The following Medical, Pharmacy and Formulary Policy updates below were made in the last quarter. Further details can be found by signing into your Provider Online Account.
All policies are reviewed at least once annually.
-
January 2023 Pharmacy Policy Updates
Published January 2023
Below is a recap of the Pharmacy and Formulary updates that went into effect from April1 to June 1, 2022. All policies are reviewed at least once annually. For more detailed information on these changes, please review updates at mvphealthcare.com/FastFax.
EFFECTIVE DECEMBER 1, 2022
PHARMACEUTICAL POLICY NAME
STATUS Crohn’s Disease, Select Agents
Archived
Inflammatory Biologic Drug Therapy Archived Ulcerative Colitis Archived Infliximab
Updated Ustekinumab New Policy Proton Pump Inhibitor Therapy Updated Colony Stimulating Factors
Reviewed Mulpleta/Doptelet
Reviewed Erythropoiesis Stimulating Agents
Reviewed Hereditary Angioedema
Reviewed Irritable Bowel Syndrome
Updated Gaucher Disease Type 1 Treatment
Updated Select Chelating Agents
Updated Hemophilia Factor
Reviewed Adakveo
Updated Dojolvi
Updated Intestinal Antibiotics
Updated Pharmacy Management Programs-External – EFFECTIVE 9/1/2022
Updated Medicare Part D Coverage Determination and Exception Policy
Updated Transthyretin Mediated Amyloidosis
Updated Spravato – EFFECTIVE 8/11/2022
Updated Ankylosing Spondylitis
Archived Rheumatoid Arthritis Archived Psoriasis Drug Therapy
Archived Psoriatic Arthritis Drug Therapy
Archived Rinvoq
Archived Ozanimod
New Policy Upadacitinib
New Policy Secukinumab
New Policy Etanercept
New Policy Adalimumab
New Policy Apremilast
New Policy Risankizumab
New Policy Tocacitinib
New Policy Guselkumab
New Policy Growth Hormone Therapy
Updated Doryx/Oracea Archived Zynteglo
New Policy Skysona New Policy Colony Stimulating Factors
Updated
EFFECTIVE JANUARY 1, 2023PHARMACEUTICAL POLICY NAME
STATUS Prostate Cancer
Reviewed GABA Receptor Modulators
Updated Movement Disorders
Reviewed Botulinum Toxin Treatment
Updated Respiratory Syncytial Virus/Synagis
Updated Select Hypnotics
Reviewed Immunoglobulin Therapy
Updated Gabapentin ER
Reviewed Multiple Sclerosis Agents
Reviewed Nuedexta
Reviewed Spinal Muscular Atrophy
Updated Oral Allergen Immunotherapy Medications
Reviewed Agents for Female Sexual Dysfunction
Updated GLP-1 Receptor Agonists
New Policy CAR-T Therapy
Updated Radicava Updated Zulresso Updated Select Oral Antipsychotics Reviewed Palforzia Updated EFFECTIVE FEBRUARY 1, 2023
PHARMACEUTICAL POLICY NAME STATUS Hepatitis C Treatment Commercial, Marketplace, Child Health Plus Updated Hepatitis C Treatment Medicaid
Updated Lyme Disease/IV Antibiotic Treatment
Updated Antibiotic/Antiviral (oral prophylaxis)
Reviewed Compounded (Extemporaneous) Medications
Reviewed Government Programs Over-the Counter (OTC) Drug Coverage
Updated Preventive Services- Medication
Updated Zinplava
Reviewed Enteral Therapy- NY – EFFECTIVE 02/02/2023
Updated -
January 2023 Formulary Updates
Published January 2023
COMMERCIAL, MARKETPLACE, AND MEDICAID FORMULARIES
New Drugs (recently FDA approved, prior authorization required, Tier 3, non-formulary for MVP Medicaid)
DRUG NAME
INDICATION
Amvuttra™
(vutrisiran)
The treatment of the polyneuropathy of hereditary transthyretin mediated amyloidosis in adults
Vivjoa™
(oteseconazole)
The reduction of incidence of recurrent vulvovaginal candidiasis (RVVC) in females with a history of RVVC who are not of reproductive potential
DRUG NAME
INDICATION
Amvuttra™
(vutrisiran)
The treatment of the polyneuropathy of hereditary transthyretin mediated amyloidosis in adults
Vivjoa™
(oteseconazole)
The reduction of incidence of recurrent vulvovaginal candidiasis (RVVC) in females with a history of RVVC who are not of reproductive potential
Aspruzyo™
(ranolazine)The treatment of chronic angina Tascenso ODT™
(fingolimod)The treatment of relapsing forms of multiple sclerosis, to include clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease, in patients aged 10 to 17 years and weighing up to 40 kg Entadfi™
(finasteride/tadalafil)
Treatment of the signs and symptoms of benign prostatic hyperplasia in men with an enlarged prostate for up to 26 weeks. Use not recommended for >26 weeks because the incremental benefit of tadalafil decreases from four weeks until 26 weeks, and the incremental benefit beyond 26 weeks is unknown Zoryve™
(roflumilast)
The treatment of plaque psoriasis in patients aged two years and older Zynteglo®
(betibeglogene autotemcel)
The treatment of beta-thalassemia in patients who require regular red blood cell transfusions Spevigo® (spesolimab)
