A quarterly publication for MVP Health Care® Providers

Welcome to this issue of Healthy Practices, MVP’s Quarterly newsletter for Providers. Every issue focuses on topics relevant to the current state of health care, as well as MVP policy information, regulatory updates, interview with your peers, and tools and resources to help you provide the best quality of care to your patients in the communities we serve.

• Featured Stories

  Introducing UVM Health Advantage

  MVP has partnered with The University of Vermont (UVM) Health Network to co-create a unique doctor-guided Medicare Advantage plan to meet the specific health care needs of eligible Members in Vermont and northern New York called UVM Health Advantage Medicare Health Plans. Quickly access the information and resources you need by logging in at mvphealthcare.com/members. UVM Health Advantage Select, UVM Health Advantage Secure, and UVM Health Advantage Preferred are Medicare Advantage PPO plans that utilize the existing MVP PPO network, meaning Providers that participate in MVP’s current Medicare Advantage network will be in-network for these Members. Members are not limited to UVM Health Network providers and are not required to select a PCP.

  UVM Health Advantage plans provide care and support services to help your patients take on their health goals and challenges. These new plans include Part D drug coverage and are affordably priced. They also offer many great benefits, such as:

  • Comprehensive hearing, dental, and vision coverage
  • A yearly stipend for over-the-countermedicine and health related items
  • Wellness and care management programs and tools
  • No cost rides to or from medical appointments andfree meal delivery after inpatient hospital stays
  • Access to Gia®—MVP’s 24/7 health care connection featuring $0 virtual care services with behavioralhealth providers and other specialists
  • Tailored support and benefits for patients living with diabetes,including: $0 co-pay for routine podiatry visits; low-costorthotics and diabetic shoes; $0 Freestyle, OneTouch, Precision,or Prodigy glucometer and related supplies; and a free homehealth kit sent to the Member
  • Tailored support and benefits for Members living with heartdisease, including: $0 co-pay for cardiology specialty care officevisits; $0 for all phases of cardiac rehab; free home health kitincluding digital blood pressure cuff and digital pulse oximeter and 12 weeks of home-delivered meals following congestiveheart failure diagnosis
  • Access to a UVM Health Advantage Care Guide to help Membersunderstand their diagnosis and treatment plan while assistingMembers in accessing their full benefits

  To learn more about these new plans, visit UVMHealthAdvantage.com.

  
  Sample UVM Health Advantage Member ID Card

  Telemedicine Podcast

  Our own Dr. Kim Kilby, Vice President, Medical Director for Health and Well-Being at MVP, recently sat down with Dr. Tucker Slingerland, CEO of Hudson Headwaters Health Network in upstate New York to discuss telehealth in general, and how we can all work together to achieve an optimal virtual-to-physical-care continuum in the future. In the podcast, the two doctors discuss how Hudson Headwaters increased their usage of telemedicine during COVID, how they’re using it now, and what they see the future of telemedicine vs. in-person visits. According to Dr. Slingerland, “We embraced it out of necessity, but it’s become a part of standard practice for now, especially for certain outpatient encounters. And I definitely feel it’s here to stay and it’s a great addition to our toolbox of ways in which we can connect with patients and their families.” He also states, “We really are going need closer relationships with key contributors, locally and regionally, and that includes insurance providers. Those folks have access to incredible amounts of data and a perspective that we don’t have.”

  Listen to the podcast now at mvphealthcare.com/providers/podcast.

  Attestation Exclusionary Database Monitoring

  Effective April 1, 2017, contracted Medicaid Providers and provider groups must have procedures in place to identify and monitor exclusionary status of employees and staff through the regular checks of New York State and Federal exclusionary databases.

  MVP requires the return of the completed form annually. It can be found at mvphealthcare.com/providers, then select Forms, then select Medicaid. After completion the form should be returned to ProviderAttestation@mvphealthcare.com.

  Additionally, a letter was sent to all Providers in the MVP commercial network outlining the regulatory requirement for Cultural and Linguistics Competency training to be completed annually. The training is helpful when assessing the diverse needs of MVP Membership. If you were notified of this requirement, please be sure to complete the training at mvphealthcare.com/culturalcompetency.

  
  

• Additional Information This Quarter

  New Pharmacy Electronic Prior Authorization Process Now Available

  On December 1, 2021, MVP launched a new tool to manage electronic prior authorizations (PA) for pharmacy and medical drug claims for Members in all plans.

