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New Massachusetts Step Therapy Law and Expedited Psychiatric Inpatient Admissions in October 2023

New Massachusetts Step Therapy Law and Expedited Psychiatric Inpatient Admissions in October 2023

October 01, 2023

Featured story: Behavioral health offerings for members at Mass General Brigham Health Plan

Mental health is a crucial component of well-being—and we're here to help your patients. Watch the video below to learn more about the resources available to your patients that support their behavioral health needs, including mental health and substance use.

In this issue:

New Massachusetts Step Therapy Law Effective October 1, 2023
Expedited Psychiatric Inpatient Admissions process
Authorization Submission via the Provider Portal
Hospital inpatient utilization report
Pharmacy benefits updates
Provider portal update
Provider enrollment changes
Medical policy updates
Code updates
Drug code updates
Formulary updates

New Massachusetts Step Therapy Law Effective October 1, 2023

Massachusetts legislation "An Act Relative to Step Therapy and Patient Safety" passed in October 2022, which aims to provide a transparent process for patients and providers to request an exception to the use of step therapy for Medicaid and commercial carriers. Additionally, this law aims to establish a state commission which will support implementation and evaluation of step therapy process revisions. This law takes effect beginning on October 1, 2023.

Mass General Brigham Health Plan applauds and appreciates the state’s efforts to increase access to healthcare and treatment through the new step therapy law. Having worked closely with the state to enhance access to medically necessary medications, we look forward to additional clarifying guidance from the state as we use permitted step therapy measures to keep care affordable for our members.

Here's what providers need to know:

This law contains broad regulations to step therapy protocols, including new step therapy exception criteria along with decision turnaround-time, continuity of care, and reporting requirements.
Mass General Brigham Health Plan's existing processes already align with many of the step therapy regulations referenced in the new law, including continuity of care requirements for members new to Mass General Brigham Health Plan.
Our updated step therapy exception criteria can be found here: Commercial, MassHealth. Please ensure all required documentation is submitted.
Medical necessity criteria are still required where applicable.

Please continue to ensure timely submission of prior authorization requests for both pharmaceutical and infusion medications. Prior authorizations for pharmacy should be submitted to CVS CareMark (contact information below)

Specialty Drugs, Pharmacy Benefit:	866-814-5506	(Fax: 866-249-6155)
Commercial:	800-294-5979	(Fax: 888-836-0730)
Health Connector:	855-582-2022	(Fax: 855-245-2134)
MassHealth	877-433-7643	(Fax: 866-255-7569)

For infused medications, please submit prior authorizations via our provider portal.

Expedited Psychiatric Inpatient Admissions process

The Expedited Psychiatric Inpatient Admissions (EPIA) process dictates that Emergency Departments (EDs) must notify the insurance Carrier when a member is in the ED, medically cleared, and awaiting psychiatric inpatient placement longer than 24-hours. To simplify this notification process for Mass General Brigham Health Plan members, Optum (our behavioral health vendor) has created a digital form for these notifications. Once a member is awaiting placement longer than 24-hours, EDs may complete the form linked below to submit their Carrier notification. Note: the form can also be used for the required daily updates on bed search efforts.

Optum MA ED Boarding Notification Form

Authorization Submission via the Provider Portal

As a reminder, to avoid delay, please ensure all clinical documentation related to the prior authorization request is included at the time of prior authorization submission.

Turn Around Time Frames:

Non-Urgent Requests- 14 Calendar Days
Urgent Requests-3 Calendar Days

Hospital inpatient utilization report

The latest quarterly hospital inpatient utilization report is now available. To review this report, click on the Reports tab in the Provider Portal and select Clinical Reports. If you do not have access to the Provider Portal, you may register here.

Pharmacy benefit updates

Changes coming for 1/1/24 for the Commercial, Exchange, and Medicaid lines of business
- Pharmacy benefit manager change from CVS Caremark to OptumRx
- Change in prior authorization review platform for medical specialty and specialty drugs from Novologix to Optum Specialty Fusion

More information regarding these changes will be shared in the coming weeks via the Provider Newsletter and our website.

If you have any initial questions please contact provider relations at healthplanprovrelations@mgb.org

Provider portal update

Effective 11/1/23, Fax number will be a mandatory field on the provider portal. This upgrade is being put in place to help facilitate requests for additional information when needed.

