The following Medical, Pharmacy and Formulary Policy updates below were made in the last quarter. Further details can be found by signing into your Provider Online Account.

All policies are reviewed at least once annually.

  • January 2023 Pharmacy Policy Updates
    Published January 2023

     

    Below is a recap of the Pharmacy and Formulary updates that went into effect from April1 to June 1, 2022. All policies are reviewed at least once annually. For more detailed information on these changes, please review updates at mvphealthcare.com/FastFax.

    EFFECTIVE DECEMBER 1, 2022

     

    PHARMACEUTICAL POLICY NAME  STATUS
    Crohn’s Disease, Select Agents  Archived
    Inflammatory Biologic Drug Therapy  Archived
    Ulcerative Colitis  Archived
    Infliximab
     Updated
    Ustekinumab  New Policy
    Proton Pump Inhibitor Therapy  Updated
    Colony Stimulating Factors
     Reviewed
    Mulpleta/Doptelet
     Reviewed
    Erythropoiesis Stimulating Agents
     Reviewed
    Hereditary Angioedema
     Reviewed
    Irritable Bowel Syndrome
     Updated
    Gaucher Disease Type 1 Treatment
     Updated
    Select Chelating Agents
     Updated
    Hemophilia Factor
     Reviewed
    Adakveo
     Updated
    Dojolvi
     Updated
    Intestinal Antibiotics
     Updated
    Pharmacy Management Programs-External – EFFECTIVE 9/1/2022
     Updated
    Medicare Part D Coverage Determination and Exception Policy
     Updated
    Transthyretin Mediated Amyloidosis
     Updated
    Spravato – EFFECTIVE 8/11/2022
     Updated
    Ankylosing Spondylitis
     Archived
    Rheumatoid Arthritis   Archived
    Psoriasis Drug Therapy
     Archived
    Psoriatic Arthritis Drug Therapy
     Archived
    Rinvoq
     Archived
    Ozanimod
     New Policy
    Upadacitinib
     New Policy
    Secukinumab
     New Policy
    Etanercept
     New Policy
    Adalimumab
     New Policy
    Apremilast
     New Policy
    Risankizumab
     New Policy
    Tocacitinib
     New Policy
    Guselkumab
     New Policy
    Growth Hormone Therapy
     Updated
    Doryx/Oracea  Archived
    Zynteglo
     New Policy
    Skysona  New Policy
    Colony Stimulating Factors
     Updated

     

    EFFECTIVE JANUARY 1, 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

    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 informationon these changes, please review mvphealthcare.com/Fastfax or visit mvphealthcare.com/Providers and Sign In to your account, and select Resources,then Medical Policies.

    EFFECTIVE DECEMBER 1, 2022

     

    • Air Medical Transport
    • Atrial Fibrillation Ablation, Catheter Based
    • Alopecia Treatment
    • Bone Density Study for Osteoporosis (Dexa)
    • BRCA Testing
    • Breast Surgery for Gynecomastia
    • Bronchial Thermoplasty
    • Cardiac Procedures
    • Children’s Family Treatment and Support Services (CFTSS)
    • Cosmetic and Reconstructive Services
    • Dermabrasion
    • Habilitation Services
    • Implantable Cardioverter Defibrillators
    • Intraoperative Neurophysiologic Monitoring
    • Investigational Procedures
    • Lymphedema Compression Garments Compression Stockings
    • Obstructive Sleep Apnea: Devices
    • Oncotype DX and Cancer Gene Expression Tests
    • Orthognathic Surgery
    • Substance Use Disorder Treatment
    • Therapeutic Footwear for Diabetics
    • Vision Therapy (Orthoptics, Eye Exercises)

     

    EFFECTIVE JANUARY 1, 2023

    • Air Medical Transport
    • Applied Behavior Analysis (ABA)
    • Assertive Community Treatment (ACT)
    • Autism Spectrum Disorders (NYS)
    • Children’s Family Treatment and Support Services (CFTSS)
    • Chiropractic Care
    • Early Childhood Developmental Disorders (VT)
    • Ground Ambulance and Ambulette Services
    • Lymphedema Compression Garments
    • Oxygen and Oxygen Equipment
  • October 2022 Pharmacy Policy Updates
    Published October 2022