  The MVP electronic PA system, powered by NovoLogix, provides a streamlined request process for medical pharmaceutical (HCPCS & CPT), pharmacy medications, and select supplies such as diabetic test strips. In addition, this new process:

  • Facilitates a rapid electronic PA intake process that allows Providers to run a test claim to see if PA is needed
  • Collects additional information (if PA is needed) and sends the PA directly to an MVP Medical Director for approval or denial
  • Provides status updates in real time so you know immediately if PA is not required (if PA is needed, you will receive a timely response if the PA is approved or denied)

  To access the NovoLogix tool, login to your Provider online account at mvphealthcare.com. Under Authorizations, select Pharmacy Request. From here Providers can initiate a PA, which will run a test claim to determine if PA is needed. Providers will be immediately notified if they submit a request for a Member who does not have pharmacy benefits through MVP.

  Training resources are available by logging in to your Provider online account. Providers who do not have access to their online account may request access at mvphealthcare.com/ProviderRegister.

  MVP D-SNP Plan Effective January 1, 2022

  As we announced in the Fall 2021 issue of Healthy Practices, as of January 1, 2022, MVP is now offering a new D-SNP plan for enrolled individuals dually eligible for Medicare and Medicaid in the Capital Region and the Hudson Valley. Special Needs Plans (SNPs) are a type of Medicare Advantage (MA) plan designed for individuals with special needs focusing on intensive care coordination.

  Important billing information to remember:

  • Be sure to bill and send prescriptions to the pharmacy using the Member Medicare ID card
  • Be sure to submit prior authorization requests using the Member Medicare ID card
  • Follow Medicare billing and coverage practices, including billing for immunizations through the Part D benefit where applicable

  As a reminder, we have created a training document with complete information about the new D-SNP plan at mvphealthcare.com/DSNPeducation.

  If you have any questions, please contact yourMVP Professional Relations Representative.

  Understanding Medicare Members’ Health Care Experience

  To measure your patients’ well-being and perception of their health care providers, services,
  and plan, the Centers for Medicare & Medicaid Services (CMS) sends an annual Consumer Assessment
  of Healthcare Providers and Systems (CAHPS®) survey. Understanding this assessment and how you can positively impact the results can help to improve Medicare Members’ health and well-being and increase the Member-experience ratings.

  Administered between March and June, CAHPS® focuses on quality aspects that Members are best qualified to evaluate (i.e., Provider communication skills and ease of access to care). More information is available at ma-pdpcahps.org.

  MVP Invites You to Connect with Us

  Granting MVP remote access to your electronic health records (EHRs) helps your practice run more efficiently. The MVP IT department will work with your office’s IT staff to establish a successful and secure connection to safeguard our Members’ PHI. To learn more, visit mvphealthcare.com/providers/quality-programs and select Learn how to grant MVP remote access.

  Understanding Medicare Members’ Health Care Experience

  To measure your patients’ well-being and perception of their health care providers, services, and plan, the CMS sends an annual Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey. Understanding this assessment and how you can positively impact the results can help to improve Medicare Members’ health and well-being and increase the Member-experience ratings.

  Administered between March and June, CAHPS® focuses on quality aspects that Members are best qualified to evaluate (i.e., Provider communication skills and ease of access to care). More information is available at ma-pdpcahps.org.

  
  

• Quality Corner

  New Study Underscores the Importance of HPV Vaccine

  A new study, published in The Lancet on November 3, 2021, found that the HPV vaccine significantly lowered cervical cancer rates in the United Kingdom since it was introduced in 2008.

  Researchers analyzed data from a population-based cancer registry in the U.K. and looked for diagnoses of cervical cancer and CIN3 (abnormal cells that grow in the cervix that can lead to cancer) in women ages 20 to 64 years old from January 1, 2006, to June 30, 2019.

  Study outcomes showed that rates of cervical cancer were 87% lower in women who were given the HPV vaccine between the ages of 12 and 13 compared to previous generations. The rates shifted slightly according to the age at which a woman got the HPV vaccine.

  Why it Matters

  According to the CDC, HPV is the most common sexually transmitted infection in the United States with nearly 80 million people currently infected with the virus, and millions of new cases every year. Long-lasting infection of HPV is the main cause of cervical cancer, and the American Cancer Society estimates 14,480 new cases of invasive cervical cancer to be diagnosed this year and an estimated 4,290 women will die from the disease.

