary restrictions. All meals are approved by a Registered Dietitian, meet the Recommended Dietary Allowance (RDA) for nutrients and considered low salt and low fat.  

You may begin the referral process managed through Western New York Integrated Care Collaborative (WNYICC) by downloading the enrollment form here, or by filling out this online form.

*** In addition to the post-discharge meal delivery offering, Assure Advantage will cover an additional round of home meal delivery (up to 14 consecutive days, up to 28 total meals) to be used at any time during the year (once per year) to ensure convenient access to healthy meals.

This is a great opportunity for care managers to explore as patients transition home and Transitional Care Management visits are scheduled. Please share this information with your teams and consider adding this topic to an upcoming practice meeting agenda for further awareness.

Additional information regarding Home Meal Delivery and other Medicare Wellness Benefits is available on Independent Health’s website.

Throughout the year, the Health Care Services and Population Health Management Departments deploy various tactics to encourage members to take a more active role in their health.

During the month of August, Independent Health will be conducting the following member engagement/outreach campaigns:

Osteoporosis Management for Women Who Had a Fracture Campaign

This campaign engages women over the age of 65 years who have had a recent fracture with the goal of completing a bone density test within 6 months following the date of fracture.  Currently, Stall Senior Medical provides outreach to identified members to schedule an in-home heel scan appointment. 

As an additional member nudge, the Independent Health Case Management team will call members to provide education and encourage members to either schedule an in-home heel scan appointment with Stall Senior Medical or outreach to their provider for a heel scan script. 

• Outreach method: Outbound telephone call campaign
• Targeted Members: Women over the age of 65 years with a recent fracture- Medicare members only
• Timeframe: Campaign began on July 17 and will continue through August

Colorectal Cancer Screening Reminder Campaign

This telephonic outreach campaign will engage members who are overdue for a colorectal cancer screening.  The purpose of the call is to provide education around the importance of colon cancer screening, address member barriers to screening, and encourage the member to follow through on screening orders received from their provider.  Members that do not have an order for a colon cancer screening test will be encouraged to have a conversation with their provider regarding screening.

• Outreach method: Outbound telephone call campaign
• Target members: Commercial, Medicare, and Medicaid members who are overdue for a colorectal cancer screening
• Timeframe: August – September 2023

Metabolic Monitoring for Children and Adolescents on Antipsychotics

The Independent Health Pediatric Case Management department 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: Medicaid members under the age of 13 who are prescribed antipsychotics and have not received metabolic monitoring (glucose and cholesterol testing).
• Timeframe: August 2023

Social Determinants of Health Screening

This telephonic outreach campaign will engage Essential Plan members in a conversation around screening for social determinants of health to identify any needs the member has for things such as food, housing, and transportation.   If a need is identified, Independent Health will assist the member in making a connection to a community resource to address the need. 

• Outreach method: Outbound telephone call campaign
• Target members: Essential Plan members
• Timeframe: August – September 2023

Diabetes Prevention Program Education Campaign

Through a series of member emails and outbound telephonic engagement, this campaign will provide commercial members with prediabetes education around the benefits of enrolling in a Diabetes Prevention Program and will address member questions regarding the program.

• Outreach method: Series of two member emails followed by outbound telephone call campaign
• Target members: Commercial members with prediabetes residing in underserved zip codes
• Timeframe: End of July – August 2023

Breast Cancer Screening Reminder Campaign

This campaign will target women ages 50 to 74 within the Medicaid line of business who are overdue for a mammogram. The goal of this telephonic outreach campaign is to maximize mammography participation. Education around the benefits of receiving a mammogram, as well as information regarding how to address any barriers, and how to follow through with their provider’s orders will be discussed. Members that do not have an order for a mammogram will be encouraged to have a conversation with their provider.

• Outreach method: Outbound telephone call campaign
• Target members: Women ages 50 to 74 who are overdue for a mammogram- Medicaid members only
• Timeframe: August – September 2023

Unnecessary expedited requests may impact turnaround times for true expedited needs.

National Imaging Associates (NIA) continues to receive higher-than-expected volume of Expedited Urgent Requests for Authorization.

This is a concern, as some of the expedited requests do not meet the criteria for this type of review, which can impact turnaround times for true expedited needs.

Please make sure to inform your office staff to use an expedited request for authorization only if the request is clinically urgent and the member’s life, health, or ability to regain maximum function would be placed in serious jeopardy if the request is not processed within 72 hours.

When submitting an expedited/urgent authorization request, please be prepared to provide clinical details that would justify an expedited review:

• Symptoms and their duration
• Physical exam findings
• Treatments or procedures already completed

Submit your expedited/urgent requests via RadMD.com or by calling NIA/Magellan at 1-800-642-7452.

If the case does not meet one of these criteria, then please initiate it as a standard (not expedited) request.

The following documents are available in PDF. We encourage you to open and download them, as they contain important information and updates:

• Medicare Advantage formulary changes for individual and group members effective August 1, 2023.
  
• Pharmacy Benefit Dimensions 5-Tier formulary changes effective August 1, 2023.
• Pharmacy Benefit Dimensions 3-Tier formulary changes effective August 1, 2023.

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.

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