The treatment of generalized pustular psoriasis flares
Xenpozyme™ (olipudase alfa) The treatment of non-central nervous system manifestations of acid sphingomyelinase deficiency (also known as Niemann-Pick disease) in adult and pediatric patients Sotyktu™ (deucravacitinib)
The treatment of moderate-to-severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy
Skysona (elivaldogene autotemcel)
The treatment of cerebral adrenoleukodystrophy in males aged 17 years and younger
Ryaltris® (mometasone/ olopatadine)
The treatment of seasonal allergic rhinitis in patients aged 12 years and older
Pheburane®
(sodium phenylbutyrate)
Adjunctive therapy to diet, for the chronic management of urea cycle disorders involving deficiencies of carbamyl phosphate synthetase, ornithine transcarbamylase or argininosuccinic acid synthetase, in adult and pediatric patients
Tadliq®
(tadalafil)
The treatment of adults with WHO Group one pulmonary arterial hypertension to improve exercise ability
Kyzatrex ™
(testosterone undecanoate)
Testosterone replacement therapy in adult males for conditions associated with deficiency or absence of endogenous testosterone
Cimerli™ (ranibizumab-eqrn)
Treatment of neovascular (wet) age-related macular degeneration (AMD) Biosimilar of Lucentis (ranibizumab)
Relyvrio™
(sodium phenylbutyrate and taurursodiol)The treatment of amyotrophic lateral sclerosis
Auvelity™ (bupropion/dextromethorphan)
The treatment of major depressive disorder in adults
Pedmark® (sodium thiosulfate)
The reduction in risk of ototoxicity associated with cisplatin in patients aged one month through 17 years with localized, non-metastatic, solid tumors
DRUGS REMOVED FROM PRIOR AUTHORIZATION- COMMERCIAL AND EXCHANGE
- Apretude(medical)
- Recorlev
- Pemfexy(medical)
- Kimmtrak(medical)
- Vabysmo(medical)
- Fleqsuvy
- Releuko
- Korsuva(medical)
- Opdualag (medical)
- Fylnetra
- Norliqva
DRUG EXCLUSION
- Leqvio
- Tarpeyo
- Dartisla
- Tezspire(medical)
- Soaanz
- Adbry
- Seglentis
- Cibinqo
- Pyrukynd
- Ibsrela
- Rolvedon(medical)
- Hemady
- Gimoti
NEW GENERICS
NEW GENERICS (all brands will be non-formulary, Tier 3)
BRAND NAME GENERIC NAME COMMERCIAL MEDICAID EXCHANGE Suprep Sodium Sulfate/Potassium Sulfate/MG Sulfate oral solution
Tier 1
Tier 1 (Brand is Tier 2) Tier 2 Vascepa
Icosapent
Tier 1 Tier 1 (Brand is Tier 2)
Tier 2 Tazorac gel
Tazarotene 0.05% gel
Tier 1 Tier 1
Tier 2 K-Phos
Potassium Phosphate Monobasic tablet
Brand to determine Tier 2. Generic to determine tier 1.
Brand to determine Tier 2. Generic to determine tier 1.
Brand to determine Tier 2. Generic to determine tier 2.
Daliresp
Roflumilast
Tier 1
Tier 1
Tier 2
Divigel Gel
Estradiol TD gel
Tier 1
Tier 1
Tier2 Xenical
Orlistat
Tier 1 with quantity limit of 365 days per lifetime
Excluded from coverage
Tier 1 with quantity limit of 365 days per lifetime
MISCELLANEOUS UPDATES
Commercial and Exchange
- Brand Toviaz to move to Tier 3 for Commercial on 01/01/2023
- Add prior authorization to brand Dexilant effective 12/01/2022
- Move Taltz, Cimzia, Kevzara, Zeposia and Orencia to Non-Formulary on 12/01/2022
- Genotropin moves to excluded effective 12/01/2022
- Nutropin moved to preferred Tier 2 effective 12/01/2022
- Brand Amitizia moves to excluded effective 12/01/2022
- Mounjaro moves from excluded to preferred Tier 2 effective 10/01/2022
- Menopur moves from Tier 3 to Tier 2 effective 01/01/2023
- Exclude Sumatriptan 4mg and 6mg injection KITS effective 12/01/2022
- Doxycycline monohydrate 40mg (generic Oracea) and brand Oracea prior authorization removed, and quantity limit added (120 capsules per 365 days) effective 12/01/2022
- BRAND Gilenya to move to Tier 3 effective 12/28/2022
Medicaid
- Move Taltz, Kevzara, and Orencia to Non-Formulary on 12/01/2022
- Exclude Sumatriptan 4mg and 6mg injection KITS effective 12/01/2022
- Doxycycline monohydrate 40mg (generic Oracea) and brand Oracea prior authorization removed, and quantity limit added (120 capsules per 365 days) effective 12/01/2022
- BRAND Gilenya to move to Tier 3/Non-Formulary effective 12/28/2022
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January 2023 Medical Policy Update
Published January 2023
Below is a recap of the Medical Policies that went into effect December and January 2022.All policies are reviewed at least once annually. For more detailed informationon these changes, please review mvphealthcare.com/Fastfax or visit mvphealthcare.com/Providers and Sign In to your account, and select Resources,then Medical Policies.