  Bottom Line

  The HPV vaccine can dramatically lower the risk of developing cervical cancer, as well as other forms of cancer. Vaccinating children when they are 11 or 12 years old can dramatically lower their risk. For patients and/or caregivers who are hesitant about the HPV vaccine, providers now have data to show that the HPV vaccine works, and that it is safe, effective, and reduces the risk of cervical cancer.

  Estimated Relative Reduction in Cervical Cancer Rates

  By Age at Time of Vaccine	Age Group Reduction Rate
  12–13	87%
  14–16	62%
  16–18	34%

  Colorectal Cancer in the US

  Colorectal cancer screenings can detect early signs of colorectal cancer. When issues are detected early, treatment is more effective. The American Cancer Society recommends the following for Members at average risk for colorectal cancer:

  • Start regular screenings at age 45
  • Members in good health should continue regular screenings through age 75
  • For Members ages 76 – 85, the decision to be screened should be based on patient preference, life expectancy, overall health, and prior screening history
  • Members over 85 should no longer get colorectal cancer screening

  Recommendations for Members at high risk (based on family and/or personal history):

  • Screening should start before age 45
  • More frequent screenings
  • Specific screenings

  Estimated Number of New Cases

  Colon Cancer	104,270
  Rectal Cancer	45,230

  Estimated Number of Deaths

  Colon and rectal cancers combined

  52,980

  Five-Year Relative Survival Rate for Early-Stage

  Colon Cancer	91%
  Rectal Cancer	89%

  Source: cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2021.html

  HEDIS Measure: Kidney Health Evaluation for Patients with Diabetes (KED)

  Here’s what you need to know:

  • The measure includes Members 18-85 years of age with diabetes, type 1 or type 2, who received a kidney health evaluation, defined by an Estimated Glomerular Filtration rate (eGFR) and a Urine Albumin-Creatinine ratio (uACR) during each measurement year. The tests may be done on the same or different dates of service in the year.
  • Members with end-stage renal disease (ESRD) or dialysis anytime in history are excluded from the measure. Members receiving Palliative Care services during the measurement year are also excluded.
  • KED is an “administrative” measure. This means that it is not necessary to submit the lab reports to MVP for gaps in care documentation. Claims for services will close the KED gap.

  Please reach out to our Quality Review staff at mvpgapclosures@mvphealthcare.com for questions related to this or any other HEDIS measures.

  Colon Cancer is: Preventable. Treatable. Beatable.

  Participating Providers can access their MVP gaps in care report to help determine the best course of action to meet the health care needs of your patients, our Members. To further help support your effort for Members who may need to complete a colorectal cancer screening, MVP has partnered with Exact Sciences, the makers of Cologuard® at-home screening kits. To learn more, contact your MVP Professional Relations representative.

  Heart Health Focus

  Controlling High Blood Pressure

  According to the American Heart Association, approximately 121.5 million adults (about 1 in 2) in the United States have high blood pressure (BP). Nearly half of those people don’t have their blood pressure controlled putting millions of Americans at risk for serious health issues such as heart attack, stroke, and death. Following evidence-based treatment guidelines, together with your clinical judgment and understanding of a Member’s unique needs, can help you get their BP under control.

  Recommended Treatment For Each BP Threshold

  mm Hg	Recommended Action	When to Reassess
  Normal <120/80	Promote optimal lifestyle habits	One year
  Elevated 120–129/<80	Non-pharmacological therapy	Three–six months
  Stage One Hypertension 130–139/80–89	Does this patient have clinical ASCVD, Diabetes, CKD or an estimated 10-year CVD risk ≥ 10%?	Yes Non-pharmacological therapy and BP-lowering medication—One month No Non-pharmacological therapy—three–six months
  Stage Two Hypertension ≥140/90	Non-pharmacological therapy and BP-lowering medication	One month

  Source: American Heart Association

  Self-measured blood pressure (SMBP)

  SMBP monitoring enables providers to better diagnose and manage hypertension — and helps Members to take an active role in the process. Treatment guidelines call for more emphasis on SMBP for high blood pressure diagnosis, treatment, and management. Providers need to train Members to accurately monitor themselves at home. Providers can accept BP readings from remote monitoring devices taken by the Member from any digital device.

