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.

Pharmacy Policy Updates
Published January 2024
Review Pharmaceutical policy updates from the last quarter of 2023. Read More

Formulary Policy Updates
Published January 2024
Review Formulary policy updates from the last quarter of 2023. Read More

Medical Policy Updates
Published January 2024
Review Medical policy updates from the last quarter of 2023. Read More

  • October 2023 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.

  • October 2023 Formulary Updates
    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.

    DRUG INDICATION
    Filspari™(sparsentan) The reduction in proteinuria in adults with primary immunoglobulin A nephropathy at risk of rapid disease progression (generally a urine protein-to-creatinine ratio greater than or equal to 1.5 g/g)
    Skyclarys™ (omaveloxolone) The treatment of Friedreich's ataxia in patients aged 16 years and older
    Lamzede® (velmanase alfa-tycv) The treatment non-central nervous system manifestations of alpha-mannosidosis in adults and pediatrics
    Daybue™ (trofinetide) The treatment of Rett syndrome in patients aged 2 years and older
    Zynyz™ (retifanlimab-dlwr) The treatment of metastatic or recurrent locally advanced Merkel cell carcinoma in adults
    Joenja® (leniolisib) The treatment of activated phosphoinositide 3-kinase delta syndrome in patients aged 12 years and older
    Konvomep™ (omeprazole/ sodium bicarbonate) The treatment of active benign gastric ulcer and the reduction of risk of upper gastrointestinal bleeding in critically ill patients, in adults
    Atorvaliq® (atorvastatin) The reduction in risk of myocardial infarction (MI), stroke, revascularization procedures, and angina in adults with multiple risk factors for coronary heart disease (CHD) but without clinically evident CHD, the reduction of risk of MI and stroke in adults with type 2 diabetes mellitus with multiple risk factors for CHD but without clinically evident CHD, the reduction in risk of non-fatal MI, fatal and non-fatal stroke, revascularization procedures, hospitalization for congestive heart failure, and angina in adults with clinically evident CHD; as an adjunct to diet to reduce low-density lipoprotein (LDL-C) in adults with primary hyperlipidemia and in patients aged 10 years and older with heterozygous familial hypercholesterolemia; as an adjunct to other LDL-C lowering therapies to reduce LDL-C in patients aged 10 years and older with homozygous familial hypercholes-terolemia; and as an adjunct to diet for the treatment of primary dysbetalipoproteinemia or hypertriglycerid-emia in adults
    Rezvoglar™ (insulin glargine-aglr) Biosimilar of Lantus (insulin glargine). The improvement of glycemic control in adults and pediatrics with type 1 diabetes mellitus, and in adults with type 2 diabetes mellitus.
    Iheezo™ Gel (chloroprocaine hydrochloride 3%) Ocular surface anesthesia and intraoperative pain management during ocular surgery
    Cuvrior (trientine) The treatment of adults with stable Wilson's disease who are de-coppered and tolerant to penicillamine
    Omisirge®  (omidubicel) To reduce the time to neutrophil recovery and the incidence of infection in patients aged 12 years and older with blood cancers planned for umbilical cord blood transplantation following a myeloablative conditioning regimen
    Prevduo™ (neostigmine/ glycopyrrolate) The reversal of the effects of non-depolarizing neuromuscular blocking agents (NMBAs) after surgery, while decreasing the peripheral muscarinic effects (e.g., bradycardia and excessive secretions) associated with cholinesterase inhibition following NMBA reversal administration, in patients aged 2 years and older
    Tembexa Tablet® (brincidofovir) The treatment of smallpox infection
    Tembexa Suspension®  (brincidofovir) The treatment of smallpox infection
    Sogroya®  (somapacitan-becol) The treatment of growth hormone deficiency in adults
    Veozah™ (fezolinetant) The treatment of moderate-to-severe vasomotor symptoms associated with menopause
    BabyBIG® (Botulism Immune Globulin Intravenous) The treatment of infant botulism types A and B
    Elfabrio®  (pegunigalsidase alfa-iwkj) The treatment of Fabry disease in adults
    Zavzpret™ (zavegepant) The acute treatment of migraine with or without aura in adults
    Epkinly™ (epcoritamab-bysp) The treatment of relapsed or refractory large B-cell lymphoma after 2 or more lines of systemic therapy
    Vyjuvek™ (beremagenegeperpavec) The treatment of dystrophic epidermolysis bullosa in patients aged 6 months and older
    Uzedy™ (risperidone extended release) The treatment of schizophrenia in adults
    Liqrev® (sildenafil) The treatment of pulmonary arterial hypertension (PAH) to improve adult patients' ability to exercise and to delay clinical worsening
    Abilify Asimtufii® (aripiprazole) The treatment of schizophrenia, and the maintenance monotherapy treatment of bipolar I disorder in adults
    Vowst™ (fecal microbiota spores, live-brpk) The prevention of recurrent Clostridium difficile infection (CDI) in adults following antibacterial treatment for recurrent CDI
    Lumryz™ (sodium oxybate) The treatment of excessive daytime sleepiness and cataplexy in patients with narcolepsy

