Formulary, Pharmacy Policy, & Medical Policy Updates

Published October 2023

EFFECTIVE AUGUST 1, 2023

Acute Inpatient Rehabilitation: Updated criteria for non-physician practitioners and group therapy.

Applied Behavior Analysis: (effective 07/01/2023): Overview was rewritten. Updated indications/criteria for coverage, updated documentation requirements for authorization requests, added documentation requirements for treatment dosage and intensity, exclusions added for time spent traveling and periods of rest. Added coverage to Medicaid Managed Care Plans for group adaptive behavior treatment (CPT 97154) and multiple-family treatment (CPT 97157), references updated.

Automatic External Defibrillators: Annual review with no changes to indications or criteria.

Bariatric Surgery: Completed formal review of policy updates effective 4/1/23.

Blepharoplasty, Brow Lift, and Ptosis Repair: Annual review with no changes to indications or criteria. Added language regarding lacrimal gland suspension exclusion.

Cold Therapy Devices: Annual review with no changes to indications or criteria. Formatted to include Medicare NCD/LCD.

Compression Devices: Formerly entitled Pneumatic Compression Devices. Koya Dayspring added as an exclusion.

Hyperhidrosis Treatment: Annual review with no changes to indications or criteria.

Intraoperative Neurophysiologic Monitoring During Spinal Surgery: Removed prior authorization from policy and codes 95925, 95926, 95927, 95940, 95941, G0453. Overview rewritten, removed specific indications, added tests that are covered when criteria is met in policy, removed “routine” from the exclusions.

Negative Pressure Wound Therapy Pumps: Annual review with no changes to indications or criteria.

Sacral Nerve Stimulation and Percutaneous Nerve Stimulation: Completed formal review of policy updates effective 4/1/23.

Temporomandibular Joint Dysfunction (TMJ) New York: Completed formal review of policy updates effective 4/1/23.

Temporomandibular Joint Dysfunction (TMJ) Vermont: Completed formal review of policy updates effective 4/1/23.

EFFECTIVE OCTOBER 1, 2023

Assertive Community Treatment: Completed formal review of policy updates effective 06/01/2023

Bone Density Study for Osteoporosis (DEXA):Completed formal review of policy updates effective 09/01/2023

Genetic and Molecular Diagnostic Testing: Added coverage for hematologic malignancies using CPT Code 81450, 81451; added exclusions for genetic testing panels for inherited genetic conditions (CPT 81443) and whole Genome Sequencing (WGS), Whole Exome Sequencing (WES), and Whole Mitochondrial Genome Sequencing

Hyperbaric Oxygen Therapy (HBO) and Topical Oxygen Therapy: Added criteria for sudden hearing loss

Lenses for Medical Conditions of the Eye: Annual review with no changes to policy indications or criteria

Light Therapy for Seasonal Affective Disorder (SAD): Annual review with no changes to policy indications or criteria

Power Mobility Devices:Completed formal review of policy updates effective 06/01/2023

Transplants: Annual review with no changes to policy indications or criteria

Vision Therapy (Orthoptics, Eye Exercises):Annual review, updated format, no changes to the indications or criteria. Removed references to learning disabilities and left exclusion to all other indications not addressed in the criteria. Added Medicare section. Updated references.

Published October 2023

For Commercial, Marketplace, and Medicaid Formularies

New Drugs (recently FDA approved, prior authorization required, Tier 3, non-formulary for MVP Medicaid).

Please note that on April 1, 2023 the pharmacy benefit for New York State (NYS) Medicaid Managed Care and Health Recovery Plan (HARP) members will transition to the NYS Medicaid fee-for-service (FFS) Pharmacy Program called NYRX. Physician administered medications under the Medicaid member’s medical benefit remain the responsibility of MVP.

Drugs removed from prior authorization- Commercial and Exchange

DRUG EXCLUSION

DRUG EXCLUSION

Miscellaneous Updates

Commercial and Exchange

Continuous Glucose Monitoring (CGM) Update

The pharmacy department will be working with the PBM to allow adjudication of CGM and supplies through the pharmacy channel. This applies to all lines of business except Medicaid as the pharmacy benefit has been carved out to FFS. This will provideadditional sites of access for our members. Utilization management will continue to review for clinical appropriateness and any criteria for approval remains with that department.

Substance Use Disorder Medications

Brand Suboxone films, and LifeMS Naloxone kit were added at Tier 3 to the Commercial and Exchange formularies.

Brand Zubsolvsublinigual tablets were added at Tier 3 to the Commercial formulary.

Medications moving Tier 2 to Tier 1 for 2024 Exchange Formulary

Medicaid

On April 1, 2023 the pharmacy benefit for New York State (NYS) Medicaid Managed Care and Health Recovery Plan (HARP) members transitioned to the NYS Medicaid fee-for-service (FFS) Pharmacy Program called NYRX.

Published October 2023

EFFECTIVE AUGUST 1, 2023

EFFECTIVE SEPTEMBER 1, 2023

EFFECTIVE OCTOBER 1, 2023

July 2023 Medical Policy Updates

Published July 2023

Below is a recap of the Medical Policies that went into effect recently. All policies are reviewed at least once annually. For more detailed information on these changes, please review mvphealthcare.com/Fastfax or Sign In to your online account atmvphealthcare.com/Providers, then select Resources, then Medical Policies.

