Featured story to share with patients: Summer tips shield yourself from sunburns
Sunshine offers major benefits when it comes to how the body processes vitamin D, but ultraviolet (UV) radiation from the sun also prompts concerns about skin damage and cancer risk, no matter what your skin tone. July has been declared UV Safety Awareness Month, to boost awareness and encourage more sun safety precautions.
In this issue:
- Continuity of care
- Chiropractic benefits
- Emergency department boarding
- Annual Updates to Physician and Outpatient Fee Schedules
- Medical policy updates
- Formulary updates
- Code updates
- Drug code updates
Continuity of care-Mass General Brigham ACO
We are extending our continuity of care (CoC) period through 8/31/23 for the Mass General Brigham ACO, which means all CoC procedures will remain in place until that time.
The extension provides more time to notify members who are seeing OON providers, continue contracting efforts and complete contract set up in QNXT.
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
Chiropractic benefits:
As a reminder, providers can confirm chiropractic benefits and authorization guidelines via the following tools and resources available to our provider network.
- Payment Policy: ChiropracticServices.PDF (massgeneralbrighamhealthplan.org)
- Prior Auth Grid: PAGuide.pdf (massgeneralbrighamhealthplan.org)
- Medical Policy: ChiropracticServices.pdf (massgeneralbrighamhealthplan.org)
Providers can check eligibility and submit prior authorizations via MGBHP’s Provider Portal:
- Provider Portal - Mass General Brigham Health Plan Provider Portal
- Provider Education Landing Page - Provider education | Mass General Brigham Health Plan
- Public Website Provider Tab - Providers | Mass General Brigham Health
Emergency department (ED) boarding
What providers need to know regarding ED boarding:
- Whether a member is boarding in the ED or observation setting, the facility must also contact Optum. You can find the appropriate customer service number on the back of the member's ID card
- Please remind hospital to clearly state “ED/ER Boarding” when contacting Optum – this kicks off the EPIA Process
- If member is boarding on an Inpatient Medical floor, please remind hospital to state “Authorization for Inpatient Medical Boarding” when calling Optum – this follows the current/existing process.
Note, even though MGB members may not need authorization for ED boarding, the facility is still required to contact Optum for the Request for Assistance notification, per the EPIA protocol.
You can also visit mass.gov for the Expedited Psychiatric Inpatient Admissions (EPIA) Policy or view this presentation.
Annual Updates to Physician and Outpatient Fee Schedules
Mass General Brigham Health Plan reviews its physician and outpatient 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.
Consistent with prior years, Mass General Brigham Health Plan updated its Commercial/PPO physician, ambulance, drug, DME, laboratory, radiology and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2023.
With a few exceptions, Mass General Brigham Health Plan will continue to base fees on the Centers for Medicare & Medicaid Services (CMS) and MassHealth fee schedules, adjusted to achieve the contracted level of reimbursement.
Commercial/PPO Physician Fee Schedules
- Rate updates to existing CPT and HCPCS codes will occur on July 1, 2023.
- Mass General Brigham Health Plan will continue to base physician reimbursement on CMS RVU’s & anesthesia conversion factor.
- Mass General Brigham Health Plan will continue to base drug, vaccine and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.
- Mass General Brigham Health Plan will continue to base DME reimbursement on the CMS DME POS/PEN fee schedules.
Commercial/PPO Outpatient Fee Schedules
- Consistent with prior years, reimbursement will be based on a combination of outpatient, ancillary and surgical fee schedules.
- Mass General Brigham Health Plan will continue to base drug, vaccine and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.
- Mass General Brigham Health Plan will continue to base DME reimbursement on the CMS DME POS/PEN fee schedules.
Medicaid Fee Schedules
- Mass General Brigham Health Plan will continue to base physician reimbursement on MassHealth published rates, where published rates exist.
- Consistent with prior years, Mass General Brigham Health Plan updated its Medicaid physician, ambulance, drug, DME, laboratory, radiology and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2023. Rate updates to existing CPT and HCPCS codes will occur within 30 days of receipt of notification of rate change from MassHealth.
Medical policy updates
Eight 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 massgeneralbrighamhealthplan.org/providers/medical-policies and select the policy under the medical policy listings.
