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Launch of comprehensive women’s health portfolio, Group Insurance Commission updates, and clinical practice guidelines in June 2023
Featured story: Mass General Brigham Health Plan Announces Launch of Comprehensive Women’s Health Portfolio
Mass General Brigham Health Plan today announced the launch of a comprehensive women’s health portfolio that will address the specific healthcare needs of women by expanding access to appropriate care and support, while advancing health equity.
The broad-based set of solutions across the full spectrum of women’s health issues – from pregnancy to post-partum support to menopause – responds to needs identified by science-based research, market demand, and feedback from Mass General Brigham Health Plan members.
“Women’s health needs are unique and require unique solutions designed around them,” said Steve Tringale, President, Mass General Brigham Health Plan. “The women’s health portfolio is consistent with our strategy to put members at the center of their healthcare and our historical commitment to supporting under-represented health needs and communities.”
The women’s health portfolio is data-driven and made available through convenient, digital platforms that provide resources, self-guided support, and connections with experts and virtual communities. Through these solutions, eligible commercial members have unlimited access to healthcare professionals and advocates. Subjects addressed by the initiative comprise maternal health (including pregnancy, postpartum, loss support and neonatal care), menopause, and mental health.
In this issue:
- Group Insurance Commission updates
- Claims with CPT codes G2023 and G2024
- Returned claims
- Provider appeal updates
- Clinical practice guidelines
- Continuity of care process for MGB ACO
- Annual updates to physician and outpatient fee schedules
- Medical policy updates
- Formulary updates
- Code updates
- Drug code updates
Group Insurance Commission
Network product update
On July 1, Mass General Brigham Health Plan, in collaboration with the Group Insurance Commission, will update the Group Insurance Commission’s network and product. The updated product will give members the opportunity to further self-manage their healthcare costs. When receiving certain services, members' cost sharing will be based on the Tier of the provider the member is receiving services from.
If you have any questions about this notice or your participation in the Group Insurance Commission Network, please contact your Contract Manager or healthplanprovrelations@mgb.org
GIC-ID number prefix change
Effective 7/1/23, our existing GIC ASO membership will be changing from the COM prefix to the 100 prefix (Example: COM1234567 to 1001234567). There is no impact to new GIC members enrolling 7/1/23.
Though Member ID#s will be changing effective 7/1/23, our internal systems will be supporting and accepting the old and new ID#s which should eliminate all impact to members and providers. We will be changing other lines of business later in 2023 or as of 1/1/24, and we will communicate ahead of those changes as well.
Claims with CPT codes G2023 and G2024
Claims billed electronically between 03/31/2023 and 04/20/2023 with CPT codes G2023 and G2024 may have rejected. This is because the original CMS code termination date was 03/31/2023. CMS has revised the termination date from 03/31/2023 to 05/11/2023 (to coincide with the end of the COVID 19 Public Health Emergency). This update was noted in the Covid-19PaymentPolicy.pdf (massgeneralbrighamhealthplan.org)
While the official termination date of these codes of 05/11/23 is now in place, providers may need to resubmit claims that were originally submitted and rejected between 03/31/23 and 04/20/23. We apologize for any inconvenience. If you have any questions, please feel free to contact healthplanprovrelations@mgb.org
Returned claims
As of 4/1/23, in order to support the sub-cap claims payment methodology for the Mass General Brigham ACO, our system was configured to require a valid attending provider to be sent on all outpatient hospital claims (UB92 claim with a bill type 013). If claims are submitted without the appropriate attending provider on the Mass General Brigham ACO claims, these claims will be rejected back to the submitter. Additionally, this requirement is only in place for the Mass General Brigham ACO line of business.
Please resubmit any rejected Mass General Brigham ACO claims with the valid attending provider to Mass General Brigham Health Plan as soon as possible.
Please note, we have since turned the edit off for our Commercial lines of business. If you received a rejection for your commercial claims, we ask that you please resubmit the claim as initially submitted to Mass General Brigham Health Plan.
We apologize for any inconvenience. If you have any questions please feel free to contact healthplanprovrelations@mgb.org
Provider appeal updates
We are currently experiencing a high volume of provider appeals, and there may be a delay in processing appeals as we work through the backlog. We appreciate your patience during this time.
