Medicaid Medical Pharmacy Benefit Changes – Botulinum Toxin and Infliximab Products

January 2022

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.

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 

Option Care Health will be contacting your office regarding the transfer of the patient from the outpatient hospital setting to the home infusion provider.