Featured story: The effects of bias on women's health
Everyone deserves equal access to quality healthcare. Unfortunately, patients can face disparities in treatment and research, fueled by both explicit and implicit bias. That’s true for many types of bias, including ableism, ageism, weight-based stigma, racism, and sexism. Continue reading to learn more about what women might face when it comes to bias and how our women’s health portfolio addresses their specific healthcare needs.
In this issue:
- Medicare Advantage billing
- Roadmap for Behavioral Health Reform Incident and Issue Reporting Portal
- Continuity of care-Mass General Brigham ACO
- Help us keep directory information up to date
- Medical policy updates
- Formulary updates
- Code updates
- Drug code updates
Medicare Advantage billing
As a reminder, HCPCS codes must be reported on FQHC PPS Medicare claims to ensure claims are adjudicated accordingly. Please utilize the CMS FQHC policy guidelines for Medicare Advantage billing. Mass General Brigham Health Plan reimburses participating Community Health Centers (CHC) and Federally Qualified Health Centers (FQHC) for the provision of medically necessary administration, professional, and related supporting services associated with member care as set forth in the policy.
Roadmap for Behavioral Health Reform Incident and Issue Reporting Portal
Introduced in 2021 and implemented in 2023 by the Commonwealth, the Massachusetts Roadmap for Behavioral Health Reform (the RoadMap) increases access to mental health and substance use disorder treatment for people across Massachusetts and offers insurance-blind behavioral health crisis services to anyone in the state. New services supporting these reforms include the Behavioral Health Help Line (BHHL), Community Behavioral Health Centers (CBHCs), and Behavioral Health Urgent Care (BHUC) sites.
In an effort to collect feedback and concerns associated with the new services, the Incident and Issue Reporting Portal was developed by the Massachusetts Behavioral Health Partnership (MBHP), Massachusetts Department of Mental Health (DMH), and MassHealth’s Office of Behavioral Health (OBH). This tool can be accessed and filled out by anyone at masspartnership.com, masshelpline.com, and mass.gov. It is intended to log feedback associated with any service component of the Roadmap, and items entered in the form will receive direct follow-up based on the level of concern. An overview of the form and the questions on the live portal can be found here.
Please note that this form is not a portal for adverse incidents or serious reportable healthcare events. For medical/surgical serious reportable events(SRE) providers can submit the SRE report via fax to 617-526-1916.
Continuity of care-Mass General Brigham ACO
The continuity of care (CoC) period will end 8/31/23 for the Mass General Brigham ACO.
Here's what providers should know:
- Please ensure prior authorizations (PA) are submitted with all required documentation for all services that require PA. For more info, click here
-
Members will need prior authorization to see specialists out of network. See our provider directory for more information.
-
Prior authorizations should be submitted via our provider portal
Mass General Brigham Health Plan’s Drug fee schedules to be updated
Mass General Brigham Health Plan reviews its drug fee schedules quarterly to ensure that they are current, comprehensive and consistent with industry standards, to the extent supported by its systems. In most cases, changes involve adding fees for new or existing codes, to supplement the fees already on the fee schedule.
The next update will occur on October 1, 2023. Changes may involve both new and existing CPT and HCPCS codes, and will include the planned quarterly update to physician administered drugs, immune globulin, vaccine and toxoid fees.
Telemedicine Notification from MassHealth
Beginning October 1, 2023, MassHealth will require that telemedicine services be billed with the appropriate telemedicine modifiers. Claims billed incorrectly will begin denying on October 1, 2023: https://www.mass.gov/doc/all-provider-bulletin-374-access-to-health-services-through-telehealth-options/download
Help us keep directory information up to date
The Centers for Medicare & Medicaid Services and other regulatory bodies, as well as the federal this ensures members have access to accurate information.
Provider demographic information in our must reflect accurate data at all times and should mirror the information members may receive directly from the practice or via patient appointment call centers.