     

     Pharmaceutical Policy Name  Status
    Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists
    Updated
    PCSK9 Inhibitors
    Updated
    Epinephrine Autoinjector
    Reviewed/No Changes
    Pulmonary Hypertension (Advanced Agents) Commercial
    Reviewed/No Changes
    Pulmonary Hypertension (Advanced Agents) Medicaid/HARP Reviewed/No Changes
    Migraine Agents- Effective September 1, 2022
    Updated
    Transthyretin Mediated Amyloidosis Therapy
    Reviewed/No Changes
    Gout Treatments
    Updated
    ACL Inhibitors
    Reviewed/No Changes
    Methotrexate Autoinjector
    Reviewed/No Changes
    Cialis for BPH
    Reviewed/No Changes
    Orphan Drugs and Biologicals
    Updated
    Specialty Procurement (Commercial, Exchange & Select ASO business only)
    Updated
    Preventive Services-Medication effective – Effective August 1, 2022
    Updated

  • October 2022 Formulary Policy Update
    Published October 2022

     

    Drug Name
     Indication  Commercial and Marketplace Tier  MVP Medicaid  Medicare Part D tier
    Mounjaro (tirzepatide)
    The improvement in blood sugar control in adults with type 2 diabetes, as an addition to diet and exercise
    Prior

    Authorization,

    Tier 3
    Prior

    Authorization,

    Tier 3/Non-Formulary
    Non-Formulary
    Voquezna™ Triple Pak (vonoprazan + amoxicillin + clarithromycin)
    The treatment of Helicobacter pylori infection in adults
    Prior

    Authorization,

    Tier 3
    Prior

    Authorization,

    Tier 3/Non-Formulary
    Non-Formulary
     Ztalmy® (ganaxolone) The treatment of seizures associated with cyclin-dependent kinase-like 5 deficiency disorder in patients aged 2 years and older Prior

    Authorization,

    Tier 3
    Prior

    Authorization,

    Tier 3/Non-Formulary
    Non-Formulary, Tier 5 when RxCui becomes available
    Tpoxx® Inj The treatment of smallpox infection
    Prior Authorization, Medical
    Prior Authorization, Medical
    Non-Formulary
    Tpoxx® Capsule
    The treatment of smallpox infection
    Prior

    Authorization,

    Tier 3
    Prior

    Authorization,

    Tier 3/Non-Formulary
    Non-Formulary
    Lyvispah® (baclofen)
    The treatment of spasticity resulting from multiple sclerosis, particularly for the relief of flexor spasms and concomitant pain, clonus, and muscular rigidity
    Prior

    Authorization,

    Tier 3
    Prior

    Authorization,

    Tier 3/Non-Formulary
    Non-Formulary
    Alymsys®

    (bevacizumab-maly)
    The treatment of metastatic colorectal cancer, in combination with intravenous fluorouracil-based chemotherapy for first- or second-line treatment, and the treatment of metastatic colorectal cancer, in combination with fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy for second-line treatment in patients who have progressed on a first-line bevacizumab product-containing regimen (biosimilar of Avastin)
    Prior Authorization, Medical
    Prior Authorization, Medical
    Prior Authorization, Medical
    Adlarity®

    (donepezil)
    The treatment of mild, moderate, and severe Alzheimer’s dementia
    Prior

    Authorization,

    Tier 3
    Prior

    Authorization,

    Tier 3/Non-Formulary
    Non-Formulary
    Byooviz® (ranibizumab-nuna)
    The treatment of neovascular (wet) age-related macular degeneration, macular edema following retinal vein occlusion, and myopic choroidal neovascularization (biosimilar of Lucentis)
    Prior Authorization, Medical
    Prior Authorization, Medical
    Medical

    Part D- Non-Formulary
    Tyvaso® DPI

    (treprostinil)
    The treatment of pulmonary arterial hypertension and the treatment of pulmonary hypertension associated with interstitial lung disease
    Prior

