february 2016 update bulletin - oxhp · 2 oxford® policy update bulletin: february 2016 oxford...

UnitedHealthcare respects the expertise of the physicians, health care professionals, and their staff who participate in our network. Our goal is to

support you and your patients in making the most informed decisions regarding the choice of quality and cost-effective care, and to support practice

staff with a simple and predictable administrative experience. The Policy Update Bulletin was developed to share important information regarding

Oxford® Medical and Administrative Policy updates.*

*Where information in this bulletin conflicts with applicable state and/or federal law, Oxford® follows such applicable federal and/or state law

February 2016

policy update bulletin Medical & Administrative Policy Updates

2 Oxford® Policy Update Bulletin: February 2016

Oxford® Medical and Administrative Policy Updates

Overview

Tips for using the Policy Update Bulletin:

From the table of contents, click the policy title to be

directed to the corresponding policy update summary.

From the policy updates table, click the policy title to view a

complete copy of a new, updated, or revised policy.

Policy Update Classifications

New

New clinical coverage criteria and/or documentation review requirements

have been adopted for a service, procedure, test, or device

Updated

An existing policy has been reviewed and changes have not been made

to the clinical coverage criteria or documentation review requirements;

however, items such as the clinical evidence, FDA information, and/or

list(s) of applicable codes may have been updated

Revised

An existing policy has been reviewed and revisions have been made to

the clinical coverage criteria and/or documentation review requirements

Replaced

An existing policy has been replaced with a new or different policy

Retired

The procedural codes and/or services previously outlined in the policy are

no longer being managed or are considered to be proven/medically

necessary and are therefore not excluded as unproven/not medically

necessary services, unless coverage guidelines or criteria are otherwise

documented in another policy

Note: The absence of a policy does not automatically indicate or imply

coverage. As always, coverage for a service or procedure must be

determined in accordance with the member’s benefit plan and any

applicable federal or state regulatory requirements. Additionally,

UnitedHealthcare reserves the right to review the clinical evidence

supporting the safety and effectiveness of a medical technology prior to

rendering a coverage determination.

This bulletin provides complete details on Oxford® Medical and

Administrative Policy updates. The appearance of a service or

procedure in this bulletin indicates only that Oxford® has recently

adopted a new policy and/or updated, revised, replaced or

retired an existing policy; it does not imply that Oxford® provides

coverage for the service or procedure. In the event of an

inconsistency or conflict between the information provided in this

bulletin and the posted policy, the provisions of the posted policy

will prevail. Note that most benefit plan documents exclude from

benefit coverage health services identified as investigational or

unproven/not medically necessary. Physicians and other health

care professionals may not seek or collect payment from a

member for services not covered by the applicable benefit plan

unless first obtaining the member’s written consent,

acknowledging that the service is not covered by the benefit plan

and that they will be billed directly for the service.

A complete library of Oxford® Medical and Administrative

Policies is available at OxfordHealth.com > Providers >

Tools & Resources > Medical Information > Medical and

Administrative Policies.



In This Issue

Clinical Policy Updates Page

NEW

Functional Endoscopic Sinus Surgery (FESS) - Effective May 1, 2016 ...................................................................................................................... 9

UPDATED

Alemtuzumab - Effective Feb. 1, 2016 ................................................................................................................................................................. 9 Contraceptives - Effective Mar. 1, 2016 ............................................................................................................................................................. 11 Deep Brain Stimulation - Effective Mar. 1, 2016 ................................................................................................................................................. 14 Electrical Stimulation and Electromagnetic Therapy for Wounds - Effective Feb. 1, 2016 .......................................................................................... 15 Hysterectomy for Benign Conditions - Effective Feb. 1, 2016 ................................................................................................................................ 16 Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors - Effective Feb. 1, 2016 ........................................................................ 16 Temporomandibular Joint Disorders - Effective Feb. 1, 2016 ................................................................................................................................ 16

REVISED

Drug Coverage Criteria - New and Therapeutic Equivalent Medications - Effective Mar. 1, 2016 ................................................................................ 18 Drug Coverage Guidelines - Effective Mar. 1, 2016 ............................................................................................................................................. 22

o Acanya (Clindamycin Phosphate 1.2% and Benzoyl Peroxide 2.5%) ................................................................................................................ 22 o Acticlate (Doxycycline Hyclate) ................................................................................................................................................................... 22 o Acuvail (Ketorlac/Tromethamine) ................................................................................................................................................................ 22 o Adoxa (Doxycycline Monohydrate) .............................................................................................................................................................. 22 o Adynovate (Antihemophillic Factor) ............................................................................................................................................................. 22 o Akynzeo (Netupitant/Palonosetron) ............................................................................................................................................................. 23 o Amrix/Cyclobenzaprine Extended Release .................................................................................................................................................... 23 o Analpram Advanced Kit (Hydrocortisone Acetate/Pramoxine) .......................................................................................................................... 23 o Aplenzin (Bupropion) ................................................................................................................................................................................. 23 o Apop 10% Gel (Sulfacetamide) ................................................................................................................................................................... 23 o AsmalPred and AsmalPred Plus (Prednisolone) .............................................................................................................................................. 23 o Asmanex HFA (Mometasone) ...................................................................................................................................................................... 24 o Atelvia (Risedronate Sodium) ..................................................................................................................................................................... 24 o Augmentin XR/Amoxicillin - Clavulanate ER (Amoxicillin and Clavulanate Potassium) ........................................................................................ 24 o Avar Foam (9.5%-5%), Avar, Avar LS (Sodium Sulfacetamid/Sulfur) .............................................................................................................. 24 o Avinza (Morphine Sulface Extended Release) (Brand Only) ............................................................................................................................. 24 o Axiron (Testosterone) ................................................................................................................................................................................ 24 o Belbuca (Buprenorphine) ........................................................................................................................................................................... 25 o Benzaclin Kit (1%-5%) (Clindamycin Phosphate-Benzoyl Peroxide) ................................................................................................................. 25 o Benzaclin Pump (Benzoyl Peroxide and Clindamycin) .................................................................................................................................... 25 o Beyaz (Drospirenone/Ethinyl Estradiol/Levomefolate) .................................................................................................................................... 25



In This Issue

o Binosto (Alendronate) ................................................................................................................................................................................ 25 o Brisdelle (Paroxetine) ................................................................................................................................................................................ 25 o Bromday (Bromfenac) ............................................................................................................................................................................... 25 o Budesonide Nasal Spray (Generic Rhinocort Aqua) ........................................................................................................................................ 26 o Celexa (Citalopram) (Brand Only) ............................................................................................................................................................... 26 o Centany AT Kit (Mupirocin)......................................................................................................................................................................... 26 o Ciclodan Kit (Ciclopirox) ............................................................................................................................................................................. 26 o Clarinex (Desloratadine) ............................................................................................................................................................................ 26 o Clarinex D (Desloratadine and Pseudoephedrine) .......................................................................................................................................... 26 o Clindacin Pack (Clindamycin Phosphate) ...................................................................................................................................................... 26 o Clindagel (Clindamycin) ............................................................................................................................................................................. 26 o Clindamycin 1%/Benzoyl Peroxide 5% (Generic Benzaclin) Gel ....................................................................................................................... 27 o Clobeta (Clobetasol) .................................................................................................................................................................................. 27 o Clobex Shampoo (Clobetasol Propionate) ..................................................................................................................................................... 27 o Cocet Plus (Acetaminophen and Codeine Phosphate) ..................................................................................................................................... 27 o Conzip (Tramadol) .................................................................................................................................................................................... 27 o Corlanor (Ivabradine) ................................................................................................................................................................................ 27 o Cosopt PF (Dorzolamide HCL/Timolol Maleate) .............................................................................................................................................. 28 o Cuprimine (Penicillamine) .......................................................................................................................................................................... 28 o Cymbalta (Duloxetine) (Brand only) ............................................................................................................................................................ 28 o Delos Lotion/Cleanser (Benzoyl Peroxide) .................................................................................................................................................... 28 o Desloratadine (Generic Clarinex) ................................................................................................................................................................. 28 o Desonil Cream/Ointment (Kit) (Desonide) .................................................................................................................................................... 28 o Differin 0.3% Gel ...................................................................................................................................................................................... 29 o Diovan (Valsartan) (Brand only) ................................................................................................................................................................. 29 o Disalcid (Salsalate) ................................................................................................................................................................................... 29 o Donepezil 23mg (Generic Aricept 23mg) ...................................................................................................................................................... 29 o Doryx (Doxycycline Hyclate) Delayed Release Tablet ..................................................................................................................................... 29 o Doxycycline 150mg Capsule (Generic Monodox) ........................................................................................................................................... 29 o Duac (Clindamycin and Benzoyl Peroxide) .................................................................................................................................................... 29 o Duac CS (Clindamycin and Benzoyl Peroxide) ............................................................................................................................................... 30 o Duragesic (Brand only) (Fentanyl) .............................................................................................................................................................. 30 o Ecoza (Econazole Nitrate Topical Foam 1%) ................................................................................................................................................. 30 o Edluar (Zolpidem) ..................................................................................................................................................................................... 30 o Effexor XR (Venlafaxine) (Brand only) ......................................................................................................................................................... 30 o Embeda (Morphine Sulphate and Naltrexone HCL)......................................................................................................................................... 30 o Enstilar Foam (Calcipotriene/Betamethasone) ............................................................................................................................................... 31 o Exalgo (Hydromorphone) ........................................................................................................................................................................... 31 o Exforge (Amlodipine Valsartan) ................................................................................................................................................................... 31 o Exforge HCT (Amlodipine, Hydrochlorothiazide and Valsartan) ........................................................................................................................ 31