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 |
| Transurethral Waterjet Ablation of Prostate [NEW POLICY] |
Effective Date: Guidelines to determine the medical necessity for transurethral waterjet ablation (also referred to as robotic waterjet ablation or Aquablation) to treat lower urinary tract symptoms (LUTS) attributable to benign prostatic hyperplasia. |
Commercial and Medicare Advantage |
7/1/2023 |
| Assisted Reproductive Services/Infertility Services |
July 2023: Annual review. The following changes were made: · Page 1: Added medicare advantage to table · Page 2: Removed statement that treatment must be provided by a Mass General Brigham Health Plan contracted provider · Page 3: o Under 3a. Changed estradiol levels from 1-2 years to 2 years. o Under 3b. Added III. o Removed Note regarding members unable to tolerate clomiphene. o Under 4a. Minor edits. Criteria unchanged o Under 5: Added “vaper” o Added 6b · Page 5: Under IVF Coverage Criteria, #2 and #4 Editorial refinements, intent unchanged. · Page 6; Under Donor Egg Services, changed age from 42 to 43 years of age. Under Note: changed age from 43 to 44. · Page 10; Removed exclusion “cryopreservation and/or storage of ovarian tissue” · Page 11: Added Medicare Variation Language · Page 13: Added hyperlink and text for Prior Authorization Form.
|
Commercial and Medicare Advantage |
7/1/2023 |
| Hearing Devices |
July 2023: Annual review. Medicare Advantage added to table one page 1. Medicare variation language added. References updated. |
All products |
7/1/2023 |
| Dental Treatment Setting |
July 2023: Annual review. July 2023: Annual review. Medicare Advantage added to table. Under Acute Hospital setting or SDC setting, revised interventions from two attempts to at least one attempt. Medicare Variation language added. References updated. |
All products |
7/1/2023 |
| Speech Generating Devices |
July 2023: Annual Update. Medicare Advantage added to table. Medicare Variation language added. References updated.
|
All products |
7/1/2023 |
| Oral and Maxillofacial Surgery and Procedures |
July 2023: Annual update. Medicare Advantage added to table. Medicare Variation language added. References updated.
|
Commercial and Medicare Advantage |
7/1/2023 |
| Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea |
July 2023: Annual update. Medicare Advantage added to table. Added new indication and medical necessity language for members 13-18 years of age with down syndrome. Medicare Variation language added. References updated. |
Commercial and Medicare Advantage |
7/1/2023 |
| Vertebral Body Tethering [NEW POLICY] |
July 2023: Effective Date. Medical criteria for vertebral body tethering (VBT) to treat idiopathic scoliosis |
Commercial |
7/1/2023 |
In addition, as of June 2023, Mass General Brigham Health Plan customized InterQual criteria and published new guidelines. The following criteria was customized and created:
- Rhinoplasty (MassHealth) (Custom) – MGB
- Septoplasty (MassHealth) (Custom) – MGB
This customization was done to distinguish the criteria after adopting recent MassHealth updated Medical Necessity Guidelines.
New codes summary
Please see the coverage summary for July 2023 new codes below:
Not covered experimental and investigational for ACO, Commercial/ASO:
| C9150 |
Xenon xe-129 hyperpolarized gas, diagnostic, per study dose |
| C9784 |
Gastric restrictive procedure, endoscopic sleeve gastroplasty, with esophagogastroduodenoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components |
| C9785 |
Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components |
| C9786 |
Echocardiography image post processing for computer aided detection of heart failure with preserved ejection fraction, including interpretation and report |
| C9787 |
Gastric electrophysiology mapping with simultaneous patient symptom profiling |
| Q4272 |
Esano a, per square centimeter |
| Q4273 |
Esano aaa, per square centimeter |
| Q4274 |
Esano ac, per square centimeter |
| Q4275 |
Esano aca, per square centimeter |
| Q4276 |
Orion, per square centimeter |
| Q4277 |
Woundplus membrane or e-graft, per square centimeter |
| Q4278 |
Epieffect, per square centimeter |
| Q4280 |
Xcell amnio matrix, per square centimeter |
| Q4281 |
Barrera sl or barrera dl, per square centimeter |
| Q4282 |
Cygnus dual, per square centimeter |