Returned claims:
As of 4/1/23, in order to support the sub cap claims payment methodology for the Mass General Brigham ACO, our system was configured to require a valid attending provider be sent on all outpatient hospital claims (UB92 claim with a bill type 013). If claims are submitted without the appropriate attending provider on the Mass General Brigham ACO claims, these claims will be rejected back to the submitter. Additionally, this requirement is only in place for the Mass General Brigham ACO line of business.
Resubmit any rejected Mass General Brigham ACO claims with the valid attending provider to Mass General Brigham Health Plan as soon as possible. Please note, we have since turned the edit off for our Commercial lines of business. If you received a rejection for your commercial claims, we ask that you please resubmit the claim as initially submitted to Mass General Brigham Health Plan.
If you have any questions please feel free to contact healthplanprovrelations@mgb.org
Claims billed electronically:
Important: claims billed electronically between 03/31/2023 and 04/20/2023 with CPT codes G2023 and G2024 may have rejected. This is because the original CMS code termination date was 03/31/2023. CMS has revised the termination date from 03/31/2023 to 05/11/2023 (to coincide with the end of the COVID 19 Public Health Emergency). This update was noted in the Covid-19PaymentPolicy.pdf (massgeneralbrighamhealthplan.org)
While the official termination date of these codes of 05/11/23 is now in place, providers may need to resubmit claims that were originally submitted and rejected between 03/31/23 and 04/20/23. We apologize for any inconvenience. If you have any questions, please feel free to contact healthplanprovrelations@mgb.org
Mass General Brigham Health Plan Ranked No. 1 in Member Satisfaction in Massachusetts by J.D. Power
Mass General Brigham Health Plan (formerly AllWays Health Partners) has been ranked No. 1 in member satisfaction among commercial health plans in Massachusetts by J.D. Power, a global expert in consumer insights.
The J.D. Power 2023 U.S. Commercial Member Health Plan Study measures satisfaction of members with their health plans nationwide. Mass General Brigham Health Plan earned the top ranking in Massachusetts across several categories, including coverage and benefits, cost, provider choice, and information and communication. Read the full press release.
Clinical practice guidelines
Mass General Brigham Health Plan develops Clinical Practice Guidelines from both local and national organizations. They are periodically updated as new information becomes available regarding best practices. Resources containing practice guidelines for the following chronic or complex conditions, as well as preventative health and perinatal care, can be found on the Mass General Brigham Health Plan provider resources page under Practice Guidelines:
ADHD - Primary Care for Children and Adolescents
Asthma
Depression
Diabetes
HIV/AIDS
Perinatal Care Guidelines
Preventive Care for Adults
Preventative Care for Children and Adolescents
These Clinical Practice Guidelines have been approved by the Mass General Brigham Health Plan’s Quality Program Committee (QPC) and can be used to help you deliver the very best patient care. Please refer to the coverage criteria to determine whether a treatment or service is covered.
Continuity of Care Process for MGB ACO
Per EOHHS , currently a 90 day Continuity of Care period is occurring from 4/1/23-6/30/23 for a new MGB ACO member with a previously approved scheduled procedure/service (for a covered service) by the previous health plan, with an in network (INN) or out of network (OON) provider, which will continue or occur post MGBHP MGB ACO effective date. Those authorizations which have been transitioned to us from MassHealth have an end date of 6/30/2023.As a reminder, in the event of active ongoing services with an OON provider, after 6/30/23, the provider must submit the request for continued service via our Mass General Brigham Health Plan Provider Portal. If the current authorization with the in network provider has expired (past 6/30/23), and the member still requires the service, then the provider will need to submit a request for prior authorization. These are considered a new request for services and not Continuity of Care as the previously approved services auth has ended and will be reviewed by our Utilization Management Team. Any historical and current supporting clinical documentation should be included with the prior authorization request.
For more information and tools regarding the MGB ACO please visit: Mass General Brigham ACO | Mass General Brigham Health Plan
For questions, contact our Provider Service Center at 855-444-4647 or via email at healthplanproviderservice@mgb.org
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
Seven 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.