EFFECTIVE DECEMBER 1, 2022
- Air Medical Transport
- Atrial Fibrillation Ablation, Catheter Based
- Alopecia Treatment
- Bone Density Study for Osteoporosis (Dexa)
- BRCA Testing
- Breast Surgery for Gynecomastia
- Bronchial Thermoplasty
- Cardiac Procedures
- Children’s Family Treatment and Support Services (CFTSS)
- Cosmetic and Reconstructive Services
- Dermabrasion
- Habilitation Services
- Implantable Cardioverter Defibrillators
- Intraoperative Neurophysiologic Monitoring
- Investigational Procedures
- Lymphedema Compression Garments Compression Stockings
- Obstructive Sleep Apnea: Devices
- Oncotype DX and Cancer Gene Expression Tests
- Orthognathic Surgery
- Substance Use Disorder Treatment
- Therapeutic Footwear for Diabetics
- Vision Therapy (Orthoptics, Eye Exercises)
EFFECTIVE JANUARY 1, 2023
- Air Medical Transport
- Applied Behavior Analysis (ABA)
- Assertive Community Treatment (ACT)
- Autism Spectrum Disorders (NYS)
- Children’s Family Treatment and Support Services (CFTSS)
- Chiropractic Care
- Early Childhood Developmental Disorders (VT)
- Ground Ambulance and Ambulette Services
- Lymphedema Compression Garments
- Oxygen and Oxygen Equipment
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October 2022 Pharmacy Policy Updates
Published October 2022
Pharmaceutical Policy Name Status Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists
Updated PCSK9 Inhibitors
Updated
Epinephrine Autoinjector
Reviewed/No Changes Pulmonary Hypertension (Advanced Agents) Commercial
Reviewed/No Changes
Pulmonary Hypertension (Advanced Agents) Medicaid/HARP Reviewed/No Changes
Migraine Agents- Effective September 1, 2022
Updated
Transthyretin Mediated Amyloidosis Therapy
Reviewed/No Changes
Gout Treatments
Updated
ACL Inhibitors
Reviewed/No Changes
Methotrexate Autoinjector
Reviewed/No Changes
Cialis for BPH
Reviewed/No Changes
Orphan Drugs and Biologicals
Updated
Specialty Procurement (Commercial, Exchange & Select ASO business only)
Updated
Preventive Services-Medication effective – Effective August 1, 2022
Updated -
October 2022 Formulary Policy Update
Published October 2022
Drug Name
Indication Commercial and Marketplace Tier MVP Medicaid Medicare Part D tier Mounjaro (tirzepatide)
The improvement in blood sugar control in adults with type 2 diabetes, as an addition to diet and exercise
Prior
Authorization,
Tier 3
Prior
Authorization,
Tier 3/Non-Formulary
Non-Formulary
Voquezna™ Triple Pak (vonoprazan + amoxicillin + clarithromycin)
The treatment of Helicobacter pylori infection in adults
Prior
Authorization,
Tier 3
Prior
Authorization,
Tier 3/Non-Formulary
Non-Formulary
Ztalmy® (ganaxolone) The treatment of seizures associated with cyclin-dependent kinase-like 5 deficiency disorder in patients aged 2 years and older Prior
Authorization,
Tier 3
Prior
Authorization,
Tier 3/Non-Formulary
Non-Formulary, Tier 5 when RxCui becomes available
Tpoxx® Inj The treatment of smallpox infection
Prior Authorization, Medical
Prior Authorization, Medical
Non-Formulary
Tpoxx® Capsule
The treatment of smallpox infection
Prior
Authorization,
Tier 3
Prior
Authorization,
Tier 3/Non-Formulary
Non-Formulary
Lyvispah® (baclofen)
The treatment of spasticity resulting from multiple sclerosis, particularly for the relief of flexor spasms and concomitant pain, clonus, and muscular rigidity
Prior
Authorization,
Tier 3
Prior
Authorization,
Tier 3/Non-Formulary
Non-Formulary
Alymsys®
(bevacizumab-maly)
The treatment of metastatic colorectal cancer, in combination with intravenous fluorouracil-based chemotherapy for first- or second-line treatment, and the treatment of metastatic colorectal cancer, in combination with fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy for second-line treatment in patients who have progressed on a first-line bevacizumab product-containing regimen (biosimilar of Avastin)
Prior Authorization, Medical
Prior Authorization, Medical
Prior Authorization, Medical
Adlarity®
(donepezil)
The treatment of mild, moderate, and severe Alzheimer’s dementia
Prior
Authorization,
Tier 3
Prior
Authorization,
Tier 3/Non-Formulary
Non-Formulary
Byooviz® (ranibizumab-nuna)
The treatment of neovascular (wet) age-related macular degeneration, macular edema following retinal vein occlusion, and myopic choroidal neovascularization (biosimilar of Lucentis)
Prior Authorization, Medical
Prior Authorization, Medical
Medical
Part D- Non-Formulary
Tyvaso® DPI
(treprostinil)
The treatment of pulmonary arterial hypertension and the treatment of pulmonary hypertension associated with interstitial lung disease
Prior
Authorization,
Tier 3
Prior
Authorization,
Tier 3/Non-Formulary
Non-Formulary
Pemetrexed (pemetrexed iv solution)