| Q4283 |
Biovance tri-layer or biovance 3l, per square centimeter |
| Q4284 |
Dermabind sl, per square centimeter |
| 0791T |
Motor-cognitive, semi-immersive virtual reality-facilitated gait training, each 15 minutes (List separately in addition to code for primary procedure) |
| 0792T |
Application of silver diamine fluoride 38%, by a physician or other qualified health care professional |
| 0793T |
Percutaneous transcatheter thermal ablation of nerves innervating the pulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imaging guidance |
| 0794T |
Patient-specific, assistive, rules-based algorithm for ranking pharmaco-oncologic treatment options based on the patient's tumor-specific cancer marker information obtained from prior molecular pathology, immunohistochemical, or other pathology results which have been previously interpreted and reported separately |
| 0795T |
Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; complete system (ie, right atrial and right ventricular pacemaker components) |
| 0796T |
Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right atrial pacemaker component (when an existing right ventricular single leadless pacemaker exists to create a dual-chamber leadless pacemaker system) |
| 0797T |
Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right ventricular pacemaker component (when part of a dual-chamber leadless pacemaker system) |
| 0798T |
Transcatheter removal of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography), when performed; complete system (ie, right atrial and right ventricular pacemaker components) |
| 0799T |
Transcatheter removal of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography), when performed; right atrial pacemaker component |
| 0800T |
Transcatheter removal of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography), when performed; right ventricular pacemaker component (when part of a dual-chamber leadless pacemaker system) |
| 0801T |
Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; dual-chamber system (ie, right atrial and right ventricular pacemaker components) |
| 0802T |
Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right atrial pacemaker component |
| 0803T |
Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right ventricular pacemaker component (when part of a dual-chamber leadless pacemaker system) |
| 0804T |
Programming device evaluation (in person) with iterative adjustment of implantable device to test the function of device and to select optimal permanent programmed values, with analysis, review, and report, by a physician or other qualified health care professional, leadless pacemaker system in dual cardiac chambers |
| 0805T |
Transcatheter superior and inferior vena cava prosthetic valve implantation (ie, caval valve implantation [CAVI]); percutaneous femoral vein approach |
| 0806T |
Transcatheter superior and inferior vena cava prosthetic valve implantation (ie, caval valve implantation [CAVI]); open femoral vein approach |
| 0807T |
Pulmonary tissue ventilation analysis using software-based processing of data from separately captured cinefluorograph images; in combination with previously acquired computed tomography (CT) images, including data preparation and transmission, quantification of pulmonary tissue ventilation, data review, interpretation and report |
| 0808T |
Pulmonary tissue ventilation analysis using software-based processing of data from separately captured cinefluorograph images; in combination with computed tomography (CT) images taken for the purpose of pulmonary tissue ventilation analysis, including data preparation and transmission, quantification of pulmonary tissue ventilation, data review, interpretation and report |
| 0809T |
Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, placement of transfixing device(s) and intra-articular implant(s), including allograft or synthetic device(s) |
| 0810T |
Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies |
Prior authorization required for ACO, Commercial/ASO:
| C9151 |
Injection, pegcetacoplan, 1 mg |
| J1440 |
Fecal microbiota, live - jslm, 1 ml |
| J1576 |
Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg
|
| J1961 |
Injection, lenacapavir, 1 mg |
| J2329 |
Injection, ublituximab-xiiy, 1mg |
| J2561 |
Injection, phenobarbital sodium (sezaby), 1 mg |