In This Issue

o Fenoglide (Fenofibrate) .............................................................................................................................................................................. 31 o Flo-Pred (Prednisolone) ............................................................................................................................................................................. 31 o Forfivo XL (Bupropion HCL) ........................................................................................................................................................................ 32 o Fortesta (Testosterone) ............................................................................................................................................................................. 32 o Giazo (Balsalazide Disodium) ...................................................................................................................................................................... 32 o Glycate (Glycopyrrolate) ............................................................................................................................................................................ 32 o Glyxambi (Empagliflozin/Linagliptin) ............................................................................................................................................................ 32 o Horizant (Gabapentin, Enacarbil) ................................................................................................................................................................ 32 o Hysingla ER (Hydrocodone Bitartrate) .......................................................................................................................................................... 32 o Imitrex (Sumatriptan) (Brand only): Tablet .................................................................................................................................................. 32 o Imitrex (Sumatriptan) (Brand only): Injection .............................................................................................................................................. 33 o Intuniv (Guanfacine) (Brand only) ............................................................................................................................................................... 33 o Jalyn (Dutasteride and Tamsulosin) ............................................................................................................................................................ 33 o Kadian (Morphine Sulfate Extended Release) ................................................................................................................................................ 33 o Khedezla (Desvenlafaxine Extended Release) ............................................................................................................................................... 33 o Levalbuterol Nebs (Generic Xopenex Nebs) .................................................................................................................................................. 33 o Lexapro (Escitalopram) (Brand only) ........................................................................................................................................................... 33 o Lidorx (Lidocaine Hydrochloride) ................................................................................................................................................................. 34 o Liptruzet (Ezetimibe and Atorvastatin) ......................................................................................................................................................... 34 o Lunesta (Eszopicione) (Brand only) ............................................................................................................................................................. 34 o Metronidazole 1% Gel (Generic Metrogel 1%) ............................................................................................................................................... 34 o Metozolv ODT (Metoclopramide Hydrochloride) ............................................................................................................................................. 34 o Minocin 50mg, 75mg, and 100mg (Minocycline HCL) ..................................................................................................................................... 34 o Mirapex ER (Pramipexole Dihydrochloride) .................................................................................................................................................. 35 o Molindone ................................................................................................................................................................................................ 35 o Momexin Combo Package (Mometasone Furoate) .......................................................................................................................................... 35 o Monodox (Doxycycline) (Brand only) .......................................................................................................................................................... 35 o Morgidox Kit/Combo Pkg (Doxycycline Plus Cleanser) .................................................................................................................................... 35 o Morphine Sulfate Extended Release Pellets (Generic Kadian) .......................................................................................................................... 35 o Namzaric (Memantine Hydrochloride) .......................................................................................................................................................... 36 o Naprelan (Naproxen Sodium) ..................................................................................................................................................................... 36 o Naprelan CR (Dose Card) (Naproxen Sodium) ............................................................................................................................................... 36 o Narcan Nasal Spray (Naloxone) .................................................................................................................................................................. 36 o Neuac 1.2%-5% (Clindamycin Phosphate and Benzoyl Peroxide) .................................................................................................................... 36 o Neuac 1.2%-5% Kit (Clindamycin Phosphate and Benzoyl Peroxide) ................................................................................................................ 37 o Nexiclon XR (Clonidine Extended Release) .................................................................................................................................................... 37 o Nicazeldoxy 30 Kit (Doxycycline Plus MVI) ................................................................................................................................................... 37 o Nitroglycerin Spray (Generic Nitrolingual) .................................................................................................................................................... 37 o Nitrolingual Pump Spray (Nitroglycerin) ....................................................................................................................................................... 37 o Noritate (Metronidazolel) ........................................................................................................................................................................... 37



In This Issue

o Nuwiq (Antihemophilic Factor) .................................................................................................................................................................... 38 o Olux-CP (Clobetasol Propionate) ................................................................................................................................................................. 38 o Orbivan (Butalbital, Acetaminophen and Caffeine) ......................................................................................................................................... 38 o Ovace Plus 9.8% Lotion (Sodium Sulfacetamide) .......................................................................................................................................... 38 o Ovace Plus Foam (Sodium Sulfacetamide) .................................................................................................................................................... 38 o Oxytrol (Oxybutynin) ................................................................................................................................................................................. 39 o Pacnex HP and Pacnex LP (Benzoyl Peroxide) ............................................................................................................................................... 39 o Pazeo (Olopatadine Hydrochloride) .............................................................................................................................................................. 39 o Pediaderm AF (Nystatin) and Pediaderm TA (Triamcinolone)........................................................................................................................... 39 o Pediprox-4 (Benzalkonium) ........................................................................................................................................................................ 39 o Pennsaid 1.5% Drops (Diclofenac Sodium) ................................................................................................................................................... 39 o Pexeva (Paroxetine Mesylate) ..................................................................................................................................................................... 39 o Plexion 9.8-4.8% Cream, Liquid, Lotion (Sulfacetamide/Sulfur) ...................................................................................................................... 40 o Plexion Cloth 9.8%-4.8% Pads (Sulfacetamide/Sulfur) .................................................................................................................................. 40 o Proair Respimat (Albuterol) ........................................................................................................................................................................ 40 o Prozac (Fluoxetine) (Brand Only) ................................................................................................................................................................ 40 o Prozena 4% Patch (Lidocaine) .................................................................................................................................................................... 40 o Qudexy XR (Topiramate)............................................................................................................................................................................ 40 o Requip XL (Ropinirole Extended Release) ..................................................................................................................................................... 41 o Rosadan Kit (Metronidazole) ....................................................................................................................................................................... 41 o Rosula (Sodium Sulfacetamide 10%/Sulfur 4%) ........................................................................................................................................... 41 o Rybix ODT (Tramadol Hydrochloride) ........................................................................................................................................................... 41 o Ryzolt (Tramadol Hydrochloride Extended Release) ....................................................................................................................................... 41 o Safyral (Drospirenone/Ethinyl Estradiol/Levomefolate) .................................................................................................................................. 41 o Seebri Neohaler (Glycopyrrolate) ................................................................................................................................................................ 42 o Silenor (Doxepin Hydrochloride) ................................................................................................................................................................. 42 o Simbrinza 1-0.2% (Brimonidine and Brinzolamide)........................................................................................................................................ 42 o Sitavig (Acyclovir) ..................................................................................................................................................................................... 42 o Skelaxin (Brand only) (Metaxalone) ............................................................................................................................................................ 42 o Sodium Sulfacetamide/Sulfur 9%-4.5% Kit (Generic Sumadan Kit) ................................................................................................................. 42 o Sorilux (Calcipotriene) ............................................................................................................................................................................... 42 o SSS 10-4 (Sodium Polystyrene Sulfonate) .................................................................................................................................................... 42 o Staxyn (Vardenafil) ................................................................................................................................................................................... 43 o Sumadan (Sodium Sulfacetamide and Sulfur) ............................................................................................................................................... 43 o Sumadan Cleanser (Sodium Sulfacetamide and Sulfur) in a Moisturizing Novasome® Vehicle) (Brand only) ......................................................... 43 o Sumadan XLT Kit (Sulfacetamide Sodium, Sulfur, Avobenzone, Octinoxate and Octisalate) ................................................................................ 43 o Sumaxin TS and Sumaxin CP (Sodium Sulfacetamide and Sulfur) ................................................................................................................... 43 o Symbicort (Budesonide/Formoterol Fumarate Dehydrate) .............................................................................................................................. 43 o Synalar (Fluocinolone Acetonide) ................................................................................................................................................................ 43 o Tekamlo (Aliskiren/Amlodipine) .................................................................................................................................................................. 44



In This Issue

o Testosterone Topical Gel (Generic Testim) ................................................................................................................................................... 44 o Testosterone Topical Gel (Generic Vogelxo) .................................................................................................................................................. 44 o Tobradex ST (Tobramycin -Dexamethasone) ................................................................................................................................................ 44 o Topicort Spray (Desoximetasone) ............................................................................................................................................................... 44 o Tramadol Extended -Release (Generic Ryzolt) .............................................................................................................................................. 44 o Tresiba (Insulin Degludec) ......................................................................................................................................................................... 44 o Tretin-X 0.075% cream (tretinoin) ............................................................................................................................................................. 45 o Treximet (Sumatriptan Naproxen) ............................................................................................................................................................... 45 o Trianex (Triamcinolone) ............................................................................................................................................................................. 45 o Tribenzor (Amlodipine, Olmesartan, Medoxomil, Hydrochlorothiazide) ............................................................................................................ 45 o Tricor/Fenofibrate 48mg and 145mg (Generic Tricor) (Fenofibrate) and Trilipix (Fenofibrate Acid) ....................................................................... 45 o Twynsta (Telmisartan, Amlodipine) ............................................................................................................................................................. 45 o Uptravi (Selexipag) ................................................................................................................................................................................... 45 o Utibron Neohaler (Indacaterol/Glycopyrrolate) .............................................................................................................................................. 45 o Utopic (Urea) 41% .................................................................................................................................................................................... 46 o Valturna 150-160mg, 300mg - 320mg (Aliskiren and Valsartan) ..................................................................................................................... 46 o Varubi (Rolapitant) .................................................................................................................................................................................... 46 o Veltassa (Patiromer) .................................................................................................................................................................................. 46 o Veltin (Clindamycin Phosphate and Tretinoin) ............................................................................................................................................... 46 o Vicodin 5/300mg (Hydrocodone and Acetaminophen) .................................................................................................................................... 47 o Vicodin ES 7.5/300mg (Hydrocodone and Acetaminophen) ............................................................................................................................. 47 o Vicodin HP 10/300mg (Hydrocodone and Acetaminophen) .............................................................................................................................. 47 o Vimovo (Naproxen Sodium Plus Proton Pump Inhibitor) ................................................................................................................................. 47 o Vivlodex (Meloxicam) ................................................................................................................................................................................ 47 o Vogelxo (Testosterone) .............................................................................................................................................................................. 47 o Wellbutrin SR (Brand only) (Bupropion) ....................................................................................................................................................... 47 o Wellbutrin XL (Bupropion Extended Release) ................................................................................................................................................ 47 o Xerese (Acyclovir or Hydrocortisone) ........................................................................................................................................................... 47 o Xopenex Nebules (Levalbuterol Hydrochloride) ............................................................................................................................................. 48 o Generic Xopenex Nebules ........................................................................................................................................................................... 48 o Ziana (Clindamycin Phosphate and Tretinoin) ............................................................................................................................................... 48 o Zipsor 25mg (Diclofenac Pottassium)........................................................................................................................................................... 48 o Zolvit (Hydrocodone Bitartrate and Acetaminophen) ...................................................................................................................................... 48 o Zonatuss (Benzonatate) ............................................................................................................................................................................. 48 o Zyprexa Zydis (Olanzapine) (Brand only) ..................................................................................................................................................... 48

Infertility Diagnosis and Treatment - Effective Mar. 1, 2016 ................................................................................................................................. 49 Mechanical Stretching and Continuous Passive Motion Devices - Effective Mar. 1, 2016 ........................................................................................... 52 Platelet Derived Growth Factors for Treatment of Wounds - Effective Mar. 1, 2016 ................................................................................................. 53 Surgical Treatment for Spine Pain - Effective Mar. 1, 2016................................................................................................................................... 54



In This Issue

Administrative Policy Updates

REVISED

Par Gastroenterologists Using Non-Par Anesthesiologists: In-Office & Ambulatory Surgery Centers - Effective Mar. 1, 2016 ......................................... 59

Reimbursement Policy Updates

NEW

Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction Policy - Effective Apr. 1, 2016 ................................................................... 62

UPDATED

Microsurgery - Effective Feb. 1, 2016 ................................................................................................................................................................ 63 Multiple Imaging Rules - Effective Feb. 1, 2016 .................................................................................................................................................. 64 Wrong Surgical or Other Invasive Procedures - Effective Feb. 1, 2016 ................................................................................................................... 64

REVISED

Injection and Infusion Services - Effective Feb. 1, 2016....................................................................................................................................... 67 Time Span Codes - Effective Mar. 1, 2016 ......................................................................................................................................................... 69


Clinical Policy Updates

NEW

Policy Title Effective Date Coverage Rationale

Functional Endoscopic Sinus Surgery (FESS)

May 1, 2016 Please note: Medical necessity reviews will also include site of service (SOS), per the member’s benefit plan. Please refer to Site of Service Guidelines for Certain Outpatient Surgical Procedures for additional information on SOS reviews for these services.

Functional endoscopic sinus surgery (FESS) is medically necessary for one or more of the following: Patients with chronic rhinosinusitis (defined as rhinosinusitis lasting longer than 12 weeks) with both of the

following: o Chronic rhinosinusitis is confirmed on computed tomography (CT) scan by one or more of the following:

Mucosal thickening Bony remodeling Bony thickening or

Obstruction of the ostiomeatal complex Opacified sinus

o Symptoms persist despite medical therapy with one or more of the following: Nasal lavage Antibiotic therapy, if bacterial infection is suspected Intranasal corticosteroids

Mucocele documented on CT scan

Complications of sinusitis such as abscess Tumor documented on CT scan (such as polyposis or malignancy) Recurrent acute rhinosinusitis (RARS) Drug eluting stents or implants are unproven and not medically necessary for maintaining sinus ostial patency after sinus surgery.