  To help MVP Medicare Advantage Members living with hypertension keep up with regular testing, MVP offers a home blood pressure cuff at no additional cost to the Member. They can order a free home blood pressure cuff from DME Supply USA at 1-844-361-8264, Monday–Friday 8 am–5 pm, or they can visit dmesupplyusa.com/mvp and select Hypertension.

  Using CPT II codes to improve quality of care and outcomes

  Utilizing CPT II tracking codes offer a more complete picture of the Member’s health and can help you close gaps in care tied to Controlling Blood Pressure HEDIS® measure. Using CPT II codes for performance measurement will reduce the need for chart reviews, further reducing administrative burdens on your staff.

  CPT II Code

  3047F	Most recent systolic blood pressure less than 130 mm Hg
  3075F	Most recent systolic blood pressure 130–139 mm Hg
  3077F	Most recent systolic blood pressure greater than or equal to 140 mm Hg
  3078F	Most recent diastolic pressure less than 80 mm Hg
  3079F	Most recent diastolic pressure 80–89 mm Hg
  3080F	Most recent diastolic pressure greater than or equal to 90 mm Hg

  American Heart Month is the perfect time to share MVP’s The Heart of the Matter education series with Members who are interested in learning more about how blood pressure affects the heart and why it’s so important to their overall health. Visit mvphealthcare.com/hhes to access all five webinars.

  
  

• Pharmacy Policy & Formulary Updates

  Below is a recap of the Pharmacy and Formulary updates that went into effect from September 1–February 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 SEPTEMBER 2021

  Pharmaceutical Policy Name	Status
  Select Injectables for Asthma	Updated
  Idiopathic Pulmonary Fibrosis	Updated
  Cystic Fibrosis (Select Agents for Inhalation)	Updated
  Cystic Fibrosis (Select Oral Agents)	Updated
  Intranasal Corticosteroids	Archived
  Medicare Transition Policy for 2022 (effective January 1, 2022)	Reviewed/No Changes
  Pain Medications	Updated
  Preventive Services	Updated
  Proton Pump Inhibitor Therapy	Updated
  Quantity Limits for Prescription Drugs	Updated
  Dupixent	New
  Onychomycosis	Updated
  Medicaid/HARP Medication Therapy Management Program	Archived
  Benlysta	Archived
  Mepron	Archived
  Minocycline ER	Archived
  Weight Loss Agents	Archived
  Atopic Dermatitis	Archived

  EFFECTIVE OCTOBER 2021

  Pharmaceutical Policy Name	Status
  Methotrexate Autoinjector	Updated
  Ankylosing Spondylitis Drug Therapy	Updated
  Inflammatory Biologic Drug Therapy	Updated
  Psoriatic Arthritis Drug Therapy	Updated
  Rheumatoid Arthritis Drug Therapy	Updated
  Gout Treatments	Updated
  Pulmonary Hypertension (Advanced Agents) Commercial	Reviewed/No Changes
  Pulmonary Hypertension (Advanced Agents) Medicaid and HARP	Reviewed/No Changes
  PCSK9 Inhibitors	Updated
  Epinephrine Autoinjector	Reviewed/No Changes
  Cialis for BPH	Updated
  Transthyretin-Mediated Amyloidosis	Updated
  ACL Inhibitors	Reviewed/No Changes
  Preventive Care Drug List (effective January 1, 2022)	Updated
  Multiple Sclerosis Agents (effective August 1, 2021)	Updated
  Aduhelm (effective June 17, 2021)	New
  CAR-T Cell Therapy (effective August 1, 2021)	Updated
  Immunoglobulin Therapy (effective July 18, 2021)	Updated
  Psoriasis Drug Therapy	Updated
  Disposable Insulin Delivery Devices – Medicaid (effective July 22, 2021)	New

  EFFECTIVE DECEMBER 2021

  Pharmaceutical Policy Name	Status
  Chelating Select Agents	Updated
  Gaucher Disease Type 1 Treatment	Updated
  Hereditary Angioedema	Updated
  Colony Stimulating Factors	Updated
  Enteral Therapy – New York	Updated
  Enteral Therapy – Vermont	Updated
  Lidocaine (Topical) Products	Updated
  Diclofenac (Topical) Products	Updated
  Adakveo	Reviewed/No Changes
  Erythropoiesis Stimulating Agents (ESAs)	Reviewed/No Changes
  Hemophilia Factor	Updated
  Patient Medication Safety	Updated
  Dojolvi	New
  Cystic Fibrosis (Select Agents for Inhalation) (effective October 1, 2021)	Updated
  Preventive Services – Medications (effective September 1, 2021)	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 FOR COMMERCIAL, MARKETPLACE, AND MEDICAID FORMULARIES