The maintenance treatment of patients with locally advanced or metastatic, nonsquamous non-small cell lung cancer (NSCLC) whose disease has not progressed after 4 cycles of platinum-based first-line chemotherapy, and the treatment of patients with recurrent, metastatic nonsquamous NSCLC after prior chemotherapy
Prior Authorization, Medical
Prior Authorization, Medical
Medical
Part D- Tier 5 if RxCui becomes available
Drugs removed from prior authorization- Commercial and Exchange
- Welireg
- Exkivity
- Tivdak
- Tavneo
- Scemblix
- Eprontia™ Oral Solution
- Vuity Solution
- Elyxyb™ Solution
- Besremi
- Fyarro
- Livtencity
DRUG EXCLUSION
- Twyneo
- Loreev XR
- Trudhesa
- Lybalvi
- Opzelura Cream
- Qulipta
- Skytrofa
- Tyrvaya
NEW GENERICS
NEW GENERICS (all brands will be non-formulary, Tier 3)BRAND NAME
GENERIC NAME COMMERCIAL MEDICAID EXCHANGE Apokyn
Apomorphine solution
Tier 1 with prior authorization
Tier 1 with prior authorization
Tier 2 with prior authorization
Vimpat
Lacosamide
Brand Tier 2, Generic Tier 1
Tier 1
Tier 2
Bidil
Isosorbide dinitrate/hydralazine
Tier 1
Tier 1
Tier 2
Ozobax
Baclofen oral solution
Tier 1
Tier 1
Tier 2
SSKI solution Potassium Iodide oral solution Exclude Prior Authorization, Tier 1
Exclude Esbriet
Pirfenidone
Prior Authorization, Tier 1
Prior Authorization, Tier 1
Prior Authorization, Tier 2
Velcade
Bortezomib
Medical
Medical
Medical
Diclofenac Sodium solution 2%
Pennsaid
Brand excluded, generic Tier 1
Brand: Non-Formulary/Tier 3 with prior authorization. Generic: Prior Authorization, Tier 1
Brand excluded, generic Tier 2
Revlimid
Lenalidomide
Tier 1
Tier 1
Tier 2
Pentasa
Mesalamine ER
Brand- Tier 2; Generic- Tier 1
Brand- Tier 2; Generic- Tier 1
Brand- Tier 2; Generic- Tier 2
Vimpat
Lacosamide
Brand- Tier 2; Generic- Tier 1
Tier 1
Tier 2
Targretin Bexarotene gel
Tier 1
Tier 1
Tier 2
Nexavar
Sorafenib
Tier 1
Tier 1
Tier
Miscellaneous Updates
Commercial and Exchange
- Shingrix age edit removed
- Quantity limit for ondansetron removed
Medicaid
- Shingrix age edit removed
- Quantity limit for ondansetron removed
- Sterile water for injection no longer covered
- Quzyttir updated to Non-Formulary
-
October 2022 Medical Policy Updates
Published October 2022
MEDICAL POLICY NAME
- Breast Reconstruction Surgery
- Cell-Free Fetal DNA Based Prenatal Screening
- Continuous Glucose Monitoring
- Endobronchial Valve Devices
- Endoscopy (Esophagogastroduodenoscopy and Colonoscopy)
- Experimental or Investigational Procedures
- Fertility Preservation Services
- Hospital Inpatient Level of Care
- Imaging Procedures
- Infertility Services (Advanced) and IVF
- Infertility Services (Basic)
- Inhaled Nitric Oxide (INOmax)
- Investigational Procedures
- Liposuction for Lipedema
- Obstructive Sleep Apnea: Devices
- Obstructive Sleep Apnea: Diagnosis
- Obstructive Sleep Apnea: Surgical
- Oncotype DX and Cancer Gene Expression Tests
- Procedures for the Management of Chronic Spinal Pain and Chronic Pain
- Rhinoplasty
-
September 2022 Pharmacy Policy Updates
Published October 2022
Pharmaceutical Policy Name
Status
Cystic Fibrosis Agents (Select Agents for Inhalation)
Reviewed/No Changes
Cystic Fibrosis Agents (Select Oral Agents)
Reviewed/No Changes
Idiopathic Pulmonary Fibrosis
Updated
Xolair
Updated
Quantity Limits for Prescription Drugs
Updated
Patient Medication Safety
Reviewed/No Changes
Ulcerative Colitis – Effective June 1, 2022
Updated
Botulinum Toxin Treatment
Updated
Entyvio – Effective July 1, 2022
New
Inflammatory Biologic Drug – Effective July 1, 2022
Updated
-
September 2022 Formulary Policy Updates
Published October 2022
Drug Name
Indication
Commercial and Marketplace Tier
MVP Medicaid
Medicare Part D tier
Quviviq™
(daridorexant)
The treatment of adults with insomnia characterized by difficulties with sleep onset and/or sleep maintenance
Prior
Authorization,
Tier 3
Prior
Authorization,
Tier 3/Non-Formulary
Non-Formulary
Camzyos™
(mavacamten)
The treatment of symptomatic New York Heart Association class II-III obstructive hypertrophic cardiomyopathy
Prior
Authorization,
Tier 3
Prior
Authorization,
Tier 3/Non-Formulary
Non-Formulary
Vijoice®
(alpelisib)
The treatment of patients aged 2 years and older with severe manifestations of PIK3CA-related overgrowth spectrum who require systemic therapy
Prior
Authorization,
Tier 3
Prior
Authorization,
Tier 3/Non-Formulary
Non-Formulary
Norliqva®
(amlodipine)
The treatment of hypertension in patients aged 6 years and older, the treatment of chronic stable angina, and the treatment of angiographically documented coronary artery disease in patients without heart failure or an ejection fraction less than 40%
Prior
Authorization,
Tier 3
Prior
Authorization,
Tier 3/Non-Formulary
Non-Formulary
-
August 2022 Pharmacy Policy Updates
Published October 2022
Pharmaceutical Policy Name
Status