The evidence is insufficient to determine whether sinus stents improve outcomes when used postoperatively following endoscopic sinus surgery. Further randomized clinical trials are needed that compare the devices to postoperative care without the device to determine whether they can improve postoperative outcomes for patients undergoing endoscopic sinus surgery.

UPDATED

Policy Title Effective Date Summary of Changes Coverage Rationale

Alemtuzumab

Feb. 1, 2016

Notice of Correction: The following

summary of changes has been modified. Revisions to the policy update announcement previously appearing in the Policy Update Bulletin are outlined in red below.

Note: This policy applies only to non-oncology indications. For additional

information regarding oncology indications, please refer to policy: Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines. Campath (alemtuzumab) is proven and medically necessary when used in the treatment of: 1. Members undergoing peripheral blood stem cell (PBSC) and/or bone



UPDATED


Alemtuzumab (continued)

Feb. 1, 2016

Updated list of applicable HCPCS codes to reflect annual code edits: o Added J0202 o Removed J9019 J9010 and

Q9979

marrow transplantation 2. Members undergoing solid organ transplantation *Effective September 4th, 2012, Campath will no longer be available commercially, but will be provided through the Campath Distribution

Program free of charge. Additional details about this program may be found

at http://www.campath.com. Oxford will not provide coverage of Campath in relapsing-remitting multiple sclerosis (RRMS). Lemtrada (alemtuzumab) is proven and medically necessary for

treatment of relapsing-remitting multiple sclerosis when all of the following criteria are met: A. Diagnosis of relapsing-remitting multiple sclerosis (RRMS); and B. One of the following:

1. Treatment - naïve to alemtuzumab: a. Member has history of failure following a trial for at least 4 weeks

or history of intolerance or contraindication to two of the

following: 1) interferon β-1a (Avonex® or Rebif®)) 2) interferon β-1b (Betaseron® or Extavia®) 3) glatiramer acetate (Copaxone®) 4) dimethyl fumarate (Tecfidera®) 5) teriflunomide (Aubagio®)

6) fingolimod (Gilenya®) 7) peginterferon beta-1a (Plegridy™) and

b. Member has not been previously treated with alemtuzumab; and

c. Member is not receiving alemtuzumab in combination with another disease modifying agent (e.g., interferon beta preparations, glatiramer acetate, natalizumab, fingolimod, or teriflunomide);

and d. Initial dosing is administered: 12 mg intravenously daily for 5

consecutive days; and e. Regimen is administered only once within 12 months

or

2. Treatment-experienced with alemtuzumab:

http://www.campath.com./



UPDATED


Alemtuzumab (continued)

Feb. 1, 2016 a. Member has previously received treatment with alemtuzumab; and

b. Member is not receiving alemtuzumab in combination with another disease modifying agent (e.g., interferon beta preparations, glatiramer acetate, natalizumab, fingolimod, or teriflunomide);

and

c. Retreatment dosing is administered: 12 mg intravenously daily for 3 consecutive days; and

d. Regimen is administered only once within 12 months Coverage of Lemtrada is limited up to two treatment courses (5 day initial and 3 day end course). Requests for additional doses/courses beyond two

courses will not be approved. Oxford will not provide coverage of Lemtrada for indications other than relapsing-remitting multiple sclerosis RRMS. Alemtuzumab is unproven and not medically necessary for the treatment

of:

1. Rheumatoid arthritis 2. Autoimmune neutropenia 3. Autoimmune hemolytic anemia 4. Pure red cell aplasia 5. Immune thrombocytopenic purpura 6. Evan's syndrome

7. Autoimmune pancytopenia

Contraceptives

Mar. 1, 2016

Reorganized conditions of coverage/special considerations

Added benefit considerations

language to indicate: o Before using this guideline,

please check the member specific benefit plan document and any federal or state mandates, if applicable

o For Essential Health Benefits for Individual and Small Group

plans:

Under the health care reform law, health plans must cover Food and Drug Administration (FDA) approved contraception methods for women without cost-sharing (copayment, coinsurance or deductible) when the method(s) is

provided by a network provider. According to the United States Preventive Services Task Force (USPSTF), reasonable cost controlling techniques such

as tiering, exclusions and step therapy can be utilized to implement this coverage. Coverage for Prescription Contraceptives Select prescription contraceptives will be covered under the pharmacy

benefit without cost-share when the item is purchased from a network



UPDATED


Contraceptives (continued)

Mar. 1, 2016

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered

individual and small group

plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”)

Large group plans (both

self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs; however, if such plans

choose to provide coverage

for benefits which are deemed EHBs (such as maternity benefits), the ACA requires all dollar limits on those benefits to be removed on all

Grandfathered and Non-Grandfathered plans

The determination of which benefits constitute EHBs is

made on a state by state basis; as such, when using this guideline, it is

important to refer to the member specific benefit document to determine benefit coverage

Updated and reorganized coverage rationale: o Removed language pertaining

pharmacy. Oxford has determined that contraceptives with the same progestin are equivalent to each other. Therefore, each unique progestin contraceptive medication will be represented in Tier 1. Contraceptives in Tier 1 will be

available without cost-share to the member.

Oral contraceptives that have the same unique active progestin as a tier 1 contraceptive but are multisource brands, (select) single source brands or generics for products where Oxford has a brand over generic strategy (and the brand is in Tier 1) will be in Tier 2 or 3 and a cost-share will apply to the member.

Notes: Hormonal contraceptives currently excluded from benefit coverage will

remain excluded since they contain the same or modified version of an active ingredient and are therapeutically equivalent to a covered product. Refer to Drug Coverage Criteria - New and Therapeutic Medications for

additional information.

Injectable contraceptives provided in a network physician’s office are covered under the member’s medical benefit (i.e., Depo Provera® 150 mg, Depo-Subq Provera 104, and Lunelle).

Contraceptive Procedures/Appliances/Devices The following contraceptive procedures/appliances/devices are covered

under the member’s medical benefit when provided by a network provider. The provider must have an appropriate specialty (OB/GYN, Certified Nurse Midwife, Family Practitioner) to be eligible to perform the service. Office contraceptive procedures/ appliances/devices include:

Insertion and removal of an intrauterine device (IUD), and other FDA approved contraceptive devices (i.e., implant, and cervical caps, etc).

Diaphragms

Note: Diaphragms are also covered under the pharmacy benefit if purchased at a network pharmacy.

Services to place/remove/inject covered FDA approved emergency contraceptive methods (i.e., Plan B® One Step one, ella, etc).

Sterilization procedures for women (i.e., tubal ligation).



UPDATED


Contraceptives (continued)

Mar. 1, 2016 to contraceptive coverage prior to Aug. 1, 2012

o Added language to indicate: Contraceptive

procedures/appliances/devi

ces are covered under the

member’s medical benefit when provided by a network provider

Diaphragms are covered under the pharmacy benefit if purchased by prescription

at a network pharmacy o Removed/relocated definition

of “religious employer” Updated definitions; added

definition of: o Religious employer – Patient

Protection and Affordable Care

Act o Religious employer –

Connecticut o Religious employer – New

Jersey o Religious employer – New

York Updated lists of applicable CPT

and HCPCS codes; consolidated notations pertaining to cost share

guidelines Updated list of applicable ICD-10

codes; added notation indicating

diagnosis code Z30.2 only applies when billed with CPT codes 00940, 00942, 00950, 00952, 01960, 01961, 01965, 01966, 01967 and 01968

Note: For additional information regarding preventive contraceptive coverage, refer to the policy titled Preventive Care Services. Exclusions: Contraceptive and contraceptive counseling coverage excludes: Abortions or abortifacient drugs (i.e., Mifiprex® [mifeprestone]).

Male contraception and sterilization. These services are not part of the

United States Preventive Services Task Force (USPSTF) requirements. Standard coverage and cost share guidelines apply to these services. Please refer to the Member's specific certificate of coverage, contract and/or prescription drug rider as applicable.

Religious employers may request a contract without coverage for contraceptives that are contrary to the religious employer’s bona fide

religious tenets. Refer to the Definitions section of this policy for state specific definitions of religious employer, which employers must meet in addition to the definition of religious employer under the Patient Protection and Affordable Care Act (PPACA).

Exception: New York Large and Small Groups; each enrollee that is part

of a group that has requested a contract without contraceptive coverage for religious tenets has the right to directly purchase such coverage.



UPDATED


Deep Brain Stimulation

Mar. 1, 2016

Updated list of applicable CPT codes; removed notation pertaining to Medical Director review/precertification requirements

Updated supporting information

to reflect the most current clinical evidence, FDA information and references

Deep brain stimulation is considered to be proven and medically necessary for treating the following: Idiopathic Parkinson's disease when used according to U.S. Food and

Drug Administration (FDA) indications. Essential tremor when used according to U.S. Food and Drug

Administration (FDA) indications.

Primary dystonia* (occurs apart from any other identifiable illness), including generalized and/or segmental dystonia, hemidystonia and cervical dystonia (torticollis) when used according to U.S. Food and Drug Administration (FDA) indications.

*Primary dystonia may include genetic torsion dystonia, acquired torsion

dystonia (not due to drugs), spasmodic torticollis, fragments of torsion dystonia, and unspecified torticollis. Deep brain stimulation is unproven and not medically necessary for treating secondary Parkinsonism (result of head trauma, metabolic conditions, toxicity, drugs or other medical disorders.

Well-designed studies demonstrating the efficacy of deep brain stimulation

for treating secondary Parkinsonism are not available. Clinical trials are needed to demonstrate the benefit of deep brain stimulation for this patient population. Deep brain stimulation is unproven and not medically necessary for treating secondary dystonia (occurs with illness, after trauma or

following exposure to certain medications or toxins). There is inadequate evidence of the safety and efficacy of deep brain stimulation for treating secondary dystonia. Questions remain with regard to patient selection criteria and long-term benefits and safety compared with

standard treatments. Formal comparisons, with large randomized controlled or comparative trials of pallidotomy, thalamotomy, and deep brain stimulation, are required before conclusions can be drawn regarding the use

of deep brain stimulation for patients with secondary dystonia. Deep brain stimulation is unproven and not medically necessary for treating conditions other than those listed as medically necessary. This includes but is not limited to the following diagnoses: Depression Obsessive-compulsive disorder (OCD)



UPDATED


Deep Brain Stimulation (continued)

Mar. 1, 2016 Epilepsy Tourette syndrome Cluster headache Impulsive or violent behavior Chronic pain

Trigeminal neuralgia

Movement disorders caused by multiple sclerosis (MS) Some studies have examined the use of deep brain stimulation for treating major depression, obsessive-compulsive disorder (OCD), epilepsy, Tourette syndrome, cluster headache, impulsive or violent behavior, stroke pain, chronic pain, phantom limb pain, trigeminal neuralgia and movement

disorders of multiple sclerosis (MS). However, because of limited studies, small sample sizes, weak study designs and heterogenous patient characteristics, there is insufficient data to conclude that deep brain stimulation is safe and/or effective for treating these indications.

