Northwest February Newsletter 2022

Thanks From the Heart

Valentine’s Day was yesterday, but our love for all you do for our members continues year-round. The first two months of 2022 have reminded our entire country and world – once again – of the importance of healthcare providers. From battling the latest surges of coronavirus variants to helping our children and older adults stay healthy throughout the winter season, you work tirelessly every day for the well-being of everyone in our communities. From our hearts to yours, thank you.

As It Relates to You

Key information for you and your staff.

Wishing You a Happy New Year

After two years unlike any others in recent memory, we’re excited to welcome 2022 and the hope and optimism it brings. We’re gearing up for another great year of partnership with each of you, and we deeply appreciate your continued dedication to the health of our members – especially in these trying times.

As always, your provider relations specialist will be at your side throughout 2022, there for you whenever you have any questions or concerns. They’re your liaison with the health plan and are dedicated to making everything easy, transparent and smooth for you and your fellow providers.

They’re available to meet with you at a time of your convenience for an educational chat about our policies and procedures, our new plans and products, and much more. If you’d like to set up a meeting, call your provider relations specialist. These meetings can be held virtually through our online system, via email or simply over the phone.

Thank you for all you do for our members, and please know we’re always here to offer you the support you need. We value your partnership, and look forward to a bright 2022 ahead.

American Heart Month

February is American Heart Month, the perfect time to chat with your patients about the importance of keeping their hearts healthy.

Heart disease is the leading cause of death in the U.S. for both men and women. According to the CDC, it leads to about 30% of all deaths in the country. This includes deaths from sudden events like heart attacks and more chronic, longer-lasting issues.

Please talk with your patients about heart health, and remind them of the importance of exercise, healthy eating and watching their blood pressure and cholesterol levels. For those who’ve been prescribed heart medications, remind them to take the drugs regularly and as directed.

Also remember to report all conditions for your patients yearly. Some of the most overlooked conditions are morbid obesity, pulmonary hypertension and atrial fibrillation. It’s extremely valuable to your patients’ health to report any and all vascular conditions, as well as any forms of chronic heart failure. Failure to report all conditions for a patient in the current year could lead to gaps in care. For more help on specific conditions, reach out to your coding consultant team.

The American Heart Association has many great resources for both you and your patients. Your guidance can help them keep their hearts beating for years to come.

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Important Information About
COVID-19 Treatments and Tests

Oral Anti-Viral Medications for COVID-19

Two oral anti-viral medications have been given Emergency Use Authorization and are currently available for the treatment of COVID-19. These therapies are Paxlovid^TM, which can be used in those age 12 and above, and molnupiravir, which can be used in those 18 and above. These medications are available by prescription only and are provided at no cost to the member. We’ll cover up to two treatment courses per year.

At-Home COVID-19 Test Kits

In January, President Biden announced that individuals who buy over-the-counter (OTC) COVID-19 diagnostic tests are able to receive reimbursement for these tests from their health plan. This is for tests bought from January 15, 2022, onward, continuing until the end of the public health emergency. Following the president’s announcement about OTC diagnostic tests, we’ve developed resources to help you and your patients understand this benefit. For more information about this benefit and the process for test reimbursement, click here to read our frequently asked questions. You can also call your provider relations specialist if you have additional questions. Important note: This coverage does not apply to those on our Medicare plans, short-term plans or self-funded plans with pharmacy carve-outs.

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Help Us Move the Needle

Together we can help people live their healthiest lives. Find reminders, tips and more in this section, to guide improvements in patient outcomes. Help us move the needle.

Closing Gaps in Care:
New Year, New Gaps To Close

It’s hard to believe, but 2022 is already two months in. As we move further into the new year, it’s important to make sure your patients are getting the appropriate preventive services they need to identify any issues and close any gaps in their care. As appropriate, please remind your patients about the following screenings.

All patients:

• Colorectal cancer screening.
• Blood pressure reading.
• Seasonal flu vaccine.
• Medication review.