Zoladex Medicaid – Effective May 14, 2022
New
Enteral Therapy- New York
Updated
Enteral Therapy- Vermont
Updated
Rinvoq – Effective June 1, 2022
New
Aduhelm
Updated
Medicare Part B vs Part D Determination
Reviewed/No Changes
Copay Adjustment for Medical Necessity
Reviewed/No Changes
Infliximab – Effective January 1, 2022
Updated
-
August 2022 Formulary Policy Updates
Published October 2022
Formulary Updates for Commercial, Marketplace, and Medicaid Formularies
New Drugs (recently FDA approved, prior authorization required, Tier 3, non-formulary for MVP Medicaid)Effective August 1, 2022
Drug Name
Indication
Commercial and Marketplace Tier
MVP Medicaid
Medicare Part D tier
Tezspire™
(tezepelumab-ekko)
The add-on maintenance treatment of patients aged 12 years and older with severe asthma
Medical
Medical
Medical Part D,
Non-formulary
Pyrukynd®
(mitapivat)
The treatment of hemolytic anemia in adults with pyruvate kinase deficiency
Tier 3
Non-Formulary
Non-Formulary
Carvykti™ (ciltacabtagene autoleucel)
The treatment of adults with relapsed or refractory multiple myeloma after 4 or more prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody
Medical
Medical
Medical
Part D,
Tier 5 if RxCUI becomes available
Ibsrela®
(tenapanor)
The treatment of irritable bowel syndrome with constipation in adults
Tier 3
Non-Formulary
Non-Formulary
Korsuva® (difelikefalin)
The treatment of moderate-to-severe pruritus associated with chronic kidney disease in adults undergoing hemodialysis
Medical
Medical
Medical
Part D,
Non-Formulary
Vonjo™ (pacritinib)
The treatment of adults with intermediate or high-risk primary or secondary myelofibrosis and severe thrombocytopenia
Tier 3
Non-Formulary
Tier 5 when RxCUI becomes available
Pluvicto™
(lutetium Lu 177 vipivotide tetraxetan)
The treatment of adults with prostate-specific membrane antigen-positive metastatic castration-resistant prostate cancer who have been treated with androgen receptor pathway inhibition and taxane-based chemotherapy
Medical
Medical
Medical
Part D,
Non-Formulary
Opdualag™ (nivolumab/ relatlimab-rmbw)
The treatment of metastatic or unresectable melanoma in patients aged 12 years and older
Medical
Medical
Medical
Part D,
Tier 5 if RxCUI becomes available
Releuko® (filgrastim-ayow)
Use to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a significant risk of severe neutropenia with fever, to reduce the time to neutrophil recovery and duration of fever following induction or consolidation chemotherapy in patients with acute myeloid leukemia, to reduce the duration of neutropenia and neutropenia-related clinical sequelae in patients with nonmyeloid malignancies undergoing myeloablative chemotherapy followed by bone marrow transplantation, and to reduce the incidence and duration of sequelae of severe neutropenia in symptomatic patients with congenital neutropenia, cyclic neutropenia, or idiopathic neutropenia (biosimilar of Neupogen)
Tier 3
Non-Formulary
Non-Formulary
Part D,
Tier 5 if RxCUI becomes available
Camcevi® (leuprolide depot 6-month formulation)
The treatment of adults with advanced prostate cancer
Medical
Medical
Medical
Part D
Tier 5 if RxCUI becomes available
-
August 2022 Medical Policy Updates
Published October 2022
MEDICAL POLICY NAME
- Ambulatory Holter Monitors and 30-Day Cardiac Event Recorders/Monitors
- Breast Pumps
- Continuous Passive Motion Devices
- Electrical Stimulation Devices & Therapies
- Emergency Department Services
- Evaluation of New Technology, Procedures, Behavioral Health Services and Programs
- Gas Permeable Scleral Contact Lenses
- Gender Affirming Treatment
- Genetic and Molecular Diagnostic Testing
- Home and Community Based Services-Adult
- Idiopathic Scoliosis Surgery and Growing Rods Technique
- Imaging Procedures
- Immunizations Childhood, Adolescent, and Adult
- Interspinous Process Decompression Systems (IPD)
- Magnetoencephalography and Magnetic Source Imaging
- Molecular Markers in Fine Needle Aspirates of the Thyroid
- Oxygen & Oxygen Equipment
- Panniculectomy/Abdominoplasty
- Personalized Recovery Oriented Services (PROS)
- Private Duty Nursing
- Prosthetic Devices (Upper & Lower Limb)
- Radiofrequency Neuroablation Procedures for Chronic Pain
- Speech Therapy (Outpatient) & Cognitive Rehabilitation
- Surgical Procedures for Glaucoma
- Temporomandibular Joint Dysfunction (TMJ) NY
- Temporomandibular Joint Dysfunction (TMJ) VT
- Tissue-Engineered Skin Substitutes (pol w/issues)
-
July 2022 Pharmacy Policy Updates
Published July 2022
Below is a recap of the Pharmacy and Formulary updates that went into effect from April1 to June 1, 2022. All policies are reviewed at least once annually. For more detailed information on these changes, please review updates at mvphealthcare.com/FastFax.