|
Medical Policies |
|||
|
Policy Title |
Summary |
Products Affected |
Effective Date |
|
Specialty Medication – Site of Care |
Off-cycle Update. Infusion Drugs Reviewed, Site of Care list updated. Table A added. |
All lines of business |
8/1/2023 |
|
Acupuncture |
Annual update. Medicare Advantage added to table on page 1. Statement regarding Medicare visit limitations added under table on page 1. Medicare Variation language added. References updated. |
All lines of business |
6/1/2023 |
|
Acute Inpatient |
Annual update. Medicare Advantage added to table. References updated. |
All lines of business |
6/1/2023 |
|
Chiropractic Services |
Annual Update. Medicare language added. Medicare Variation language added. References updated. |
All lines of business |
6/1/2023 |
|
Definition of Skilled Care |
Annual Review. Medicare language added. References updated. |
All lines of business |
6/1/2023 |
|
Extended Care Facility |
Annual Review. Medicare language added. References updated. |
All lines of business |
6/1/2023 |
|
Home Health Care |
Annual Review. Medicare language added. References updated. |
All lines of business |
6/1/2023 |
Formulary updates
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 08/01/2023
The following changes are being made to the listed medications:
|
Amvuttra Briumvi Enjaymo Krystexxa Nexviazyme Panzyga Tezspire Xenpozyme |
These medications will be added to our mandatory site-of-care program. They will now require administration in the home or in a non-hospital outpatient setting.
All medications included in this program are safe to be administered outside a hospital setting.
For additional information regarding our site-of-care program, please visit MassGeneralBrighamHealthPlan.org.
Please note: There will be no change to any infusions until the current authorization has expired. However, members will be required to switch to a home infusion provider or a doctor’s office upon renewal of your authorization, should they need to continue the same medication. |
Updates for MassHealth Members
Reminder, effective 7/1/23 Mass General Brigham Health Plan will align with the MassHealth Opioid Program.
|
Opioids and Analgesics |
The accumulated high dose threshold will now be 120 mg of morphine milligram equivalent (MME) per day for an individual agent, and 180 MME per day for the entire regimen.
Mass General Brigham Health Plan understands that opioid dose adjustments require an individualized care plan to avoid harm. Mass General Brigham Health Plan does not require nor expect providers to terminate or taper appropriate opioid prescribing. Please contact the plan if there are any concerns regarding these changes or questions on how to submit a request if the dosing needed is above the limit. |
|
Opioids and Analgesics that require prior authorization |
|
|
Long acting |
Short-acting |
|
Belbuca (buprenorphine buccal film |
Actiq (fentanyl transmucosal system) |
Effective 07/31/2023
The following generic medications will become non-preferred. Please use the brand name alternatives:
|
Generic Medication |
Brand Name Alternative |
|
Sodium Sulfate/Potassium Sulfate/Magnesium Sulfate |
Suprep |
|
Bismuth subcitrate Pot/metronidazole/tetracycline/hydro |
Pylera |
|
omeprazole/sodium bicarbonate |
Zegerid suspension packets |
|
omeprazole/sodium bicarbonate |
Zegerid capsules |
The following brand name medications will become non-preferred. Approval will require a trial of its generic medication:
|
Brand Name |
Generic Medication |
|
Gilenya |
fingolimod capsule |
Effective ASAP, the brand preferred status will be removed from the following products. This change is due to the discontinuation of the brand name products:
|
Brand Name |
Generic Medication |
|
Hepsera |
adefovir |
|
Androgel |
testosterone 1.62% gel pump |
Effective 07/31/2023
The following changes are being made to the listed medications to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List):
|
Antioxidants (formerly Coenzyme Q10) |
Pedmark (sodium thiosulfate) was added to the medical benefit with prior authorization. |
|
|
Antipsychotics |
Prior authorization was removed from Perseris on the pharmacy benefit and quantity limits will remain as 1 injection per 28 days. |
|
|
Antiretroviral Agents |
• Sunlenca (lenacapavir) was added to the pharmacy and medical benefit with prior authorization. |
|
|
Anticoagulants |
· Prior authorization was added to Pradaxa oral pellets on the pharmacy benefit. Criteria was added for the treatment or reduction of risk of recurrent DVT and/or PE in pediatrics. · Xarelto suspension age requirement was updated to 8 to < 18 years of age. |
|
|
Anticonvulsants |
· Off-label indications for Xcopri are now included within criteria for patients 12 years and older. · Treatment failure criteria was simplified for Lennox-Gastaut syndrome or Dravet syndrome to require any two anticonvulsants. · Diacomit step-through was updated from one trial to two trials for Dravet syndrome. · Prior authorization and quantity limit for Vimpat tablets and solution have been removed from the pharmacy benefit. · Primidone 125mg tablet was added to the pharmacy benefit without prior authorization. |
|
|
Antidiabetic Agents – Non-insulin and comb: Biguanides/GLP1 products |
· Prior authorization was added to metformin 625mg tablet on the pharmacy benefit. · Ozempic 2 mg/1.5 mL pen: quantity limit was updated to 1 pen per 28 days for all strengths. |
