Long Acting Insulin Products – Semglee, Insulin Glargine YFGN, Semglee YFGN
Viatris Pharmaceuticals manufactures three (3) insulin glargine products; Semglee (insulin glargine non-interchangeable), Insulin Glargine YFGN, and Semglee YFGN.
- As of January 1, 2022, Viatris Pharmaceuticals promoted two (2) insulin glargine products to market that are interchangeable with Lantus, Insulin Glargine YFGN and Semglee YFGN. Semglee (non-interchangeable) is currently being phased out of production.
While Insulin Glargine YFGN and Semglee YFGN are interchangeable products, the net cost of the products are not comparable. As of January 1, 2022, Neighborhood’s Medicaid Formulary will have two (2) preferred formulary long-acting insulins:
- Insulin Glargine YFGN
Neighborhood members currently utilizing Semglee (non interchangeable) will need to have a prescription written for Insulin Glargine YFGN or Basaglar to continue to have access to long-acting insulin.
Botulinum Toxin Products – Pharmacy Benefit Only
Effective January 1, 2022, Neighborhood will exclusively cover the following medications on the Pharmacy Benefit for Medicaid members:
- Botox (onabotulinumtoxinA, J0585)
- Dysport (abobotulinumtoxinA, J0586)
- Myobloc (rimabotulinumtoxinB, J0587)
- Xeomin (incobotulinumtoxinA, J0588)
For Medicaid members with active Botox, Dysport, Myobloc and Xeomin authorizations on the Medical Benefit as of January 1, 2022, their authorization will continue to be eligible and active on the Medical Benefit until the authorization end date.
- Claims for Botox, Dysport, Myobloc and Xeomin for Neighborhood’s Commercial and INTEGRITY line of business can continue to be billed under the Medical Benefit.
Neighborhood’s utilization management protocols for Medicaid, Commercial and INTEGRITY remain unchanged and authorization is required prior to dispensing Botox, Dysport, Myobloc and Xeomin. When choosing a Pharmacy Benefit Supplier, please be aware that CVS Health does not have access to Botox.
Prior Authorization requests may be submitted electronically via Covermymeds or using the Botox specific PA request form on our website. https://www.nhpri.org/wp-content/uploads/2022/01/Botox-PA-Form-Final-1.1.22.pdf
Infliximab Products – Home Infusion Requirement for Medicaid Members
Effective February 1, 2022, Neighborhood will exclusively cover the administration of Remicade (infliximab (J1745)), Inflectra (infliximab-dyyb, biosimilar (Q5103)), Renflexis (infliximab-abda (Q5104)), and Avsola (infliximab-axxq (Q5121)) for adult Medicaid members, stable on their infusion, through a home infusion provider instead of in the outpatient hospital setting.
- Remicade, Inflectra, Renflexis, and Avsola for Neighborhood’s Commercial and INTEGRITY lines of business can continue to be administered in the outpatient hospital setting.
- For Medicaid members with active Remicade, Inflectra, Renflexis, and Avsola authorizations on the Medical Benefit approved beyond February 1st, 2022, their authorization will continue to be eligible and active in the outpatient hospital setting until the authorization end date.
For adult Neighborhood Medicaid members stable on Remicade, Inflectra, Renflexis, and Avsola on or after February 1, 2022, please send member information (prescription and chart notes) to our in-network home infusion provider, Option Care Health (see contact information below).
Option Care Health
- Phone: 1-800-431-4250 or 401-431-1300
- Fax: 401-633-6076
- Email: OC-ProvidenceIntake@optioncare.com
The network home infusion provider will be contacting your office regarding the transfer of the patient from the outpatient hospital setting to the home infusion provider.
Erythropoiesis-Stimulating Agent (ESA) Backorder
Pfizer has notified Neighborhood that Retacrit (Q5105 and Q5106) will be on manufacturer backorder staring in May 2022 and will continue throughout 2022.
- To prevent access to care issues, as of May 1, 2022, members with an active authorization on the Medical Benefit for Retacrit will also be provided access to Epogen/Procrit (J0885 and Q4081) through the remainder of their Authorization.
- For members new to ESA therapy, please consider prescribing Epogen/Procrit instead of Retacrit in 2022.
Preferred Glucagon-like Peptide-1 Receptor Agonist
As of July 1, 2022, Neighborhood’s preferred glucagon-like-peptide-1 (GLP-1) agonist for Medicaid members is changing to Trulicity or Ozempic.
- Members 18 years of age and older currently taking other GLP-1 agonists (Victoza, Bydureon, or Byetta) will be required to transition to Trulicity or Ozempic when their current Prior Authorization expires.
- If the member needs to continue on their current therapy, an exception request for medical necessity will be required.
- Members 10-18 years of age currently taking Victoza or Bydureon will be able to stay on their medication as long as it remains medically necessary, through the prior authorization renewal process.
- For members/providers who would like to transition to Trulicity or Ozempic before July 1, 2022, please submit a prior authorization request for Trulicity or Ozempic before July 1, 2022.
Last updated: April 6, 2022 @ 11:44 am