    Drugs removed from prior authorization- Commercial and Exchange

    Ryaltris
    Auvelity™
    Byooviz®
    Alymsys®
    Cimerli™
    Furoscix
    Terlivaz
    Imjudo
    Tecvayli
    Lytgobi
    Elahere
    Ermeza
    Rezlidhia

    DRUG EXCLUSION

    Rolvedon
    Xelstrym
    Basaglar Tempo pen
    Humalog Tempo pen
    Lyumjev Tempo pen

    DRUG EXCLUSION

    BRAND NAME GENERIC NAME COMMERCIAL MEDICAID EXCHANGE
    Aubagio Teriflunomide Tier 1 (brand Aubagio moves from Tier 2 to Tier 3) NYRX Medicaid Transition Tier 1 (brand Aubagio moves from Tier 2 to Tier 3)
    Millipred Prednisolone tablets Tier 1 NYRX Medicaid Transition Tier 2
    Fleqsuvy Baclofen suspension Tier 1 NYRX Medicaid Transition Tier 2
    Naftin Naftifine gel 2% Tier 1 NYRX Medicaid Transition Tier 2
    Iressa Gefitinib Tier 1 NYRX Medicaid Transition Tier 2
    Firvanq Vancomycin solution Tier 1 NYRX Medicaid Transition Tier 2
    Uceris Budesonide rectal foam Tier 1 NYRX Medicaid Transition Tier 2
    Celontin Methosuximide Tier 1 (brand Tier 2) NYRX Medicaid Transition Tier 2 (brand Tier 2)
    Prezista Darunavir Tier 1 (brand will move Tier 2 to Tier 3 effective 08/01/2023) NYRX Medicaid Transition Tier 2 (brand will move Tier 2 to Tier 3 effective 08/01/2023)

    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

    Calcitriol capsules 0.25mg

    Ropinirole immediate release

    Sucralfata tablet 1gm

    Acamprosate Calcium Delayed Release tablet 333mg

    Levalbuterol nebulizer solution

    Naloxone Nasal Spray 4mg/0.1ml

    Nebivolol tablet

    Pramipexole tablet

    Generic Suprep: Sod Sulfate-Pot Sulf- SOL 17.5-3.13-1.6 GM/177ML

    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.

  • October 2023 Pharmacy Policy Updates
    Published October 2023

    EFFECTIVE AUGUST 1, 2023

    Pharmaceutical Policy Name Status
    Immunoglobulin Therapy Updated
    Pharmacy Programs Administration – Effective 04/01/2023 Updated
    Eylea Updated
    Medicare Part B vs Part D Determination Updated
    Spesolimab – Effective 06/01/2023 New
    Copayment Adjustment for Medical Necessity Reviewed