Provider enrollment changes

The Centers for Medicare & Medicaid Services and other regulatory bodies, as well as the federal No Surprises Act of 2021, require health plans to maintain and update data in provider directories. We rely on providers to review their data and notify us of changes as they happen, this ensures members have access to accurate information.

Provider demographic information in our Provider Directory 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.

To keep accurate network provider information, Mass General Brigham Health Plan must be promptly notified in writing of relevant changes pertaining to a provider’s practice. The primary way to notify Mass General Brigham Health Plan of enrollment changes is through the Provider Enrollment Portal within the Mass General Brigham Health Plan Provider Portal https://provider.massgeneralbrighamhealthplan.org/Authentication/LogIn?ReturnUrl=%2F.

The Provider Enrollment Portal gives you easy access to submit requests such as the following
• Enroll a new provider into your group

• Terminate an existing provider from your group

• Open and close your panels

• Submit demographic changes

• Generate a complete HCAS form

The Provider Enrollment Portal gives you real time status information of your enrollment request as well as sends you an email notification when your request has been completed.

Providers can also submit provider enrollment changes via the following tools:

Provider directory information landing page:

Update directory | Mass General Brigham Health Plan

Standardized Information Change Form http://www.masscollaborative.org/Provider_Information_Change_Form.pdf or with a signed document on the provider’s stationery. Completed forms should be emailed to HealthPlanPEC@mgb.org. Verbal requests and/or those submitted by third-parties or billing agents not on record as authorized to act on a provider’s behalf cannot be accepted.

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 HealthPlanProvidersService@mgb.or

Help us keep directory information up to date

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 provider.massgeneralbrighamhealthplan.org or by submitting a Provider Change via the Provider-Enrollment-Form to Mass General Brigham Health Plans Provider Enrollment Team by email at HealthPlanPEC@mgb.org.

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

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 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
Adstiladrin [NEW POLICY]	Effective Date: Guidelines to determine the medical necessity for Adstiladrin for the treatment of patients with high-risk Bacillus Calmette-Guérin (BCG)-unresponsive non-muscle invasive bladder cancer (NMIBC) with carcinoma in situ (CIS) with or without papillary tumors.	Commercial and Medicare Advantage	10/1/2023
Zolgensma	October 2023: Annual Review. Medicare language added.	All products	10/1/2023
Early Intensive Behavioral Intervention (EIBI)	October 2023: Annual update. Medicare Advantage added to table.	Commercial and MassHealth	10/1/2023
IV-Ketamine for Treatment-Resistant Depression	October 2023: Annual Update. Medicare Advantage added to table. Minor editorial refinements to overview section; moved language to coverage guidelines; intent unchanged. Medicare Variation language added. References updated.	Commercial and Medicare Advantage	10/1/2023
Enteral Nutrition Formulas and Supplements	October 2023: Annual review. Medicare Advantage added to table. Medicare variation language added. References updated.	All products	10/1/2023
Bariatric Surgery	October 2023: Annual review. Medicare Advantage added to table. Medicare variation language added. References updated.	All products	10/1/2023
Pylarify and Gallium Ga-68 PSMA-11 Imaging for Patients with Prostate Cancer	October 2023: Annual review. Medicare Advantage added to table. Initial Work-up criteria edited for clarity. Medicare Variation language added. References updated.	Commercial and Medicare Advantage	10/1/2023

New codes

Please see the coverage summary for October 2023 new codes below:

Not covered experimental and investigational for ACO, Commercial/ASO:

A2022	Innovaburn or innovamatrix xl, per square centimeter
A2023	Innovamatrix pd, 1 mg
A2024	Resolve matrix, per square centimeter
A2025	Miro3d, per cubic centimeter
A9156	Oral mucoadhesive, any type (liquid, gel, paste, etc.), per 1 ml
A9292	Prescription digital visual therapy, software-only, fda cleared, per course of treatment
C9788	Opto-acoustic imaging, breast (including axilla when performed), unilateral, with image documentation, analysis and report, obtained with ultrasound examination
C9789	Instillation of anti-neoplastic pharmacologic/biologic agent into renal pelvis, any method, including all imaging guidance, including volumetric measurement if performed
C9790	Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including image guidance
C9791	Magnetic resonance imaging with inhaled hyperpolarized xenon-129 contrast agent, chest, including preparation and administration of agent
C9792	Blinded or nonblinded procedure for symptomatic new york heart association (nyha) class ii, iii, iva heart failure; transcatheter implantation of left atrial to coronary sinus shunt using jugular vein access, including all imaging necessary to intra procedurally map the coronary sinus for optimal shunt placement (e.g., tee or ice ultrasound, fluoroscopy), performed under general anesthesia in an approved investigational device exemption (ide) study)
E0490	Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, controlled by hardware remote
E0491	Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by hardware remote, 90-day supply
K1036	Supplies and accessories (e.g., transducer) for low frequency ultrasonic diathermy treatment device, per month
L5991	Addition to lower extremity prostheses, osseointegrated external prosthetic connector
Q4285	Nudyn dl or nudyn dl mesh, per square centimeter
Q4286	Nudyn sl or nudyn slw, per square centimeter
0019M	Cardiovascular disease, plasma, analysis of protein biomarkers by aptamer-based microarray and algorithm reported as 4-year likelihood of coronary event in high-risk populations
0402U	Infectious agent (sexually transmitted infection), Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium, multiplex amplified probe technique, vaginal, endocervical, or male urine, each pathogen reported as detected or not detected
0404U	Oncology (breast), semiquantitative measurement of thymidine kinase activity by immunoassay, serum, results reported as risk of disease progression
0406U	Oncology (lung), flow cytometry, sputum, 5 markers (meso-tetra [4- carboxyphenyl] porphyrin [TCPP], CD206, CD66b, CD3, CD19), algorithm reported as likelihood of lung cancer
0407U	Nephrology (diabetic chronic kidney disease [CKD]), multiplex electrochemiluminescent immunoassay (ECLIA) of soluble tumor necrosis factor receptor 1 (sTNFR1), soluble tumor necrosis receptor 2 (sTNFR2), and kidney injury molecule 1 (KIM-1) combined with clinical data, plasma, algorithm reported as risk for progressive decline in kidney function
0408U	Infectious agent antigen detection by bulk acoustic wave biosensor immunoassay, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19])
0412U	Beta amyloid, Aβ42/40 ratio, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and qualitative ApoE isoformspecific proteotyping, plasma combined with age, algorithm reported as presence or absence of brain amyloid pathology
0415U	Cardiovascular disease (acute coronary syndrome [ACS]), IL-16, FAS, FASLigand, HGF, CTACK, EOTAXIN, and MCP-3 by immunoassay combined with age, sex, family history, and personal history of diabetes, blood, algorithm reported as a 5-year (deleted risk) score for ACS
0416U	Infectious agent detection by nucleic acid (DNA), genitourinary pathogens, identification of 20 bacterial and fungal organisms, including identification of 20 associated antibiotic-resistance genes, if performed, multiplex amplified probe technique, urine

Not covered benefit for ACO, commercial/ASO:

A9268	Programmer for transient, orally ingested capsule
A9269	Programable, transient, orally ingested capsule, for use with external programmer, per month
V2526	Contact lens, hydrophilic, with blue-violet filter, per lens

Redirect to Optum for ACO, Commercial/ASO:

H2040	Coordinated specialty care, team-based, for first episode psychosis, per month
H2041	Coordinated specialty care, team-based, for first episode psychosis, per encounter

Prior authorization required for ACO, Commercial/ASO:

L1681	Hip orthosis, bilateral hip joints and thigh cuffs, adjustable flexion, extension, abduction control of hip joint, postoperative hip abduction type, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
J7353	Anacaulase-bcdb, 8.8% gel, 1 gram

Prior authorization required for Commercial/ASO:

C9156	Flotufolastat f 18, diagnostic, 1 millicurie
0403U	Oncology (prostate), mRNA, gene expression profiling of 18 genes, first-catch post-digital rectal examination urine (or processed first-catch urine), algorithm reported as percentage of likelihood of detecting clinically significant prostate cancer
0405U	Oncology (pancreatic), 59 methylation haplotype block markers, next-generation sequencing, plasma, reported as cancer signal detected or not detected
0409U	Oncology (solid tumor), DNA (80 genes) and RNA (36 genes), by next-generation sequencing from plasma, including single nucleotide variants, insertions/deletions, copy number alterations, microsatellite instability, and fusions, report showing identified mutations with clinical actionability
0410U	Oncology (pancreatic), DNA, whole genome sequencing with 5-hydroxymethylcytosine enrichment, whole blood or plasma, algorithm reported as cancer detected or not detected
0411U	Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6
0413U	Oncology (hematolymphoid neoplasm), optical genome mapping for copy number alterations, aneuploidy, and balanced/complex structural rearrangements, DNA from blood or bone marrow, report of clinically significant alterations
0414U	Oncology (lung), augmentative algorithmic analysis of digitized whole slide imaging for 8 genes (ALK, BRAF, EGFR, ERBB2, MET, NTRK1-3, RET, ROS1), and KRAS G12C and PD-L1, if performed, formalin-fixed paraffinembedded (FFPE) tissue, reported as positive or negative for each biomarker
0417U	Rare diseases (constitutional/heritable disorders), whole mitochondrial genome sequence with heteroplasmy detection and deletion analysis, nuclear-encoded mitochondrial gene analysis of 335 nuclear genes, including sequence changes, deletions, insertions, and copy number variants analysis, blood or saliva, identification and categorization of mitochondrial disorder-associated genetic variants
0418U	Oncology (breast), augmentative algorithmic analysis of digitized whole slide imaging of 8 histologic and immunohistochemical features, reported as a recurrence score
0419U	Neuropsychiatry (eg, depression, anxiety), genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotype

No prior authorization required for ACO, Commercial/ASO:

A9573	Injection, gadopiclenol, 1 ml
A9603	Injection, pafolacianine, 0.1 mg
A9697	Injection, carboxydextran-coated superparamagnetic iron oxide, per study dose
B4148	Enteral feeding supply kit; elastomeric control fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape

Drug codes no prior authorization required for ACO:

C9153	Injection, amisulpride, 1 mg
J0801	Injection, corticotropin (acthar gel), up to 40 units
J0802	Injection, corticotropin (ani), up to 40 units
J0874	Injection, daptomycin (baxter), not therapeutically equivalent to j0878, 1 mg
J7214	Injection, factor viii/von willebrand factor complex, recombinant (altuviiio), per factor viii i.u.
J7519	Injection, mycophenolate mofetil, 10 mg
J9051	Injection, bortezomib (maia), not therapeutically equivalent to j9041, 0.1 mg

Drug codes prior authorization required for ACO:

J2781	Injection, pegcetacoplan, intravitreal, 1 mg
J9064	Injection, cabazitaxel (sandoz), not therapeutically equivalent to j9043, 1 mg

Drug codes redirect to Pharmacy for ACO:

C9152	Injection, aripiprazole, (abilify asimtufii), 1 mg
C9158	Injection, risperidone,:(uzedy), 1 mg
J0889	Daprodustat, oral, 1 mg, (for esrd on dialysis)
J2359	Injection, olanzapine, 0.5 mg

Drug codes no prior authorization required for Commercial/ASO:

J0874	Injection, daptomycin (baxter), not therapeutically equivalent to j0878, 1 mg
J2359	Injection, olanzapine, 0.5 mg
J7519	Injection, mycophenolate mofetil, 10 mg
J9345	Injection, retifanlimab-dlwr, 1 mg

Drug codes prior authorization required for Commercial/ASO:

C9155	Injection, epcoritamab-bysp, 0.16 mg
C9157	Injection, tofersen, 1 mg
J2781	Injection, pegcetacoplan, intravitreal, 1 mg
J7214	Injection, factor viii/von willebrand factor complex, recombinant (altuviiio), per factor viii i.u.
J9051	Injection, bortezomib (maia), not therapeutically equivalent to j9041, 0.1 mg

Drug codes redirect to Pharmacy for Commercial/ASO:

C9158	Injection, risperidone, (uzedy), 1 mg
J0801	Injection, corticotropin (acthar gel), up to 40 units
J0802	Injection, corticotropin (ani), up to 40 units
J0889	Daprodustat, oral, 1 mg, (for esrd on dialysis)

Drug codes no prior authorization required for Med Adv:

C9152	Injection, aripiprazole, (abilify asimtufii), 1 mg
C9153	Injection, amisulpride, 1 mg
C9154	Injection, buprenorphine extended-release (brixadi), 1 mg
C9158	Injection, risperidone, (uzedy), 1 mg
J0874	Injection, daptomycin (baxter), not therapeutically equivalent to j0878, 1 mg
J2359	Injection, olanzapine, 0.5 mg
J7353	Anacaulase-bcdb, 8.8% gel, 1 gram
J7519	Injection, mycophenolate mofetil, 10 mg
J9051	Injection, bortezomib (maia), not therapeutically equivalent to j9041, 0.1 mg

Drug codes prior authorization required for Med Adv:

C9155	Injection, epcoritamab-bysp, 0.16 mg
C9157	Injection, tofersen, 1 mg
J0801	Injection, corticotropin (acthar gel), up to 40 units
J0802	Injection, corticotropin (ani), up to 40 units
J2781	Injection, pegcetacoplan, intravitreal, 1 mg
J7214	Injection, factor viii/von willebrand factor complex, recombinant (altuviiio), per factor viii i.u.
J9345	Injection, retifanlimab-dlwr, 1 mg

Code updates

The following drug(s) are now covered under the medical benefit with prior authorization required for the Commercial/ASO lines of business:

Code	Description	Brand Name	Effective Date
No Specific Code	Injection, pegunigalsidase alfa-iwxj, for intravenous use	Elfabrio	09/01/2023
No Specific Code	Injection, epcoritamab-bysp, for subcutaneous use (Effective 10.1.2023 CMS has assigned a HCPCS code (C9155))	Epkinly	09/01/2023

The following drug(s) are now covered under the medical benefit no prior authorization required for the ACO lines of business:

Code	Description	Brand Name	Effective Date
J2278	Injection, ziconotide, 1 mcg	Prialt	10/02/2023

The following drug(s) are now covered with prior authorization required for ACO lines of business:

Code	Description	Brand Name	Effective Date
J0174	Injection, lecanemab-irmb, 1 mg	Leqembi	10/02/2023
J1306	Injection, inclisiran, 1 mg	Leqvio	10/02/2023
J9177	Injection, enfortumab vedotin-ejfv, 0.25 mg	Padcev	10/02/2023
J1300	Injection, eculizumab, 10 mg	Soliris	10/02/2023
C9151	Injection, pegcetacoplan, 1 mg	Syfovre	10/02/2023
J1823	Injection, inebilizumab-cdon, 1 mg	Uplizna	10/02/2023

The following drug(s) are now covered under the medical benefit with prior authorization required for Medicare Advantage lines of business:

Code	Description	Brand Name	Effective Date
No Specific Code	Injection, pegunigalsidase alfa-iwxj, for intravenous use	Elfabrio	09/01/2023
No Specific Code	Injection, epcoritamab-bysp, for subcutaneous use (Effective 10.1.2023 CMS has assigned a HCPCS code (C9155))	Epkinly	09/01/2023

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 All Members

Effective 10/01/2023

The following changes are being made to the listed medications:

Step Therapy Exception

New criteria have been developed in accordance with the Massachusetts Step Therapy Exception Law. Medical necessity criteria are still required where applicable.

Commercial/Exchange Step Therapy Exception Criteria

MassHealth Step Therapy Exception Criteria

Click here for more information related to the Step Therapy Law.

Updates for Commercial Members

Effective Immediately

The following changes are being made to the listed medications:

Narcan (naloxone) OTC

These products have been added to our formulary with no copay.

Naloxone Nasal Spray

Naloxone Syringe

Naloxone Vial

These products have been updated on our formulary to no longer charge a copay.

Updates for MassHealth Members

Effective 12/04/2023

The following generic medications will become non-preferred. Please use the brand name alternative(s):

Generic Medication	Brand Name Alternative
lisdexamfetamine capsule, chewable tablet	Vyvanse capsule, chewable tablet

The following brand name medications will become non-preferred. Approval will require a trial of its generic medication:

Brand Name	Generic Medication
Viibryd	vilazodone
Canasa	mesalamine suppository
Coreg CR	carvedilol extended-release
Veletri	epoprostenol
Zytiga 500 mg tablet	abiraterone 500 mg tablet

Effective 10/02/2023 - Reminders

Beyfortus

This medication was added to the pharmacy benefit with a prior authorization if member is > 8 months of age.

This medication will be available on the medical benefit without a prior authorization.

Abrysvo

Arexvy

As of 10/02/23, these vaccines will be available on the pharmacy and medical benefit without prior authorization.

Please note: upcoming update for 12/04/23 below.

Effective 12/04/2023

The following changes are being made to the listed medications to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List):

Inhaled Respiratory Agents

GSK intends to discontinue branded Flovent HFA (all strengths) and Flovent Diskus (all strengths) on Dec 2023. Pharmacies may continue to dispense branded Flovent under DAW-9 while supplies last.

Generic Flovent (fluticasone proprionate inhalation) will require a prior authorization as of 12/04/23.

Current members will be grandfathered through 03/04/2024 as long as they have been on the medication continuously for at least 90 days within the past 120-day period. Thereafter, these members will be subject to the prior authorization on 03/05/2024.