EFFECTIVE JUNE 2022
Pharmaceutical Policy Name
Status
Valchlor
Reviewed/ No Changes
Eylea
Reviewed/ No Changes
Topical Agents for Pruritus
Reviewed/ No Changes
Cosmetic Drug Agents
Updated
Psoriasis Drug Therapy
Updated
Psoriatic Arthritis Drug Therapy- Effective April 1, 2022
Updated
Onychomycosis
Reviewed/ No Changes
Duchenne Muscular Dystrophy- Effective April 1, 2022
Updated
Formulary Exception for Non-Covered Drug – Effective April 1, 2022
Updated
CAR-T Cell Therapy
Updated
Drug Utilization Review and Monitoring Program
Reviewed/ No Changes
Luxturna
Reviewed/ No Changes
Parsabiv
Reviewed/ No Changes
Preventive Services-Medication – Effective April 1, 2022
Reviewed/ No Changes
Pain Medications- Effective March 22, 2022
Reviewed/ No Changes
Zoladex-Medicaid Effective May 14, 2022
New Policy
-
July 2022 Formulary Updates
Published July 2022
Commercial, Marketplace, and Medicaid Formularies
New Drugs (recently FDA approved, prior authorization required, Tier 3, non-formulary for MVP Medicaid)
Drug Name
Indication
Commercial and Marketplace Tier
MVP Medicaid
Medicare Part D tier
Vyvgart™
(efgartigimod alfa-fcab)
The treatment of generalized myasthenia gravis in adults who are anti-acetylcholine receptor antibody positive
Medical
Medical
Medical
Part D-
Non-formulary
Leqvio®
(inclisiran)
The treatment of clinical atherosclerotic cardiovascular disease or heterozygous familial hypercholesterolemia, as an adjunct to diet and maximally tolerated statin therapy, in adults who require additional lowering low-density lipoprotein cholesterol and the treatment of heterozygous familial hypercholesterolemia in adults
Tier 3
Non-Formulary
Non-Formulary
Recorlev® (levoketoconazole)
The treatment of endogenous hypercortisolemia in adults with Cushing’s syndrome for whom surgery is not an option or has not been curative
Tier 3
Non-Formulary
Non-Formulary
Adbry™ (tralokinumab-ldrm)
The treatment of moderate-to-severe atopic dermatitis in adults whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable
Tier 3
Non-Formulary
Non-Formulary
Kimmtrak® (tebentafusp-tebn)
The treatment of HLA-A*02:01 positive adults with unresectable or metastatic uveal melanoma
Medical
Medical
Medical
Part-D,
Tier 5 if RxCUI becomes available
Vabysmo® (faricimab-svoa)
The treatment of neovascular (wet) age-related macular degeneration and diabetic macular edema
Medical
Medical
Medical
Part-D, Non-formulary
Enjaymo™ (sutimlimab-jome)
The treatment of adults with cold agglutinin disease to decrease the need for red blood cell transfusion due to hemolysis
Medical
Medical
Medical
Part-D,
Non-formulary
Apretude (cabotegravir)
The pre-exposure prophylaxis to reduce the risk of sexually acquired human immunodeficiency virus-1 infection in at-risk adults and adolescents weighing at least 35 kilograms
Medical
Medical
Medical
Part-D,
Tier 5 if RxCUI becomes available
Tarpeyo™ (budesonide-controlled release)
The reduction of proteinuria in adults with primary IgA nephropathy at risk of rapid disease progression
Tier 3
Non-Formulary
Non-Formulary
Dartisla ODT™
(glycopyrrolate)
The reduction of symptoms of peptic ulcer as an adjunct to treatment
Tier 3
Non-Formulary
Non-Formulary
Soaanz®
(torsemide)
The treatment of edema associated with heart failure or renal disease in adults
Tier 3
Non-Formulary
Non-Formulary
Pemfexy™
(pemetrexed)
The initial treatment of patients with locally advanced or metastatic non-squamous, non-small cell lung cancer (NSCLC) and mesothelioma, in combination with cisplatin; as a single agent for the maintenance treatment of patients with locally advanced or metastatic non-squamous NSCLC whose disease has not progressed after 4 cycles of platinum-based first-line chemotherapy; and as a single agent for the treatment of patients with recurrent, metastatic non-squamous NSCLC after prior chemotherapy
Medical
Medical
Medical
Part-D,
Not Covered
Seglentis®
(celecoxib/ tramadol)
The management of acute pain in adults that is severe enough to require an opioid analgesic and for which alternative treatments are inadequate
Tier 3
Non-Formulary
Non-Formulary
Cibinqo™
(abrocitinib)
The treatment of adults with refractory, moderate-to-severe atopic dermatitis whose disease is not adequately controlled with other systemic drug products, including biologics, or when use of those therapies is inadvisable
Tier 3
Non-Formulary
Non-Formulary
Fleqsuvy™ Oral Suspension
(baclofen)
Treatment of spasticity resulting from multiple sclerosis particularly for the relief of flexor spasms and concomitant pain, clonus, and muscular rigidity; may also be of some value in patients with spinal cord injuries and other spinal cord diseases
Tier 3
Non-Formulary
Non-Formulary
Drugs removed from prior authorization- Commercial and Exchange
- Kloxxado
- Kerendia (non-formulary for Medicaid)
- Rylaze (medical)
- Saphnelo (medical)
- Zimhi
DRUG EXCLUSION
- Brexafemme
- Azstarys
New Generics
NEW GENERICS (all brands will be non-formulary, Tier 3)
BRAND NAME
GENERIC NAME
COMMERCIAL
MEDICAID
EXCHANGE
Cuvposa solution
Glycopyrrolate solution
Tier 1
Tier 1
Tier 2
Dexilant
Dexlansoprazole
Tier 1 with quantity limit 2 capsules per day
Tier 1 with quantity limit 2 capsules per day
Tier 2 with quantity limit 2 capsules per day
Restasis
Cyclosporine ophthalmic emulsion
Tier 1
Tier 1
Tier 2
Selzentry
Maraviroc
Brand Tier 2, generic Tier 1
Brand Tier 2, generic Tier 1
Brand Tier 2, generic Tier 2
Deferiprone
Ferriprox
Tier 1
Tier 1
Tier 2
Combigan
Brimidone tartrate-timolol maleate
Tier 1
Tier 1
Tier 2
-
July 2022 Medical Policy Updates
Published July 2022
Below is a recap of the Medical Policies that went into effect May 1, 2022.All policies are reviewed at least once annually. For more detailed informationon these changes, please review mvphealthcare.com/Fastfax or visitmvphealthcare.com/Providers and Sign In to your account, and select Resources,then Medical Policies.