    Authorization,

    Tier 3
    Prior

    Authorization,

    Tier 3/Non-Formulary
    Non-Formulary
    Pemetrexed (pemetrexed iv solution)
    The maintenance treatment of patients with locally advanced or metastatic, nonsquamous non-small cell lung cancer (NSCLC) whose disease has not progressed after 4 cycles of platinum-based first-line chemotherapy, and the treatment of patients with recurrent, metastatic nonsquamous NSCLC after prior chemotherapy
    Prior Authorization, Medical
    Prior Authorization, Medical
    Medical

    Part D- Tier 5 if RxCui becomes available

     

    Drugs removed from prior authorization- Commercial and Exchange

     

    • Welireg
    • Exkivity
    • Tivdak
    • Tavneo
    • Scemblix
    • Eprontia™ Oral Solution
    • Vuity Solution
    • Elyxyb™ Solution
    • Besremi
    • Fyarro
    • Livtencity

     

    DRUG EXCLUSION

     

    • Twyneo
    • Loreev XR
    • Trudhesa
    • Lybalvi
    • Opzelura Cream
    • Qulipta
    • Skytrofa
    • Tyrvaya

     

    NEW GENERICS

     

                                                    NEW GENERICS (all brands will be non-formulary, Tier 3)
    BRAND NAME
    GENERIC NAME  COMMERCIAL  MEDICAID  EXCHANGE 
    Apokyn
    Apomorphine solution
    Tier 1 with prior authorization 
    Tier 1 with prior authorization
    Tier 2 with prior authorization
    Vimpat
    Lacosamide
    Brand Tier 2, Generic Tier 1
    Tier 1
    Tier 2
    Bidil
    Isosorbide dinitrate/hydralazine
    Tier 1
    Tier 1
    Tier 2
    Ozobax
    Baclofen oral solution
    Tier 1
    Tier 1
    Tier 2
    SSKI solution Potassium Iodide oral solution Exclude Prior Authorization, Tier 1
    Exclude
    Esbriet
    Pirfenidone
    Prior Authorization, Tier 1
    Prior Authorization, Tier 1
    Prior Authorization, Tier 2
    Velcade
    Bortezomib
    Medical 
    Medical 
    Medical 
    Diclofenac Sodium solution 2%
    Pennsaid
    Brand excluded, generic Tier 1
    Brand: Non-Formulary/Tier 3 with prior authorization. Generic: Prior Authorization, Tier 1
    Brand excluded, generic Tier 2
    Revlimid
    Lenalidomide
    Tier 1
    Tier 1
    Tier 2
    Pentasa
    Mesalamine ER
    Brand- Tier 2; Generic- Tier 1
    Brand- Tier 2; Generic- Tier 1
    Brand- Tier 2; Generic- Tier 2
    Vimpat
    Lacosamide
    Brand- Tier 2; Generic- Tier 1
    Tier 1
    Tier 2
    Targretin Bexarotene gel
    Tier 1
    Tier 1
    Tier 2
    Nexavar
    Sorafenib
    Tier 1
    Tier 1
    Tier 

     

    Miscellaneous Updates

    Commercial and Exchange

    • Shingrix age edit removed
    • Quantity limit for ondansetron removed

     

    Medicaid

    • Shingrix age edit removed
    • Quantity limit for ondansetron removed
    • Sterile water for injection no longer covered
    • Quzyttir updated to Non-Formulary
     

     

  • October 2022 Medical Policy Updates
    Published October 2022

    MEDICAL POLICY NAME

    • Breast Reconstruction Surgery
    • Cell-Free Fetal DNA Based Prenatal Screening
    • Continuous Glucose Monitoring
    • Endobronchial Valve Devices
    • Endoscopy (Esophagogastroduodenoscopy and Colonoscopy)
    • Experimental or Investigational Procedures
    • Fertility Preservation Services
    • Hospital Inpatient Level of Care
    • Imaging Procedures
    • Infertility Services (Advanced) and IVF
    • Infertility Services (Basic)
    • Inhaled Nitric Oxide (INOmax)
    • Investigational Procedures
    • Liposuction for Lipedema
    • Obstructive Sleep Apnea: Devices
    • Obstructive Sleep Apnea: Diagnosis
    • Obstructive Sleep Apnea: Surgical
    • Oncotype DX and Cancer Gene Expression Tests
    • Procedures for the Management of Chronic Spinal Pain and Chronic Pain
    • Rhinoplasty
  • September 2022 Pharmacy Policy Updates
    Published October 2022