On at least a quarterly basis, providers should review and verify the accuracy of their demographic data displayed in our Provider Directory. To report any changes to demographic data or to your address, panel status (open or closed) for each individual provider, institutional affiliations, phone number, or other practice data requests should be reported via the Mass General Brigham Health Plan Provider Portal
Consistent with provisions related to the federal No Surprises Act of 2021, failure to review and update demographic information at least quarterly may result in suppression from Mass General Brigham Health Plan Provider Directory until the information is validated. In addition, if Mass General Brigham Health Plan identifies potentially inaccurate provider information in the directory, we may outreach to your practice to validate or obtain accurate information. If we are unable to obtain a timely response, the provider’s applicable location may be subject to suppression in the directory until up-to-date information is received.
In addition, please keep the following in mind:
- Practice location — As new providers join your practice, it is important that only practice locations where the provider regularly administers direct patient care are submitted for inclusion in the Mass General Brigham Health Plan provider directory. Locations in which a provider may occasionally render indirect care — such as interpretation of tests or inpatient-only care — should be specified to ensure the location information is included in the provider’s demographic profile, but not in the provider directory.
- Timely notice — As a reminder, notification of address, acceptance of new patients, provider terminations, and other demographic information changes should be submitted at least 30 days in advance.
For questions, contact our Provider Service Center at 855-444-4647 or provider.massgeneralbrighamhealthplan.org
Medical policy updates
Five medical policies were reviewed and passed by the Mass General Brigham Health Plan’s Medical Policy Committee. These policies are now posted to MassGeneralBrighamHealthPlan.org. The table below is a summary.
For more information or to download our medical policies, go to https://www.massgeneralbrighamhealthplan.org/providers/medical-policies and select the policy under the medical policy listings.
|
Medical policies |
|||
|
Policy title |
Summary |
Products affected |
Effective date |
|
Autologous Chondrocyte Implantation in the Knee |
August 2023: Annual review. Medicare Advantage added to table. Minor editorial refinement to coverage guidelines; intent unchanged. Medicare variation language added. References updated. |
All products |
8/1/2023 |
|
Arthrodesis for Sacroiliac Joint Pain |
August 2023: Annual review. Medicare Advantage added to table. Medicare variation language added. References updated. |
All products |
8/1/2023 |
|
Bone Growth Stimulators |
August 2023: Annual review. Medicare Advantage added to table. Medicare variation language added. References updated. |
All products |
8/1/2023 |
|
Prostheses – Lower Limb |
August 2023: Annual review. Medicare Advantage added to table. Medicare variation language added. References updated. |
All products |
8/1/2023 |
|
Prostheses – Upper Limb |
August 2023: Annual review. Medicare Advantage added to table. Medicare variation language added. References updated. |
All products |
8/1/2023 |
Formulary updates
DEFINITIONS
Formulary These drugs are included in Mass General Brigham’s covered drug list.
Non-Formulary These drugs are not included in Mass General Brigham’s formulary. The plan would only cover formulary alternatives. Providers can request Non-Formulary drugs as an exception, and the plan would require trial of all appropriate formulary alternatives prior to approving coverage of a Non-Formulary drug. If a Non-Formulary drug is approved, the member’s cost sharing would be the highest tier.
Preferred These drugs are on Mass General Brigham’s formulary and offer a lower cost to members.
Non-Preferred These drugs are on Mass General Brigham’s formulary but offer a higher cost to members.
Excluded Mass General Brigham does not cover these drugs. Members will receive a denial for all Excluded drug requests.