| J9063 |
Injection, mirvetuximab soravtansine-gynx, 1 mg |
| J9347 |
Injection, tremelimumab-actl, 1 mg |
| J9350 |
Injection, mosunetuzumab-axgb, 1 mg |
| J9380 |
Injection, teclistamab-cqyv, 0.5 mg |
| J9381 |
Injection, teplizumab-mzwv, 5 mcg |
No prior authorization required for ACO, Commercial/ASO:
| J0137 |
Injection, acetaminophen (hikma) not therapeutically equivalent to j0131, 10 mg |
| J0206 |
Injection, allopurinol sodium, 1 mg |
| J0216 |
Injection, alfentanil hydrochloride, 500 micrograms |
| J0457 |
Injection, aztreonam, 100 mg |
| J0665 |
Injection, bupivicaine, not otherwise specified, 0.5 mg |
| J0736 |
Injection, clindamycin phosphate, 300 mg |
| J0737 |
Injection, clindamycin phosphate (baxter), not therapeutically equivalent to j0736, 300 mg |
| J1805 |
Injection, esmolol hydrochloride, 10 mg |
| J1806 |
Injection, esmolol hydrochloride (wg critical care) not therapeutically equivalent to j1805, 10 mg |
| J1811 |
Insulin (fiasp) for administration through dme (i.e., insulin pump) per 50 units |
| J1812 |
Insulin (fiasp), per 5 units |
| J1813 |
Insulin (lyumjev) for administration through dme (i.e., insulin pump) per 50 units |
| J1814 |
Insulin (lyumjev), per 5 units |
| J1836 |
Injection, metronidazole, 10 mg |
| J1920 |
Injection, labetalol hydrochloride, 5 mg |
| J1921 |
Injection, labetalol hydrochloride (hikma) not therapeutically equivalent to j1820, 5 mg |
| J1941 |
Injection, furosemide (furoscix), 20 mg |
| J2305 |
Injection, nitroglycerin, 5 mg |
| J2371 |
Injection, phenylephrine hydrochloride, 20 micrograms |
| J2372 |
Injection, phenylephrine hydrochloride (biorphen), 20 micrograms |
| J2427 |
Injection, paliperidone palmitate extended release (invega hafyera, or invega trinza), 1 mg |
| J2806 |
Injection, sincalide (maia) not therapeutically equivalent to j2805, 5 micrograms |
| J9056 |
Injection, bendamustine hydrochloride (vivimusta), 1 mg |
| J9058 |
Injection, bendamustine hydrochloride (apotex), 1 mg |
| J9059 |
Injection, bendamustine hydrochloride (baxter), 1 mg |
| J9259 |
Injection, paclitaxel protein-bound particles (american regent) not therapeutically equivalent to j9264, 1 mg |
No prior authorization required for ACO; prior authorization required Commercial/ASO:
| J2598 |
Injection, vasopressin, 1 unit |
| J2599 |
Injection, vasopressin (american regent) not therapeutically equivalent to j2598, 1 unit |
| J7213 |
Injection, coagulation factor ix (recombinant), ixinity, 1 i.u. |
| J9322 |
Injection, pemetrexed (bluepoint) not therapeutically equivalent to j9305, 10 mg |
| J9323 |
Injection, pemetrexed ditromethamine, 10 mg |
Prior authorization required for ACO; No prior authorization required for Commercial/ASO:
| J2249 |
Injection, remimazolam, 1 mg |
Prior authorization for Commercial/ASO and Med Adv via eviCore:
| 0388U |
Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and structural variants in 37 cancer-related genes, plasma, with report for alteration detection |
| 0389U |
Pediatric febrile illness (Kawasaki disease [KD]), interferon alpha-inducible protein 27 (IFI27) and mast cell-expressed membrane protein 1 (MCEMP1), RNA, using reverse transcription polymerase chain reaction (RT-qPCR), blood, reported as a risk score for KD |
| 0391U |
Oncology (solid tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 437 genes, interpretive report for single nucleotide variants, splice-site variants, insertions/deletions, copy number alterations, gene fusions, tumor mutational burden, and microsatellite instability, with algorithm quantifying immunotherapy response score |
| 0392U |
Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication analysis of CYP2D6, reported as impact of gene-drug interaction for each drug |
| 0395U |
Oncology (lung), multi-omics (microbial DNA by shotgun next-generation sequencing and carcinoembryonic antigen and osteopontin by immunoassay), plasma, algorithm reported as malignancy risk for lung nodules in early-stage disease |
| 0396U |
Obstetrics (pre-implantation genetic testing), evaluation of 300000 DNA single-nucleotide polymorphisms (SNPs) by microarray, embryonic tissue, algorithm reported as a probability for single-gene germline conditions |
| 0397U |
Oncology (non-small cell lung cancer), cell-free DNA from plasma, targeted sequence analysis of at least 109 genes, including sequence variants, substitutions, insertions, deletions, select rearrangements, and copy number variations |