     

    Pharmaceutical Policy Name
    Status
    Cystic Fibrosis Agents (Select Agents for Inhalation)
    Reviewed/No Changes
    Cystic Fibrosis Agents (Select Oral Agents)
    Reviewed/No Changes
    Idiopathic Pulmonary Fibrosis
    Updated
    Xolair
    Updated
    Quantity Limits for Prescription Drugs
    Updated
    Patient Medication Safety
    Reviewed/No Changes
    Ulcerative Colitis – Effective June 1, 2022
    Updated
    Botulinum Toxin Treatment
    Updated
    Entyvio – Effective July 1, 2022
    New
    Inflammatory Biologic Drug – Effective July 1, 2022
    Updated

  • September 2022 Formulary Policy Updates
    Published October 2022

     

    Drug Name

    Indication

    Commercial and Marketplace Tier

    MVP Medicaid

    Medicare Part D tier

    Quviviq™

    (daridorexant)

    The treatment of adults with insomnia characterized by difficulties with sleep onset and/or sleep maintenance

    Prior

    Authorization,

    Tier 3

    Prior

    Authorization,

    Tier 3/Non-Formulary

    Non-Formulary

    Camzyos™

    (mavacamten)

    The treatment of symptomatic New York Heart Association class II-III obstructive hypertrophic cardiomyopathy

    Prior

    Authorization,

    Tier 3

    Prior

    Authorization,

    Tier 3/Non-Formulary

    Non-Formulary

    Vijoice®

    (alpelisib)

    The treatment of patients aged 2 years and older with severe manifestations of PIK3CA-related overgrowth spectrum who require systemic therapy

    Prior

    Authorization,

    Tier 3

    Prior

    Authorization,

    Tier 3/Non-Formulary

    Non-Formulary

    Norliqva®

    (amlodipine)

    The treatment of hypertension in patients aged 6 years and older, the treatment of chronic stable angina, and the treatment of angiographically documented coronary artery disease in patients without heart failure or an ejection fraction less than 40%

    Prior

    Authorization,

    Tier 3

    Prior

    Authorization,

    Tier 3/Non-Formulary

    Non-Formulary

  • August 2022 Pharmacy Policy Updates
    Published October 2022

     

    Pharmaceutical Policy Name

    Status

    Zoladex Medicaid – Effective May 14, 2022

    New

    Enteral Therapy- New York

    Updated

    Enteral Therapy- Vermont

    Updated

    Rinvoq – Effective June 1, 2022

    New

    Aduhelm

    Updated

    Medicare Part B vs Part D Determination

    Reviewed/No Changes

    Copay Adjustment for Medical Necessity

    Reviewed/No Changes

    Infliximab – Effective January 1, 2022

    Updated

  • August 2022 Formulary Policy Updates
    Published October 2022

    Formulary Updates for Commercial, Marketplace, and Medicaid Formularies

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

    Effective August 1, 2022


    Drug Name

    Indication

    Commercial and Marketplace Tier

    MVP Medicaid

    Medicare Part D tier

    Tezspire™

    (tezepelumab-ekko)

    The add-on maintenance treatment of patients aged 12 years and older with severe asthma

    Medical

    Medical

    Medical Part D,

    Non-formulary

    Pyrukynd®

    (mitapivat)

    The treatment of hemolytic anemia in adults with pyruvate kinase deficiency

    Tier 3

    Non-Formulary

    Non-Formulary

    Carvykti™ (ciltacabtagene autoleucel)

    The treatment of adults with relapsed or refractory multiple myeloma after 4 or more prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody

    Medical

    Medical

    Medical

    Part D,

    Tier 5 if RxCUI becomes available

    Ibsrela®

    (tenapanor)

    The treatment of irritable bowel syndrome with constipation in adults

    Tier 3

    Non-Formulary

    Non-Formulary

    Korsuva® (difelikefalin)

    The treatment of moderate-to-severe pruritus associated with chronic kidney disease in adults undergoing hemodialysis

    Medical

    Medical

    Medical

    Part D,

    Non-Formulary

    Vonjo™ (pacritinib)

    The treatment of adults with intermediate or high-risk primary or secondary myelofibrosis and severe thrombocytopenia

