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Updating your directory information and a provider webinar on utilization and authorization in April 2023

Updating your directory information and a provider webinar on utilization and authorization in April 2023

April 01, 2023

Featured story: How to manage adult scoliosis

“Adult scoliosis isn’t a new diagnosis, but it’s still growing in recognition. The treatment for adults is much different than the treatment for adolescents,” says John Chi, MD, MPH.

Dr. Chi is a Mass General Brigham neurosurgeon and director of the Spine Center at Brigham and Women’s Hospital. Below, he joins James D. Kang, MD, Mass General Brigham orthopaedic surgeon and chairman of the Department of Orthopaedic Surgery at the Brigham, to answer common questions about adult scoliosis.

Spine image

In this issue:

Help us keep directory information up to date
Provider webinar on utilization and authorization
The Mass General Brigham Accountable Care Organization
Hospital inpatient utilization report
Mass General Brigham Health Plan’s Drug fee schedules are to be updated
Medical policy updates
Code updates
Drug code updates
Formulary updates

Provider webinar on utilization and authorization

We value our provider network and want to support you and your practice staff in working with us. Our webinars and trainings offer an opportunity to hear about new updates and programs and get your questions answered. This month’s topic is around Utilization Management and how to submit authorizations to Mass General Brigham Health Plan. Watch the recording of the Mass General Brigham Health Plan Prior Authorization Overview.

Help us keep directory information up to date

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.

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

The Mass General Brigham Accountable Care Organization

As a reminder, the Mass General Brigham Health Plan has been chosen by the Commonwealth to be a plan for the MassHealth ACO program. This program went live on April 1, 2023 and will uniquely support the healthcare needs of MassHealth-eligible residents of Massachusetts.

We would like to underscore that your participation in the ACO Plan will not affect your participation in other MGBHP products. Also, please note that non-MGB Primary Care Providers are not included as part of this program. For more information and tools, visit massgeneralbrighamhealthplan.org/providers/mgb-aco

You can also review the ACO provider manual here: Provider resources | Mass General Brigham Health Plan

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 online at massgeneralbrighamhealthplan.org/providers

Mass General Brigham Health Plan’s Drug fee schedules to be updated

Mass General Brigham Health Plan reviews its drug fee schedules quarterly to ensure that they are current, comprehensive, and consistent with industry standards to the extent supported by its systems. In most cases, changes involve adding fees for new or existing codes to supplement the fees already on the fee schedule.

The latest update occured on April 1, 2023. Changes may involve both new and existing CPT and HCPCS codes and will include the planned quarterly update to physician-administered drugs, immune globulin, vaccine, and toxoid fees.

Medical policy updates

Six 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
Mobile Cardiac Outpatient Telemetry	April 2023: Annual review. Medicare Advantage added to table. Medicare Variation language added.	All lines of business	4/1/2023
Outpatient Chest Physical Therapy	April 2023: Annual review. Medicare Advantage added to table. Medicare Variation language added.	All lines of business	4/1/2023
External Counterpulsation	April 2023. Prior authorization removed. Policy Retired.	All lines of business	4/1/2023
Bronchial Thermoplasty	April 2023: Annual review. Medicare Advantage added to table. Medicare Variation language added.	All lines of business	4/1/2023
Gender Affirming Procedures	April 2023: Annual review. 1. Medicare Advantage added to table. 2. Term gender incongruence added throughout policy. 3. On page 3, under Chest/Breast surgeries, added statement “will be reviewed by a Medical Director for individual consideration”. 4. On page 3 under Genital Surgery, removed requirement that second health care provider submit documentation. Also changed continuous months of hormone therapy requirement to 6 months. 5. On page 4, added vocal cord surgery. 6. On Page 5, Medicare Variation language added. 7. On Page 5, Gender Affirming Surgery definition revised for clarity. 8. On page 5, removed vocal cord surgery from exclusion list. 9. References updated.	All lines of business	4/1/2023
Therapeutic Lens	April 2023: Off-cycle remove. Statement added “Restrictions may apply. Please refer to member handbook.”	All lines of business	4/1/2023

In addition, as of March 2023, Mass General Brigham Health Plan edited its Breast Reconstruction customized InterQual criteria to allow approval for members under the age of 18. To access this criteria, providers should log in to Mass General Brigham Health Plan’s provider website at MassGeneralBrighamHealthPlan.org and click the InterQual® Criteria Lookup link under the Resources Menu.