Electrical

Stimulation and Electromagnetic Therapy for Wounds

Feb. 1, 2016

Updated supporting information

to reflect the most current clinical evidence, FDA information and references; no change to non-coverage rationale or list of applicable codes

Electrical stimulation is unproven and not medically necessary for

the treatment of wounds including venous stasis ulcers, arterial ulcers, diabetic foot ulcers, and chronic pressure sores. There is insufficient evidence from randomized, controlled trials that electrical stimulation, as an adjunct to standard wound care, can increase the healing rate of chronic dermal or cutaneous wounds. There were substantial methodological flaws in the available studies, which make it difficult to define the magnitude of treatment effects and to determine what

types of wounds are most likely to benefit from electrical stimulation. There is also insufficient evidence to determine the type of device or form of electrical current for use in wound healing. Electromagnetic therapy is unproven and not medically necessary for

the treatment of wounds including venous stasis ulcers, arterial ulcers, diabetic foot ulcers, chronic pressure sores and soft tissue

injuries. The available evidence regarding the use of pulsed high-frequency electromagnetic energy for the treatment of chronic wounds and soft tissue injuries is insufficient to support conclusions regarding the efficacy of this technology. The data from clinical trials are insufficient to prove efficacy, to define optimal treatment protocols, to establish patient selection criteria, or

to evaluate the relative efficacy of this therapy compared with other



UPDATED


Electrical Stimulation and Electromagnetic Therapy for Wounds

(continued)

Feb. 1, 2016 treatment options. The available studies involved small numbers of subjects and because significant differences were noted between intervention and control groups, it is not possible to draw valid conclusions about the efficacy of this technology.

Hysterectomy for Benign Conditions

Feb. 1, 2016 Updated supporting information to reflect the most current clinical evidence, FDA information and references; no change to coverage rationale or list of

applicable codes

For information regarding medical necessity review, when applicable, see the following MCG™ Care Guidelines, 19th edition, 2015: Hysterectomy, Abdominal, ORG: S-650 (ISC) Hysterectomy, Vaginal, ORG: S-660 (ISC) Hysterectomy, Laparoscopic, ORG: S-665 (ISC)

Implantable Beta-Emitting Microspheres for Treatment of

Malignant Tumors

Feb. 1, 2016 Updated supporting information to reflect the most current clinical evidence, FDA information and references; no change to

coverage rationale or list of applicable codes

Yttrium-90 (90Y) microsphere radioembolization is proven and medically necessary for the following indications: Unresectable metastatic liver tumors from primary colorectal cancer

(CRC)

Unresectable metastatic liver tumors from neuroendocrine tumors Unresectable primary hepatocellular carcinoma (HCC) Yttrium-90 (90Y) microsphere radioembolization is unproven and not medically necessary for all other indications. Limited evidence suggests that treatment with intrahepatic microsphere

radiation (IMR) might shrink tumors and relieve symptoms in some patients, sometimes enough to render some inoperable tumors operable. However, limited available evidence has not shown improved survival. In addition, the treatment's potential impact on quality of life has not been studied. No studies have yet compared the effects of IMR therapy with alternative

treatments, such as chemoembolization. Randomized controlled trials are needed to determine the clinical utility of this treatment.

Temporomandibular Joint Disorders

Feb. 1, 2016

Updated supporting information to reflect the most current description of services, clinical evidence, FDA information and references; no change to coverage rationale or lists of applicable codes

The following services are proven and medically necessary for treating disorders of the temporomandibular joint (TMJ): Arthrocentesis Arthroplasty [For information regarding medical necessity review, when

applicable, see MCG™ Care Guidelines, 19th edition, 2015, Temporomandibular Joint Arthroplasty, ACG: A-0523 (AC)]

Arthroscopy (with or without FDA approved bone anchor devices)



UPDATED


Temporomandibular Joint Disorders (continued)

Feb. 1, 2016

Arthrotomy/open joint surgery (with or without FDA approved bone anchor devices)

Injections of corticosteroids for rheumatoid arthritis-related TMJ disorders Physical therapy Stabilization and repositioning splint therapy (This does not include low-

load prolonged-duration stretch (LLPS) devices discussed below)

Partial or total joint replacement with an artificial prosthesis is proven and medically necessary for treating disorders of the temporomandibular joint (TMJ) when all other treatments have failed.

Not all services treat all TMJ disorders; specific treatments are based upon the specific diagnosis. The following services are unproven and not medically necessary for treating disorders of the temporomandibular joint (TMJ): Biofeedback

Craniosacral manipulation

Passive rehabilitation therapy Low-load prolonged-duration stretch (LLPS) devices There are limited studies evaluating biofeedback for the treatment of musculoskeletal pain, including TMJ pain. One small uncontrolled study reported positive effects, while a larger randomized controlled study failed to

demonstrate any treatment effect. Well-designed randomized, blinded and placebo-controlled outcome studies published on craniosacral manipulation for TMJ are not available. For

additional information regarding manipulation under anesthesia for TMJ disorders, see the Manipulation Under Anesthesia medical policy.

While there are some data from several randomized trials and case series studies that certain types of passive rehabilitation techniques may improve jaw mobility early in recovery in patients who have undergone TMJ surgery, or have lost jaw mobility due to TMJ derangement or to contracture following radiation therapy, these studies all included very small numbers of patients, and did not provide blinded assessment of outcomes, long-term follow-up, or information on optimal treatment protocols.



UPDATED


Temporomandibular Joint Disorders (continued)

Feb. 1, 2016 Further prospective controlled clinical trials that directly compare LLPS devices to other treatment modalities are needed.

REVISED


Drug Coverage

Criteria - New and Therapeutic Equivalent Medications

Mar. 1, 2016

Revised list of medications

requiring precertification through the pharmacy benefit manager (PBM): o Added Adynovate, Avar Foam

(9.5%-5%,10-2%), Avar, Avar LS, Belbuca, Diovan (brand only), Edluar, Enstilar

foam, Fenoglide, Intuniv (brand only), Lunesta (brand only), Molindone, Narcan

Nasal Spray, Nuwiq, Ovace Plus Foam, Seebri Neohaler, Staxyn, Synjardy, Tresiba, Utibron Neohaler, Veltassa,

Vimovo and Vivlodex o Removed Akynzeo, Aplenzin,

Apop 10% gel, AsmalPred, AsmalPred Plus, Asmanex HFA, Avinza, Celexa (brand only), Clobeta, Cocet Plus,

Corlanor, Cymbalta (brand only), Delos Lotion, Delos

Cleanser, Desonil cream/ointment (Kit), Effexor XR (brand only), Embeda, Exalgo, Forfivo XL, Glyxambi, Hysingla ER, Kadian, Lexapro

(brand only), Lidorx, Liptruzet, Momexin Combo Pkg, Morphine sulfate Extended Release (generic Kadian),

Refer to the policy for complete details on the coverage guidelines for Drug

Coverage Criteria - New and Therapeutic Equivalent Medications.



REVISED


Drug Coverage Criteria - New and Therapeutic Equivalent Medications

(continued)

Mar. 1, 2016

Naprelan CR (Dose Card), Neuac 1.2%, Neuac 1.2% kit, Nexiclon XR Tablet, Nexiclon XR Suspension, Olux-CP, Orbivan, Oxytrol, Pacnex HP,

Pacnex LP, Pexeva, ProAir

Respimat, Prozac (brand only), Prozena 4% patch, Qudexy XR, Rybix ODT, Synalar, Trokendi XR, Uptravi, Valturna 150-160, 300-320mg tablet, Varubi,

Viekira Pak, Wellbutrin SR (brand only), Wellbutrin XL (brand only), Zoloft (brand only), and Zolvit

o Updated drug/medication description for Antara,

Cuprimine, Khedezla, Minocin,

Naftin 1% and Naftin 2% gel or cream combined, Neo-Synalar Kit, Nystatin/triamcinolone (generic Mycolog II) cream and ointment combined,

Pennsaid Drops, Tramadol extended release (generic Ryzolt), Tretin-X cream, Vicodin, Vicodin ES, and

Vicodin HP o Updated formulary

alternatives for Acanya,

Acticlate, Acuvail, Adoxa, Amrix/cyclobenzaprine extended release, Analpram Advanced Kit, Atelvia, Augmentin XR/Amoxicillin-Clavulanate ER, Axiron, Benzaclin Kit (1%-5%),



REVISED



(continued)

Mar. 1, 2016

Benzaclin Pump, Beyaz, Binosto, Brisdelle, Bromday, Budesonide nasal spray (generic Rhinocort Aqua), Centany AT Kit, Ciclodan Kit,

Clarinex/desloratadine,

Clarinex-D, Clindacin Pac, Clindagel, Clindamycin 1% / benzoyl peroxide 5% (generic BenzaClin) gel, Clobex shampoo, ConZip, Cosopt PF, Desloratadine (generic

Clarinex), Differin 0.3% gel, Disalcid, donepezil 23mg (generic Aricept 23mg), Doryx/Doxycycline hyclate delayed release tablet, doxycycline monohydrate

150mg capsule (generic for

Adoxa), Duac, Duac CS, Duragesic (Brand only), Dymista, Ecoza, Exforge, Exforge HCT, Flo-Pred, Fortesta, Giazo, Glycate, Horizant, Imitrex tablets

(brand only), Imitrex injection (brand only), Jalyn, Levalbuterol nebs (generic Xopenex nebs), Lipitor (brand

only), metronidazole 1% gel (generic Metrogel 1%), Metozolv ODT, Minocin,

Mirapex ER, Monodox (brand only), Morgidox Kit (Combo Pkg), Namzaric, Nicazeldoxy 30 kit (Doxycycline plus MVI), Nitroglycerin Spray (generic Nitrolingual), Nitrolingual Pump Spray, Noritate,



REVISED



(continued)

Mar. 1, 2016

Nystatin/triamcinolone (generic Mycolog II) cream and ointment, Pazeo, Pediaderm AF, Pediaderm TA, Pedipirox-4, Plexion 9.8-4.8%

cream-liquid- lotion, Plexion

Cloth 9.8%-4.8% pads, Requip XL, ropinirole extended release (Requip XL), Rosadan Kit Cream, Rosadan Kit Gel, Rosula, tramadol extended release (generic Ryzolt),

Safyral, Sancuso, Silenor, Simbrinza 1-0.2%, Sitavig, Skelaxin (brand only), Sodium Sulfacetamide/sulfur 9%-4.5% kit (generic Sumadan Kit), Sorilux (calcipotriene),

SSS 10-4, Subsys, Sumadan,

Sumadan Cleanser (brand only), Sumadan XLT Kit, Sumaxin CP, Sumaxin TS, Symbicort, Tekamlo, testosterone topical gel (generic Testim), testosterone

topical gel (genetic Volgelxo), Tobradex ST, Topicort Spray, Tramadol extended-release (generic Ryzolt), Tretin-X

cream, Treximet, Trianex, Tribenzor, Tricor/Fenofibrate 48mg and 145mg (generic

Tricor), Tuzistra XR, Twynsta, Umecta emulsion-foam-suspension, Umecta Kit (nail film pen / film suspension), Uramaxin GT 45%, Utopic (urea) 41%, Veltin, Vogelxo, Vusion, Xerese, Xopenex



REVISED



(continued)

Mar. 1, 2016 Nebules, Ziana, Zipsor 25mg, Zonatuss, and Zyprexa Zydis (brand only)