    Tier 3

    Non-Formulary

    Tier 5 when RxCUI becomes available

    Pluvicto™

    (lutetium Lu 177 vipivotide tetraxetan)

    The treatment of adults with prostate-specific membrane antigen-positive metastatic castration-resistant prostate cancer who have been treated with androgen receptor pathway inhibition and taxane-based chemotherapy

    Medical

    Medical

    Medical

    Part D,

    Non-Formulary

    Opdualag™ (nivolumab/ relatlimab-rmbw)

    The treatment of metastatic or unresectable melanoma in patients aged 12 years and older

    Medical

    Medical

    Medical

    Part D,

    Tier 5 if RxCUI becomes available

    Releuko® (filgrastim-ayow)

    Use to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a significant risk of severe neutropenia with fever, to reduce the time to neutrophil recovery and duration of fever following induction or consolidation chemotherapy in patients with acute myeloid leukemia, to reduce the duration of neutropenia and neutropenia-related clinical sequelae in patients with nonmyeloid malignancies undergoing myeloablative chemotherapy followed by bone marrow transplantation, and to reduce the incidence and duration of sequelae of severe neutropenia in symptomatic patients with congenital neutropenia, cyclic neutropenia, or idiopathic neutropenia (biosimilar of Neupogen)

    Tier 3

    Non-Formulary

    Non-Formulary

    Part D,

    Tier 5 if RxCUI becomes available

    Camcevi® (leuprolide depot 6-month formulation)

    The treatment of adults with advanced prostate cancer

    Medical

    Medical

    Medical

    Part D

    Tier 5 if RxCUI becomes available

  • August 2022 Medical Policy Updates
    Published October 2022

     

    MEDICAL POLICY NAME

    • Ambulatory Holter Monitors and 30-Day Cardiac Event Recorders/Monitors 
    • Breast Pumps
    • Continuous Passive Motion Devices 
    • Electrical Stimulation Devices & Therapies 
    • Emergency Department Services 
    • Evaluation of New Technology, Procedures, Behavioral Health Services and Programs 
    • Gas Permeable Scleral Contact Lenses
    • Gender Affirming Treatment 
    • Genetic and Molecular Diagnostic Testing
    • Home and Community Based Services-Adult
    • Idiopathic Scoliosis Surgery and Growing Rods Technique
    • Imaging Procedures 
    • Immunizations Childhood, Adolescent, and Adult
    • Interspinous Process Decompression Systems (IPD)
    • Magnetoencephalography and Magnetic Source Imaging
    • Molecular Markers in Fine Needle Aspirates of the Thyroid
    • Oxygen & Oxygen Equipment
    • Panniculectomy/Abdominoplasty
    • Personalized Recovery Oriented Services (PROS)
    • Private Duty Nursing 
    • Prosthetic Devices (Upper & Lower Limb)
    • Radiofrequency Neuroablation Procedures for Chronic Pain 
    • Speech Therapy (Outpatient) & Cognitive Rehabilitation
    • Surgical Procedures for Glaucoma
    • Temporomandibular Joint Dysfunction (TMJ) NY
    • Temporomandibular Joint Dysfunction (TMJ) VT
    • Tissue-Engineered Skin Substitutes (pol w/issues)
  • July 2022 Pharmacy Policy Updates
    Published July 2022

    Below is a recap of the Pharmacy and Formulary updates that went into effect from April1 to June 1, 2022. All policies are reviewed at least once annually. For more detailed information on these changes, please review updates at mvphealthcare.com/FastFax.

     

    EFFECTIVE JUNE 2022

     

    Pharmaceutical Policy Name

    Status

    Valchlor

    Reviewed/ No Changes

    Eylea

    Reviewed/ No Changes

    Topical Agents for Pruritus

    Reviewed/ No Changes

    Cosmetic Drug Agents

    Updated

    Psoriasis Drug Therapy

    Updated

    Psoriatic Arthritis Drug Therapy- Effective April 1, 2022

    Updated

    Onychomycosis

    Reviewed/ No Changes

    Duchenne Muscular Dystrophy- Effective April 1, 2022

    Updated

    Formulary Exception for Non-Covered Drug – Effective April 1, 2022

    Updated

    CAR-T Cell Therapy

    Updated

    Drug Utilization Review and Monitoring Program

    Reviewed/ No Changes

    Luxturna

    Reviewed/ No Changes

    Parsabiv

    Reviewed/ No Changes

    Preventive Services-Medication – Effective April 1, 2022

    Reviewed/ No Changes

    Pain Medications- Effective March 22, 2022

    Reviewed/ No Changes

    Zoladex-Medicaid Effective May 14, 2022

    New Policy

  • July 2022 Formulary Updates
    Published July 2022

     