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

  DRUG	INDICATION
  Brexafemme (Non-formulary for Medicaid)	Vulvovaginal Candidiasis
  Kerendia (Non-formulary for Medicaid)	Diabetic Kidney Disease
  Bylvay (Non-formulary for Medicaid)	Progressive Familial Intrahepatic Cholestasis
  Saphnelo (medical)	Moderate-to-Severe Systemic Lupus Erythematosus
  Azstarys (Non-formulary for Medicaid)	Attention Deficit Hyperactivity Disorder
  Kloxxado (Non-formulary for Medicaid)	Opioid Overdose
  Rylaze (medical)	Acute Lymphoblastic Leukemia and Lymphoblastic Lymphoma in patients who are allergic to E.coli-derived asparaginase products
  Nexviazyme (medical)	The treatment of late onset Pompe disease (Glycogen storage disease type II) in patients aged 1year and older
  Welireg (Non-formulary for Medicaid)	The treatment of adults with von Hippel-Lindau disease who requires therapy for associated renal cell carcinoma, central nervous system hemangioblastomas, or pancreatic neuroendocrine tumors, not requiring immediate surgery
  Loreev XR (Non-formulary for Medicaid)	Management of anxiety disorders or short-term (≤4 months) relief of anxiety
  Exkivity (Non-formulary for Medicaid)	The treatment of locally advanced or metastatic Non-small cell lung cancer with EGFR 20 insertion mutations, in adults whose disease has progressed on or after platinum-based chemotherapy
  Tivdak (medical)	The treatment of recurrent or metastatic cervical cancer in adults with disease progression on or after chemotherapy
  Livmarli (Non-formulary for Medicaid)	The treatment of cholestatic pruritus in patients aged 1 year and older with Alagille syndrome
  Qulipta (Non-formulary for Medicaid)	The preventive treatment of episodic migraine in adults
  Skytrofa (Non-formulary for Medicaid)	The treatment of patients aged 1 to 17 years who weigh at least 11.5 kg and have growth failure due to inadequate secretion of endogenous growth hormone
  Tavneos (Non-formulary for Medicaid)	The treatment of anti-neutrophil cytoplasmic antibody associated vasculitis in combination with immunosuppressants
  Trudhesa (Non-formulary for Medicaid)	The treatment of acute migraine with or without aura in adults
  Lybalvi (Non-formulary for Medicaid)	The treatment of adults with schizophrenia, and the treatment of adults with bipolar I disorder, including acute treatment of manic or mixed episodes as monotherapy or as adjunct to lithium or valproate, and as maintenance monotherapy treatment
  Opzelura Cream (Non-formulary for Medicaid)	The short-term and non-continuous chronic treatment of mild-to-moderate atopic dermatitis in non-immunocompromised patients aged 12 years and older whose disease is not adequately controlled with topical prescription therapies, or when those therapies are not advisable

  DRUGS REMOVED FROM PRIOR AUTHORIZATION- COMMERCIAL AND EXCHANGE

  Verquvo (Non-formulary for Medicaid)

  Cabenuva (Medical)

  Bronchitol (Non-formulary for Medicaid)

  Tepmetko (Non-formulary for Medicaid)

  Cosela (Medical)

  Margenza (Medical)

  Barhemsys (Medical)

  Elepsia XR (Non-formulary for Medicaid)

  Fotivda (Non-formulary for Medicaid)

  Qelbree (Non-formulary for Medicaid)

  Orgovyx (Non-formulary for Medicaid)

  Nextstellis (Non-formulary for Medicaid)

  Jemperli (Medical)

  Kimyrsa (Medical)

  Rybrevant (Medical)

  DRUG EXCLUSION

  • Imcivree (Medicaid)
  • Klisyri (Commercial / Exchange / Medicaid)
  • Lupkynis (Commercial / Exchange / Medicaid)
  • Roszet (Commercial / Exchange / Medicaid)
  • Zealogue (Commercial / Exchange / Medicaid)
  • Accrufer (Commercial / Exchange / Medicaid)
  • Exservan (Commercial / Exchange / Medicaid)
  • Dextenza (Commercial / Exchange / Medicaid)