Code Updates

As a reminder to the network the following service(s) are not covered for all lines of business:

Code	Description
No Code	Vibrant Gastro for chronic idiopathic constipation

The following service(s) previously not covered will be covered with prior authorization for ACO lines of business:

Code	Description	Effective Date
64583	Revision or replacement of hypoglossal nerve neurostimulator array and distal respiratory sensor electrode or electrode array, including connection to existing pulse generator	1/1/2022
64584	Removal of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array	1/1/2022

The following service(s) will be covered with no prior authorization for Commercial/ASO and ACO lines of business:

Code	Description	Effective Date
A4239	Supply allowance for nonadjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service	3/1/2023
E2102	Adjunctive, nonimplanted continuous glucose monitor (CGM) or receiver	3/1/2023
E2103	Nonadjunctive, nonimplanted continuous glucose monitor (CGM) or receiver	3/1/2023

The following service(s) previously not covered will be covered with no prior authorization for Commercial/ASO lines of business:

Code	Description	Effective Date
33267	Exclusion of left atrial appendage, open, any method (eg, excision, isolation via stapling, oversewing, ligation, plication, clip)	3/9/2023
33268	Exclusion of left atrial appendage, open, performed at the time of other sternotomy or thoracotomy procedure(s), any method (eg, excision, isolation via stapling, oversewing, ligation, plication, clip) (List separately in addition to code for primary procedure)	3/9/2023
33269	Exclusion of left atrial appendage, thoracoscopic, any method (eg, excision, isolation via stapling, oversewing, ligation, plication, clip)	3/9/2023

The following service(s) will be covered with prior authorization for plans have infertility benefit:

Code	Description	Effective Date
89250	Culture of oocyte(s)/embryo(s), less than 4 days;	06/01/2023
89254	Oocyte identification from follicular fluid	06/01/2023
89255	Preparation of embryo for transfer (any method)	06/01/2023
89260	Sperm isolation; simple prep (eg, sperm wash and swim-up) for insemination or diagnosis with semen analysis	06/01/2023
89261	Sperm isolation; complex prep (eg, Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis	06/01/2023
89268	Insemination of oocytes	06/01/2023
89272	Extended culture of oocyte(s)/embryo(s), 4-7 days	06/01/2023
89280	Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes	06/01/2023
89281	Assisted oocyte fertilization, microtechnique; greater than 10 oocytes	06/01/2023
89258	Cryopreservation; embryo(s)	06/01/2023

Drug Code Updates

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

Code	Description	Brand Name	Effective Date
J1954	Injection, leuprolide acetate for depot suspension (Lutrate), 7.5 mg	Lutrate	01/01/2023
No Specific Code	Injection, tremelimumab-actl, for intravenous use	Imjudo	03/01/2023
No Specific Code	Injection, mirvetuximab soravtansine-gynx, for intravenous use	Elahere	03/01/2023
No Specific Code	Injection, teclistamab-cqyv for subcutaneous use	Tecvayli	03/01/2023

The following service(s) will be covered with no prior authorization for ACO lines of business; Covered with PA for Commercial/ASO lines of business:

Code	Description	Brand Name	Effective Date
J9314	Injection, pemetrexed (Teva) not therapeutically equivalent to J9305, 10 mg	Pemetrexed	01/01/2023

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, tremelimumab-actl, for intravenous use	Imjudo	03/01/2023
No Specific Code	Injection, mirvetuximab soravtansine-gynx, for intravenous use	Elahere	03/01/2023
No Specific Code	Injection, teclistamab-cqyv for subcutaneous use	Tecvayli	03/01/2023
J0218	Injection, olipudase alfa-rpcp, 1 mg	XENPOZYME	04/01/2023
J1747	Injection, spesolimab-sbzo, 1 mg	SPEVIGO	04/01/2023
J2327	Injection, risankizumab-rzaa, intravenous, 1 mg	SKYRIZI IV	06/01/2023
Q5128	Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg	CIMERLI	04/01/2023

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 Commercial Members

Effective 06/01/2023

The following changes are being made to the listed medications:

Calcitriol Ointment

This medication will become non-formulary.

