SCRIPT | Pharmacy Update

Summary of the most significant changes impacting pharmacies

New: Medicare Prescription Payment Plan for Part D covered drugs
Starting in January, Medicare members will have the option to pay $0 at point of sale for their Part D covered drug(s) by enrolling in a payment plan. The new program is anticipated to roll out as follows:

• The pharmacy will be PAID IN FULL by the plan.
• The plan will bill a monthly invoice to the member.
• For members who enroll in the plan, two transactions will happen at the pharmacy:
  1. Pharmacy submits the initial Part D claim.
  2. After this submission, the pharmacy receives a response from the plan which will include instructions for submitting the second transaction.
• All Part D claims that cost the member $600 or more out of pocket will require the pharmacy to provide a “likely to benefit” notification in most cases at the point of sale.
  • Exceptions include members who have already opted in to the Medicare Prescription Payment Plan, ITU Pharmacies, or claims in the month of December.
• The pharmacy will be provided a model template from CMS to give to Medicare members for these claims and will be notified with a new NCPDP code.

Part D Redesign: No more donut hole
The Medicare Part D plan structure is changing for 2025. There is NO MORE donut hole for Medicare members. Members will go through only three phases of coverage:

• Deductible Phase: member pays 100% of the cost-share up to the deductible amount.
• Initial Phase: member pays the cost-share associated with the drug coverage tier up until the $2,000 out of pocket max is reached.
• Catastrophic Coverage Phase: all drug costs are $0 for the member for the remainder of the plan year.

As we learn more about these changes and further enhance our processes to manage the changes, we will continue to communicate with our pharmacy partners. Thank you for your continued hard work to care for our members. 

Initiatives to increase access to diabetes and maternity care

Beginning January 1, the following changes will be in place in the state of New York:

• Reduction of copays to $0 for most Commercial and Essential Plan members to increase access to insulin
• Reduction of diabetic treatment copays to $0 for some Commercial and Essential plan members to increase access to diabetic care
• Elimination of cost-shares for most services for some Commercial and Essential members during pregnancy and postpartum to expand prenatal and pregnancy care

We will continue to watch for and communicate changes at the state level for the upcoming year.

Limiting Risky Medication Combinations in Older Adults

What to look for to keep patients safe

Anticholinergic Agents

Anticholinergics have consistently appeared on the Beers Criteria as potentially inappropriate medications for older adults due to their heightened sensitivity to side effects from these medications. These adverse effects include tachycardia, urinary retention, constipation, dry mouth, blurred vision, exacerbation of narrow-angle glaucoma, cognitive impairment, psychomotor slowing, confusion, sedation, and delirium.

Current guidelines advise avoiding the concurrent use of two or more anticholinergic drugs due to the elevated risk of these side effects, particularly cognitive decline (such as delirium, dementia, and cognitive impairment). The longer these medications are used, the greater the associated risk.

To promote safer prescribing, limit anticholinergic medication use in individuals over 65 and consider deprescribing when feasible. When an anticholinergic drug is necessary, recommend using the lowest effective dose for the shortest duration and regularly reassessing its benefit. Additionally, explore alternative agents with lower anticholinergic activity to minimize or eliminate the anticholinergic burden.

Below is a list of alternatives for reference:

Opioids & Benzodiazepines

Simultaneous use of opioids and benzodiazepines raises the risk of potentially fatal severe respiratory depression or overdose. According to the 2023 Geriatric Beers Criteria, healthcare providers should avoid prescribing opioid pain medications and benzodiazepines together whenever possible, except when patient circumstances necessitate appropriate concurrent use (e.g., severe acute pain in a patient on long-term, stable low-dose benzodiazepine therapy).

For chronic pain management, non-pharmacologic options include acupuncture, chiropractic care, cold and heat therapy, exercise, movement, massages, occupational therapy, physical therapy, rehabilitation therapy, and high-tech treatments using radio waves and electrical signals.

Cognitive behavioral therapy has demonstrated effectiveness in treating depression, anxiety, stress, and chronic pain. For safer alternatives for anxiety treatment, consider escitalopram, venlafaxine, duloxetine, or buspirone.

The CDC recommends tapering opioid medications before tapering benzodiazepines due to the higher risks associated with benzodiazepine withdrawal compared to opioid withdrawal.

Helpful link: https://deprescribing.org/resources/deprescribing-guidelines-algorithms/

Up-to-date list of GLP-1s covered only with a type 2 diabetes diagnosis

Independent Health continues to closely review claims to ensure appropriate medication use of glucagon-like peptide-1 (GLP-1) receptor agonists for glucose control. In addition, our team updates diagnosis codes monthly of members identified with type 2 diabetes through medical claims.

While GLP-1s are FDA-approved for both type 2 diabetes management and the treatment of obesity, these agents are only covered without restrictions for patients with type 2 diabetes.

Therefore, submission of a valid diagnosis code is required for coverage of the following GLP-1 agonists: Ozempic, Mounjaro, Rybelsus, Trulicity, Victoza, Byetta, and Bydureon. Note: Byetta and Bydureon are non-formulary and require prior authorization.

To correctly process non-Medicare claims:

• Pharmacies are required to enter a type 2 diagnosis code (E11) for members who Independent Health could not proactively verify. You must document and verify the diagnosis with the prescriber before submitting.

• Independent Health will recover on claims inappropriately coded. If selected for audit, documents from your pharmacy records will be requested to confirm the diagnosis as submitted on the claim.
  

GLP-1 coverage for Medicare members:

• Effective January 1, 2024, Independent Health requires Step Therapy through drugs that treat type 2 diabetes for all Medicare Advantage members. New starts must go through the step therapy requirements. If a new start does not meet the step, a coverage determination will need to be submitted.

• As a reminder, Centers for Medicare & Medicaid Services (CMS) excludes all medications used for weight loss and does not allow coverage for drugs like Zepbound, Wegovy, and Saxenda.
  • The GLP-1s not indicated for weight loss, such as Ozempic and Mounjaro, should not be prescribed for this purpose alone.

Lastly, it is important to confirm the diagnosis with the prescriber entered with each medication fill and remove any codes that have not been verified by the prescriber. Inappropriate diagnosis codes submitted on the original claim can carry over to subsequent refills on the same prescription.

Please call the Pharmacy Help Desk at (716) 631-2927 or 1-800-993-9898 if you have questions.

Find the Pharmacy Manual, payer sheets by BIN number, billing guidance, and more by logging in to our secure provider portal.

Need help logging in? Email us.

Second quarter changes are available for review in PDF. We encourage you to open and download them, as they contain important information and updates.

• Policy changes for the Second Quarter of 2024 are summarized here.
• Formulary changes for the Second Quarter of 2024 are summarized here.

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

Independent Health's Drug Formularies

Access Independent Health's drug formularies here.

If you have any questions regarding information in this issue, please call our Pharmacy Help Desk at (716) 631-2927 or 1-800-993-9898, Monday through Sunday from 7 a.m. to 11 p.m.

Thank you for your continued care of our community.