|
|
Asthma and Allergy Monoclonal Antibodies |
New formulation of Tezspire 210 mg/1.91 mL pen was added to criteria and the pharmacy benefit with prior authorization. |
|
|
Benzodiazepines and other Antianxiety Agents |
Seizure disorder was added as an acceptable diagnosis for oxazepam and clorazepate. |
|
|
Bowel Preparation Agents |
Prior authorization was removed from Suprep from the pharmacy benefit. |
|
|
Breast Cancer Agents |
· Expanded indication for Tukysa in combination with trastuzumab for RAS WT, HER2-positive unresectable or metastatic colorectal cancer was added. · Expanded indication for Trodelvy for HR-positive, HER2-negative unresectable locally advanced or metastatic breast cancer was added. · Trodelvy was removed from the pharmacy benefit and will still be available on the medical benefit with prior authorization. |
|
|
Crysvita (burosumab) |
The following medication was added to the pharmacy benefit with prior authorization and will remain on the medical benefit with prior authorization. |
|
|
Cardiovascular Agents |
The following medications have been added to the pharmacy benefit with prior authorization and quantity limit: · Aspruzyo – 60 packets per 30 days · Furoscix kit - 8 kits per 30 days |
|
|
CFTR Modulators |
Criteria was updated to include an age expansion for Trikafta to ≥ 2 years of age and Kalydeco to ≥ 1 month.
The following medications were added to the pharmacy benefit with prior authorization and quantity limits: · Kalydeco 13.4mg packet: quantity limit of 60 packets per 30 days. · Trikafta 80-40-60mg/59.5mg packet: quantity limit of 60 packets per 30 days. · Trikafta 100-50-75mg/75mg packet: quantity limit of 60 packets per 30 days. |
|
|
Colorectal Cancer Agents |
The following medications have been removed from the pharmacy benefit and will still be available on the medical benefit without prior authorization: · Fluorouracil injection, Oxaliplatin injection |
|
|
Continuous Subcutaneous Insulin Infusion |
Criteria was updated to include quantity requirements for V-Go, Omnipod 5, Omnipod Classic, and Omnipod Dash. |
|
|
COVID Test Kits |
Covered COVID testing kits will now be limited to 2 tests per 28 days. |
|
|
Enzyme and Metabolic Disorder Therapies |
New drug, Lamzede, was added to the medical benefit with prior authorization. |
|
|
Skyclarys |
This new drug was added to the pharmacy benefit with prior authorization and quantity limit of 90 capsules per 30 days. |
|
|
Gastrointestinal Drugs-PPIs, H2 Antagonists, and Miscellaneous Agents |
· Prior authorization for famotidine suspension and Zegerid suspension packets has been removed from the pharmacy benefit. · Konvomep has been added to the pharmacy benefit with prior authorization. · Gimoti criteria: replaced metoclopramide ODT tablet trial with metoclopramide solution trial. |
|
|
Glaucoma Agents |
The following medication has been removed from the pharmacy benefit and will still be available on the medical benefit with prior authorization: · Durysta
The following medications have been removed from the pharmacy benefit and were added to the medical benefit without prior authorization: · Miochol-E, Miostat |
|
|
Headache Therapy: Ergot Alkaloids and Serotonin Receptor Agents |
· Naratriptan tablet and sumatriptan nasal spray – prior authorization was removed from the pharmacy benefit but quantity limits will remain. · Indication of cyclic vomiting syndrome added for sumatriptan injection. · An age requirement of members ≥ 6 years of age was added for sumatriptan nasal spray. |
|
|
Herceptin Products |
· Expanded indication for use of Tukysa (tucatinib) to be used in combination with trastuzumab for the treatment of adult patients with RAS wild-type (WT), HER2-positive unresectable or metastatic colorectal cancer (mCRC) that has progressed following treatment with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy was added to criteria. |
|
|
Isocitrate Dehydrogenase (IDH) Inhibitors |
· Removed requirement that members be >60 years of age for first line use of Tibsovo and Idhifa as well as step-through requirements. · Rezlidhia was added to the pharmacy benefit with prior authorization and quantity limit of 60 capsules per 30 days. |
|
|
Lipid Lowering Agents |
· Caduet (amlodipine/atorvastatin) was updated to only require medical necessity for use of the combination product instead of the commercially available separate agents. · Evkeeza had an age expansion to members aged 5 and older. · New drug, Atorvaliq, was added to the pharmacy benefit with prior authorization. · Praluent and Repatha criteria were updated to become less restrictive. · Praluent and Repatha trial may be bypassed for Leqvio if there are concerns with member using self-injections. |
|
|
Elahere |
New drug, Elahere (mirvetuximab soravtansine-gynx), was added to the medical benefit with prior authorization. |
|
|
Multiple Myeloma Agents |
The following medications was removed from the pharmacy benefit and have been added to the medical benefit with prior authorization: · Darzalex Faspro
The following medication was removed from the pharmacy benefit and will remain on the medical benefit with prior authorization: · Sarclisa
|
|
|
Multiple Sclerosis Agents |
New drug, Briumvi (ublituximab-xiiy), was added to the pharmacy benefit and medical benefit with prior authorization.