| 0398U |
Gastroenterology (Barrett esophagus), P16, RUNX3, HPP1, and FBN1 DNA methylation analysis using PCR, formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as risk score for progression to high-grade dysplasia or cancer |
| 0400U |
Obstetrics (expanded carrier screening), 145 genes by nextgeneration sequencing, fragment analysis and multiplex ligationdependent probe amplification, DNA, reported as carrier positive or negative |
| 0401U |
Cardiology (coronary heart disease [CAD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a coronary event |
Not covered experimental and investigational for Commercial/ASO:
| 0387U |
Oncology (melanoma), autophagy and beclin 1 regulator 1 (AMBRA1) and loricrin (AMLo) by immunohistochemistry, formalin-fixed paraffin-embedded (FFPE) tissue, report for risk of progression |
| 0390U |
Obstetrics (preeclampsia), kinase insert domain receptor (KDR), Endoglin (ENG), and retinol-binding protein 4 (RBP4), by immunoassay, serum, algorithm reported as a risk score |
| 0393U |
Neurology (eg, Parkinson disease, dementia with Lewy bodies), cerebrospinal fluid (CSF), detection of misfolded a-synuclein protein by seed amplification assay, qualitative |
| 0394U |
Perfluoroalkyl substances (PFAS) (eg, perfluorooctanoic acid, perfluorooctane sulfonic acid), 16 PFAS compounds by liquid chromatography with tandem mass spectrometry (LC-MS/MS), plasma or serum, quantitative |
| 0399U |
Neurology (cerebral folate deficiency), serum, detection of anti-human folate receptor IgG-binding antibody and blocking autoantibodies by enzyme-linked immunoassay (ELISA), qualitative, and blocking autoantibodies, using a functional blocking assay for IgG or IgM, quantitative, reported as positive or not detected |
Prior authorization required for Medicare Advantage:
| J2329 |
Injection, ublituximab-xiiy, 1mg |
| J9063 |
Injection, mirvetuximab soravtansine-gynx, 1 mg |
| C9151 |
Injection, pegcetacoplan, 1 mg |
| J9347 |
Injection, tremelimumab-actl, 1 mg |
| J7213 |
Injection, coagulation factor ix (recombinant), ixinity, 1 i.u. |
| J9350 |
Injection, mosunetuzumab-axgb, 1 mg |
| J1440 |
Fecal microbiota, live - jslm, 1 ml |
| J2561 |
Injection, phenobarbital sodium (sezaby), 1 mg |
| J1961 |
Injection, lenacapavir, 1 mg |
| J9380 |
Injection, teclistamab-cqyv, 0.5 mg |
| J9381 |
Injection, teplizumab-mzwv, 5 mcg |
| J2598 |
Injection, vasopressin, 1 unit |
| J2599 |
Injection, vasopressin (american regent) not therapeutically equivalent to j2598, 1 unit |
| J9056 |
Injection, bendamustine hydrochloride (vivimusta), 1 mg |
No prior authorization required for Medicare Advantage:
| J0137 |
Injection, acetaminophen (hikma) not therapeutically equivalent to j0131, 10 mg |
| J0216 |
Injection, alfentanil hydrochloride, 500 micrograms |
| J0206 |
Injection, allopurinol sodium, 1 mg |
| J0457 |
Injection, aztreonam, 100 mg |
| J9058 |
Injection, bendamustine hydrochloride (apotex), 1 mg |
| J9059 |
Injection, bendamustine hydrochloride (baxter), 1 mg |
| J0665 |
Injection, bupivicaine, not otherwise specified, 0.5 mg |
| J2249 |
Injection, remimazolam, 1 mg |
| J0736 |
Injection, clindamycin phosphate, 300 mg |
| J0737 |
Injection, clindamycin phosphate (baxter), not therapeutically equivalent to j0736, 300 mg |
| J1805 |
Injection, esmolol hydrochloride, 10 mg |
| J1806 |
Injection, esmolol hydrochloride (wg critical care) not therapeutically equivalent to j1805, 10 mg |
| J1811 |
Insulin (fiasp) for administration through dme (i.e., insulin pump) per 50 units |
| J1812 |
Insulin (fiasp), per 5 units |
| J1836 |
Injection, metronidazole, 10 mg |
| J1941 |
Injection, furosemide (furoscix), 20 mg |
| J2427 |
Injection, paliperidone palmitate extended release (invega hafyera, or invega trinza), 1 mg |
| J1920 |
Injection, labetalol hydrochloride, 5 mg |
| J1921 |
Injection, labetalol hydrochloride (hikma) not therapeutically equivalent to j1820, 5 mg |
| J1813 |
Insulin (lyumjev) for administration through dme (i.e., insulin pump) per 50 units |
| J1814 |
Insulin (lyumjev), per 5 units |
| J2305 |
Injection, nitroglycerin, 5 mg |
| J9259 |
Injection, paclitaxel protein-bound particles (american regent) not therapeutically equivalent to j9264, 1 mg |