Women:

• Breast cancer screening.
• Cervical cancer screening.
• Osteoporosis screening for women who’ve had a fracture.
• Prenatal and postpartum care for pregnant women.

Patients with diabetes:

• A1C test.
• Nephropathy screening.
• Diabetic retinal eye exams.

Patients with rheumatoid arthritis:

• Treatment with a disease-modifying anti-rheumatic drug (DMARD).

Patients with clinical atherosclerosis:

• Statins therapy.

Also, please remember we have health coaching and care coordination services that can help your patients (who are members of our health plans) manage their conditions at no extra cost to them. We know you worry about your patients’ health between visits, and these services can help improve their outcomes and overall well-being throughout the entire year.

HEDIS Quality Measure –
Child and Adolescent Well-Care Visits (W30, WCV)

By working together, we can improve health outcomes for your patients. The Healthcare Effectiveness Data and Information Set (HEDIS®) is a set of standards that helps us together assess the care patients receive. This article gives you information on the HEDIS quality measure for well-child visits in a patient’s first 30 months of life, and tips on how to meet this measure and provide best care.

Why is this measure important?

Assessing a child’s physical, emotional and social development during the first 30 months of life is particularly important. Regular well-care visits let you check up on – and influence positively – a child’s health and development. They’re also a critical opportunity for screening and counseling.

What is the measure?

HEDIS looks at, and reports, the following:

1. The percentage of children who turned 15 months old during the measurement year and had at least six well-child visits with a primary care provider (PCP) during their first 15 months of life.
2. The percentage of children who turned 30 months old during the measurement year and had at least two well-child visits with a PCP in the last 15 months.

Important Notes

• The PCP does not have to be the child’s assigned PCP.
• The well-child visits are to be completed on different dates of service on or before the 15-month and 30-month birthdays, respectively.

Tips To Meet the Measure – and Improve Your Quality Score

• Completing all milestone visits in a timely manner is very important. For patients who are off track, schedule a catch-up well-child visit appointment for each required evaluation.
• Acute or chronic condition visits, inpatient visits and emergency department visits do not count toward the measure.
• Make sure to code the visits appropriately.
• At new patient visits and any future visits, always review the patient’s need for well-child evaluation care with the parents. Schedule all needed upcoming well-child visits before the patient and parents leave your office.
• Provide parents with the recommended child vaccine schedule from the CDC. Click here to view and print the schedule.
• Include the following in the medical record:
  • Progress notes or office visit notes with dated growth chart.
  • Complete Physical Examination Form.
  • Anticipatory Guidance or Developmental Milestone Form.

Thank you for all you do every day to give your patients the best care. We are deeply grateful for all your efforts.

HEDIS Quality Measure –
Update to Prenatal and Postpartum Measure

There’s been an update to the HEDIS Prenatal and Postpartum (PPC) Measure for 2022. Here’s what you need to know.

Why is this measure important?

Every year, 1 million U.S. women have complications during pregnancy, labor, delivery or the postpartum period. Research indicates that up to 60% of all pregnancy-related deaths could be prevented if women had better access to healthcare, received better quality of care, and made lifestyle and health-related changes. High-quality, timely prenatal and postpartum care is incredibly important for the long-term health and well-being of new mothers and their children.

What is the measure?

HEDIS looks at, and reports, the following:

• The percentage of deliveries (of live births) in which women had a prenatal care visit in the first trimester, on or before the enrollment start date in the health plan, or within 42 days of enrollment in the health plan.
• The percentage of deliveries (of live births) in which women had a postpartum visit on or between seven and 84 days after their delivery.

Summary of Changes

For 2022, the measure has:

• Added instructions to report rates stratified by race and ethnicity for each product line.
• Removed the definition of last enrollment segment and clarified continuous enrollment requirements for steps 1 and 2 of the Timeliness of Prenatal Care numerator.
• Clarified that members in hospice or using hospice services any time during the measurement year are a required exclusion.
• Clarified that services provided during a telephone visit, e-visit or virtual check-in may be used for Administrative and Hybrid collection methods.
• Added required exclusions to the Rules for Allowable Adjustments.
• Added new data elements tables for race and ethnicity stratification reporting.