Updates for MassHealth Members

Effective 06/05/2023

The following generic medications will become non-preferred. Please use the brand name alternatives:

Generic Medication	Brand Name Alternative
fluticasone / salmeterol inhalation aerosol	Advair HFA
lisdexamfetamine capsule, chewable tablet	Vyvanse
penciclovir	Denavir
rifabutin	Mycobutin
sodium oxybate	Xyrem
tafluprost	Zioptan
tasimelteon	Hetlioz

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

Brand Name	Generic Medication
Evamist	estradiol
Jublia	efinaconazole
Sandostatin LAR	octreotide injectable suspension
Strattera	atomoxetine

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

Opioids	Mass General Brigham Health Plan will align with the MassHealth Opioid Program no later than 07/01/2023. Additional details to follow.
Imlygic	This medication will now require a prior authorization and will only be available through the medical benefit.
Acromegaly, Carcinoid, Cushing Agents	· Recorlev tablet will now require a prior authorization and will only be available through the pharmacy benefit. · The step through requirement for Isturisa has been clarified in the criteria.
Anesthetics – Topical	Prior authorization for Lidocaine 5% ointment has been removed.
Antidepressants	· Antidepressant polypharmacy has been added to the criteria. · Auvelity (dextromethorphan/ bupropion) and Fetzima (levomilnacipran) will both now require a prior authorization through the pharmacy benefit. · Quantity limits have been added for the following medications: Fetzima, Trintellix, Viibryd, Auvelity, Aplenzin, Pristiq, Wellbutrin XL.
Angiogenesis Inhibitors	· Vegzelma (bevacizumab-adcd) will now require prior authorization and will only be available through the medical benefit. · Indication of myopic choroidal neovascularization (mCNV) was added for Avastin.
Benzodiazepines and other Antianxiety Agents	· Clarified diagnosis within criteria · Added quantity limit criteria for Triazolam 0.25mg · Criteria was updated to reflect inclusion of hospice/palliative care in the COBI clinical criteria as rationales for using combination therapy
Breast Cancer Agents	The following medication will require prior authorization and quantity limit on the pharmacy benefit: · Orserdu (elacestrant) 86mg tablet –90 tablets per 30 days · Oserdu (elacestrant) 345mg tablet – 30 tablets per 30 days.
Constipation Agents: Motegrity Amitiza	· Off-label indications are now included within criteria for select drugs. · Amitiza has been designated as a brand preferred product.
Erythropoiesis Stimulating Agents	· Off-label indications are now included within criteria
Neuromuscular Blockers	· Age requirement was updated for the diagnosis of primary axillary hyperhidrosis criteria. · Added specific criteria points to Concomitant CGRP and Botox therapy and 10-week Botox dosing for migraine prophylaxis.
Pediculicides and Scabicides	· Added indication for treatment of pubic lice for lindane shampoo.
Pulmonary Hypertension (PH) Agents	· Cialis (tadalafil) has been added for PAH and Raynaud Phenomenon and sildenafil (Viagra) to off-label indications. · Tadliq has been added to the pharmacy benefit with prior authorization.
Respiratory Agents - Oral	· Off-label indication of eosinophilic esophagitis has been added for Singular.
Androgen Therapy Kyzatrex (testosterone undecanoate capsule)	This medication will now require prior authorization and will only be available through the pharmacy benefit.
Cerebral Stimulants and ADHD Agents: Xelstrym patch Relexxi tablet	· Xelstrym patch and Relexxi tablet will now require prior authorization on the pharmacy benefit. · All references to Ritalin LA were updated to include “long-acting capsule” in the generic name. · Brand name requests for Kapvay and Desoxyn will require a previous trial with the generic. · Specific criteria regarding swallowing disorders have been added throughout the policy.
Multiple Sclerosis Agents Tascenso ODT 0.5mg tablet	· This medication will now require prior authorization on the pharmacy benefit. · Criteria was also updated to include new strength and weight requirement for this medication.
