Clinical Connections: December 2024

Clinical Connections: December 2024

Dear Colleagues,

I wanted to take a moment to introduce myself to our clinical partners. My name is Dr. Kiran Biring, I am WHAs Chief Pharmacy Officer, this role is designed to help support our members and providers navigate the complex area of pharmaceuticals. One key area of focus for us over the next several years is operational excellence, and we are focused on making some great enhancements in 2025. 

As such, I am proud to announce that WHA will be launching electronic prior authorization (ePA) through CoverMyMeds by January 1st, 2025. WHA will now be integrated in that system to allow your teams greater ease and improved efficiencies as they submit requests through that service.

We appreciate the partnership and want to wish each of you a very Happy and Healthy Holiday Season.

Dr. Kiran Biring, PharmD., RPh, MPH, BS
Chief Pharmacy Officer,
Western Health Advantage
 

WHA NEWS 

WHA is enhancing our formularies to the new Premium and Essential Health Benefits (EHB) formularies. This update will allow you and your team access to the latest pharmaceutical products, prescription options and utilization management information. Updated formularies and criteria will be posted on our website for review, or you can always call and request copies through our member services contact center.

If your patients are currently taking appropriately prescribed medication and you believe this is the right treatment for the patient, your patient may remain on this medication, in accordance with state law. However, the medication may be subject to placement on a different tier resulting in a change in cost sharing. Please refer to your annual partner update for any additional information or reach out to Dr. Kiran Biring (k.biring@westernhealth.com)

PHARMACY UPDATE

Class 1 Drug Recall Notice

Western Health Advantage (WHA) is committed to ensuring our members and providers have access to FDA-issued Class 1 drug recall and withdrawal information.

On 11/19/2024, Endo announced an expansion of a consumer level recall to now include 16 lots of clonazepam ODT tablets because of potential product carton strength mislabeling. A drug recall notification was mailed to 4 potentially affected WHA members and their providers on 12/03/2024. 

• For more information on this and other recent FDA Class 1 recalls, including a list of affected NDCs,  visit WHA’s Drug Recalls and Withdrawals webpage.

HEDIS UPDATES

Controlling High Blood Pressure

Healthcare providers can help individuals manage their high blood pressure by prescribing medications, encouraging low-sodium diets, increased physical activity and smoking cessation. (Read more) 

Comprehensive Diabetes Care 

Healthcare providers can help individuals address their diabetes by managing their high blood glucose (blood sugar) with self-care, taking medications as instructed, eating a healthy diet, being physically active and quitting smoking. (Read more)

Well-Women’s Health Screening

Early detection reduces the risk of dying from breast and cervical cancer leading to a greater range of treatment options, lower health care costs and significant reduction in death rates. Chlamydia is the most commonly reported bacterial sexually transmitted disease in the United States. Untreated chlamydia infections can lead to serious and irreversible complications. (Read more)

Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

AOD dependence in the primary care setting is an increasing concern. The early recognition of patients with AOD issues and timely referral to behavioral health services promotes the most effective treatment. Treatment, including MAT, in conjunction with counseling or other behavioral therapies has shown to reduce AOD-associated morbidity and mortality, improve health, productivity and social outcomes and reduce health care spending. (Read more) 

Additional HEDIS Information

UTILIZATION MANAGEMENT UPDATE 

ADVANTAGE REFERAL PROGRAM AT WHA - Important things for you to know 

The Advantage Referral Program was developed by WHA to allow members access to any appropriate participating specialist within the Plan’s network rather than limiting their choice to a specialist within their PCP’s medical group/IPA. For example, if a Mercy Medical Group PCP determines that a patient needs to see a specialist, the member may see any WHA network specialist through WHA’s Advantage Referral Program, regardless of group affiliation. 

Please be on the lookout for this information in the 2025 Provider Manual and an updated version of the Advantage Referral Handbook. Both will provide further details regarding the Advantage Referral Program. For now, you can refer to the Provider Manual, along with the most current version of the Advantage Referral Program Handbook. Both links will be updated in 2025 to reflect any revisions.