    EFFECTIVE SEPTEMBER 1, 2023

    Pharmaceutical Policy Name Status
    Cystic Fibrosis (Select Agents for Inhalation) Reviewed
    Xolair Reviewed
    Drug Utilization Review and Monitoring Program Reviewed
    Specialty Drug Procurement ExceptionEffective 07/01/2023 Archived
    Cystic Fibrosis (Select Oral Agents) Updated
    Select injectable for Asthma Updated
    Idiopathic Pulmonary Fibrosis Updated
    Pharmacy Programs Management Effective 07/01/2023 Updated
    C. difficile Drug Therapy Effective 08/01/2023 New
    Certolizumab Updated
    Preventative Services- Medication Updated
    Quantity Limits for Prescription Drugs Updated

    EFFECTIVE OCTOBER 1, 2023

    Pharmaceutical Policy Name Status
    Calcitonin Gene-Related Peptide (CGRP) Antagonists  Updated
    PCSK9 Inhibitors Updated
    Pulmonary Hypertension (Advanced Agents) Commercial Updated
    Pulmonary Hypertension (Advanced Agents) Medicaid and HARP Updated
    Pain Medications Updated
    Epinephrine Autoinjector Reviewed
    Migraine Agents Updated
    Cialis for BPH Reviewed 
    Gout Agents Reviewed
    Transthyretin-Mediated Amyloidosis Therapy Updated
    ACL Inhibitors Updated 
    Methotrexate Autoinjector Reviewed
    Syfovre New
    Infliximab Updated
    Orphan Drug(s) and Biologicals Updated
    GLP-1 Receptor Agonists (prospective) Effective 08/01/2023 New
    Patient Medication Safety Reviewed
    Enteral Therapy New York  Updated
    AduhelmEffective 08/01/2023 Updated
  • July 2023 Medical Policy Updates

    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)
  • July 2023 Pharmacy Policy Updates
    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

    Pharmaceutical Policy Name

                             Status

    SGLT2 Inhibitors- Medicaid

    Archived

    Hepatitis C Treatment- Medicaid

    Archived

    Disposable Insulin Delivery Devices- Medicaid

    Archived

    Infertility Drug Therapy- Medicaid/HARP

    Archived

    Lidocaine (topical) Products

    Archived

    Transgender Hormone Therapy- Medicaid/HARP

    Reviewed/No changes

    Male Hypogonadism

    Reviewed/No changes

    Multiple Sclerosis Agents

    Reviewed/No changes

    Pulmonary Hypertension (Advanced Agents)-Medicaid/HARP

    Reviewed/No changes

    Hemophilia Factor

    Reviewed/No changes

    Diclofenac (topical) Products

    Updated

    Select Hypnotics

    Updated

     

    EFFECTIVE JUNE 1, 2023

    Pharmaceutical Policy Name

                                 Status

    Mail Order

    Updated

    Dupixent

    Updated

    Valchlor

    Updated

    Onychomycosis

    Updated

    Cosmetic Drug Agents

    Updated

    Adalimumab

    Updated

    Luxturna

    Reviewed/No changes

    Topical Agents for Pruritis 

    Reviewed/No changes

    Parsabiv 

    Reviewed/No changes

     

    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.

     

    Drug Name

       Indication                                                                                                           

    Rebyota® (fecal microbiota, live-jslm)

    The prevention of recurrence of Clostridioides difficile infection (CDI) in adults, following antibiotic treatment for recurrent CDI

    Krazati® (adagrasib)

    The treatment of adults with KRAS G12C-mutated locally advanced or metastatic non-small cell lung cancer who have received at least one prior systemic therapy

    Lunsumio™ (mosunetuzumab-axgb)

    The treatment of relapsed or refractory follicular lymphoma in adults who have received at least two prior systemic therapies

    Sunlenca® (lenacapavir)

    The treatment of human immunodeficiency virus (HIV)-1 infection in heavily treatment experienced adults with multidrug resistant HIV-1 infection failing their current antiretroviral regimen due to resistance, intolerance, or safety considerations, in combination with an optimized background regimen

    Briumvi™ (ublituximab-xiiy)

    The treatment of relapsing forms of multiple sclerosis, to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults

    Leqembi™ (lecanemab-irmb)

    The treatment of early-stage Alzheimer's disease

    NexoBrid® (anacaulase-bcdb)