Criteria was updated to include the following: · Briumvi and Tysabri as step through options for Kesimpta. · Briumvi as another step through option for Lemtrada. · Briumvi as a step through option for Ocrevus for requests under pharmacy benefit.
The following medications had prior authorization removed from the pharmacy benefit and quantity limits will remain: · Ampyra 60 per 30 days · Aubagio 30 per 30 days · Tecfidera 60 per 30 days · Gilenya 30 per 30 days |
|
|
Neuromuscular Blockers |
Off-label criteria was added for Botox for myofascial pain syndrome and for myofascial pelvic pain syndrome. |
|
|
Oncology Immunotherapies |
· Criteria was updated to include an expanded indication for use for Keytruda (pembrolizumab) as a single agent for adjuvant treatment following resection and platinum-based chemotherapy for adults with stage IB (T2a ≥4 cm), II, or IIIA NSCLC. · Prior authorization has been removed for Jemperli and Opdualag on the pharmacy benefit. However, this medication will continue to be available through the medical benefit with a prior authorization. |
|
|
Pediatric Behavioral Health Medications |
Gralise (gabapentin ER) tablet was added to the pharmacy benefit with prior authorization. |
|
|
Pediculicides and Scabicides |
· Prior authorization and quantity limit removed from Stromectol (ivermectin) 3mg tablet on the pharmacy benefit. · Off label indication was added for lindane shampoo. |
|
|
Respiratory Agents - Oral |
Criteria montelukast granules for the off-label indication of eosinophilic esophagitis (EoE) was updated to be consistent with requested trials for Dupixent approval criteria of EoE. |
|
|
Systemic Chemotherapy |
Etopophos (etoposide phosphate) was removed from the pharmacy benefit and will remain on the medical benefit without prior authorization. |
|
|
Targeted Immunomodulators: Kevzara |
Criteria updated to include expanded indication for Polymyalgia Rheumatica. |
|
|
T-Cell Immunotherapies: Lunsumio |
New drug, Lunsumio (mosunetuzumab-axgb), will be available on the medical benefit with a prior authorization. |
|
|
Urinary Dysfunction Agents |
· Oxybutynin solution was added to the pharmacy benefit with prior authorization. · Oxybutynin 2.5mg tablet – was added to the pharmacy benefit with prior authorization and quantity limit of 90 tablets per 30 days · Darifenacin – prior authorization was removed and quantity limit of 30 tablets per 30 days remains for the pharmacy benefit. · Added darifenacin as an alternative for Gemtesa and trospium extended release. |
|
|
Veklury |
Prior authorization has been removed for this medication on the pharmacy and medical benefit. However, this medication will continue to be available through the medical benefit. |
|
Code updates
The following service(s) will be not covered for all lines of business:
|
Code |
Description |
Effective Date |
|
K1034 |
Provision of COVID-19 test, nonprescription self-administered and self-collected use, FDA approved, authorized, or cleared, one test count |
05/12/2023 |
|
K1035 |
Molecular diagnostic test reader, nonprescription self-administered and self-collected use, FDA approved, authorized or cleared |
05/12/2023 |
The following service(s) previously covered will be not covered experimental and investigational for ACO, Commercial/ASO Plans:
|
Code |
Description |
Effective Date |
|
41512 |
Tongue base suspension, permanent suture technique
|
8/1/2023 |
The following service(s) previously not covered will be covered with no prior authorization for ACO, Commercial/ASO Plans:
|
Code |
Description |
Effective Date |
|
33745 |
Transcatheter intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies to establish effective intracardiac flow, including all imaging guidance by the proceduralist, when performed, left and right heart diagnostic cardiac catheterization for congenital cardiac anomalies, and target zone angioplasty, when performed (e.g., atrial septum, Fontan fenestration, right ventricular outflow tract, Mustard/Senning/Warden baffles); initial intracardiac shunt