Providing Quality Care for Patients with Schizophrenia

Schizophrenia is one of the top 10 diagnoses affecting the global burden of disease, according to the World Health Organization. Beyond what’s well known, here are some additional facts about those diagnosed with this chronic disorder:

• They’re at high risk of developing hypertension, diabetes and hyperlipidemia.
• Many are prescribed antipsychotic medications. These medications can contribute to the development of metabolic syndrome.
• Heart disease contributes readily to lower life expectancy in those with schizophrenia.
• Even outside of antipsychotic therapy, those with schizophrenia often have altered glucose homeostasis which puts them at risk for diabetes.

HEDIS standards for quality schizophrenia care pay particular attention to metabolic monitoring of those with the diagnosis. These HEDIS measures include:

• Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD). Metabolic syndrome is a risk for those with serious mental illness, and the risk is even greater when antipsychotic medications are prescribed. This HEDIS measure assesses the percentage of people age 18 to 64 diagnosed with schizophrenia, schizoaffective disorder or bipolar disorder who were dispensed an antipsychotic medication and had a diabetes screening during the year.
• Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD). Olanzapine and mid- and low-potency first generation antipsychotics including clozapine are often used to treat serious mental illness. These can increase the risk of metabolic syndrome. This HEDIS measure assesses the percentage of people age 18 to 64 diagnosed with schizophrenia or schizoaffective disorder and diabetes, who had an LDL-C and HbA1c test during the year. Improving the treatment of diabetes in this population may lead to better emotional well-being, higher quality of life and the reduced need for additional healthcare services.
• Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC). Having high levels of blood cholesterol is a risk factor for people with schizophrenia. This population is also less likely to seek treatment for high cholesterol. Additionally, some atypical antipsychotic drugs can increase total and LDL (or “bad”) cholesterol and triglycerides, and decrease HDL (or “good”) cholesterol – which increases the risk of coronary heart disease. This HEDIS measure assesses the percentage of people age 18 to 64 diagnosed with schizophrenia or schizoaffective disorder and cardiovascular disease, who had an LDL-C test during the year.

References

Asche, C.J., C. LaFleur, C. Conner. 2011. A Review of Diabetes Treatment Adherence and the Association with Clinical and Economic Outcomes. Clinical Therapeutics 33(1): 74–109.

Cohn, T., D. Prud’homme, D. Streiner, H. Kameh, G. Remington. 2004. Characterizing Coronary Heart Disease Risk in Chronic Schizophrenia: High Prevalence of the Metabolic Syndrome. Can J Psychiatry 49(11): 753–60.

Fischer and Buchanan (2021). Schizophrenia in adults: Clinical manifestations, course, assessment, and diagnosis. UpToDate.

Hennekens, C.H., A.R. Hennekens, D. Hollar, D.E. Casey. 2005. “Schizophrenia and Increased Risks of Cardiovascular Disease.” Am Heart J 150: 1115–21.

Nasrallah H.A. 2008. Atypical Antipsychotic-Induced Metabolic Side Effects: Insights From Receptor-Binding Profiles. Mol Psychiatry 13(1): 27–35.

Nasrallah, H.A., J.M. Meyer, D.C. Goff, J.P. McEvoy, S.M. Davis, T.S. Stroup, et al. 2006. Low Rates of Treatment for Hypertension, Dyslipidemia and Diabetes in Schizophrenia: Data from the CATIE Schizophrenia Trial Sample at Baseline. Schizophr Res 86(1-3): 15–22.

Nielsen, J., S. Skadhede, C.U. Correll. 2010. Antipsychotics Associated with the Development of Type 2 Diabetes in Antipsychotic-Naive Schizophrenia Patients. Neuropsychopharmacology 35(9): 1997–2004.

Saatci, E., G. Tahmiscioglu, N. Bozdemir, et al. 2010. The Well-Being and Treatment Satisfaction of Diabetic Patients in Primary Care. Health Quality of Life Outcomes 8: 67.