MEDICAL POLICY NAME
- Acute Inpatient Rehabilitation
- Artificial Intervertebral Discs-Cervical and Lumbar
- Autism Spectrum Disorder NY
- Benign Prostatic Hyperplasia (BPH) Treatments
- Biofeedback Therapy
- Bone Growth Stimulator
- BRCS Testing (Genetic Testing for Susceptibility to Breast and Ovarian Cancer)
- Cardiac Output Monitoring by Thoracic Electrical Bioimpedance
- Cell-Free Fetal DNA-Based Testing for Fetal Aneuploidy
- Clinical Guideline Development, Implementation, and Review Process
- Cochlear Implants and Osseointegrated Devices
- Epidermal Nerve Fiber Density Testing
- Heart and Kidney Transplant Rejection Testing
- Home and Community Based Services (HCBS) Children’s
- Infertility Services (Basic)
- Medical Policy Development, Implementation, and Review Process
- Mental Health Services
- Minimally Invasive GI Procedures
- Sacral Nerve Stimulation
- Skin Endpoint Titration
- Speech Generating Devices
Medical Policy Updates Effective June 1, 2022
- Continuous Glucose Monitoring
- COVID-19 Related Medical Management
- Custodial Care Long Term (LT) Placement in a Nursing Home (NH) for MVP Medicaid Managed Care
- Electromyography and Nerve Conduction Studies
- Erectile Dysfunction
- External Breast Prosthesis
- Extracorporeal Shock Wave Therapy
- Fluorescence In Situ Hybridization (FISH) Testing for Bladder Cancer
- Hospice Care
- Inhaled Nitric Oxide (INOmax)
- Joint Replacement for Hallux Rigidus
- Laser Treatment of Port Wine Stains
- Leadless Cardiac Pacemakers
- Orthotic Devices (other than therapeutic diabetic footwear)
- Percutaneous Vertebral Augmentation (PVA)
- Personal Care and Consumer Directed Services for MVP Medicaid Managed Care
- Prophylactic Mastectomy and Prophylactic Oophorectomy
- Prosthetic Devices (External) Eye and Facial and Scleral Shells
- Sinus Surgery-Endoscopic
- Umbilical Cord Blood Banking
- Ventricular Reduction Surgery
-
July 2022 Miscellaneous Updates
Published July 2022
Medicaid
New Medication Assisted Treatment (MAT) Formulary Requirement Effective March 22, 2022
- On December 22, 2021, Governor Hochul signed Chapter 720 of the Laws of 2021. This law amends Social Services Law and the Public Health Law, in relation to medication for the treatment of substance use disorders. Effective March 22, 2022, prior authorization will not be required for medications used for the treatment of substance use disorder when prescribed according to generally accepted national professional guidelines for the treatment of a substance use disorder.
- Current quantity limits on this category will still apply
- Managed Care Plans are required to align to the Fee-For-Service formulary for a single Statewide MAT Formulary. More information is available on the NYS DOH’s website at newyork.fhsc.com/providers/mat.asp
-
April 2022 Pharmacy Policy Updates
Published April 2022
EFFECTIVE JANUARY 2022
Pharmaceutical Policy Name
Status
Crohn’s Disease Select Agents
Updated
Dupixent
Updated
Quantity Limits for Prescription Drugs (effective October 1, 2021)
Updated
Mulpleta/Doptelet
Updated
Prostate Cancer
Updated
Radicava
Updated
Zulresso
Reviewed/No changes
Palforzia
Reviewed/No changes
Formulary Exception for Non-Covered Drug (External)
Reviewed/No changes
Infliximab
Updated
Growth Hormone Therapy
Updated
Ulcerative Colitis, Select Agents
Updated
SGLT2 Inhibitors Medicaid
New
Multiple Sclerosis Agents
Updated
Select Oral Antipsychotics
Reviewed/No changes
GABA-Receptor Modulators (formerly Xyrem)
Updated
Movement Disorder
Updated
Select Hypnotics
Updated
Respiratory Syncytial Virus/Synagis
Reviewed/No changes
Spravato
Updated
Nuedexta
Reviewed/No changes
Gabapentin ER
Reviewed/No changes
Spinal Muscular Atrophy
Reviewed/No changes
Oral Allergen Immunotherapy Medications
Updated
Agents for Female Sexual Dysfunction
Reviewed/No changes
Ankylosing Spondylitis Drug Therapy
Updated
Rheumatoid Arthritis Drug Therapy
Updated
Psoriatic Arthritis Drug Therapy
Updated
EFFECTIVE FEBRUARY 2022
Pharmaceutical Policy Name
Status
Doryx/Oracea (doxycycline)
Reviewed/No changes
Antibiotic/Antiviral (Oral) Prophylaxis
Updated
Government Programs Over the Counter (OTC) Drug Coverage (For MVP Medicaid, Child Health Plus, and select Essential Plan Members Only)
Updated
Compounded (Extemporaneous) Medications
Updated
-
April 2022 Formulary UpdatesSee the full list of generic and name brand drugs covered by MVP Health Care plans that offer prescription drug coverage here.