    Commercial, Marketplace, and Medicaid Formularies

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

     

     

    Drug Name

    Indication

    Commercial and Marketplace Tier

    MVP Medicaid

    Medicare Part D tier

    Vyvgart™

    (efgartigimod alfa-fcab)

    The treatment of generalized myasthenia gravis in adults who are anti-acetylcholine receptor antibody positive

    Medical

    Medical

    Medical

    Part D-

    Non-formulary

    Leqvio®

    (inclisiran)

    The treatment of clinical atherosclerotic cardiovascular disease or heterozygous familial hypercholesterolemia, as an adjunct to diet and maximally tolerated statin therapy, in adults who require additional lowering low-density lipoprotein cholesterol and the treatment of heterozygous familial hypercholesterolemia in adults

    Tier 3

    Non-Formulary

    Non-Formulary

    Recorlev® (levoketoconazole)

    The treatment of endogenous hypercortisolemia in adults with Cushing’s syndrome for whom surgery is not an option or has not been curative

    Tier 3

    Non-Formulary

    Non-Formulary

    Adbry™ (tralokinumab-ldrm)

    The treatment of moderate-to-severe atopic dermatitis in adults whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable

    Tier 3

    Non-Formulary

    Non-Formulary

    Kimmtrak® (tebentafusp-tebn)

    The treatment of HLA-A*02:01 positive adults with unresectable or metastatic uveal melanoma

    Medical

    Medical

    Medical

    Part-D, 

    Tier 5 if RxCUI becomes available

    Vabysmo® (faricimab-svoa)

    The treatment of neovascular (wet) age-related macular degeneration and diabetic macular edema

    Medical

    Medical

    Medical

    Part-D, Non-formulary

    Enjaymo™ (sutimlimab-jome)

    The treatment of adults with cold agglutinin disease to decrease the need for red blood cell transfusion due to hemolysis

    Medical

    Medical

    Medical

    Part-D,

    Non-formulary

    Apretude (cabotegravir)

    The pre-exposure prophylaxis to reduce the risk of sexually acquired human immunodeficiency virus-1 infection in at-risk adults and adolescents weighing at least 35 kilograms

    Medical

    Medical

    Medical

    Part-D,

    Tier 5 if RxCUI becomes available

    Tarpeyo™ (budesonide-controlled release)

    The reduction of proteinuria in adults with primary IgA nephropathy at risk of rapid disease progression

    Tier 3

    Non-Formulary

    Non-Formulary

    Dartisla ODT™

    (glycopyrrolate)

    The reduction of symptoms of peptic ulcer as an adjunct to treatment

    Tier 3

    Non-Formulary

    Non-Formulary

    Soaanz®

    (torsemide)

    The treatment of edema associated with heart failure or renal disease in adults

    Tier 3

    Non-Formulary

    Non-Formulary

    Pemfexy™

    (pemetrexed)

    The initial treatment of patients with locally advanced or metastatic non-squamous, non-small cell lung cancer (NSCLC) and mesothelioma, in combination with cisplatin; as a single agent for the maintenance treatment of patients with locally advanced or metastatic non-squamous NSCLC whose disease has not progressed after 4 cycles of platinum-based first-line chemotherapy; and as a single agent for the treatment of patients with recurrent, metastatic non-squamous NSCLC after prior chemotherapy

    Medical

    Medical

    Medical

    Part-D,

    Not Covered

    Seglentis®

    (celecoxib/ tramadol)

    The management of acute pain in adults that is severe enough to require an opioid analgesic and for which alternative treatments are inadequate

    Tier 3

    Non-Formulary

    Non-Formulary

    Cibinqo™

    (abrocitinib)