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2022 Desk Reference Release –
Coding and Documentation Tips Made for You

We’re excited to announce our updated 2022 Coding and Documentation Tips flier, a handy tool made just for you and your staff. This flier can be used as a quick and comprehensive reference for many commonly diagnosed conditions and includes helpful reminders on how to create documentation to support them.

Click here to view the flier. You can even print it out to keep it always at hand.

Thank you for your help with accurate coding and documentation. We’re grateful for how hard you work and all you do for our members’ health. For short videos with coding tips, click here. And for even more helpful tips and resources, visit our Coding Counts page or contact our consulting team at [email protected].

Coagulation Defects – How To Properly Code and Document

Supporting documentation and accurate coding are key to making sure your patients receive the care they need. Failure to document chronic conditions on an annual basis impacts your patients, fellow providers and our organization. Here are some helpful documentation and coding tips for several common coagulation defects.

It’s important to specify if the coagulation disorder is primary, inherited or secondary; and whether it’s due to chronic disease, drugs or medical treatment.

When reporting a secondary hypercoagulable state (D68.69) caused by a chronic illness (such as malignancy, atrial fibrillation or CHF), chemotherapy, pregnancy or trauma, document using  language such as “due to” or “caused by” to show the linkage to the primary condition.

Sickle cell disease is the most common inherited blood disorder in the U.S. When documenting, it’s important to specify:

• When a patient is a carrier of sickle cell trait (D57.3).
• When a patient has sickle cell disease, with crisis (D57.0X) or without crisis (D57.1).
• Manifestations of sickle cell disease, such as sickle cell anemia (D57.1) or hemoglobin (Hb) SC disease (D57.2X).
• Complications from manifestations of sickle cell disease, such as sickle cell/Hb-C disease with acute chest syndrome (D57.211) or sickle cell/Hb-C disease with splenic sequestration (D57.212).

Other genetic clotting disorders – such as factor V Leiden mutation, prothrombin G20210A mutation or other rare clotting disorders – should also be documented and reported annually.

As always, you can reach out to us at [email protected] if you have any questions. Thank you for your help with accurate coding and documentation. We’re grateful for your hard work and attention to detail.

Pharmacy Updates

All Plans

New Drug Reviews

• Amondys 45 (casimersen)—Treatment of Duchenne muscular dystrophy (DMD) in patients who have a confirmed mutation of the DMD gene that is amenable to exon 45 skipping
  • Formulary placements­
    • WA Individual—Excluded
    • Medicare—Non-Formulary
• Imcivree (setmelanotide)— Indicated for chronic weight management in adult and pediatric patients 6 years of age and older with obesity due to proopiomelanocortin (POMC), proprotein convertase subtilisin/kexin type 1 (PCSK1), or leptin receptor (LEPR) deficiency
  • Formulary placements
    • WA Individual—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary
• Myfembree (relugolix, estradiol and norethindrone)—Indicated for the management of heavy menstrual bleeding associated with uterine leiomyomas (fibroids) in premenopausal women
  • Formulary placements
    • WA Individual—Preferred Brand with PA
    • Medicare—Non-Formulary

Criteria Changes

• Lemtrada (alemtuzumab)
  • Removed exclusion regarding conditions decreasing life expectancy
  • This criteria will also apply to Medicare Part B
• Ocrevus (ocrelizumab)
  • Removed exclusion regarding conditions decreasing life expectancy and updated J code
  • This criteria will also apply to Medicare Part B

Specialty Drugs

New Policies

• Cystadrops policies for WA Individual and Medicare
  • Patients tend to be more compliant due to fewer doses required
• Ivermectin policies for WA Individual and Medicare
  • PA policy is needed to exclude coverage for COVID-19 treatment