New members starting on generic Flovent will be subject to the prior authorization on 12/04/2023.

Prior authorization was removed from the pharmacy benefit for the following medications:

· Anoro Ellipta

· Arnuity

· Serevent Diskus

Generic Spiriva Handihaler (tiotroprium powder) has been added to the pharmacy benefit without prior authorization.

Vaccine Agents

The following vaccines have been added to the pharmacy benefit with prior authorization if member is < 60 years of age.

· Abrysvo

· Arexvy

These medications will continue to be available on the medical benefit without prior authorization.

Adstiladrin

(nadofaragene firadenovec-vncg)

New drug, Adstiladrin (nadofaragene firadenovec-vncg), was added to the medical benefit only with prior authorization.

Antibiotics – Oral Agents

The following medications have been added to the pharmacy benefit with prior authorization:

· Nitrofurantoin 50mg/5ml suspension

· Cefaclor suspension

Prior authorization was removed from tinidazole tablet on the pharmacy benefit.

Anti-Acne & Rosacea Agents

Generic Retin-A Micro 0.08% gel pump (tretinoin microsphere gel) was added to the pharmacy benefit with prior authorization.

Anticoagulants

Xarelto 2.5mg tablet had prior authorization removed, however, quantity limit of 60 tablets per 30 days will remain on the pharmacy benefit.

Xarelto suspension will require a prior authorization for those over 18 years of age on the pharmacy benefit.

Dabigatran oral pellets criteria was updated in members ≥8 years of age to allow for use in members who are unable to swallow capsules rather than requiring member to have a swallowing condition.

Anticonvulsants

The following was updated:

· Stability criteria for concomitant use of gabapentin and pregabalin was updated to require additional provider documentation for requests to be eligible for provisional approval if they do not meet full approval criteria.

· Stability criteria for gabapentin or pregabalin over the dose limits was updated to clarify that requests for members with seizure and/or psychiatric diagnoses are approvable regardless of specified approval criteria.

Bile Acid Agents

Bylvay is now approved in cholestatic pruritis in patients ≥1 year old with Alagille syndrome. Criteria was updated for Alagille syndrome which will now require a step through Livmarli, and approval duration was updated from 6 months to one year for consistency with Livmarli.

Livmarli is now approved in patients ≥3 months and older with Alagille syndrome, where it previously was limited to approval in patients ≥1 years old and will now require member’s current weight for Alagille syndrome.

Enzyme and Metabolic Disorder Therapies

The following medication was removed from the pharmacy benefit and will remain on the medical benefit with prior authorization:

· Nexviazyme injection

Genetic testing requirement was removed from criteria for Kuvan and Palynziq.

Federal Rebate Program

The following medication will remain on the pharmacy benefit with prior authorization and added to the federal rebate program:

· Aemcolo

The following medications will remain on the pharmacy benefit with prior authorization and have been removed from the federal rebate program:

· Oracea

· Qbrexa

Friedrichs Ataxia Agents

Criteria was clarified to include quantity limit for reauthorizations.

Gastrointestinal – PPIs H2 Antagonist & Misc. Agents

Konvomep criteria will require total of three trials including Zegerid and 2 others.

Growth Hormone Agents

New drug, Sogroya (somapacitan-beco), was added to the pharmacy benefit with prior authorization.

Hypnotic Agents

For Silenor (doxepin tablet) criteria, Quviviq was added as another step through option.

Zolpidem 7.5mg capsule was added to the pharmacy benefit with prior authorization and quantity limit of 30 capsules per 30 days.

Inflammatory Bowel Disorder Agents

Brand name Uceris will require a trial with its corresponding generic equivalent first.

Insulin Products

The following medications were added to the pharmacy benefit with prior authorization:

· Rezvoglar (insulin glargine-aglr)

· Fiasp Pump Cartridge (insulin aspart)

· Generic Semglee (insulin glargine-yfgn)

Rezvoglar will be a step through option for Basaglar.

Oncology Immunotherapies

New drug, Zynyz (retifanlimab-dlwr), was added to the medical benefit with prior authorization.

Opioid Dependence and Reversal Agents

New drug, Brixadi (buprenorphine extended-release injection) was added to the pharmacy benefit with prior authorization and medical benefit without prior authorization.

Rinvoq

New FDA approved indication for Crohn’s disease was added.

Topical Hyperhidrosis Agents

Qbrexza criteria was updated to require an additional step through Botox.