    The treatment of adults with refractory, moderate-to-severe atopic dermatitis whose disease is not adequately controlled with other systemic drug products, including biologics, or when use of those therapies is inadvisable

    Tier 3

    Non-Formulary

    Non-Formulary

    Fleqsuvy™ Oral Suspension

    (baclofen)

    Treatment of spasticity resulting from multiple sclerosis particularly for the relief of flexor spasms and concomitant pain, clonus, and muscular rigidity; may also be of some value in patients with spinal cord injuries and other spinal cord diseases

    Tier 3

    Non-Formulary

    Non-Formulary

     

    Drugs removed from prior authorization- Commercial and Exchange

    • Kloxxado
    • Kerendia (non-formulary for Medicaid)
    • Rylaze (medical)
    • Saphnelo (medical)
    • Zimhi

     

    DRUG EXCLUSION

    • Brexafemme
    • Azstarys

     

    New Generics

     

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

    BRAND NAME

    GENERIC NAME

    COMMERCIAL

    MEDICAID

    EXCHANGE

    Cuvposa solution

    Glycopyrrolate solution

    Tier 1

    Tier 1 

    Tier 2

    Dexilant

    Dexlansoprazole

    Tier 1 with quantity limit 2 capsules per day

    Tier 1 with quantity limit 2 capsules per day

    Tier 2 with quantity limit 2 capsules per day

    Restasis

    Cyclosporine ophthalmic emulsion

    Tier 1

    Tier 1 

    Tier 2

    Selzentry

    Maraviroc

    Brand Tier 2, generic Tier 1

    Brand Tier 2, generic Tier 1

    Brand Tier 2, generic Tier 2

    Deferiprone

    Ferriprox

    Tier 1

    Tier 1 

    Tier 2

    Combigan

    Brimidone tartrate-timolol maleate

    Tier 1

    Tier 1 

    Tier 2

  • July 2022 Medical Policy Updates
    Published July 2022

    Below is a recap of the Medical Policies that went into effect May 1, 2022.All policies are reviewed at least once annually. For more detailed informationon these changes, please review mvphealthcare.com/Fastfax or visitmvphealthcare.com/Providers and Sign In to your account, and select Resources,then Medical Policies.

     

    MEDICAL POLICY NAME

     

    • Acute Inpatient Rehabilitation
    • Artificial Intervertebral Discs-Cervical and Lumbar
    • Autism Spectrum Disorder NY
    • Benign Prostatic Hyperplasia (BPH) Treatments
    • Biofeedback Therapy
    • Bone Growth Stimulator
    • BRCS Testing (Genetic Testing for Susceptibility to Breast and Ovarian Cancer)
    • Cardiac Output Monitoring by Thoracic Electrical Bioimpedance
    • Cell-Free Fetal DNA-Based Testing for Fetal Aneuploidy
    • Clinical Guideline Development, Implementation, and Review Process
    • Cochlear Implants and Osseointegrated Devices
    • Epidermal Nerve Fiber Density Testing
    • Heart and Kidney Transplant Rejection Testing
    • Home and Community Based Services (HCBS) Children’s
    • Infertility Services (Basic)
    • Medical Policy Development, Implementation, and Review Process
    • Mental Health Services
    • Minimally Invasive GI Procedures
    • Sacral Nerve Stimulation
    • Skin Endpoint Titration
    • Speech Generating Devices

     

    Medical Policy Updates Effective June 1, 2022

    • Continuous Glucose Monitoring
    • COVID-19 Related Medical Management
    • Custodial Care Long Term (LT) Placement in a Nursing Home (NH) for MVP Medicaid Managed Care 
    • Electromyography and Nerve Conduction Studies
    • Erectile Dysfunction
    • External Breast Prosthesis
    • Extracorporeal Shock Wave Therapy
    • Fluorescence In Situ Hybridization (FISH) Testing for Bladder Cancer
    • Hospice Care
    • Inhaled Nitric Oxide (INOmax)
    • Joint Replacement for Hallux Rigidus
    • Laser Treatment of Port Wine Stains
    • Leadless Cardiac Pacemakers
    • Orthotic Devices (other than therapeutic diabetic footwear)
    • Percutaneous Vertebral Augmentation (PVA)
    • Personal Care and Consumer Directed Services for MVP Medicaid Managed Care
    • Prophylactic Mastectomy and Prophylactic Oophorectomy
    • Prosthetic Devices (External) Eye and Facial and Scleral Shells
    • Sinus Surgery-Endoscopic
    • Umbilical Cord Blood Banking
    • Ventricular Reduction Surgery
  • July 2022 Miscellaneous Updates
    Published July 2022