Epinephrine Products	· Criteria for Auvi-Q 0.1mg was updated to require only appropriate diagnosis. · Weight for 0.15mg and 0.3mg strengths were updated to include medical necessity for the requested agent.
Anticonvulsants: Zoniside capsule Ztalmy suspension	· Removed rationale for the following: “specific types of tube feedings” as well as the rationale of why member is unable to utilize opened medication for Zoniside capsules. · Ztalmy 50mg/ml suspension was added to the criteria and will now require a quantity limit of 1080 mL per 30 days as well as prior authorization on the pharmacy benefit.
Immunotherapy – Oral (Allergen Specific Immunotherapy)	· The criteria for non-rebated drugs/medications was removed. · Criteria was updated for Grastek for the request of an additional trial with Oralair. · The age limit for Odactra was updated to be in line with FDA-approved label.
Pediatric Behavioral Health Medication Initiative (PBHMI)	· Spravato was removed from PBHMI as it is restricted to medical benefit only with prior authorization. · Auvelity (dextromethorphan/bupropion) was added to PBHMI.
Targeted Immunomodulators (TIMs)	· Rinvoq – Criteria added for indication of non-radiographic axial spondylitis: requirement of a step through Taltz for Rinvoq requests in this indication. · Adbry and Cibinqo – Atopic dermatitis criteria was updated following dermatology standards to guide the review of cases where the affected area is too widespread. · Sotyktu – Criteria was updated to add the requirement for the member to be at least 18 years of age. · Cosentyx – Criteria was updated to require a step through Taltz for Cosentyx requests for non-radiographic axial spondylarthritis. · Infliximab – The appendix for more frequent or higher doses of injectable biologics was updated to allow more aggressive dosing of Infliximab products to be approved if the request documents concern that standard-weight based dosing would not be adequate in a pediatric member. · Skyrizi 180mg on-body injector will now require prior authorization and will be available on the pharmacy benefit.
Pulmonary Hypertension Agents	· Tadliq will now require prior authorization and will be available on the pharmacy benefit. · Reauthorization criteria and approval durations were updated. · The criteria for Revatio suspension was updated regarding swallowing disorders. · Sildenafil (generic for Viagra) was added to the Raynaud phenomenon criteria
Enzyme and Metabolic Disorder Therapies	· Initial and reauthorization criteria have been added for Xenpozyme for the treatment of non-central nervous system manifestations of acid sphingomyelinase deficiency (ASMD) in adult and pediatric patients. · Ryplazim (plasminogen, human-tvmh) will now require prior authorization and will be available through both pharmacy and medical benefits.
Rituximab Agents	· The criteria for PV was updated to remove the trial requirement with systemic immunosuppressive therapy as initial therapy with a steroid and rituximab is now preferred. · Off-label criteria for GVHD was updated to remove thalidomide from the acceptable trials and to add several agents as acceptable trials, as recommended by NCCN. · Criteria for ITP was updated to remove required splenectomy trial. · Several new off label indications were added to the policy.
Continuous Glucose Monitoring Products	· Updated criteria to allow for CGM access in any member receiving insulin regardless of dosing frequency and requests that exceed quantity limit due to adhesion issues.
Topical hyperhidrosis agents	The following specific criteria’s have been removed: · Symptoms affecting activities of daily living for Drysol · Requirement of a dermatologist for Qbrexza New indication of craniofacial hyperhidrosis was added to Qbrexza.
Growth Hormone Agents	· Criteria was added for short stature secondary to sickle cell disease and Silver-Russell syndrome. · Reauthorization criteria was updated to include guidance on pediatric members nearing end of growth potential who do not meet 2.5cm/yr. requirement.