Updates for Commercial Members
Effective 10/01/2023
The following changes are being made to the listed medications:
|
Rezurock |
This drug will require prior authorization. |
Updates for MassHealth Members
Effective 10/02/2023
The following generic medications will become non-preferred. Please use the brand name alternative(s):
|
Generic Medication |
Brand Name Alternative |
|
Trientine capsule |
Syprine |
The following brand name medications will become non-preferred. Approval will require a trial of its generic medication:
|
Brand Name |
Generic Medication |
|
Invega tablet |
Paliperidone tablet |
Effective ASAP, the brand preferred status will be removed from the following product. This change is due to the discontinuation of the brand name product:
|
Brand Name |
Generic Medication |
|
Asacol HD |
Mesalamine tablet |
Effective 10/01/2023
|
Pharmaceutical Compounding Program |
Mass General Brigham Health Plan will align with the MassHealth Compounding Program no later than 10/01/2023. The following will require a prior authorization for compounded pharmaceutical products (with the exception of infusion, intravenous, intravenous piggyback, intravenous push, and subcutaneous routes of administration): · With a total cost of greater than or equal to $100 · With topical route of administration Please note, the following compounding ingredients are not covered and may be subject to change at any time: · benzodiazepine powders (alprazolam, clonazepam, diazepam, lorazepam, midazolam powders) · chorionic gonadotropin, human, powder · clomiphene powder · cocaine crystals, powder · diethylpropion powder · flibanserin powder · ketamine powder · methylphenidate powder · opioid powders (apomorphine, buprenorphine, cocaine, codeine, fentanyl, hydrocodone, hydromorphone, levorphanol, methadone, morphine sulfate, oxycodone, sufentanil powders) · papaverine · PCCA compounding ingredients (including but not limited to proprietary bases, active pharmaceutical ingredients, and excipients) · phentolamine · tadalafil powder |
Effective 10/02/2023
The following changes are being made to the listed medications to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List):
|
Alzheimer Agents |
New drug, Leqembi (lecanemab-irmb), was added to the pharmacy and medical benefits with prior authorization required. The following updates were made to the criteria: · Saint Louis University Mental Status (SLUMS) test was added as another assessment option. · Aduhelm criteria will require a step through of Leqembi. · Aduhelm reauthorization criteria was further simplified to require current objective assessments and attestation that all MRI monitoring has been completed. |
|
Antioxidant Agents |
Prior authorization and age limit restrictions were removed from Coenzyme Q10 powder and ubiquinol powder on the pharmacy benefit. |
|
Antipsychotic Agents |
The following medication has been added to the pharmacy benefit with prior authorization and quantity limit: · Abilify Asimtufii – 1 injection per 56 days.
The following medication strengths have been added to the pharmacy benefit with quantity limits: · Uzedy 50mg/75mg/100mg/125mg – 1 injection per 28 days · Uzedy 150mg/200mg/250mg – 1 injection per 56 days
Expanded indication of agitation in Alzheimer’s Disease was added for Rexulti. |
|
Benzodiazepines and other Antianxiety Agents |
Tranxene (clorazepate) criteria was further clarified |
|
Beta Thalassemia Myelodysplastic Syndrome & Sickle Cell Disease Agents |
Criteria was updated for Oxbryta tablets for oral suspension to include age due to medical necessity for consistency. |
|
C. Difficile Prevention Agents |
New drug, Vowst (fecal microbiota spores, live-brpk), was added to the pharmacy benefit with prior authorization and quantity limit of 12 tablets per lifetime. |
|
Chronic Myelogenous Leukemia (CML) Agents |
· Notation of Ph+ was added for acute lymphoblastic leukemia criteria on Iclusig. · Confirmed T315I mutation added as option for Iclusig based on FDA-labeled indication. · For Synribo (omacetaxine mepesuccinate), notation of confirmed T315I mutation removed as it no longer seems applicable per NCCN guideline and Iclusig (ponatinib) was added as a potential trial. |
|
Complement Inhibitors and Misc. Immunosuppressive Agents |
New drug, Syfovre (pegcetacoplan), was added to the medical benefit with prior authorization. The following medications have been removed from the pharmacy benefit and will remain on the medical benefit with prior authorization. · Soliris (eculizumab) · Uplizna (inebilizumab-cdon) Step through requirement of pyridostigmine was added to Ultomiris criteria. Enjaymo was updated and now requires members to have received a vaccine against encapsulated bacteria at least two weeks prior to treatment initiation. |
|
Continuous Subcutaneous Insulin Infusion
|
Omnipod GO has been added to the pharmacy benefit with prior authorization and quantity limit of 10 pods per 30 days. |
|
Entyvio |
The initial approval duration was updated to 4 months. Criteria regarding high dose or more frequent dosing was added for reauthorization requests. |
|
Erythropoiesis Stimulating Agents |
Criteria was further clarified for embers who have anemia due to chronic renal failure (CRF) who were stable on one of the ESAs previously (not a new member and no previous approval on file) with higher Hb levels must meet initial criteria. |
|
Gout Agents
|
The following medication has been added to the pharmacy benefit with prior authorization: · Allopurinol 200mg tablet |
|
Immune Globulin |
The stability section was updated to allow the approval of requests documenting positive response to therapy and to remove the requirement for the documentation of current labs showing normal Ig levels. |
|
Intranasal Corticosteroids Agents
|
Dymista (azelastine/fluticasone propionate) was added to criteria as another combination alternative without prior authorization.