Formulary Updates for Commercial, Marketplace, and Medicaid Formularies
New Drugs (recently FDA approved, prior authorization required, Tier 3, non-formulary for MVP Medicaid)
Drug Name
Commercial and Marketplace Tier
MVP Medicaid
Medicare Part D Tier
Nexviazyme
Medical
Medical
Non-Formulary
Welireg
Tier 3
Non-Formulary
Non-Formulary
Loreev XR
Tier 3
Non-Formulary
Non-Formulary
Exkivity™
(mobocertinib)
Tier 3
Non-Formulary
MedicalPart D-Tier 5, if RxCuibecomes available
Tivdak™
(tisotumab vedotin-tftv)
Medical
Medical
MedicalPart D-Tier 5, if RxCuibecomes available
Livmarli™ (maralixibat)
Tier 3
Non-Formulary
Non-Formulary
Qulipta™ (atogepant)
Tier 3
Non-Formulary
Non-Formulary
Skytrofa™ (lonapegsomatropin-tcgd)
Tier 3
Non-Formulary
Non-Formulary
Tavneos™ (avacopan)
Tier 3
Non-Formulary
Non-Formulary
Trudhesa™ (dihydroergotamine)
Tier 3
Non-Formulary
Non-Formulary
Lybalvi™ (olanzapine/ samidorphan)
Tier 3
Non-Formulary
Non-Formulary
Opzelura Cream™ (ruxolitinib)
Tier 3
Non-Formulary
Non-Formulary
Scemblix®
(asciminib)
Tier 3
Non-Formulary
Medical
Part D-Tier 5, if RxCuibecomes available
Besremi®
(ropeginterferon alfa-2b)
Tier 3
Non-Formulary
Non-Formulary
Voxzogo™ (vosoritide)
Tier 3
Non-Formulary
Non-Formulary
Fyarro™ (sirolimus)
Medical
Medical
Medical
Livtencity™ (maribavir)
Tier 3
Non-Formulary
Non-Formulary
Tyrvaya™ (varenicline)
Tier 3
Non-Formulary
Non-Formulary
Eprontia™ Oral Solution (topiramate)
Tier 3
Non-Formulary
Tier 5
Vuity™ Solution (pilocarpine)
Tier 3
Non-Formulary
Non-Formulary
Elyxyb™ Solution
(celecoxib)
Tier 3
Non-Formulary
Non-Formulary
DRUGS REMOVED FROM PRIOR AUTHORIZATION- COMMERCIAL AND EXCHANGE
- Myfembree (non-formulary for Medicaid)
- Truseltiq (non-formulary for Medicaid)
- Lumakras (non-formulary for Medicaid)
DRUG EXCLUSION
Formulary Updates for Commercial, Exchange, and Medicaid
Drug Name
Action
Dextenza
Excluded
NEW GENERICS- NONE
MISCELLANEOUS UPDATES
2022 Formulary Updates for Commercial and Exchange
Drug Name
Action
Aimovig, Emgality, and Ajovy
Move from Tier 3 to Tier 2
Stelara and Tremfya
Move from Tier 3 to Tier 2 for Psoriatic Arthritis. Prior authorization still required.
Zeposia
Move from Tier 3 to Tier 2 for Ulcerative Colitis. Prior authorization still required.
Nurtec ODT
Quantity limit increase to 16 tablets per 30 days
Bystolic
Move to Tier 3
Zolpidem ER (generic)
Add a quantity limit of 30 tablets per 30 days
2022 Formulary Updates for Medicaid
Drug Name
Action
Notes
Segluromet and Steglatro
Move to preferred Tier 2
Invokamet, Invokamet XR, Invokana, and Xigduo XR to Excluded status
Exclude
Farxiga
Add prior authorization, Tier 2
New policy
Advair HFA and Symbicort
Exclude
Fasenra pen
Move to preferred Tier 2/specialty
Norditropin Injection (ALL formulations)
Move to preferred Tier 2/specialty
Growth Hormone Therapy policy updated
Viokace and Zenpep
Move to preferred Tier 2
Movantik
Move to preferred Tier 2
Nurtec
Move to preferred Tier 2
Quantity limit of 15 tablets/30 days remains the same. Will only require prior authorization if exceeding the quantity limit.
Sofosbuvir-velpatasvir (generic Epclusa)
Move to preferred Tier 2 with a quantity limit of 84 tablets/year
Quantity reflects standard 12 weeks of therapy
Truvada
Move to non-formulary
Nurtec ODT
Quantity limit increase to 16 tablets per 30 days
Bystolic Diclegis and Chantix
Move to non-formulary
Zolpidem ER (generic)
Add a quantity limit of 30 tablets per 30 days
Nurtec ODT
Quantity limit increase to 16 tablets per 30 days
Bystolic, Diclegis and Chantix
Move to non-formulary
Zolpidem ER (generic)
Add a quantity limit of 30 tablets per 30 days
-
April 2022 Medical Policy Updates
Published April 2022
- Adult Day Care Service
- Bariatric Surgery
- Benign Prostatic Hyperplasia (BPH) Treatments
- Colorectal Cancer Genetic Testing
- Continuous Glucose Monitoring
- Dental Care Services Accidental Injury
- Dental Care Services Medical Services for Complications of Dental Problems
- Dental Care Services Facility Services for Dental Care
- Dental Care Services Prophylactic Dental Extractions
- Endoscopy (Colonoscopy)
- Ground Ambulance/Ambulette Services
- Investigational Procedures
- Needle-free Insulin Injectors
- Neuropsychological Testing
- Oncotype DX Test
- Phototherapy, Photochemotherapy, Excimer Laser Therapy
- Power Mobility Devices
- Tissue-Engineered Skin Substitutes
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