Continuous Subcutaneous Insulin Infusion/Disposable Insulin Delivery	· Updated criteria to note that CGM may be accepted for blood glucose monitoring requirement, A1c ≥7% was changed to be one of the reasons for approval, and a quantity requirement was added.
Acute Lymphoblastic Leukemia, Single Agent Therapies	· Criteria was updated to align Blincyto criteria with NCCN guideline by removing requirement that the member be MDR-positive.
Tzield (teplizumab-mzwv)	This medication will now require prior authorization and will be available through both the pharmacy and medical benefits.
Insulin Products Basaglar Tempo Humalog Tempo Lyumjev Tempo	The following medications have been added to the Insulin criteria requiring prior authorization and will be available through the pharmacy benefit.
Padcev (enfortunmab vedotin-ejfv)	· Updated approval criteria based on expanded indications for patients with locally advanced or metastatic urothelial cancer (mUC) who are ineligible for cisplatin-containing chemotherapy and have previously received one or more prior lines of therapy.
Tecvayli (teclistamab-cqyv)	This medication will now require a prior authorization and will only be available through the medical benefit.
Asthma/Allergy Monoclonal Antibodies Dupixent	· Expanded indication for Dupixent in prurigo nodularis was added. · Revision to Dupixent atopic dermatitis note section to allow for bypass of Eucrisa trial if disease is noted to be severe or if the affected area is noted to be too widespread.
Kinase Inhibitors	· Lytgobi tablet will now require prior authorization as well as quantity limit of 4 tablets per 30 days on the pharmacy benefit. · Lytgobi will follow the same criteria as Truseltiq for the following indications: treatment of adult patients with previously treated, unresectable, locally advanced, or metastatic intrahepatic cholangiocarcinoma harboring fibroblast growth factor receptor 2 (FGFR2) gene fusions or other rearrangements. Criteria was updated for Hyftor (sirolimus gel) with the following: · Expand eligible prescriber to neurologist. · Quantity limit increase for patients < 12 years of age to 2 tubes per 30 days · Quantity limit increase for patients ≥ 12 years of age to 3 tubes per 30 days. · Initial requests for the following medications will now be approved for 6 months: Fyarro, Lytgobi, Rezurock, Truseltiq.
Oncology immunotherapies	· Imjudo will now require prior authorization on the medical benefit. · Bavencio – diagnosis update was made to include “diagnosis of locally advanced or metastatic urothelial carcinoma” · Imfinzi – expanded labeling for BTC, NSCLC, uHCC. · Keytruda – criteria update for unresectable or metastatic NSCLC and gastric or GEJ adenocarcinoma. · Libtayo – criteria update for NSCLC. · Opdivo – expanded indication for stage IIB, IIC, or III melanoma. · Tecentriq – expanded indication for ASPS. · The following was removed due to FDA voluntary withdrawal: Tecentriq for locally advanced or metastatic urothelial carcinoma from and Keytruda for 3rd-line setting for gastric cancer (locally advanced or metastatic gastric or gastroesophageal (GEJ) adenocarcinoma whose tumors expressed PD-L1 and had disease progression on or after ≥ 2 prior lines of therapy). BTC - bile duct cancer; NSCLC - non small cell lung cancer ; uHCC - unresectable hepatocellular carcinoma ; ASPS - alveolar soft part sarcoma
PARP Inhibitors: Lynparza®(olaparib) Zejula®(niraparib) Rubraca®(rucaparib)	Criteria updates made for Lynparza, Rubraca, Zejula for the following: · treatment of epithelial ovarian, fallopian tube, or primary peritoneal cancers to further specify first-line maintenance therapy, monotherapy vs combination. The following was removed due to FDA voluntary withdrawal: · Indication of fourth line treatment in adults with deleterious or suspected deleterious germline BRCA-mutated advanced ovarian cancer for Lynparza®(olaparib), the indication of homologous recombination deficiency (HRD) positive ovarian cancer after > 3 lines of chemotherapy for Zejula®(niraparib). Zejula®(niraparib) and Rubraca®(rucaparib) in epithelial ovarian, fallopian tube, or primary peritoneal cancer were restricted for use in patients with deleterious or suspected deleterious germline BRCA mutations.