    The removal of eschar in adults with deep partial thickness and/or full-thickness thermal burns

    Jaypirca™ (pirtobrutinib)

    The treatment of relapsed or refractory mantle cell lymphoma in patients previously treated with a BTK inhibitor

    Orserdu™ (elacestrant) 

    The treatment of advanced or metastatic estrogen receptor-positive, HER2-negative breast cancer

    Filspari™ (sparsentan)

    The treatment of immunoglobulin A nephropathy in adults

    Stimufend® (pegfilgrastim-fpgk)

    Use to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia (biosimilar of Neulasta)

    Sezaby™ (phenobarbital)

    The treatment of neonatal seizures in term and preterm infants

    Tlando (testosterone undecanoate)

    The treatment of conditions associated with a deficiency or absence of endogenous testosterone in adult men

    Aponvie™ (aprepitant)

    The prevention of postoperative nausea and vomiting in adults

    Amjevita™ (adalimumab-atto)

    The treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, ulcerative colitis, and plaque psoriasis in adults and the treatment of juvenile idiopathic arthritis in patients four years of age and older (biosimilar of Humira)

    Vegzelma® (bevacizumab-adcd)

    The treatment of metastatic colorectal cancer; unresectable, locally advanced, recurrent, or metastatic non-squamous non-small cell lung cancer; recurrent glioblastoma; metastatic renal cell carcinoma; persistent, recurrent, or metastatic cervical cancer; and epithelial ovarian, fallopian tube, or primary peritoneal cancer (biosimilar of Avastin)

    Syfovre™ (pegcetacoplan)

    The treatment of geographic atrophy associated with dry age-related macular degeneration

     


    Drugs removed from prior authorization- Commercial and Exchange

    Entadfi

    Zoryve

     


    New Generics

    NEW GENERICS (all brands will be non-formulary, Tier 3)

    BRAND NAME

    GENERIC NAME

    COMMERCIAL

    MEDICAID

    EXCHANGE

    Xyrem

    Sodium Oxybate solution 

    Tier 3 with PA per GABA-Receptor Modulator policy and QL (Daily Dose Limit= 18)

    Transitioned to NYRx

    Tier 3 with PA per GABA-Receptor Modulator policy and QL (Daily Dose Limit= 18)

    Cambia

    Diclofenac packets

    Tier 1 with QL (QL= 9 packets per 45 days)

    Transitioned to NYRx

    Tier 2 with QL (QL= 9 packets per 45 days)

    Hetlioz

    Tasimelteon

    Tier 1 with PA per Select Hypnotics policy

    Transitioned to NYRx

    Tier 2 with PA per Select Hypnotics policy

    Mirvaso gel

    Brimonidine tartrate ge

    Tier 1 

    Transitioned to NYRx

    Tier 2

    Trokendi XR

    Topiramate capsules ER

    Tier 1

    Transitioned to NYRx

    Tier 2

    Treanda

    Benamustine

    Medical (brand and generic)

    Medical (brand and generic)

    Medical (brand and generic)

    Adrenalin Inj 1mg/ml

    Epinephrine ing 1mg/ml

    Brand Tier 2, Generic Tier 1

    Transitioned to NYRx

    Brand Tier 2, Generic Tier 2

     

    MISCELLANEOUS UPDATES

    Commercial and Exchange

    Formulary Updates for Commercial and Exchange

    Drug Name Action Effective date                                        
    Brand Latuda Move to Tier 3 04/22/2023
    Lurasidone (generic) Add at Tier 1 03/09/2023
    Brand Aubagio Move to Tier 3 05/01/2023
    Teriflunomide (generic) Add at Tier 1 03/16/2023
  • April 2023 Pharmacy Policy Updates
    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

    Pharmaceutical Policy Name

            Status

    Colony Stimulating Factors

    Updated

    Doryx/Oracea

     

    Aduhelm (aducanumab-avwa) 

     

    EFFECTIVE JANUARY 1, 2023

    Pharmaceutical Policy Name

    Status

    Zynteglo

    New Policy

    Skysona

    New Policy

    Drug Utilization Review and Monitoring Program 

    Updated

    Specialty Drug Procurement Exception (Commercial, Exchange, & Select ASO business)