REVISED

Policy Title Effective Date Drug/Medication Status Summary of Changes

Drug Coverage Guidelines

Mar. 1, 2016

Acanya (Clindamycin Phosphate 1.2% and Benzoyl Peroxide 2.5%)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with clindamycin 1.2% /benzoyl peroxide 5% gel (generic Duac), clindamycin solution + OTC benzoyl peroxide (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Acticlate (Doxycycline Hyclate)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with Doxycycline hyclate (generic Vibramycin, Vibra-Tabs), doxycycline

monohydrate (generic Monodox) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Acuvail (Ketorlac/ Tromethamine)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with ketorolac (generic Acular, Acular LS) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Adoxa (Doxycycline Monohydrate)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with doxycycline hyclate (generic Vibramycin, Vibra-Tab), doxycycline monohydrate 50 or 100mg (generic Monodox) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic

Equivalent Medications)

Adynovate (Antihemophillic Factor)

New Added coverage criteria/precertification requirements to indicate precertification is required through the Pharmacy Benefit Manager (PBM)

Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with Advate, Eloctate, Helixate FS, Kogenate FS, Recombinate, Xyntha, Xyntha Solofuse (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic


https://www.oxhp.com/secure/policy/drug_coverage_criteria_new_and_therapeutic_equivalent_medications.pdf

https://www.oxhp.com/secure/policy/drug_coverage_criteria_new_and_therapeutic_equivalent_medications.pdf



REVISED


Drug Coverage Guidelines (continued)

Mar. 1, 2016

Akynzeo (Netupitant/ Palonosetron)

Revised Revised coverage criteria/precertification requirements to indicate precertification is no longer required: o Removed language indicating precertification is required through the

Pharmacy Benefit Manager (PBM) o Removed therapeutic equivalent guidelines requiring history of

intolerance or therapeutic failure to treatment with dolasetron (generic

Anzemet), granisetron (generic Kytril), ondansetron (generic Zofran), Emend and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Amrix/Cyclobenzaprine Extended Release

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with

cyclobenzaprine HCL (generic Flexeril), Flexeril (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Analpram Advanced Kit (Hydrocortisone

Acetate/Pramoxine)


hydrocortisone acetate/pramoxine HCl (generic for Analpram HC) (see

Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Aplenzin (Bupropion) Revised Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with Buproprion XL (generic for Wellbutrin XL) and corresponding reference link to policy

titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Apop 10% Gel (Sulfacetamide)



intolerance or therapeutic failure to treatment with Sulfacetamide lotion, solution, suspension and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

AsmalPred and AsmalPred Plus (Prednisolone)

Revised

Revised coverage criteria/precertification requirements to indicate precertification is no longer required: o Removed language indicating precertification is required through the




REVISED



Mar. 1, 2016

AsmalPred and AsmalPred Plus (Prednisolone) (continued)

Revised intolerance or therapeutic failure to treatment with Prednisolone sodium phosphate (generic Orapred) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Asmanex HFA (Mometasone)

Revised Revised coverage criteria/precertification requirements to indicate precertification is no longer required:

o Removed language indicating precertification is required through the Pharmacy Benefit Manager (PBM)

o Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with Asmanex TwistHaler, Alvesco, QVAR and corresponding reference link to policy

titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Atelvia (Risedronate Sodium)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with risedronate (generic Actonel), Actonel (see Therapeutic Equivalent

Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent

Medications)

Augmentin XR/ Amoxicillin - Clavulanate ER (Amoxicillin and Clavulanate Potassium)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with amoxicillin/clavulanate potassium (generic Augmentin), Augmentin (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and

Therapeutic Equivalent Medications)

Avar Foam (9.5%-5%), Avar, Avar LS (Sodium Sulfacetamid/Sulfur)


Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with sulfacetamide sodium/sulfur 10-5%

(see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Avinza (Morphine Sulface Extended Release) (Brand Only)

Revised Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with orphine sulfate extended-release tablet (generic MS Contin), morphine sulfate extended-release capsule (generic Avinza) and corresponding reference link to

policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Axiron (Testosterone)

Revised

Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with Testim, Androderm (see Therapeutic Equivalent Guidelines: Drug



REVISED



Mar. 1, 2016

Axiron (Testosterone) (continued)

Revised Coverage Criteria - New and Therapeutic Equivalent Medications)

Belbuca (Buprenorphine) New Added coverage criteria/precertification requirements to indicate precertification is required through the Pharmacy Benefit Manager (PBM)

Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with Butrans (see Therapeutic Equivalent

Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Benzaclin Kit (1%-5%) (Clindamycin Phosphate-

Benzoyl Peroxide)


clindamycin 1.2% /benzoyl peroxide 5% gel (generic Duac), clindamycin solution + OTC benzoyl peroxide (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Benzaclin Pump (Benzoyl Peroxide and

Clindamycin)


clindamycin 1.2% /benzoyl peroxide 5% gel (generic Duac), clindamycin solution + OTC benzoyl peroxide (see Therapeutic Equivalent Guidelines:

Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Beyaz (Drospirenone/ Ethinyl Estradiol/ Levomefolate)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with drospirenone/ethinyl estradiol (generic Yaz) or Yaz + Folic Acid (see


Binosto (Alendronate) Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with alendronate (generic for Fosamax), Fosamax (see Therapeutic Equivalent


Brisdelle (Paroxetine) Revised Revised therapeutic equivalent guidelines; added coverage criterion

requiring history of intolerance or therapeutic failure to treatment with estradiol (generic Estrace), paroxetine (generic Paxil), paroxetine extended-release (generic Paxil CR), Enjuvia, Premarin (see Therapeutic

Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Bromday (Bromfenac) Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with bromfenac (generic for Xibrom) (see Therapeutic Equivalent Guidelines:




REVISED



Mar. 1, 2016

Budesonide Nasal Spray (Generic Rhinocort Aqua)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with two of the following: flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, or Nasacort OTC (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent

Medications)

Celexa (Citalopram) (Brand Only)

Revised Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with citalopram (generic Celexa) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Centany AT Kit (Mupirocin)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with mupirocin ointment (generic Bactroban), Bactroban (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Ciclodan Kit (Ciclopirox) Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with

ciclopirox nail lacquer (generic Penlac), Penlac (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Clarinex (Desloratadine) Revised Revised therapeutic equivalent guidelines; added coverage criterion

requiring history of intolerance or therapeutic failure to treatment with levocetirizine (generic for Xyzal), Xyza (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Clarinex D

(Desloratadine and Pseudoephedrine)

Revised Revised therapeutic equivalent guidelines; added coverage criterion

requiring history of intolerance or therapeutic failure to treatment with levocetirizine (generic for Xyzal), Xyzal (+ OTC pseudoephedrine) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and


Clindacin Pack (Clindamycin Phosphate)


clindamycin gel 1% (generic for Cleocin-T), clindamycin solution, clindamycin lotion (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Clindagel (Clindamycin)

Revised

Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with

clindamycin gel 1% (generic for Cleocin-T), clindamycin solution,



REVISED



Mar. 1, 2016

Clindagel (Clindamycin) (continued)

Revised clindamycin lotion (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Clindamycin 1%/Benzoyl Peroxide 5% (Generic

Benzaclin) Gel


clindamycin 1.2% /benzoyl peroxide 5% gel (generic Duac), clindamycin solution + OTC benzoyl peroxide (see Therapeutic Equivalent Guidelines:


Clobeta (Clobetasol) Revised Revised coverage criteria/precertification requirements to indicate precertification is no longer required: o Removed language indicating precertification is required through the


intolerance or therapeutic failure to treatment with Clobetasol 0.05% + OTC coal tar and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Clobex Shampoo (Clobetasol Propionate)


clobetasol (generic Temovate), Temovate (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Cocet Plus

(Acetaminophen and Codeine Phosphate)

Revised Revised coverage criteria/precertification requirements to indicate

precertification is no longer required: o Removed language indicating precertification is required through the


intolerance or therapeutic failure to treatment with Acetaminophen with codeine and corresponding reference link to policy titled Drug

Coverage Criteria - New and Therapeutic Equivalent Medications

Conzip (Tramadol) Revised Revised therapeutic equivalent guidelines; added coverage criterion

requiring history of intolerance or therapeutic failure to treatment with tramadol (generic Ultram), tramadol ER (generic for Ultram ER), Ultram, Ultram ER (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Corlanor (Ivabradine)

Revised





REVISED



Mar. 1, 2016

Corlanor (Ivabradine) (continued)

Revised intolerance or therapeutic failure to treatment with benazepril (generic Lotensin), benazepril/HCTZ (generic Lotensin HCT), enalapril (generic Vasotec), enalapril/HCTZ (generic Vaseretic), irbesartan (generic Avapro), irbesartan/HCTZ (generic Avalide), lisinopril (generic Prinivil, Zestril), losartan (generic Cozaar), losartan/HCTZ (generic Hyzaar),

ramipril (generic Altace), valsartan (generic Diovan), valsartan/HCTZ

(generic Diovan HCT), Benicar, Benicar HCT and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Cosopt PF (Dorzolamide HCL/Timolol Maleate


Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with dorzolamide/timolol(generic Cosopt), Cosopt (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Cuprimine

(Penicillamine)

Updated Updated medication/drug title listing to correct spelling

Cymbalta (Duloxetine) (Brand only)

Revised Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with duloxetine (generic Cymbalta) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Delos Lotion/Cleanser (Benzoyl Peroxide)



intolerance or therapeutic failure to treatment with OTC benzoyl

peroxide and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Desloratadine (Generic Clarinex)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with levocetirizine (generic for Xyzal), Xyzal (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent

Medications)

Desonil Cream/Ointment (Kit) (Desonide)

Revised


Pharmacy Benefit Manager (PBM)



REVISED



Mar. 1, 2016

Desonil Cream/Ointment (Kit) (Desonide) (continued)

Revised o Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with Desonide 0.05% cream, ointment and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Differin 0.3% Gel Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with

tretinoin (generic Retin-A), Differin 0.1% gel (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Diovan (Valsartan)

(Brand only)

New Added coverage criteria/precertification requirements to indicate

precertification is required through the Pharmacy Benefit Manager (PBM) Added therapeutic equivalent guidelines requiring history of intolerance or

therapeutic failure to treatment with valsartan (generic Diovan) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Disalcid (Salsalate) Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with

salsalate (generic Disalcid) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Donepezil 23mg (Generic Aricept 23mg)


donepezil 10 mg (generic Aricept 10 mg) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Doryx (Doxycycline Hyclate) Delayed

Release Tablet


doxycycline hyclate (generic Morgidox, Vibramycin), doxycycline monohydrate 50 mg or 100 mg (generic Monodox) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic


Doxycycline 150mg Capsule (Generic

Monodox)


doxycycline hyclate (generic Vibramycin, Vibra-Tab), doxycycline monohydrate 50 or 100mg (generic Monodox) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Duac (Clindamycin and

Benzoyl Peroxide)

Revised

Revised therapeutic equivalent guidelines; added coverage criterion

requiring history of intolerance or therapeutic failure to treatment with



REVISED



Mar. 1, 2016

Duac (Clindamycin and Benzoyl Peroxide) (continued)

Revised clindamycin 1.2% /benzoyl peroxide 5% gel (generic Duac) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Duac CS (Clindamycin

and Benzoyl Peroxide)


requiring history of intolerance or therapeutic failure to treatment with clindamycin 1.2% /benzoyl peroxide 5% gel (generic Duac) (see


Duragesic (Brand only) (Fentanyl)


fentanyl transdermal patch 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr (generic Duragesic) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Ecoza (Econazole Nitrate Topical Foam 1%)


two of the following: econazole (generic Spectazole), ketoconazole (generic Nizoral), terbinafine (generic Lamisil) (see Therapeutic