  NEW GENERICS

  Brand name	Generic name	Commercial	Medicaid	Exchange
  Sutent	Sunitinib	Tier 1 and oral chemo copay	Tier 1	Tier 2 and oral chemo copay
  Epaned	Enalapril oral solution	Tier 1	Tier 1 (Brand will be Tier 2)	Tier 2
  Belbuca	Buprenorphine Buccal Film	Tier 1 with Quantity limit 60 films per 30 days	Tier 1 with Quantity limit 60 films per 30 days	Tier 2 with Quantity limit 60 films per 30 days
  Bystolic	Nebivolol	Generic- Tier 1; Brand- Tier 2	Generic- Tier 1; Brand- Tier 2	Generic- Tier 2; Brand- Tier 2
  Paxil suspension	Paroxetine suspension	Tier 1	Tier 1	Tier 2
  Durezol	Difluprednate	Tier 1	Tier 1	Tier 2
  Chantix	Varenicline	Tier 1 (Brand Tier 2). Both brand and generic have a 168-day supply per calendar year maximum.	Tier 1 (Brand Tier 2).	Tier 2 (Brand Tier 2). Both brand and generic have a 168-day supply per calendar year maximum.
  Affinitor	Everolimus	Tier 1	Tier 1	Tier 2

  Unless noted above, all other brands are Non-formulary, Tier 3

  MISCELLANEOUS UPDATES

  ALL LINES OF BUSINESS

  Due to recent attention of off-label use of ivermectin tablets for COVID-19 treatment, MVP added a point-of-sale safety edit with a quantity limit of nine tablets per 90 days. This applies to all lines of business and will be effective as soon as coding can be put into place.

  COMMERCIAL / EXCHANGE FORMULARY – EFFECTIVE JANUARY 1, 2022

  2022 Formulary Updates for Commercial and Exchange

  Drug	Action	Notes
  Betaseron	Remove prior authorization Move from Tier 3 to Tier 2	Multiple Sclerosis policy has been updated and brought to October 2021 Pharmacy & Therapeutics Meeting
  Saxenda	Move from Tier 3 to Tier 2
  Wegovy	Move from Tier 3 to Tier 2
  Zenpep	Move from Tier 3 to Tier 2

  High-Cost Drug Exclusions and Utilization Management for Commercial and Exchange

  Drug	Action	Formulary Alternatives	Effective Date
  Mefenamic capsules	Add a quantity limit of 14 capsules per 30 days	Etodolac ER, ibuprofen tablets, meloxicam, nabumetone	December 1, 2021
  Flurandrenolide cream 0.05%	Add a quantity limit of 60g per 30 days	Prior authorization only required if the quantity limit is exceeded	December 1, 2021
  Flurandrenolide lotion 0.05%	Exclude high cost NDC (51672-5298-08) and add a quantity limit of 120ml per 30 days	Prior authorization only required if the quantity limit is exceeded	December 1, 2021
  Flurandrenolide ointment 0.05%	Add a quantity limit of 60g per 30 days	Prior authorization only required if the quantity limit is exceeded	December 1, 2021
  Triamcinolone ointment 0.05%	Exclude	Triamcinolone ointment 0.1%	December 1, 2021
  Diflorasone cream	Add a quantity limit of 60g per 30 days	Prior authorization only required if the quantity limit is exceeded	December 1, 2021
  Ketoconazole cream	Add a quantity limit of 120g per 30 days	Prior authorization only required if the quantity limit is exceeded	December 1, 2021
  Clobetasol ointment 0.05%	Add a quantity limit of 120g per 30 days	Prior authorization only required if the quantity limit is exceeded	December 1, 2021