    Updated

    EFFECTIVE FEBRUARY 1, 2023

    Pharmaceutical Policy Name

    Status

    Hepatitis C Treatment Commercial, Marketplace, CHP

    Updated

    Hepatitis C Treatment Medicaid

    Updated

    Lyme Disease/IV Antibiotic Treatment

    Updated

    Enteral Therapy- NY 

    Updated

    Antibiotic/Antiviral (oral prophylaxis)

    Reviewed/No changes

    Compounded (Extemporaneous) Medications

    Reviewed/No changes

    Government Programs Over-the Counter (OTC) Drug Coverage

    Updated

    Preventive Services- Medication

    Updated

    Zinplava

    Reviewed/No changes

    Adalimumab 

    Updated

    Etanercept 

    Updated

    Guselkumab 

    Updated

    Infliximab 

    Updated

    Risankizumab 

    Updated

    Secukinumab 

    Updated

    Ustekinumab 

    Updated

    Apremilast 

    Updated

    Abatacept 

    New Policy

    Certolizumab 

    New Policy

    EFFECTIVE APRIL 1, 2023

    Pharmaceutical Policy Name

    Status

    SGLT2 Inhibitors- Medicaid

    Updated

    Growth Hormone Therapy 

    Updated

    Disposable Insulin Delivery Devices – Medicaid

    Updated

    Metformin ER

    Updated

    Acthar

    Updated

    Select Injectables for Asthma

    Updated

    Zulresso (brexanolone) 

    Updated

    Upadacitinib 

    Updated

    Phenylketonuria Agents

    Reviewed/No changes

    Infertility Drug Therapy (Commercial/Marketplace)

    Reviewed/No changes

    Infertility Drug Therapy (Medicaid/HARP)

    Reviewed/No changes

    Jynarque

    Reviewed/No changes

    Transgender Hormone Therapy (Medicaid/HARP)

    Reviewed/No changes

    Transgender Hormone Therapy (COMM/EXCH/CHP)

    Reviewed/No changes

    Male Hypogonadism

    Reviewed/No changes

    Tepezza

    Reviewed/No changes

    Physician Prescription Eligibility

    Reviewed/No changes

    Prescribers Treating Self or Family Members

    Reviewed/No changes

  • April 2023 Formulary Updates
    Published April 2023

    FOR COMMERCIAL, MARKETPLACE, AND MEDICAID FORMULARIES

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

    Drug Name

    Indication

    Relyvrio™

    (sodium phenylbutyrate and taurursodiol)

    The treatment of amyotrophic lateral sclerosis

    Auvelity™ (bupropion/dextromethorphan)

    The treatment of major depressive disorder in adults

    Rolvedon™ (eflapegrastim-xnst) 

    Used to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with clinically significant incidence of febrile neutropenia

    Pedmark® (sodium thiosulfate)

    The reduction in risk of ototoxicity associated with cisplatin in patients aged 1 month through 17 years with localized, non-metastatic, solid tumors

    Rolvedon™ (eflapegrastim-xnst) 

    Used to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with clinically significant incidence of febrile neutropenia

    Drug Name

    Indication

    Terlivaz®

    (terlipressin)

    The improvement of kidney function in adults with hepatorenal syndrome with rapid reduction in kidney function

    Imjudo® (tremelimumab) 

    The treatment of unresectable hepatocellular carcinoma in adults, in combination with Imfinzi (durvalumab)

    Tecvayli™ (teclistamab-cqyv)

    The treatment of relapsed or refractory multiple myeloma in adults who have received at least 4 prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody

    Lytgobi® (futibatinib)

    The treatment of adults with previously treated unresectable, locally advanced, or metastatic intrahepatic cholangiocarcinoma harboring FGFR2 gene fusions or other rearrangements

    Elahere™ (mirvetuximab)

    The treatment of patients with folate receptor alpha high platinum-resistant ovarian cancer who have been previously treated with 1 to 3 systemic treatments

    Tzield™ (teplizumab-mzwv)

    The delay of clinical type 1 diabetes in at-risk adults and pediatric patients aged 8 years and older 

    Rezlidhia™ (olutasidenib) 

    The treatment of relapsed or refractory acute myeloid leukemia in patients with an IDH1 mutation

    Hemgenix® (etranacogene dezaparvovec)

    The treatment of hemophilia B in adults who currently use Factor IX prophylaxis therapy, or have current or historical life-threatening hemorrhage, or have repeated, serious spontaneous bleeding episodes.

