MVP Medical Policy Updates Effective April 1 2021

March 16, 2021

MVP Health Care has updated a number of policies found on the site for provider review. Changes include New policies, Updated policies, Reviewed without changes as well as archived as no longer active.

The following list includes the policies that received these changes and will be available for viewing 30 days prior to the effective date of April 1, 2021.

Medical Policy Name

Status

Breast Implantation and Removal

Updated

Breast Reduction Surgery(reduction mammoplasty)

Updated

Deep Brain Stimulation

Updated

Endovenous Ablation of Varicose Veins

Updated

High Frequency Chest Wall Oscillation Device

Reviewed

Hyperbaric Oxygen Therapy(HBO)

Reviewed

Indirect Handheld Calorimeter

Reviewed

Mechanical Stretching Devices

Updated

Non-Invasive Liver Fibrosis Testing

Updated

Orthognathic Surgery

Reviewed

Sacroiliac Joint Fusion

Updated

Serological Testing for IBD

Updated

 

The following as well is a listing of updates in regards to Pharmaceutical Policies effective April 1, 2021

Pharmaceutical Policy Name

Status

Male Hypogonadism

Updated

Metformin ER

Reviewed

Growth Hormone Therapy (effective 1/1/21)

Updated

Phenylketonuria Agents

Updated

Infertility Drug Therapy (commercial/marketplace)(effective 2/1/21)

Updated

Infertility Drug Therapy(Medicaid/HARP)

Reviewed

Acthar

Updated

Jynarque (effective 2/1/21)

New

Physician Prescription Eligibility

Reviewed

Prescribers Treating Self or Family Members

Updated

Mail Order

Reviewed

Migraine Agents

Updated

Zinplava

Updated

Lyme Disease/IV Antibiotic Treatment(effective 2/1/21)

Updated

Erythropoiesis Stimulating Agents (ESAs)

Reviewed

Eylea (aflibercept) Intravitreal(effective 2/1/21)

New

Intranasal Corticosteroids (effective 1/1/21)

Updated

Calcitonin Gene-related peptide (CGRP) Antagonists (effective 2/1/21)

Updated

Orphan Drugs and Biologicals

Updated

 

MVP Health Care Pharmacy and Therapeutics Committee has determined that the following drugs, which have been recently approved by the FDA, will require prior authorization for at least the first six months following the date they are available on the market.

New Drugs (prior authorizations required)

Drug Name

Indication

Commercial & Marketplace Tier

Medicare Part D Tier

MVP Medicaid

Olinvyk

Pain Management

Medical

Not Covered

Medical

Sutab

Bowel Preparation for Colonoscopy

Tier 3

Non-Formulary

Non-Formulary

Oxlumo

Primary Hyperoxaluria Type 1 (PH1)

Tier 3

Non-Formulary

Non-Formulary

Danyelza

Relapsed or Refractory High-Risk Beuroblastoma

Medical

Not Covered

Medical

Orladeyo

Hereditary Angioedema (HAE)

Tier 3

Tier 5

Non-Formulary

Winlevi

Acne Vulgaris

Tier 3

Non-Formulary

Non-Formulary

Qdolo

Pain Management

Tier 3

Non-Formulary

Non-Formulary

Eysuvis

Dry Eye

Tier 3

Non-Formulary

Non-Formulary

Nyvepria

Febrile Neutropenia

Tier 3

Non-Formulary

Non-Formulary

 

Commercial & Exchange (non-Medicare)

 

New generic formulary additions

Drug Name

Tier 1

Nitazoxanide (Alinia)

Tier 1 (Tier 2 Exchange)

Ivermectin (Skilce) *

Tier 1 (Tier 2 Exchange)

Asenapine (Saphris) *

Tier 1 (Tier 2 Exchange)

Abiretone 500mg (Zytiga)

Tier 1 (Tier 2 Exchange)

All brands will be non-formulary, Tier 3

*Brand name Sklice and Saphris will be Tier 2 for Medicaid

Miscellaneous Updates

Covid-19 Vaccines

Claims for Covid-19 vaccines are processing. Vaccines are covered by the federal government and the administration costs are covered by the plans.

Commercial and Exchange Business: February 2021 Changes

Breztri, Rhopressa and Orilissa will be added to Tier 2.

Sign in to mvphealthcare.com and select Resource, then Medical policies. 

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