  MEDICAID FORMULARY – EFFECTIVE DECEMBER 1, 2021

  Medicaid Over the Counter Exclusions

  Drug	Action	Formulary Alternatives
  Liquid Multivitamins not covered on FFS (GPI 78310000000900) such as Centrum liquid, Alive, Lysiplex	Exclude	Various multivitamin with minerals as tablets, capsules
  Gummy multivitamins not covered on FFS (GPI 78421000000500) such as Zoo Friends, Vitachew, Flintstones, Vitalets	Exclude	Various multivitamins as tablets, capsules, suspensions, drops, chewables
  Eye vitamins that are not covered on FFS (GPI 78310000000100) examples: Preservision, Ocuvite, Viteyes, Zyvana, Multipro	Exclude	Various Multi-vitamin capsules under GPI 78200000000100 and Dekas Plus capsules
  Immune system vitamins that are not covered on FFS (GPI 78310000000800) such as Airshield, Airborne, Berocca	Exclude	Not a covered service; alternatives would be various multi-vitamin capsules
  Multivitamins not covered on FFS (GPI 78350000000300) such as Essential one tablets, One-A-Day, Signacal tablets	Exclude	Various multivitamins as tablets, capsules
  Chewable Multivitamins with iron not covered on FFS (GPI 78430000000515) such as Bite-A-Mins, QC Children’s, Fruity Chews	Exclude	Various pediatric multi-vitamins with irons (drops, chewable tablets 18mg) under GPIs 78430000002010, 78430000000518, 78430000002012
  Acetaminophen chewable and disintegrating tablets	Exclude	Acetaminophen tablets, suspension, solution, suppository
  Albumin test strips	Exclude	Not a covered service
  Simethicone liquid	Exclude	Simethicone chewables, tablets and suspension
  Antihistamine-pseudoephedrine combinations (such as fexofenadine + pseudoephedrine, loratadine + pseudoephedrine, cetirizine + pseudoephedrine	Exclude	Individual ingredients covered
  Throat lozenges (Dentiva, Salese)	Exclude	Not a covered service
  Dextromethorphan/guaifenesin granules	Exclude	Dextromethorphan/guaifenesin syrup, tablets, liquid
  Omega-3 fatty acid capsules, delayed release, and liquid (such as Fish Oil, Ovega-3, Theromega, Eskimo)	Exclude	Not a covered service
  Phenazopyridine 95mg, 97.5mg tablets	Exclude	Phenazopyridine 100mg, 200mg tablets
  Docosahexaenoic acid capsules (DHA) such as Super DHA, Atabex	Exclude	Various Prenatal vitamins with DHA
  Hydrocortisone 1% gel, lotion, and with aloe vera	Exclude	Hydrocortisone 1% cream, ointment
  Miconazole 2% powder (such as Zeasorb-AF powder)	Exclude	Tolnaftate powder
  Cobalamin combination tablets (GPI 82991000000300) such as Folic+ B12 tablets,	Exclude	Individual ingredients covered
  Prevident Solution 0.2%, Sodium Fluroride solution 0.2%	Exclude	Dentagel 1.1%, deta 5000 cream plus
  Fluticasone 50MCG nasal spray (prescription version)	Exclude	Fluticasone 50MCG nasal spray (OTC version)
  Levomefolic acid (5-MTHF) capsule	Exclude	Not a covered service
  Liquid Multivitamins not covered on FFS (GPI 78310000000900) such as Centrum liquid, Alive, Lysiplex	Exclude	Various multivitamin with minerals as tablets, capsules
  Gummy multivitamins not covered on FFS (GPI 78421000000500) such as Zoo Friends, Vitachew, Flintstones, Vitalets	Exclude	Various multivitamins as tablets, capsules, suspensions, drops, chewables
  Eye vitamins that are not covered on FFS (GPI 78310000000100) examples: Preservision, Ocuvite, Viteyes, Zyvana, Multipro	Exclude	Various Multi-vitamin capsules under GPI 78200000000100 and Dekas Plus capsules
  Immune system vitamins that are not covered on FFS (GPI 78310000000800) such as Airshield, Airborne, Berocca	Exclude	Not a covered service; alternatives would be various multi-vitamin capsules
  Multivitamins not covered on FFS (GPI 78350000000300) such as Essential one tablets, One-A-Day, Signacal tablets	Exclude	Various multivitamins as tablets, capsules
  Chewable Multivitamins with iron not covered on FFS (GPI 78430000000515) such as Bite-A-Mins, QC Children’s, Fruity Chews	Exclude	Various pediatric multi-vitamins with irons (drops, chewable tablets 18mg) under GPIs 78430000002010, 78430000000518, 78430000002012
  Acetaminophen chewable and disintegrating tablets	Exclude	Acetaminophen tablets, suspension, solution, suppository
  Albumin test strips	Exclude	Not a covered service
  Simethicone liquid	Exclude	Simethicone chewables, tablets and suspension
  Antihistamine-pseudoephedrine combinations (such as fexofenadine + pseudoephedrine, loratadine + pseudoephedrine, cetirizine + pseudoephedrine	Exclude	Individual ingredients covered
  Throat lozenges (Dentiva, Salese)	Exclude	Not a covered service
  Dextromethorphan/guaifenesin granules	Exclude	Dextromethorphan/guaifenesin syrup, tablets, liquid
  Omega-3 fatty acid capsules, delayed release, and liquid (such as Fish Oil, Ovega-3, Theromega, Eskimo)	Exclude	Not a covered service
  Phenazopyridine 95mg, 97.5mg tablets	Exclude	Phenazopyridine 100mg, 200mg tablets
  Docosahexaenoic acid capsules (DHA) such as Super DHA, Atabex	Exclude	Various Prenatal vitamins with DHA
  Hydrocortisone 1% gel, lotion, and with aloe vera	Exclude	Hydrocortisone 1% cream, ointment