Formulary Additions

• Gemtesa (vibegron)—Treatment of overactive bladder (OAB) with symptoms of urge urinary incontinence (UUI), urgency, and urinary frequency in adults
  • Formulary placements
    • WA Individual—Non-Preferred Brand
    • Medicare—Non-Formulary
• Zokinvy (lonafarnib)—(1) To reduce the risk of mortality in Hutchinson-Gilford progeria syndrome (HGPS); (2) For the treatment of processing-deficient progeroid laminopathies (PLs) in patients 12 months or older with a body surface area of 0.39m2 and above with either: (a) Heterozygous LMNA mutation with progerin-like protein accumulation or (b) Homozygous or compound heterozygous ZMPSTE24 mutations
  • Formulary placements
    • WA Individual—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary
• Nulibry (fosdenopterin)—To reduce the risk of mortality in patients with molybdenum cofactor deficiency (MoCD) Type A
  • Formulary placements
    • WA Individual—Non-Preferred Specialty Medical with PA
    • Medicare—Non-Formulary
• Nexviazyme (avalglucosidase alfa-ngpt)—xTreatment of patients 1 year of age and older with late-onset Pompe disease (lysosomal acid alpha-glucosidase [GAA] deficiency)
  • Formulary placements
    • WA Individual—Non-Preferred Specialty Medical with PA
    • Medicare—Non-Formulary

WA Individual

Criteria Changes

• IVIG
  • Updated approval period according to 215 ILCS 5/356z.24

Specialty Drugs

Criteria Changes

• Cerdelga (eliglustat tartrate)
  • Added exclusion criteria and updated references
• Cerezyme (imiglucerase)
  • Added exclusion criteria and updated references
• Elelyso (taliglucerase alfa)
  • Added exclusion criteria and updated references
• VPRIV (velaglucerase alfa)
  • Added exclusion criteria and updated references
• Fabrazyme (agalsidase beta)
  • Updated age requirement
• Hereditary Angioedema
  • Added Sajazir criteria, updated approval period for Orladeyo, added Haegarda HCPCS code, updated references
• Xiaflex (collagenase clostridium histolyticum)
  • Added exclusion criteria and updated references
• Leuprolide Acetate (Fensolvi, Lupron Depot, Lupron Depot-Ped, Leuprolide acetate)
  • Lupaneta brand removed from policy due to its removal from market
• Sodium Glucose Co-Transporter (SGLT2) Non-Diabetes Indications
  • Changed name of policy from “Farxiga”
  • Added Jardiance coverage to heart failure criteria
  • Added step therapy to heart failure criteria

Retired Policies

• Jetrea (ocriplasmin)
  • Drug has been removed from market so policy is no longer needed

Tier Changes

• Icatibant acetate: Move from non-preferred specialty pharmacy to preferred specialty pharmacy
  • Positive member change
• Sajazir: Move from non-preferred specialty pharmacy to preferred specialty pharmacy
  • Positive member change
• Cystaran: Move from non-formulary to non-preferred brand
  • Positive member change, alternate option for Cystadrops
• Oriahnn: Move from Non-Preferred Brand to Preferred brand
• Orilissa: Move from non-preferred brand to preferred brand
• Baqsimi: Move from non-preferred brand to preferred brand
• Zegologue: Move from not covered to preferred brand
• Glucagen: Move from preferred brand to excluded
  • Negative change for 4/1/22
  • 2 affected members will be notified

Medicare

Medicare Tier Changes

Endocrinology

• Humulin N; R; 70/30 Vials—Move from Tier 1 to Tier 2
  • Included in senior savings model on most plans which caps copays
• Tresiba—Move from Tier 4 to Tier 3
  • Included in senior savings model on most plans which caps copays
• Bydureon, Invokamet, Invokana, Jardiance, Ozempic, Rybelsus, Synjardy, Trulicity, and Victoza- Removed step therapy requirement
• Novolog, Novolog Flexpen, Novolog Mix 70/30, Novolog Mix Flexpen- Added to Formulary at Tier 4 with Step Therapy requirement
• Banzel Removed- generic (rufinamide) on formulary
• Demser removed- generic (metyrosine) on formulary
• Desmopressin 0.01% spray removed- others on formulary
• Kuvan removed- generic (sapropterin) on formulary
• Cinacalcet- move from Tier 5 to Tier 4
• Trelstar Mix inj 11.25mg- move from Tier 5 to Tier 4
• Defov Dip 10mg- move from Tier 5 to Tier 2
• Diazoxide sus 50mg/ml- move from Tier 5 to Tier 2
• Oxandrolone tab – move from Tier 5 to Tier 2