Edluar (Zolpidem) Revised Added coverage criteria/precertification requirements: o Added language to indicate precertification is required through the

Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines requiring history of

intolerance or therapeutic failure to treatment with two of the following: zolpidem (generic Ambien), zalepelon (generic Sonata), eszopiclone (generic Lunesta) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Effexor XR (Venlafaxine) (Brand only)

Revised Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with venlafaxine extended-

release capsule (generic Effexor XR) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Embeda (Morphine Sulphate and Naltrexone HCL)

Revised Removed duplicate entry for Embeda (morphine/naltrexone) Removed therapeutic equivalent guidelines requiring history of

intolerance or therapeutic failure to treatment with morphine sulfate extended-release (generic MS Contin), Opana ER, Oxycontin, Nucynta ER, Zohydro ER and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications



REVISED



Mar. 1, 2016

Enstilar Foam (Calcipotriene/ Betamethasone)


Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with calcipotriene/betamethasone ointment (generic Taclonex), Taclonex Suspension (see Therapeutic

Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic


Exalgo (Hydromorphone) Revised Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with hydromorphone extended-release tablet (generic Exalgo) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent

Medications

Exforge (Amlodipine Valsartan)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with amlodipine (generic Norvasc) plus losartan (generic Cozaar), Benicar, Diovan, telmisartan (generic Micardis), or valsartan (generic Diovan)

(see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New

and Therapeutic Equivalent Medications)

Exforge HCT (Amlodipine, Hydrochlorothiazide and Valsartan)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with amlodipine (generic Norvasc) plus losartan/hydrochlorothiazide (generic Hyzaar), valsartan/hydrochlorothiazide (generic Diovan HCT), Benicar

HCT, or telmisartan/hydrochlorothiazide (generic Micardis HCT) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Fenoglide (Fenofibrate) New Added coverage criteria/precertification requirements to indicate precertification is required through the Pharmacy Benefit Manager (PBM)

Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with fenofibrate 54mg, 160 mg (generic

Lofibra) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Flo-Pred (Prednisolone) Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with

prednisolone sodium phosphate (generic Orapred, Pedipred, Prelone), Orapred, Pedipred, Prelone (generic Duac) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)



REVISED



Mar. 1, 2016

Forfivo XL (Bupropion HCL)

Revised Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with Bupropion (generic Wellbutrin), bupropion SR (Wellbutrin SR), buproprion XL (generic Wellbutrin XL), Wellbutrin, Wellbutrin SR, Wellbutrin XL and corresponding reference link to policy titled Drug Coverage Criteria - New

and Therapeutic Equivalent Medications

Fortesta (Testosterone) Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with Testim, Androderm (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Giazo (Balsalazide Disodium)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with balsalazide (generic for Colazal), Colazal (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Glycate (Glycopyrrolate)


glycopyrrolate (generic Robinul), Robinul (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Glyxambi (Empagliflozin/

Linagliptin)

Revised Removed therapeutic equivalent guidelines requiring history of

intolerance or therapeutic failure to treatment with Nesina, Onglyza or Tradjenta + Invokana or Jardiance and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Horizant (Gabapentin,

Enacarbil)


requiring history of intolerance or therapeutic failure to treatment with gabapentin (generic Neurontin) or ropinirole (generic Requip )or pramipexole (generic Mirapex) (see Therapeutic Equivalent Guidelines:


Hysingla ER (Hydrocodone Bitartrate)

Revised Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with morphine sulfate

extended-release (generic MS Contin), Opana ER, Oxycontin, Nucynta ER, Zohydro ER and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Imitrex (Sumatriptan) (Brand only): Tablet

Revised


sumatriptan injection or tablets (generic Imitrex) (see Therapeutic



REVISED



Mar. 1, 2016

Imitrex (Sumatriptan) (Brand only): Tablet (continued)

Revised Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Imitrex (Sumatriptan)

(Brand only): Injection


requiring history of intolerance or therapeutic failure to treatment with sumatriptan injection or tablets (generic Imitrex) (see Therapeutic


Intuniv (Guanfacine) (Brand only)

Revised Revised Medication/Drug name; added (brand only) Revised coverage criteria:

o Removed step therapy guidelines and corresponding reference to policy titled Step Therapy Guidelines: Intuniv

o Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment guanfacine extended-release (generic Intuniv) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Jalyn (Dutasteride and

Tamsulosin)


requiring history of intolerance or therapeutic failure to treatment with dutasteride (generic Avodart) + tamsulosin (generic Flomax) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Kadian (Morphine Sulfate Extended Release)

Revised Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with Morphine sulfate sustained action and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Khedezla

(Desvenlafaxine Extended Release)

Updated Updated medication/drug title listing to correct spelling

Levalbuterol Nebs

(Generic Xopenex Nebs)


requiring history of intolerance or therapeutic failure to treatment with albuterol nebulized solution (generic Proventil Inhalation Solution) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and


Lexapro (Escitalopram) (Brand only)

Revised Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with escitalopram (generic Lexapro) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications



REVISED



Mar. 1, 2016

Lidorx (Lidocaine Hydrochloride)



intolerance or therapeutic failure to treatment with lidocaine 2% gel

and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Liptruzet (Ezetimibe and Atorvastatin)



intolerance or therapeutic failure to treatment with atorvastatin (generic Lipitor) plus Zetia and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Lunesta (Eszopicione) (Brand only)

Revised Added coverage criteria/precertification requirements: o Added language to indicate precertification is required through the

Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines requiring history of

intolerance or therapeutic failure to treatment with two of the following: zolpidem (generic Ambien), zalepelon (generic Sonata),

eszopiclone (generic Lunesta) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Metronidazole 1% Gel (Generic Metrogel 1%)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with metronidazole gel 0.75% (generic Metrogel) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent

Medications)

Metozolv ODT (Metoclopramide Hydrochloride)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with Metoclopramide (generic for Reglan), Reglan (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent

Medications)

Minocin 50mg, 75mg, and 100mg (Minocycline HCL)

Revised

Updated medication/drug title listing; previously titled Minocin (all strengths) (minocycline hcl)




REVISED



Mar. 1, 2016

Minocin 50mg, 75mg, and 100mg (Minocycline HCLl) (continued)

Revised requiring history of intolerance or therapeutic failure to treatment with minocycline capsule (generic Dynacin, Minocin) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Mirapex ER (Pramipexole Dihydrochloride)


pramipexole (generic for Mirapex), Mirapex (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Molindone New Added coverage criteria/precertification requirements to indicate


therapeutic failure to treatment with haloperidol (generic Haldol), fluphenazine (generic Prolixin), risperidone (generic Risperdal) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Momexin Combo

Package (Mometasone Furoate)




intolerance or therapeutic failure to treatment with Mometasone

furoate cream + ammonium lactate and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Monodox (Doxycycline) (Brand only)


doxycycline hyclate (generic Vibramycin), doxycycline monohydrate 50 or 100mg (generic Monodox) (see Therapeutic Equivalent Guidelines: Drug

Coverage Criteria - New and Therapeutic Equivalent Medications)

Morgidox Kit / Combo Pkg (Doxycycline Plus Cleanser)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with doxycycline hyclate (generic Vibramycin), doxycycline monohydrate 50 or

100mg (generic Monodox) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Morphine Sulfate Extended Release Pellets (Generic Kadian)

Revised




REVISED



Mar. 1, 2016

Morphine Sulfate Extended Release Pellets (Generic Kadian) (continued)

Revised Pharmacy Benefit Manager (PBM) o Removed therapeutic equivalent guidelines requiring history of

intolerance or therapeutic failure to treatment with Morphine sulfate sustained-action tablet (generic MS Contin), MS Contin and corresponding reference link to policy titled Drug Coverage Criteria -

New and Therapeutic Equivalent Medications

Namzaric (Memantine Hydrochloride)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with Donepezil (generic Aricept) plus Namenda ZXR (generic Monodox) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Naprelan (Naproxen Sodium)

Updated Removed Naprelan CR (Dose Card) (Naproxen Sodium) from medication/drug title listing; created separate entry for content specific to Naprelan CR (Dose Card) (Naproxen Sodium) (see below)

Naprelan CR (Dose Card)

(Naproxen Sodium)




intolerance or therapeutic failure to treatment with Naproxen sodium and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Narcan Nasal Spray (Naloxone)


Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with naloxone injection (generic Narcan) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New

and Therapeutic Equivalent Medications)

Neuac 1.2%-5%

(Clindamycin Phosphate and Benzoyl Peroxide)

Revised

Revised coverage criteria/precertification requirements to indicate



intolerance or therapeutic failure to treatment with Clindamycin-benzoyl peroxide (generic Benzaclin jar) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications



REVISED



Mar. 1, 2016

Neuac 1.2%-5% Kit (Clindamycin Phosphate and Benzoyl Peroxide)



intolerance or therapeutic failure to treatment with Clindamycin-

benzoyl peroxide (generic Benzaclin jar) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Nexiclon XR (Clonidine Extended Release)



o Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with clonidine immediate release tablets (generic for Catapres) and corresponding reference link to policy titled Drug Coverage Criteria - New and

Therapeutic Equivalent Medications

Nicazeldoxy 30 Kit (Doxycycline Plus MVI)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with doxycycline hyclate (generic Vibramycin, Vibra-Tab), doxycycline monohydrate 50 or 100mg (generic Monodox) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic


Nitroglycerin Spray (Generic Nitrolingual)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with nitroglycerin spray (generic Nitromist), Nitromist, Nitrostat (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Nitrolingual Pump Spray (Nitroglycerin)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with nitroglycerin spray (generic Nitromist), Nitromist, Nitrostat (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Noritate (Metronidazolel)

Revised

Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with metronidazole 0.75% cream (generic Metrocream), metronidazole -.75% gel (generic Metrogel) (see Therapeutic Equivalent Guidelines: Drug



REVISED



Mar. 1, 2016

Noritate (Metronidazolel) (continued)

Revised Coverage Criteria - New and Therapeutic Equivalent Medications)

Nuwiq (Antihemophilic Factor)


Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with Advate, Helixate FS, Kogenate FS,

Recombinate, Xyntha, Xyntha Solofuse (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Olux-CP (Clobetasol

Propionate)




intolerance or therapeutic failure to treatment with Clobetasol propionate foam and corresponding reference link to policy titled Drug

Coverage Criteria - New and Therapeutic Equivalent Medications

Orbivan (Butalbital, Acetaminophen and Caffeine)



intolerance or therapeutic failure to treatment with butalbital/acetaminophen/caffeine (generic for Fioricet) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Ovace Plus 9.8% Lotion

(Sodium Sulfacetamide)


requiring history of intolerance or therapeutic failure to treatment with sulfacetamide sodium 10% lotion, gel (see Therapeutic Equivalent


Ovace Plus Foam (Sodium Sulfacetamide)

New

Added coverage criteria/precertification requirements to indicate precertification is required through the Pharmacy Benefit Manager (PBM)

Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with sulfacetamide sodium 10% lotion, gel (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)



REVISED



Mar. 1, 2016

Oxytrol (Oxybutynin) Revised Revised coverage criteria/precertification requirements to indicate precertification is no longer required: o Removed language indicating precertification is required through the


intolerance or therapeutic failure to treatment with Oxytrol OTC,

oxybutynin, oxybutynin extended-release, Ditropan, Ditropan XL, Toviaz and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Pacnex HP and Pacnex LP (Benzoyl Peroxide)



o Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with OTC benzoyl peroxide and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Pazeo (Olopatadine Hydrochloride)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with Azelastine (generic for Optivar) and Lastacaft (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Pediaderm AF (Nystatin) and Pediaderm TA (Triamcinolone)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with nystatin cream (generic Mycostatin) for Pediaderm AF and triamcinolone 0.1% cream (generic Aristocort) for Pediaderm TA (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Pediprox-4