| J1576 |
Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg |
| J9322 |
Injection, pemetrexed (bluepoint) not therapeutically equivalent to j9305, 10 mg |
| J9323 |
Injection, pemetrexed ditromethamine, 10 mg |
| J2371 |
Injection, phenylephrine hydrochloride, 20 micrograms |
| J2372 |
Injection, phenylephrine hydrochloride (biorphen), 20 micrograms |
| J2806 |
Injection, sincalide (maia) not therapeutically equivalent to j2805, 5 micrograms |
Code updates
As a reminder to the network the following service(s)or item(s) are not covered for all lines of business:
| Code |
Description |
| No Code |
Laser treatment experimental and investigational for removal nail fungus (Onychomycosis). |
| No Code |
Freespira Digital Therapeutic for Panic Disorder and PTSD |
| No Code |
Kinova® Jaco® assistive robotic arm |
| No Code |
SNOO Smart Baby Sleeper Bassinet |
The following service(s) will be covered with no prior authorization for all LOB:
| Code |
Description |
Effective Date |
| 0121A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; single dose |
04/18/2023 |
| 0141A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage; first dose |
04/18/2023 |
| 0142A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage; second dose |
04/18/2023 |
| 0151A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; single dose |
04/18/2023 |
| 0171A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; first dose |
04/18/2023 |
| 0172A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; second dose |
04/18/2023 |
Drug Code Updates
The following drug(s) will be covered with prior authorization for the ACO and Commercial/ASO lines of business:
| Code |
Description |
Brand Name |
Effective Date |
| Q5129 |
Injection, bevacizumab-adcd (Vegzelma), biosimilar, 10 mg |
Vegzelma |
COMM: 06/01/2023 ACO: 06/05/2023 |
The following drug(s) are now covered under the medical benefit with prior authorization for the Commercial/ASO lines of business ONLY:
| Code |
Description |
Brand Name |
Effective Date |
| No Specific Code |
Injection, antihemophilic factor[recombinant], Fc-VWF-XTEN fusion protein-ehtl, IV Solution |
Altuviiio |
06/01/2023 |
|
J2356 |
Injection, tezepelumab-ekko, 1 mg |
Tezspire (Subcutaneous Auto Injector Pen) ** |
06/01/2023 |
**Please Note: Tezspire (Subcutaneous Auto Injector Pen) is not covered under the medical benefit for the ACO Line of Business
The following drug(s) will be covered with no prior authorization for the Commercial/ASO lines of business ONLY:
| Code |
Description |
Brand Name |
Effective Date |
| No Specific Code |
Injection, phenobarbital sodium (sezaby), 1 mg
New HCPCS CODE J2561 EFF 7.1.2023 |
Sezaby |
06/01/2023 |
| No Specific Code |
Injection, pegcetacoplan, Intravitreal Solution |
Syfovre |
06/01/2023 |
The following drug(s) will be covered with no prior authorization for ACO lines of business:
| Code |
Description |
Brand Name |
Effective Date |
| No Specific Code |
Injection, inotersen, for subcutaneous use |
Tegsedi |
06/30/2023 |
|
C9101 |
Injection, oliceridine, 0.1 mg |
Olinvyk |
07/01/2023 |
The following drug(s) are now Not Covered, Experimental/Investigational under the medical benefit for the ACO lines of business:
| Code |
Description |
Brand Name |
Effective Date |
| J1726 |
Injection, hydroxyprogesterone caproate, (Makena), 10 mg |
Makena Hydroxyprogesterone caproate |
06/01/2023 |
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 |
Injection, antihemophilic factor[recombinant], Fc-VWF-XTEN fusion protein-ehtl, IV Solution |
Altuviiio |
06/01/2023 |
| No Specific Code |
Injection, phenobarbital sodium (sezaby), 1 mg
New HCPCS CODE J2561 EFF 7.1.2023 |
Sezaby |
06/01/2023 |
| No Specific Code |
Injection, pegcetacoplan, Intravitreal Solution |
Syfovre |
06/01/2023 |
| Q5129 |
Injection, bevacizumab-adcd (Vegzelma), biosimilar, 10 mg |
Vegzelma |
06/01/2023 |
Formulary updates
Effective 09/01/2023
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 09/01/2023
The following changes are being made to the listed medications:
| Calcipotriene Ointment |
This medication will no longer be considered formulary. |
| Dysport Myobloc Xeomin |
Criteria will be updated to require a trial of Botox prior to approval. |
| Nyvepria Udenyca Ziextenzo |
Criteria will be updated to require a trial of Neulasta and Fulphila prior to approval. |