  MEDICAID FORMULARY – EFFECTIVE DECEMBER 1, 2021

  High-Cost Drug Exclusions and Utilization Management for Medicaid

  Drug	Drug	Drug
  Triamcinolone ointment 0.05%	Exclude	Triamcinolone ointment 0.1%
  Ketoconazole cream	Add a quantity limit of 120g per 30 days	Prior authorization only required if the quantity limit is exceeded

  
  

• Medical Policy Updates

  EFFECTIVE DECEMBER 1, 2021

  Below is a recap of the Medical Policies that went into effect December 1, 2021. All policies are reviewed at least once annually. For more detailed information on these changes, please review mvphealthcare.com/Fastfax or visit mvphealthcare.com/Providers and Sign In to your account, and select Resources, then Medical Policies.

  Medical Policy Name	Status
  Assertive Community Treatment (ACT)	Updated
  Biventricular Pacing	New Policy
  Continuous Glucose Monitoring	Updated
  Electrical Stimulation Devices and Therapies	Updated
  Home and Community Based Services (Adult)	Reviewed / No changes
  Imaging Procedures	Updated
  Infertility Services (Advances) and IVF	Updated
  Insulin Infusion Pumps	Updated
  Investigational Procedures	Updated
  Light Therapy for Seasonal Affective Disorder	Reviewed / No changes
  Penile Implants for Erectile Dysfunction	Reviewed / No changes
  Personalized Recovery Oriented Services (PROS)	Reviewed / No changes
  Speech Therapy (Outpatient) and Cognitive Rehabilitation	Updated
  Transcranial Magnetic Stimulation	New Policy
  Transperineal Placement of Biodegradable Material (SpaceOAR™) for Prostate Cancer	New Policy
  Transplants	Reviewed / No changes
  Vision Therapy (Orthoptics, Eye Exercises)	Reviewed / No changes

  
  

• Resource Focus

  The Provider Resource Manual is now called Provider Policies and Payment Policies

  Starting January 1, 2022, MVP will no longer use the name “Provider Resource Manual” to refer to its policies. For better clarity, we have changed the name to Provider Policies and Payment Policies. Policies are updated quarterly and can be found at mvphealthcare.com/policies. The page contains the most current provider and payment policies at the top of the page. In the center of the page, the policies are listed with an indication of the date of their last update. At the bottom of the page, you will find an archive of previous policies for your reference. If you have any questions, please reach out to your Professional Relations Representative.

  Provider Policies Updated as of January 1, 2022

  • MVP Network Vendors
  • MVP Plan Type
  • Claims
  • MVP Medicare Advantage Plans
  • NYS Government Programs Payment Policies updated

  Payment Policies Updated as of January 1, 2022

  • Audio Only (VT Only) (New policy)
  • EyeMed Payment Policy (New policy)
  • Aft er Hours
  • Allergy Testing and Serum Preparation Claims
  • Mental Health and Substance Use Disorder
  • Contrast Materials
  • JW Modifier
  • Preoperative Lab Testing
  • Preventive Health Care
  • Radiology
  • Shared Split Visits—Policy archived
  • Virtual Check-ins

  
  

• MVP in the Community

  Concerned for the Hungry

  

  On November 18, 2021, MVP assisted in packaging up fruits and vegetables which were distributed to families in need for their Thanksgiving dinner. Our efforts supported Concerned for the Hungry, Inc., which is an entirely volunteer organization working to fight hunger throughout Schenectady County.

  
  

Use the link below to review previous issues of Healthy Practices and find previously published information and articles from MVP.

More Healthy Practices