EFFECTIVE APRIL 1, 2023

• Alopecia Treatment
• Bariatric Surgery
• Breast Implantation and Removal
• Breast Reconstruction Surgery
• Breast Reduction Surgery
• Cochlear Implants and Osseointegrated Devices
• Colorectal Cancer Susceptibility Genetic Testing
• Cranial Orthotics
• Deep Brain Stimulation
• Durable Medical Equipment (Includes Prosthetics & Orthotics)
• Endovascular Repair of Aortic Aneurysms
• Endovenous Ablation of Varicose Veins
• External Breast Prosthesis
• Genetic and Molecular Diagnostic Testing
• High Frequency chest Wall Oscillation Devices
• Hospital Beds
• Hyperbaric Oxygen Therapy (HBO)
• Implantable Cardioverter Defibrillators
• Indirect Handheld Calorimeters
• Infertility Services (Advanced) and In Vitro Fertilization
• InterQual Criteria Medical Policies: Pectus Excavatum, Spinal Cord Stimulator
• Lymphedema Compression Garments & Compression Stockings
• Neuropsychological Testing
• Non-Invasive Liver Fibrosis Testing
• Obstructive Sleep Apnea Diagnosis and Other Sleep Disorders
• Prostate Cancer Interventions
• Prosthetic Devices (External): Eye and Facial and Scleral Shells
• Radiofrequency Neuroablation (Rhizotomy) Facet Joint Injections, Medial Branch Blocks, Procedures for Chronic Pain
• Sacral Nerve Stimulation and Percutaneous Nerve Stimulation
• Serological Testing for Inflammatory Bowel Disease (IBD)
• Temporomandibular Joint Dysfunction (New York)
• Temporomandibular Joint Dysfunction (Vermont)
• Transcranial Magnetic Stimulation for Treatment Resistant Depression
• Ventricular Assist Devices (VADs) and Total Artificial Heart

EFFECTIVE APRIL 16, 2023

• Continuous Glucose Monitoring

EFFECTIVE JUNE 1, 2023

• Benign Prostatic Hyperplasia (BPH) Treatments
• Dental Care Services Facility Services for Dental Care
• Dental Care Services Medical Services for Complications of Dental Problems
• Durable Medical Equipment (Includes Prosthetics and Orthotics)
• Electrical Stimulation Devices and Therapies
• Insulin Infusion Pumps (External Continuous Subcutaneous)
• Investigational Procedures, Devices, Medical Treatments, and Tests
• Percutaneous Left Atrial Appendage (LAA) Closure Devices
• Phototherapeutic Keratectomy (PTK) and Refractive Surgery
• Prosthetic Devices (Upper & Lower Limb)
• Scoliosis Bracing
• Wheelchairs (Manual)

Published July 2023

Below is a recap of the Pharmacy and Formulary updates that recently went into effect. All policies are reviewed at least once annually. For more detailed information on these changes, please review updates at mvphealthcare.com/FastFax.

EFFECTIVE APRIL 1, 2023

EFFECTIVE JUNE 1, 2023

FORMULARY UPDATES FOR COMMERCIAL, MARKETPLACE, AND MEDICAID FORMULARIES

New Drugs (recently FDA approved, prior authorization required, Tier 3, non-formulary for MVP Medicaid).

Please note that on April 1, 2023, the pharmacy benefit for New York State (NYS) Medicaid Managed Care and HARP Members transitioned to the NYS Medicaid Fee-for-Service (FFS) Pharmacy Program called NYRx. Physician administered medications under the Medicaid member’s medical benefit remain the responsibility of MVP.

Drugs removed from prior authorization- Commercial and Exchange

New Generics

MISCELLANEOUS UPDATES

Commercial and Exchange

Published April 2023

Below is a recap of the Pharmacy and Formulary updates that went into effect from December 1, 2022, to April 1, 2023. 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

EFFECTIVE JANUARY 1, 2023

EFFECTIVE FEBRUARY 1, 2023

EFFECTIVE APRIL 1, 2023

Published April 2023

FOR COMMERCIAL, MARKETPLACE, AND MEDICAID FORMULARIES

New Drugs (recently FDA approved, prior authorization required, Tier 3, non-formulary for MVP Medicaid)

DRUGS REMOVED FROM PRIOR AUTHORIZATION- COMMERCIAL AND EXCHANGE

DRUG EXCLUSION

NEW GENERICS

MISCELLANEOUS UPDATES

COMMERCIAL AND EXCHANGE

MEDICAID 

Published April 2023

Below is a recap of the Medical Policies that went into effect February 1, 2023.All policies are reviewed at least once annually. For more detailed informationon these changes, please review mvphealthcare.com/Fastfax or sign in at mvphealthcare.com/providers and selectResources, then Medical Policies.

EFFECTIVE FEBRUARY 1, 2023

• Allergy Testing and Allergen Immunotherapy
• Autologous Chondrocyte Implantation (ACI)
• Court Ordered Services
• Electroconvulsive Therapy (ECT)
• Electrical Stimulation Devices and Therapies
• Home Care Services
• Investigational Procedures, Devices, Medical Treatments, and Tests
• Mechanical Stretching Devices
• Procedures for the Management of Chronic Spinal Pain and Chronic Pain
• Sacroiliac Joint Fusion
• Sinus Surgery (Endoscopic)

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

EFFECTIVE JANUARY 1, 2023

EFFECTIVE FEBRUARY 1, 2023

Published January 2023

COMMERCIAL, MARKETPLACE, AND MEDICAID FORMULARIES

New Drugs (recently FDA approved, prior authorization required, Tier 3, non-formulary for MVP Medicaid)

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

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

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 information 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