Psychiatry

• Paliperidone ER 9mg tablets- Move from Specialty Tier 5 to Tier 4
• Fluvoxamine ER- Removed step therapy requirement
• Amoxapine tablets—Move from Tier 1 to Tier 2
  • Aligns with other options in class
• Saphris removed from formulary- generic (asenapine) on formulary
• Bupropion 450mg XL- requires prior paid claim immediate-release
• Forfivo XL- now requires step therapy
• Paxil suspension- now requires step therapy

Gastroenterology

• Diphenoxylate/Atropine tablets—Move from Tier 1 to Tier 4
• Hydrocortisone enema—Move from Tier 1 to Tier 4
  • Other options on lower tiers
• Cromolyn sodium concentration 100mg/5mL—Move from Tier 1 to Tier 4
• Dexilant- Added to formulary at Tier 4 with Step Therapy
• Mesalamine 400mg DR- Move from Tier 4 to Tier 2
• Alinia suspension and 500mg tablets- Removed from formulary (generic nitazoxanide is on formulary)
• Atripla removed- generic efavirenz-emtricitab-tenofovir on formulary
• Daraprim 25mg- generic (pyrimethamine) on formulary
• Emtriva removed- generic (emtricitabine) on formulary
• Moviprep removed- multiple generics on formulary
• Symfi, Symfi Lo – removed from formulary- generic (efavirenz-lamivudine-tenofovir) on formulary
• Truvada – removed from formulary- generic (emtricitabine-tenofovir) on formulary
• Bynfezia pen- move from Tier 5 to Tier 4
• Efavirenz 200mg, 600mg move from Tier 5 to Tier 4
• Etravirine 100mg- move from Tier 5 to Tier 4
• Hyperhep B inj- move from Tier 5 to Tier 4
• Intelence 100mg- move from Tier 5 to Tier 4
• Lopin/riton sol- move from Tier 5 to Tier 4
• Octreotide inj 1000mcg and 5000/5ml move from Tier 5 to Tier 4
• Xermelo- added to formulary at Tier 5 with Prior Authorization
• Engerix-B inj- move from Tier 4 to Tier 3
• Havrix- move from Tier 4 to Tier 3

Cardiology

• Lanoxin 125mcg tablets—Move from Tier 3 to Tier 4
  • Moving to align with Lanoxin 250mcg
  • No utilization since digoxin and similar products are at Tier 2
• Lanoxin ped inj- move from Tier 3 to Tier 4
• Nexlizet- Added to Formulary at Tier 3 with Prior Authorization
• Diltiazem 120mg ER, 180mg ER and 240mg ER- Move from Tier 2 to Tier 1
• Minitran Dis patches- removed from formulary as generic nitroglycerin patches at Tier 1
• Vascepa 1gm removed from formulary- generic (ICOSAPENT CAP 1GM) on formulary
• Heparin/NaCl inj- move from Tier 1 to Tier 2
• Northera- requires step therapy now

Pulmonology

• Theophylline ER tablets (12 and 24 hour formulations)—Move from Tier 1 to Tier 2
• Cromolyn sodium 20mg/mL nebs—Move from Tier 1 to Tier 4
• Terbutaline tablets—Move from Tier 1 to Tier 2
• Oralair Child sub 100mg- removed from formulary- others on the formulary
• Aralast NP- move from Tier 5 to Tier 4
• Prolastin-C 1000mg inj- move from Tier 5 to Tier 4
• Epoprostenol inj 0.5mg- move from Tier 5 to Tier 2