|
5/1/2023 |
|
33746 |
Transcatheter intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies to establish effective intracardiac flow, including all imaging guidance by the proceduralist, when performed, left and right heart diagnostic cardiac catheterization for congenital cardiac anomalies, and target zone angioplasty, when performed (e.g., atrial septum, Fontan fenestration, right ventricular outflow tract, Mustard/Senning/Warden baffles); each additional intracardiac shunt location (List separately in addition to code for primary procedure)
|
5/1/2023 |
Drug Code Updates
The following drug(s) are now covered under the medical benefit with prior authorization for the Commercial/ASO lines of business:
|
Code |
Description |
Brand Name |
Effective Date |
|
No Specific Code |
Injection, ublituximab-xiiy, for intravenous use |
Briumvi |
5/1/2023 |
|
No Specific Code |
Injection, lecanemab-irmb, IV solution |
Leqembi |
5/1/2023 |
The following drug(s) will be covered with no prior authorization for the Commercial/ASO lines of business:
|
Code |
Description |
Brand Name |
Effective Date |
|
C9145 |
Injection, aprepitant, (Aponvie), 1 mg |
Aponvie |
5/1/2023 |
The following drug(s) will be covered with no prior authorization for the ACO lines of business:
|
Code |
Description |
Brand Name |
Effective Date |
|
J1449 |
Injection, eflapegrastim-xnst, 0.1 mg |
Rolvedon |
6/5/2023 |
|
J3299 |
Injection, triamcinolone acetonide (Xipere), 1 mg |
Xipere |
6/5/2023 |
|
Q5124 |
Injection, ranibizumab-nuna, biosimilar, (Byooviz), 0.1 mg |
Byooviz |
6/5/2023 |
|
Q5127 |
Injection, pegfilgrastim-fpgk (Stimufend), biosimilar, 0.5 mg |
Stimufend |
6/5/2023 |
|
Q5128 |
Injection, ranibizumab-eqrn (Cimerli), biosimilar, 0.1 mg |
Cimerli |
6/5/2023 |
|
Q5130 |
Injection, pegfilgrastim-pbbk (Fylnetra), biosimilar, 0.5 mg |
Fylnetra |
6/5/2023 |
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 |
|
No Specific Code |
fecal microbiota, live – jslm suspension, for rectal use |
Rebyota |
6/5/2023 |
|
C9147 |
Injection, tremelimumab-actl, 1 mg |
Imjudo |
6/5/2023 |
|
C9148 |
Injection, teclistamab-cqyv, 0.5 mg |
Tecvayli |
6/5/2023 |
|
C9149 |
Injection, teplizumab-mzwv, 5 mcg |
Tzield |
6/5/2023 |
|
J0218 |
Injection, olipudase alfa-rpcp, 1 mg |
Xenpozyme |
6/5/2023 |
|
J2998 |
Injection, plasminogen, human-tvmh, 1 mg |
Ryplazim |
6/5/2023 |
|
J9153 |
Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine |
Vyxeos |
6/5/2023 |
|
J9325 |
Injection, talimogene laherparepvec, per 1 million plaque forming units |
Imlygic |
6/5/2023 |
|
Q5129 |
Injection, bevacizumab-adcd (Vegzelma), biosimilar, 10 mg |
Vegzelma |
6/5/2023 |
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, ublituximab-xiiy, for intravenous use |
Briumvi |
5/1/2023 |
|
No Specific Code |
Injection, lecanemab-irmb, IV solution |
Leqembi |
5/1/2023 |
As a reminder the following codes have been deleted effective 5/12/2023
|
Code |
Description |
Effective Date |
|
G2023 |
Specimen collection for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source |
5/12/2023 |
|
G2024 |
Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source |
5/12/2023 |
|
U0003 |
Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R |
5/12/2023 |
|
U0004 |
2019-nCoV coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R |
5/12/2023 |
|
U0005 |
Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique, CDC or non-CDC, making use of high throughput technologies, completed within 2 calendar days from date of specimen collection (list separately in addition to either HCPCS code U0003 or U0004) as described by CMS-2020-01-R2 |
5/12/2023 |