Showing Up Where It Matters Most | News and Featured | Compliance | Pharmacy Update | Member Update | Doc Talk | Behavior Health
Showing Up Where It Matters Most by Tasnim Khan, MD. Chief Medical Officer
One of the most important questions we often ask ourselves at Western Health Advantage– and one we think is worth sharing– is this: “Where does health care truly matter most?”
We believe the answer isn’t found in numbers, charts or computer programs. It’s found in the quiet courage of the people we serve. It’s in the quiet strength of a family trying to manage rising health costs or in how they navigate the complex landscape of healthcare. It’s in a doctor or provider who shows up every day, despite the administrative challenges, because they still care.
At WHA, we choose to show up where it matters most. That means working hard to make care more personal, more local and easier to access. It means we’re expanding mental health support, applying the latest science to guide better care, and standing behind the local providers and doctors who know our communities best.
We also recognize that health care can feel confusing– especially when approvals, medications, or coverage rules become barriers. When that happens, we step in and focus on how we can make the path clearer while paying attention to the care that is proven best for our members. For us at WHA, every approval, every benefit, every clinical decision is a human story.
Health care isn’t just about doing more. It’s about doing what matters– and doing it with heart. That’s why we don’t just think of ourselves as a health plan. We are a human plan- and we believe connection with you is a form of care.
NEWS AND FEATURED
Biannual formulary reviews are conducted to ensure member access to clinically effective and cost-efficient therapies. These updates may affect medication coverage, tiering, and preferred products, including the adoption of biosimilar alternatives. Formulary changes may occur monthly – WHA keeps you up-to-date on such changes through our publication called Pharmacy Passages.
COMPLIANCE
Provider Appointment Availability Survey (PAAS)
Each year, WHA is required by the Department of Managed Health Care (DMHC) to survey our network of contracted providers to measure enrollee access to timely appointments for urgent and non-urgent care. The specific appointment wait time standards are set forth in section Health and Safety Code 1367.03(a)(5) and Rule 1300.67.2.2(c)(5). You can view these standards at Access and Availability.
The PAAS process runs from July through December 2025 and will randomly sample primary care, specialists, and ancillary care providers. WHA greatly appreciates the participation of its contracted Medical Groups/IPAs.
WHA has contracted with QMetrics to validate provider data and administer the PAAS on our behalf. Please let your office staff know that if they receive communications from QMetrics, it is vitally important to respond. Be on the looking for such communications and further PAAS information and instructions.
PHARMACY UPDATE
Biannual Formulary Changes & Biosimilar Guidance
Effective: July 1, 2025
Key Updates:
- Exclusion of brand products with generics available
- Addition or revision of quantity limits (QL) and step therapy (ST)
- Biosimilar(s) are preferred over reference biologics
Biosimilar Transition Highlights:
- Stelara is replaced by Yesintek as the preferred agent. Stelara is excluded from both formularies.
- Humira by Abbvie and Amjevita by Nuvalia (NDC:84612-XXXX-XX) are preferred agents. All other biosimilars are excluded on the formularies.
- Optum Specialty Pharmacy will transition members to preferred agents automatically
- FDA-approved biosimilars are considered safe, effective, and interchangeable where applicable
- Coverage of reference products or biosimilars will require prior authorization (PA) with supporting clinical documentation
What Providers Should Do:
- Select the plan/formulary that matches the member’s benefits:
- Premium: Large and small employer group plans
- Essential Health Benefits (EHB): Covered California, individual, and family plan
- Federal Employees Health Benefits (FEHB): Federal employees and their families
- Search for the medication you would like to find. This resource will tell you if a drug is covered or not and what restrictions may apply such as PA, ST, or QL
2. Prescribe Preferred Products – Prevent treatment delays by aligning with the updated formulary
3. Educate Your Patients – Support patient’s understanding and confidence in biosimilars
4. Continuity of Care – If the member is taking an appropriately prescribed medication and you continue to prescribe the medication, the member may remain on the medication, in accordance with California state law. However, the medication may be put on a different tier resulting in a change to cost sharing. Please submit relevant clinical documentation via the PA process for review.