Neurology

• Carbidopa/Levodopa ER tablets—Move from Tier 1 to Tier 2
• Ajovy—Move to Non-Formulary
  • Covering Aimovig and Emgality
• Diastat Pediatric 2.5mg gel (diazepam)—Move from Tier 2 to Tier 4
• Diastat Acudial 5-10mg gel (diazepam)—Move from Tier 2 to Tier 4
• Diastat Acudial 12.5-20mg gel (diazepam)—Move from Tier 2 to Tier 4
• Tecfidera- removed from formulary- generic (dimethyl fumarate) on formulary
• Vimpat sol 10mg/ml move from Tier 3 to Tier 5
• Rufinamide tab- move from Tier 5 to Tier 3

Dermatology

• Mupirocin 2% ointment—Move from Tier 1 to Tier 2
  • Price comparable with Tier 2 drug
• Mupirocin 2% cream—Non-Formulary
  • Ointment is more cost efficient
• Minocycline ER 45mg, 90mg, 135mg tablets—Move from Tier 1 to Tier 2
  • No other Medicare plans cover at Tier 1
• Erythromycin gel 2%—Move from Tier 1 to Tier 2
  • Align with coverage of solution, which is at Tier 2
• Ery pad 2% (erythromycin pads)—Move from Tier 1 to Tier 2
  • Align with coverage of solution, which is at Tier 2
• Hydrocortisone 5, 10, 20mg tablets—Move from Tier 1 to Tier 2
  • Should be short term use
• Gentamicin sulfate 0.1% cream—Move from Tier 1 to Tier 2
• Gentamicin sulfate 0.1% ointment—Move from Tier 1 to Tier 2
• Acyclovir 5% cream—Move from Tier 2 to Tier 4
• Acyclovir 5% ointment—Move from Tier 3 to Tier 4
• Fluocinonide 0.05% gel—Move from Tier 2 to Tier 4
  • Most plans have at Tier 4
• Fluocinonide 0.05% ointment—Move from Tier 2 to Tier 4
  • Most plans have at Tier 4
• Lidocaine gel 2% jelly—Move from Tier 1 to Tier 4
  • Available OTC now as 4% patch
• Flurandrenol 0.05% cream—Move from Tier 2 to Tier 4
  • Some options already at Tier 4
• Nolix 0.05% cream (flurandrenol)—Move from Tier 2 to Tier 4
  • Some options already at Tier 4
• Flurandrenol 0.05% ointment—Move from Tier 2 to Tier 4
  • Some options already at Tier 4
• Mometasone 0.1% solution—Move from Tier 2 to Tier 1
  • Cost aligns with Tier 1 drug
• Cosentyx—Add to formulary at Tier 5 with Prior Authorization
  • Positive formulary addition
• Skyrizi—Add to formulary at Tier 5 with Prior Authorization
  • Positive formulary addition
• Tremfya- Add to formulary at Tier 5 with Prior Authorization
• Sklice- removed from formulary- generic (IVERMECTIN LOT 0.5%) on formulary
• Clobetasol aer 0.05%- move from Tier 4 to Tier 2

Pain Management

• Codeine 15mg, 30mg, 60mg tablets—Move from Tier 1 to Tier 2
  • Will align with other opioids, and not allowing tier-lowering requests on other opioids if all options are at Tier 2
• Butrans dis 7.5/HR removed from formulary- generic buprenorphine weekly on formulary
• Gablofen inj 40000/20 removed- other strengths on formulary
• Lioresal int inj 40mg/20- other strengths on formulary
• Hydro/acet sol 10/325mg- move from Tier 2 to Tier 4
• Duexis added to formulary with step therapy
• Baclofen inj 40mg/20 – move from Tier 5 to Tier 2

Ophthalmology

• Lumigan—Add to formulary at Tier 3
• Vyzulta—Add to formulary at Tier 4
• Oxervate- Add to formulary at Tier 5 with Prior Authorization

