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.

  • Medical Policy Updates

    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


  • Pharmacy Policy Updates

    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


  • Formulary Updates

    See 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


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