The following medications have been added to the pharmacy benefit with prior authorization and quantity limit: · Ryaltris – 29 grams per 30 days
|
|
Leqvio |
This medication has been added to the pharmacy benefit with a prior authorization and will remain on the medical benefit with a prior authorization. |
|
Lymphoma & Leukemia Agents |
The following medications had criteria updates: · Imbruvica suspension added to policy using the existing Imbruvica criteria. · Calquence criteria: Off-label use of MZL for Calquence was added to criteria based on NCCN guidelines. Criteria for CLL/SLL was updated by removing requirement that the agent be used in combination with obinutuzumab based on NCCN guidelines. · Expanded indication of CLL/SLL was added for Brukinsa criteria. · Zydelig criteria for CLL was updated to be consistent with the NCCN guideline. · Criteria for Imbruvica for cGVHD was updated to reflect expansion to pediatric patients 1 year of age and older.
The following medication has been added to the pharmacy benefit with prior authorization: · Imbruvica suspension |
|
Methotrexate Agents |
Criteria for Xatmep was updated to expand approvable age from < 13 to <18, medical necessity criteria was updated to be more in-line with the criteria for special formulations in other policies, and off-label indications were added to criteria. |
|
Multiple Sclerosis Agents |
Criteria was updated to consolidate Ocrevus and Briumvi into a single alternative option given the same mechanism of action. |
|
Oncology Immunotherapies |
Criteria was updated to include expanded indication for Keytruda (pembrolizumab) in combination with Padcev for the treatment of adult patients with locally advanced (la) or metastatic urothelial cancer (mUC) who are not eligible for cisplatin-containing chemotherapy. |
|
Opioids and Analgesics |
Prialt (ziconotide) intrathecal injection was added to the pharmacy benefit with prior authorization and will continue to be available on the medical benefit without prior authorization.
The high dose criteria was revised to be inclusive of: · scenarios where an imminent taper is planned · circumstances where a pain consult is in process but not specifically completed |
|
Padcev (enfortunmab vedotin) |
· This medication was removed from the pharmacy benefit and will remain on the medical benefit with prior authorization.
· Criteria updated to include expanded indication of Padcev used in combination with Keytruda (pembrolizumab) for the treatment of adult patients with locally advanced (la) or metastatic urothelial cancer (mUC) who are not eligible for cisplatin-containing chemotherapy. |
|
Synagis (palivizumab) |
Diagnosis of lower respiratory tract disease (LRTD) was added throughout the criteria. The start and duration of RSV season was further defined as per NREVSS recommendations. |
|
Pediculicides & Scabicides |
Over-the-counter (OTC) Sklice (ivermectin lotion) has been added to criteria with prior authorization on the pharmacy benefit.