Obstetrics/Gynecology

• Mifepristone 200mg tab- excluded drug list for CMS, removed from formulary
• Prostin E2- removed from formulary
• Vinate II- removed from formulary- multiple generics available on formulary
• Methergine 0.2mg- move from Tier 2 to Tier 5
• Methylergon 0.2mg- move from Tier 2 to Tier 5mupri

Nephrology

• Samsca removed from formulary- generic (tolvaptan) on formulary
• Thiola 100mg removed from formulary- generic (tiopronin) on formulary
• Thiola EC 100mg, 300mg move from Tier 4 to Tier 5
• Sevelamer tab from from Tier 4 to Tier 2

Oncology

• Tykerb- removed from formulary- generic (lapatinib) on formulary
• Zytiga- removed from formulary- generic (abiraterone) on formulary
• Zortress- removed from formulary- generic (everolimus) on formulary
• Adcetris inj- moved to Tier 5
• Lupron Depot inj 30mg- move from Tier 4 to Tier 5
• Venclexta 50mg move from Tier 3 to Tier 5
• Retacrit- added to formulary with prior authorization
• Ruxience- added to formulary with prior authorization
• Cyclophosphamide 1mg, 500mg- move from Tier 5 to Tier 2
• Docetaxel- move from Tier 5 to Tier 2
• Floxuridine inj 0.5mg- move from Tier 5 to Tier 2
• Fludarabine inj 50mg/2ml- move from Tier 5 to Tier 1
• Gemcitabine 200mg, 1gm, 2gm- move from Tier 5 to Tier 2
• Idarubicin inj- move from Tier 5 to Tier 2
• Melphalan inj – move from Tier 5 to Tier 2
• Oxaliplatin inj- move from Tier 5 to Tier 2
• Topotecan inj- move from Tier 5 to Tier 2

Infectious Disease

• Azithromycin inj 500mg- moved from Tier 1 to Tier 2
• Caspofungin inj- move from Tier 5 to Tier 4
• Colistimeth inj 150mg- move from Tier 2 to Tier 4
• Vancomycin 205mg inj- move from Tier 2 to Tier 4
• Voriconazole 200mg tab- move from Tier 5 to Tier 4
• Voriconazole 200mg inj- requires PA now
• Dificid sus and tablets- removed step therapy requirements
• Acthib inj- move from Tier 4 to Tier 3
• Atovaquone – move from Tier 5 to Tier 2
• Bexsero inj- move from Tier 4 to Tier 3
• Cefixime cap 400mg 0 move from Tier 4 to Tier 2
• Linezolid inj- move from Tier 5 to Tier 2
• Menactra inj- move from Tier 4 to Tier 3
• Menquadfi inj- move from Tier 4 to Tier 3
• Menveo inj- move from Tier 4 to Tier 3
• Micafungin inj- move from Tier 5 to Tier 2
• Nafcillin inj- move from Tier 5 to Tier 2
• Hiberix- move from Tier 4 to Tier 3
• Pedvax Hib inj- move from Tier 4 to Tier 3
• Recombiva HB inj- move from Tier 4 to Tier 3
• Tigecycline inj – move from Tier 5 to Tier 2
• Trumenba inj – move from Tier 4 to Tier 3
• Valganciclov tab – move from Tier 5 to Tier 2
• Vaqta inj- move from Tier 4 to Tier 3
• Varivax inj- move from Tier 4 to Tier 3

General

• Deferox mesylate inj- move from Tier 1 to Tier 4
• Deferoxamine inj- move from Tier 1 to Tier 4
• Neo/Poly/HC Sus 1% otic- move from Tier 1 to Tier 2
• Lidocaine Products: Glydo 2% gel, Imvexxy sup 4mcg, 10mcg, lido/priloc cream, lidocaine gel 2%, lidocaine oin 5%, lidocaine 4% sol, Pliaglis cream 7-7% all require prior authorization due to Fraud Waste & Abuse Issues- Part D vs. excluded indications

Immunology

• Winrho SDF inj 2500unit and 5000unit- move from Tier 4 to Tier 5

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