    Medicaid

     

    New Medication Assisted Treatment (MAT) Formulary Requirement Effective March 22, 2022

    • On December 22, 2021, Governor Hochul signed Chapter 720 of the Laws of 2021. This law amends Social Services Law and the Public Health Law, in relation to medication for the treatment of substance use disorders. Effective March 22, 2022, prior authorization will not be required for medications used for the treatment of substance use disorder when prescribed according to generally accepted national professional guidelines for the treatment of a substance use disorder.
    • Current quantity limits on this category will still apply
    • Managed Care Plans are required to align to the Fee-For-Service formulary for a single Statewide MAT Formulary. More information is available on the NYS DOH’s website at newyork.fhsc.com/providers/mat.asp
  • April 2022 Pharmacy Policy Updates
    Published April 2022

     

    EFFECTIVE JANUARY 2022

     

    Pharmaceutical Policy Name

    Status

    Crohn’s Disease Select Agents

    Updated

    Dupixent

    Updated

    Quantity Limits for Prescription Drugs (effective October 1, 2021)

    Updated

    Mulpleta/Doptelet

    Updated

    Prostate Cancer

    Updated

    Radicava

    Updated

    Zulresso

    Reviewed/No changes

    Palforzia

    Reviewed/No changes

    Formulary Exception for Non-Covered Drug (External)

    Reviewed/No changes

    Infliximab

    Updated

    Growth Hormone Therapy

    Updated

    Ulcerative Colitis, Select Agents

    Updated

    SGLT2 Inhibitors Medicaid

    New

    Multiple Sclerosis Agents

    Updated

    Select Oral Antipsychotics

    Reviewed/No changes

    GABA-Receptor Modulators (formerly Xyrem)

    Updated

    Movement Disorder

    Updated

    Select Hypnotics

    Updated

    Respiratory Syncytial Virus/Synagis

    Reviewed/No changes

    Spravato

    Updated

    Nuedexta

    Reviewed/No changes

    Gabapentin ER

    Reviewed/No changes

    Spinal Muscular Atrophy

    Reviewed/No changes

    Oral Allergen Immunotherapy Medications

    Updated

    Agents for Female Sexual Dysfunction

    Reviewed/No changes

    Ankylosing Spondylitis Drug Therapy

    Updated

    Rheumatoid Arthritis Drug Therapy

    Updated

    Psoriatic Arthritis Drug Therapy

    Updated

     

    EFFECTIVE FEBRUARY 2022

     

    Pharmaceutical Policy Name

    Status

    Doryx/Oracea (doxycycline)

    Reviewed/No changes

    Antibiotic/Antiviral (Oral) Prophylaxis

    Updated

    Government Programs Over the Counter (OTC) Drug Coverage (For MVP Medicaid, Child Health Plus, and select Essential Plan Members Only)

    Updated

    Compounded (Extemporaneous) Medications

    Updated

  • April 2022 Formulary 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

  • April 2022 Medical Policy Updates
    Published April 2022

     

    • Adult Day Care Service
    • Bariatric Surgery
    • Benign Prostatic Hyperplasia (BPH) Treatments
    • Colorectal Cancer Genetic Testing
    • Continuous Glucose Monitoring
    • Dental Care Services Accidental Injury
    • Dental Care Services Medical Services for Complications of Dental Problems
    • Dental Care Services Facility Services for Dental Care
    • Dental Care Services Prophylactic Dental Extractions
    • Endoscopy (Colonoscopy)
    • Ground Ambulance/Ambulette Services
    • Investigational Procedures
    • Needle-free Insulin Injectors
    • Neuropsychological Testing
    • Oncotype DX Test
    • Phototherapy, Photochemotherapy, Excimer Laser Therapy
    • Power Mobility Devices
    • Tissue-Engineered Skin Substitutes

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