    Furoscix® (furosemide-controlled release on-body infusor)

    The treatment of chronic heart failure

    Xelstrym™

    (dextroamphetamine)

    The treatment of attention deficit hyperactivity disorder in patients aged 6 years and older

    Basaglar® Tempo Pen™ (insulin glargine)

    Tempo Pen™ is a part of Personalized Diabetes Management Platform from Lilly - Prefilled, disposable pen compatible with multiple Lilly insulins;

    Functions similarly to a Lilly KwikPen®;

    Can be used on its own or with the Tempo Smart Button* once available

    Humalog Tempo Pen™ (insulin lispro)

    Tempo Pen™ is a part of Personalized Diabetes Management Platform from Lilly - Prefilled, disposable pen compatible with multiple Lilly insulins;

    Functions similarly to a Lilly KwikPen®;

    Can be used on its own or with the Tempo Smart Button* once available

    Lyumjev Tempo Pen™ (insulin lispro)

    Tempo Pen™ is a part of Personalized Diabetes Management Platform from Lilly - Prefilled, disposable pen compatible with multiple Lilly insulins;

    Functions similarly to a Lilly KwikPen®;

    Can be used on its own or with the Tempo Smart Button* once available

    Ermeza™ (levothyroxine)

    The replacement therapy in primary (thyroidal), secondary (pituitary), and tertiary (hypothalamic) congenital or acquired hypothyroidism, and as an adjunct to surgery and radioiodine therapy in the management of thyrotropin-dependent well-differentiated thyroid cancer

    DRUGS REMOVED FROM PRIOR AUTHORIZATION- COMMERCIAL AND EXCHANGE

    Fylnetra

    Norliqva

    Lyvispah

    Voquezna™ Triple Pak

    Adlarity

    DRUG EXCLUSION

    Rolvedon

    NEW GENERICS

    NEW GENERICS (all brands will be non-formulary, Tier 3)

    Brand Name

    Generic Name

    Commercial

    Medicaid

    Exchange

    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

    Cetrotide Kit

    Cetrorelix acetate

    Tier 1 with QL (9 fills per lifetime)

    Exclude

    Tier 2 with QL (9 fills per lifetime)

    Denavir cream

    Peniciclovir cream 1%

    Tier 1

    Tier 1

    Tier 2

    Zioptan

    Tafluprost PF ophthalmic solution

    Tier 1

    Tier 1

    Tier 2

    MISCELLANEOUS UPDATES

    COMMERCIAL AND EXCHANGE

    Formulary Updates for Commercial/Exchange

    Drug

    Action

    Effective Date

    Sumatriptan 4mg and 6mg injection KITS

    Exclude

    December 1, 2022

    Doxycycline monohydrate 40mg (generic Oracea) and brand Oracea

    Remove prior authorization and quantity limit added (120 capsules per 365 days)

    December 1, 2022

    BRAND Gilenya

    move to Tier 3

    December 1, 2022

    MEDICAID 

    Formulary Updates for Medicaid

    Drug

    Action

    Effective Date

    Sumatriptan 4mg and 6mg injection KITS

    Exclude

    December 1, 2022

    Doxycycline monohydrate 40mg (generic Oracea) and brand Oracea

    Remove prior authorization and quantity limit added (120 capsules per 365 days)

    December 1, 2022

    BRAND Gilenya

    move to Tier 3/Non-Formulary

    December 1, 2022

  • April 2023 Medical Policy Updates
    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)
  • 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, 2023

    PHARMACEUTICAL 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
  • 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 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

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