|
|
Skeletal Muscle Relaxants |
The following medications have been added to the pharmacy benefit with prior authorization: · Methocarbamol 1,000 mg tablet · Orphenadrine 25mg/aspirin 385mg/caffeine 30mg tablet
|
|
SMA Agents |
Documentation of baseline motor function skills, member being on established care with SMA care center, and member not having other factors will no longer be required. |
|
Cuvrior (trientine tetrahydrochloride) |
New drug, Cuvrior (trientine tablet), was added to the pharmacy benefit with prior authorization. |
Code updates
The following service(s) are covered with no prior authorization required for Commercial and ASO Plans:
|
Code |
Description |
Effective Date |
|
81513 |
Infectious disease, bacterial vaginosis, quantitative real-time amplification of RNA markers for Atopobium vaginae, Gardnerella vaginalis, and Lactobacillus species, utilizing vaginal-fluid specimens, algorithm reported as a positive or negative result for bacterial vaginosis |
03/01/2023 |
|
81514 |
Infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, Bacterial Vaginosis Associated Bacteria-2 (BVAB-2), and Lactobacillus species (L. crispatus and L. jensenii), utilizing vaginal-fluid specimens, algorithm reported as a positive or negative for high likelihood of bacterial vaginosis, includes separate detection of Trichomonas vaginalis and/or Candida species (C. albicans, C. tropicalis, C. parapsilosis, C. dubliniensis), Candida glabrata, Candida krusei, when reported |
03/01/2023 |
The following service(s) are reviewed by Optum for ASO Plans:
|
Code |
Description |
Effective Date |
|
G2067 |
Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
04/01/2023 |
|
G2068 |
Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
04/01/2023 |
|
G2073 |
Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
04/01/2023 |
|
G2074 |
Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
04/01/2023 |
|
G2076 |
Intake activities, including initial medical examination that is a complete, fully documented physical evaluation and initial assessment by a program physician or a primary care physician, or an authorized health care professional under the supervision of a program physician qualified personnel that includes preparation of a treatment plan that includes the patient's short-term goals and the tasks the patient must perform to complete the short-term goals; the patient's requirements for education, vocational rehabilitation, and employment; and the medical, psycho-social, economic, legal, or other supportive services that a patient needs, conducted by qualified personnel (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure |
04/01/2023 |
|
G2078 |
Take home supply of methadone; up to 7 additional day supply (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure |
04/01/2023 |
|
G2079 |
Take home supply of buprenorphine (oral); up to 7 additional day supply (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure |
04/01/2023 |
The following service(s) is covered when prior authorized for Commercial and ASO Plans:
|
Code |
Description |
Effective Date |
|
A9800 |
Gallium Ga-68 gozetotide, diagnostic, (Locametz), 1 mCi |
11/01/2022 |
Drug Code Updates
The following drug(s) are now covered under the medical benefit with prior authorization for ACO and Commercial/ASO lines of business:
|
Code |
Description |
Brand Name |
Effective Date |
|
No Specific Code |
(velmanase alfa-tycv) IV Solution |
Lamzede |
COMM: 07/01/2023
|
|
ACO: 07/31/2023 |
The following drug(s) are now covered under the medical benefit no prior authorization for the Commercial/ASO lines of business:
|
Code |
Description |
Brand Name |
Effective Date |
|
No Specific Code |
(retifanlimab-dlwr) IV Solution |
Zynyz |
07/01/2023 |
The following drug(s) are now covered with no prior authorization for ACO lines of business:
|
Code |
Description |
Brand Name |
Effective Date |
|
J0739 |
Injection, cabotegravir, 1 mg |
Apretude |
07/31/2023 |
|
J0248 |
Injection, remdesivir, 1 mg |
Veklury (remdesivir) injection |
07/31/2023 |
The following drug(s) are now covered under the medical benefit with prior authorization for ACO lines of business:
|
Code |
Description |
Brand Name |
Effective Date |
|
J9144 |
Injection, daratumumab, 10 mg and hyaluronidase-fihj |
Darzalex Faspro |
07/31/2023 |
|
J0208 |
Injection, sodium thiosulfate, 100 mg |
Pedmark |
07/31/2023 |
The following drug(s) are now covered under the medical benefit with prior authorization for Medicare Advantage lines of business:
|
Code |
Description |
Brand Name |
Effective Date |
|
No Specific Code |
(velmanase alfa-tycv) IV Solution |
Lamzede |
07/01/2023 |
|
No Specific Code |
(retifanlimab-dlwr) IV Solution |
Zynyz |
07/01/2023 |