Antitubercular Agents	· Prior authorization and quantity limits for Pretomanid have been removed on the pharmacy benefit. · Capastat (capreomycin) and isoniazid were added to the criteria to not require prior authorization for completeness purposes. · Criteria for Sirturo (bedaquiline) was updated to provide specific diagnosis and change to use with at least two other anti-TB agents.
Antibiotics - Ophthalmic	· Prior authorization has been removed for the following on the pharmacy benefit: Tobradex ST, Zylet, and Zymaxid · Gatifloxacin and tobramycin/loteprednol was added to single-entity agents criteria as one of the trial options.
Antifungals – Oral and Injectable	· Criteria for Brexafemme in RVVC was added. · Noxafil (posaconazole powder for oral suspension) will now require prior authorization on the pharmacy benefit
Antihistamines	· Criteria regarding swallowing disorders was added. · Language was updated to require one or contraindication to all trial agents. · Fexofenadine 60mg and 180mg tablets will no longer require a prior authorization on the pharmacy benefit.
Antipsychotics	· Quantity limit was added to quetiapine 150mg tablet of 90 tablets per 30 days on the pharmacy benefit. · Criteria was updated to allow approval for requests noting intent to bypass Abilify Maintena to avoid gluteal injections. · Expanded indication for Vraylar for treatment resistant depression. · Criteria regarding swallowing disorders was added.
Rebyota (fecal microbiota, live-jslm)	This medication will now require prior authorization and will be available through both the medical and pharmacy benefits.
Qutenza (capsaicin)	Criteria regarding medical necessity for the use of a transdermal formulation was added.
Oral Corticosteroids	Prior authorization for generic Uceris (budesonide ER tablet) has been removed from the pharmacy benefit
Emflaza	Approval durations for reauthorizations has been updated to 12 months for this medication.
Granulocyte Stimulating Agents	The following Biosimilars to Neulasta have been added to the criteria without prior authorization: Fylnetra (pegfilgrastim-pbbk), Rolvedon (eflapegrastim-xnst), and Stimufend (pegfilgrastim-fpgk). Fylnetra and Stimufend are now available through both pharmacy and medical benefits with no prior authorization. Rolvedon will now only be available through the medical benefit with no prior authorization.
Erivedge and Odomzo	Criteria point was updated to quantity limit of ≤1 unit/day.
Esbriet (pirfenidone tablet)	New strength of this medication (534 mg) has been added to the pharmacy benefit with a quantity limit of 90 tablets per 30 days as well as a prior authorization.
Oxlumo (lumasiran)	The approval durations for this medication has been updated to 12 months.
Tivdak (tisotumab)	Criteria was update based on NCCN recommendations to remove nivolumab as a step through.
Urinary Dysfunction Agents	Toviaz (fesoterodine) has been designated as a preferred drug on the pharmacy benefit.
IVIG	The following off-label indications have been added to the policy: · Antibody mediated rejection (AMR), Immune-mediated necrotizing myopathy (IMNM), Interstitial Lung Disease (ILD), Pemphigus Vulgaris (PV), Polymyositis (PM), and Prevention of recurrent infection in pediatric HIV members.
Lung Cancer Agents	The following new medication has been added to the pharmacy benefit with prior authorization and quantity limits: · Krazati (adagrasib) added with prior authorization and quantity limit of 180 tablets per 30 days. The quantity limit has been updated for the following medication on the pharmacy benefit: · Lumakras (sotorasib): quantity limit updated to 90 tablets per 30 days.
Plan Exclusions	Daxxify and Qwo are considered cosmetic and will be considered plan exclusions.
Systemic Chemotherapy	Vyxeos will now require prior authorization and will only be available through the medical benefit.
Drugs restriction to medical billing	Byooviz, Cimerli, Xipere will only be available through the medical benefit without prior authorization.