Support & Resources:
Pharmacy Support Contact: pharmacy@westernhealth.com
MEMBER CONTENT
Calm Health App Now Available to WHA Members at No Added Cost
Western Health Advantage is proud to offer Calm Health—the #1 app for meditation, sleep, and relaxation—to all members at no additional cost. With mental well-being playing a critical role in overall health, Calm Health provides evidence-based self-management tools to reduce stress, improve sleep, and support emotional resilience. Members gain unlimited access to guided meditations, Sleep Stories, mindfulness programs, breathing exercises, gentle movement videos, and more—all easily accessible via smartphone, tablet, or desktop.
This new benefit offered through Optum Behavioral Health aligns with our ongoing commitment to whole-person care, especially as more patients seek out digital tools to manage stress and anxiety. We encourage you to recommend Calm Health to patients who may benefit from additional support with sleep, focus, or emotional regulation.
To activate the benefit, members can log into their WHA member account and follow the instructions to link their Calm Health subscription. No claims process or referral is required.
If you’d like patient-facing materials, please contact your WHA provider liaison.
DOC TALK
Why 45 Is the New Starting Point for Colorectal Cancer Screening
An interview with Dr. Tasnim Khan, Chief Medical Officer, Western Health Advantage
Dr. Khan, why has the recommended starting age for colorectal cancer screening changed?
For years, age 50 was the standard. But in recent years, we’ve seen a sharp rise in colorectal cancer among younger adults. In fact, the rate of colorectal cancer in adults under 50 has more than doubled in the past 15 years. As a result, national guidelines now recommend starting at 45. The earlier we screen, the better chance we have to detect cancer early — or even prevent it entirely.
Many people in their 40s feel healthy. Is it hard to convince them to get screened?
That’s very common. People in their mid-40s are often busy raising families, building careers, and managing life. They feel fine and don’t see an urgent reason to screen. But that’s exactly why we need to have these conversations now — before symptoms appear. Screening is about staying ahead of potential problems, not waiting until something feels wrong.
Does screening always mean a colonoscopy?
Not at all. While colonoscopy remains the gold standard, there are excellent non-invasive options like FIT kits or stool DNA tests that can be done easily at home. These are highly effective first steps for many people. If results show something concerning, that’s when we move to further testing.
What is Western Health Advantage doing to support members with screening?
We’re proactively identifying members who are due for screening and reaching out directly. We’re partnering with providers to close care gaps and investing in data tools, member incentives, and personalized reminders. But ultimately, the decision rests with each individual — and a conversation with their doctor is often the most powerful motivator.
What’s your message to members who might be putting this off?
If you’re 45 or older, don’t wait. Schedule your screening. Start the conversation with your doctor. Preventive care works best when we take action early. A simple screening today could save your life tomorrow.
BEHAVIORAL HEALTH
Prioritizing Maternal Mental Health: Depression Screenings During Pregnancy
Depression is one of the most common complications of pregnancy, affecting up to 1 in 7 individuals. Early identification through routine screening is a critical step in safeguarding both maternal and infant health. The U.S. Preventive Services Task Force recommends depression screening for all pregnant and postpartum individuals using validated tools such as the Edinburgh Postnatal Depression Scale (EPDS) or PHQ-9.
And, beginning 1/1/2025, per CA Health & Safety Code § 1367.625, mental health screenings must be done at least once during pregnancy, once within 6 weeks of postpartum, and additional postpartum screenings if deemed medical necessary. Mental health screenings are intended to screen for any behavioral health condition that occurs during pregnancy and postpartum, and are not limited to post-partum depression. These screenings can be completed by an obstetrician, other medical provider, or a behavioral health clinician. Depression screenings, in particular, are measured by HEDIS. Therefore, the proper codes must be used to capture the screening tool and score, and the follow-up within 30 days for a positive depression screening.
Addressing mental health is integral to whole-person care. Western Health Advantage encourages all providers to incorporate perinatal depression screenings into routine prenatal visits to improve the health our of members, and to comply with state regulations.
Together, we can help normalize mental health conversations during pregnancy and ensure better outcomes for families.
Learn more: New state regulations require at least one mental health screening during pregnancy and postpartum
If you need support accessing behavioral health resources or want help connecting patients to services, WHA’s provider support team is here to assist.
Last review date: August 13, 2025