(Benzalkonium)


requiring history of intolerance or therapeutic failure to treatment with Ciclopirox (generic Penlac), Penlac (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Pennsaid 1.5% Drops (Diclofenac Sodium)

Updated Updated medication/drug title listing; added 1.5%

Pexeva (Paroxetine Mesylate)

Revised

Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with paroxetine (generic Paxil), paroxetine extended-release (generic Paxil CR), Paxil, Paxil CR and



REVISED



Mar. 1, 2016

Pexeva (Paroxetine Mesylate) (continued)

Revised corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Plexion 9.8-4.8% Cream, Liquid, Lotion

(Sulfacetamide/Sulfur)

Revised Revised therapeutic equivalent guidelines to require a history of

intolerance or therapeutic failure to treatment of sulfacetamide sodium/sulfur 10-5% (see Therapeutic Equivalent Guidelines: Drug

Coverage Criteria - New and Therapeutic Equivalent Medications)

Plexion Cloth 9.8%-4.8% Pads (Sulfacetamide/Sulfur)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with sulfacetamide sodium/sulfur 10-5% (see Therapeutic Equivalent


Proair Respimat (Albuterol)



intolerance or therapeutic failure to treatment with Ventolin HFA and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prozac (Fluoxetine)

(Brand Only)


intolerance or therapeutic failure to treatment with fluoxetine (generic Prozac) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prozena 4% Patch (Lidocaine)



o Removed therapeutic equivalent guidelines requiring history of

intolerance or therapeutic failure to treatment with lidocaine transdermal patch (generic Lidoderm) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Qudexy XR (Topiramate)

Revised

Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with topiramate (generic Topamax), Topamax and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications



REVISED



Mar. 1, 2016

Requip XL (Ropinirole Extended Release)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with ropinirole (Generic for Requip), Requip (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Rosadan Kit

(Metronidazole)


requiring history of intolerance or therapeutic failure to treatment with Metronidazole cream (Metrocream), metronidazole 0.75% gel (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Rosula (Sodium Sulfacetamide 10%/ Sulfur 4%)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with sodium sulfacetamide/sulfur 10-5% (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Rybix ODT (Tramadol Hydrochloride)



o Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with tramadol and corresponding reference link to policy titled Drug Coverage Criteria -

New and Therapeutic Equivalent Medications

Ryzolt (Tramadol Hydrochloride Extended Release)



o Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with Tramadol IR

(generic for Ultram), tramadol ER (generic for Ultram ER) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Safyral

(Drospirenone/Ethinyl Estradiol/Levomefolate)

Revised


requiring history of intolerance or therapeutic failure to treatment with drospirenone/ethinyl estradiol (generic Yasmin), Yasmin + folic acid (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)



REVISED



Mar. 1, 2016

Seebri Neohaler (Glycopyrrolate)


Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with Incruse Ellipta, Spiriva or Tudorza Pressair (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria -

New and Therapeutic Equivalent Medications)

Silenor (Doxepin Hydrochloride)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with doxepin (generic Sinequan); zolpidem (generic Ambien), zaleplon (generic Sonata) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Simbrinza 1-0.2% (Brimonidine and Brinzolamide)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with brimonidine (generic Alphagan) or Alphagan plus Azopt (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Sitavig (Acyclovir) Revised Revised therapeutic equivalent guidelines; added coverage criterion

requiring history of intolerance or therapeutic failure to treatment with acyclovir tablets (Zovirax), acyclovir ointment (Zovirax ointment), Zovirax cream, Zovirax tablets (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Skelaxin (Brand only) (Metaxalone)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with metaxolone (generic for Skelaxin) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Sodium Sulfacetamide/Sulfur 9%-4.5% Kit (Generic

Sumadan Kit)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with Sodium sulfacetamide/sulfur 10-5% (see Therapeutic Equivalent


Sorilux (Calcipotriene)

Revised


requiring history of intolerance or therapeutic failure to treatment with calcipotriene (Dovonex), Dovonex (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

SSS 10-4 (Sodium

Polystyrene Sulfonate)

Revised


requiring history of intolerance or therapeutic failure to treatment with



REVISED



Mar. 1, 2016

SSS 10-4 (Sodium Polystyrene Sulfonate) (continued)

Revised Sulfacetamide sodium/sulfur 10-5% (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Staxyn (Vardenafil) Revised Added therapeutic equivalent guidelines requiring history of intolerance or

therapeutic failure to treatment with Levitra (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent

Medications)

Sumadan (Sodium Sulfacetamide and Sulfur)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with sulfacetammide sodium/sulfur 10-5% (see Therapeutic Equivalent


Sumadan Cleanser (Sodium Sulfacetamide and Sulfur) in a

Moisturizing Novasome® Vehicle)

(Brand only)



Sumadan XLT Kit (Sulfacetamide Sodium, Sulfur, Avobenzone,

Octinoxate and Octisalate)



Sumaxin TS and Sumaxin CP (Sodium Sulfacetamide and

Sulfur)



Symbicort (Budesonide/

Formoterol Fumarate Dehydrate)


requiring history of intolerance or therapeutic failure to treatment with Advair (HFA or Diskus) and Dulera or Breo Ellipta (for Asthma); Advair (HFA or Diskus) and Breo Ellipta (for COPD) (see Therapeutic Equivalent


Synalar (Fluocinolone Acetonide)

Revised





REVISED



Mar. 1, 2016

Synalar (Fluocinolone Acetonide) (continued)

Revised o Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with Fluocinolone (generic Synalar) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Tekamlo (Aliskiren/ Amlodipine)


amlodipine (generic Norvasc) or Norvasc + Tekturna (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Testosterone Topical Gel

(Generic Testim)


requiring history of intolerance or therapeutic failure to treatment with Testim, Androderm (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Testosterone Topical Gel (Generic Vogelxo)


Testim, Androderm (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Tobradex ST (Tobramycin -Dexamethasone)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with Tobramycin/dexamethasone ophthalmic drops (generic for Tobradex), Tobradex (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria

- New and Therapeutic Equivalent Medications)

Topicort Spray (Desoximetasone)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with desoximetasone (generic Topicort), Topicort (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent

Medications)

Tramadol Extended -Release (Generic Ryzolt)


tramadol (generic Ultram), tramadol extended-release (generic Ultram ER) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Tresiba (Insulin Degludec)

New


Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with Levemir and Lantus (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic




REVISED



Mar. 1, 2016

Tretin-X 0.075% cream (tretinoin)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with tretinoin (generic Retin-A) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Treximet (Sumatriptan Naproxen)


sumatriptan (generic Imitrex) plus naproxen (generic Naprosyn) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Trianex (Triamcinolone) Revised Revised therapeutic equivalent guidelines; added coverage criterion

requiring history of intolerance or therapeutic failure to treatment with triamcinolone ointment (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Tribenzor (Amlodipine, Olmesartan, Medoxomil,

Hydrochlorothiazide)


amlodipine (generic Norvasc) + HCTZ + Benicar OR Benicar HCT + amlodipine (generic Norvasc) (see Therapeutic Equivalent Guidelines:


Tricor/Fenofibrate 48mg and 145mg (Generic Tricor) (Fenofibrate) and

Trilipix (Fenofibrate Acid)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with Fenofibrate 54mg, 160m (generic Tricor) (see Therapeutic Equivalent


Twynsta (Telmisartan, Amlodipine)

Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with telmisartan (generic Micardis) + amlodipine (generic Norvasc) or Norvasc

(see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Uptravi (Selexipag)

New

Added coverage criteria/precertification requirements to indicate


therapeutic failure to treatment with sildenafil citrate tablets (generic

Revatio), Adcirca, Adempas, Letairis, Opsumit, Tracleer (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Utibron Neohaler (Indacaterol /

Glycopyrrolate)

New


Added therapeutic equivalent guidelines requiring history of intolerance or



REVISED



Mar. 1, 2016

Utibron Neohaler (Indacaterol / Glycopyrrolate) (continued)

New therapeutic failure to treatment with Anoro Ellipta or (Striverdi Respimat + Incruse Ellipta, Spiriva or Tudorza Pressair) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Utopic (Urea) 41% Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with

urea 40% (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Valturna 150-160mg, 300mg - 320mg

(Aliskiren and Valsartan)



o Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with Diovan + Tekturna and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Varubi (Rolapitant) Revised Revised coverage criteria/precertification requirements to indicate



intolerance or therapeutic failure to treatment with granisetron

(generic Kytril), ondansetron (generic Zofran), Anzemet, Emend and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Veltassa (Patiromer) New Added coverage criteria/precertification requirements to indicate precertification is required through the Pharmacy Benefit Manager (PBM)

Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with sodium polystyrene sulfonate

(generic Kayexalate) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Veltin (Clindamycin Phosphate and Tretinoin)

Revised


clindamycin gel, solution or lotion + tretinoin gel (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)



REVISED



Mar. 1, 2016

Vicodin 5/300mg (Hydrocodone and Acetaminophen)

Updated Updated medication/drug title listing; added 5/300mg

Vicodin ES 7.5/300mg

(Hydrocodone and Acetaminophen)

Updated Updated medication/drug title listing; added 7.5/300mg

Vicodin HP 10/300mg (Hydrocodone and Acetaminophen)

Updated Updated medication/drug title listing; added 10/300mg

Vimovo (Naproxen Sodium Plus Proton Pump Inhibitor)

Revised Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with naproxen (generic Naprosyn) + omeprazole (generic Prilosec), pantoprazole (generic Protonix), rabeprazole (generic Aciphex), Dexilant (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Vivlodex (Meloxicam) New Added coverage criteria/precertification requirements to indicate precertification is required through the Pharmacy Benefit Manager (PBM)

Added therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with meloxicam (generic Mobic) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Vogelxo (Testosterone) Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with Androderm, Testim (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Wellbutrin SR (Brand only) (Bupropion)

Revised Removed therapeutic equivalent guidelines requiring history of intolerance or therapeutic failure to treatment with bupropion sustained-release (generic Wellbutrin SR) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent

Medications

Wellbutrin XL (Bupropion

Extended Release)


intolerance or therapeutic failure to treatment with bupropion sustained-release (generic Wellbutrin XR) and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Xerese (Acyclovir or

Hydrocortisone)

Revised


requiring history of intolerance or therapeutic failure to treatment with acyclovir capsule/tablet (generic Zovirax), famciclovir tablet (generic



REVISED



Mar. 1, 2016

Xerese (Acyclovir or Hydrocortisone) (continued)

Revised Famvir), valacyclovir tablet (generic Valtrex), OTC Abreva (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Xopenex Nebules

(Levalbuterol Hydrochloride)

Generic Xopenex Nebules


requiring history of intolerance or therapeutic failure to treatment with albuterol nebulized solution (generic Proventil Inhalation Solution) (see


Ziana (Clindamycin Phosphate and Tretinoin)


clindamycin gel, solution or lotion + tretinoin gel (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Zipsor 25mg (Diclofenac Pottassium)


Diclofenac potassium (generic Cataflam) or diclofenac sodium (generic Voltaren) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria

- New and Therapeutic Equivalent Medications)

Zolvit (Hydrocodone Bitartrate and Acetaminophen)



intolerance or therapeutic failure to treatment with acetaminophen with hydrocodone solution and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Zonatuss (Benzonatate) Revised Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with

benzonatate (generic Tessalon Perles) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)

Zyprexa Zydis (Olanzapine) (Brand only) (continued)

Revised

Revised therapeutic equivalent guidelines; added coverage criterion requiring history of intolerance or therapeutic failure to treatment with olanzapine orally disintegrating tablet (generic Zyprexa Zydis) (see Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications)



REVISED


Infertility Diagnosis and Treatment

Mar. 1, 2016

Revised conditions of coverage/special considerations; added notation to indicate: o For commercial plans,

precertification is not required,

but is encouraged for out-of-

network services performed in the office that are covered under the member's general benefits package

o If precertification is not obtained, Oxford may review

for medical necessity after the service is rendered

Updated benefit considerations; removed language indicating covered services are subject to medical necessity review and will

be determined based upon review

of the members benefit Updated supporting information

to reflect the most current clinical evidence, FDA information and references

Diagnostic Procedures

Females The following tests or procedures are proven and medically

necessary for diagnosing infertility in female patients: Antral follicle count

Clomiphene citrate challenge test The following hormone level tests:

o Antimüllerian hormone (AMH) o Estradiol o Follicle-stimulating hormone (FSH)

o Luteinizing hormone (LH) o Progesterone o Prolactin o Thyroid-stimulating hormone (TSH)

Hysterosalpingogram (HSG) Diagnostic hysteroscopy Diagnostic laparoscopy with or without chromotubation

Pelvic ultrasound (transabdominal or transvaginal) Sonohysterogram or saline infusion ultrasound The following tests are unproven and not medically necessary for diagnosing infertility in female patients: Inhibin B

Uterine/endometrial receptivity testing [e.g., E-tegrity® and Endometrial Function Test® (EFT®)]

There is insufficient evidence to permit conclusions regarding the use of these tests. More studies are needed to support improved outcomes (i.e., increased successful pregnancies with delivery of liveborn children) with use

of these diagnostic tests.

Males The following tests or procedures are proven and medically necessary for diagnosing infertility in male patients: Antisperm antibodies The following genetic screening tests:

o Cystic fibrosis gene mutations

o Karyotyping for chromosomal abnormalities



REVISED


Infertility Diagnosis and Treatment (continued)

Mar. 1, 2016

o Y-chromosome microdeletions testing The following hormone level tests:

o LH o FSH o prolactin

o testosterone (total and free)

Leukocyte count in semen Post-ejaculatory urinalysis Scrotal, testicular or transrectal ultrasound Semen analysis Testicular biopsy Vasography

The following tests are unproven and not medically necessary for diagnosing infertility in male patients: Computer-assisted sperm analysis (CASA) Hyaluronan binding assay (HBA) Postcoital cervical mucus penetration test

Reactive oxygen species (ROS) test

Sperm acrosome reaction test Sperm DNA integrity/fragmentation tests [e.g., sperm chromatin

structure assay (SCSA), single-cell gel electrophoresis assay (Comet), deoxynucleotidyl transferase-mediated dUTP nick end labeling assay (TUNEL), sperm chromatin dispersion (SCD) or Sperm DNA Decondensation™ Test (SDD)]

Sperm penetration assays There is insufficient evidence to permit conclusions regarding the use of these tests. More studies are needed to support improved outcomes (i.e.,

increased successful pregnancies with delivery of liveborn children) with use of these diagnostic tests.

Therapeutic Procedures

For medical necessity reviews, refer to the Optum Infertility Clinical Performance Guideline. The following procedures are unproven and not medically necessary

for treating infertility:



REVISED



Mar. 1, 2016

Co-culture of embryos EmbryoGlue® In vitro maturation (IVM) of oocytes Studies describe different techniques of co-culture of embryos, but no

standardized method of co-culturing has been defined. The use of co-cultures

may improve blastocyst development but may not result in an improved pregnancy or delivery rate. There is inadequate published scientific data to permit conclusions regarding the use of EmbryoGlue.

Although preliminary results with IVM are promising, studies to date show that implantation and pregnancy rates are significantly lower than those achieved with standard IVF. Further evidence from well-designed trials is needed to determine the long-term safety and efficacy of the procedure. Cryopreservation

Cryopreservation of sperm, semen or embryos is proven and medically necessary for individuals who are undergoing treatment with assisted reproductive technologies or are planning to undergo therapies that threaten their reproductive health, such as cancer chemotherapy.

Cryopreservation of mature oocytes (eggs) is proven and medically necessary for women, under the age of 42, who are undergoing treatment with assisted reproductive technologies or are planning to undergo therapies that threaten their reproductive health, such as cancer chemotherapy.

Cryopreservation of immature oocytes (eggs) is unproven and not medically necessary. Further evidence from well-designed trials is needed to determine the long-term safety and efficacy of cryopreserving immature oocytes for future in vitro maturation. Cryopreservation of ovarian or testicular tissue is unproven and not

medically necessary.



REVISED



Mar. 1, 2016

Ovarian tissue banking remains a promising clinical technique because it avoids ovarian stimulation and provides the opportunity for preserving gonadal function in prepubertal, as well as adult patients. However, this procedure has produced very few live births.

Testicular tissue or testis xenografting are in the early phases of

experimentation and have not yet been successfully tested in humans.

Mechanical Stretching and Continuous Passive Motion Devices

Mar. 1, 2016

Revised coverage rationale: o Clarified language to indicate

the use of specific devices is proven/medically necessary or unproven/not medically

necessary o Added language to indicate

the use of low-load prolonged-duration stretch devices are proven and medically

necessary for the treatment of existing joint contractures of

the upper and lower extremities as an adjunct to therapy in patients with symptoms of significant joint motion stiffness unresponsive to other therapies in the immediate post-operative

period Updated supporting information

to reflect the most current

description of services, clinical evidence, FDA information and references

The use of continuous passive motion (CPM) devices is proven and medically necessary for the prevention of joint contractures of the upper and lower extremities. The use of continuous passive motion devices are medically

necessary for patients in the immediate post-operative phase of joint surgery as an adjunct to (and not replacement of) physical therapy to prevent contractures of the joints of the upper and/or lower extremities.

The use of lumbar continuous passive motion device is unproven and not medically necessary. Clinical evidence is limited to manufacturer data.

There is no scientific evidence in the published peer-reviewed medical literature that these devices for patient controlled therapy are safe or effective. The use of low-load prolonged-duration stretch devices is proven and medically necessary for the treatment of existing joint contractures of the upper and lower extremities as an adjunct to therapy in

patients with symptoms of significant joint motion stiffness unresponsive to other therapies in the immediate post-operative period.

The use of static progressive (SP) stretch splint devices and patient actuated serial stretch (PASS) devices for the treatment of joint

contractures of the extremities alone or combined with standard physical therapy are unproven and not medically necessary. Clinical evidence is not sufficient to demonstrate that the use of static progressive or patient actuated devices is a safe or effective treatment option. Studies are limited to small sample sizes.



REVISED


Platelet Derived Growth Factors for Treatment of Wounds

Mar. 1, 2016

Removed reference link to policy titled Becaplermin Gel (Regranex)

Added conditions of coverage to indicate: o Precertification is required for

services covered under the

Member's General Benefits package when performed in the office of a participating provider

o Precertification is not required, but is encouraged, for out-of-

network services performed in the office that are covered under the member's general benefits package

o If precertification is not obtained, Oxford may review

for medical necessity after the

service is rendered Revised coverage rationale;

added language pertaining to recombinant-human platelet derived growth factors to indicate:

o When used according to U.S. Food and Drug Administration

(FDA) approved indications, becaplermin (Regranex® Gel)

is proven and medically necessary for the treatment of lower extremity diabetic neuropathic ulcers

o In June 2008, the U.S. Food

and Drug Administration (FDA) announced the addition of a boxed warning to the labeling of becaplermin

Recombinant-Human Platelet Derived Growth Factors

When used according to U.S. Food and Drug Administration (FDA) approved indications, becaplermin (Regranex® Gel) is proven and

medically necessary for the treatment of lower extremity diabetic neuropathic ulcers.

In June 2008, the U.S. Food and Drug Administration (FDA) announced the addition of a boxed warning to the labeling of becaplermin (Regranex Gel). Please see the U.S. Food and Drug Administration section for more information.

Platelet Rich Plasma

Autologous platelet rich plasma (e.g., Procuren®, AutoloGel®, or SafeBlood®) is unproven and not medically necessary for the treatment of wounds. The better designed studies do not demonstrate that autologous platelet rich

plasma such as Procuren, AutoloGel or SafeBlood improves health outcomes in patients with wounds. The remaining studies have design flaws that do not

allow confidence in analyzing final study results. The clinical utility of autologous platelet rich plasma remains to be determined in larger well-designed controlled clinical trials comparing their use with standard wound care.



REVISED


Platelet Derived Growth Factors for Treatment of Wounds (continued)

Mar. 1, 2016

(Regranex Gel)

Surgical Treatment

for Spine Pain

Mar. 1, 2016

Reorganized policy content

Added benefit considerations language for Essential Health Benefits for Individual and Small Group plans to indicate: o For plan years beginning on or

after January 1, 2014, the

Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to

provide coverage for ten categories of Essential Health

Benefits (“EHBs”) o Large group plans (both self-

funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs; however, if such plans choose

to provide coverage for benefits which are deemed EHBs (such as maternity

benefits), the ACA requires all dollar limits on those benefits to be removed on all

Grandfathered and Non-Grandfathered plans

o The determination of which benefits constitute EHBs is made on a state by state basis; as such, when using

Spinal fusion using extreme lateral interbody fusion (XLIF) or direct

lateral interbody fusion (DLIF) is proven and medically necessary. Coding Clarification The North American Spine Society (NASS) recommends that anterior or

anterolateral approach techniques performed via an open approach should be billed with CPT codes 22554 – 22585. These codes should be

used to report the use of extreme lateral interbody fusion (XLIF) and direct lateral interbody fusion (DLIF) procedures (NASS, 2010).

Laparoscopic approaches should be billed with an unlisted procedure code.

For information regarding medical necessity review, see the following MCG™ Care Guidelines, 19th edition, 2015:

Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy, S-310 (ISC)

Lumbar Diskectomy, Foraminotomy, or Laminotomy S-810 (ISC) Cervical Laminectomy S-340 (ISC) Lumbar Laminectomy S-830 (ISC) Cervical Fusion, Anterior S-320 (ISC) Cervical Fusion, Posterior S-330 (ISC)

Lumbar Fusion S-820 (ISC) The following spinal procedures are unproven and not medically

necessary: A. Spinal fusion when performed via the following methods:

1. Laparoscopic anterior lumbar interbody fusion (LALIF)

2. Transforaminal lumbar interbody fusion (TLIF) which utilizes only endoscopy visualization (such as a percutaneous incision with video visualization)

3. Axial lumbar interbody fusion (AxiaLIF) 4. Interlaminar lumbar instrumented fusion ( ILIF)



REVISED


Surgical Treatment for Spine Pain (continued)

Mar. 1, 2016

this guideline, it is important to refer to the member specific benefit document to determine benefit coverage

Revised coverage rationale:

o Added language to indicate if

service is “proven” or “unproven” to applicable medically necessary/not medically necessary statement

o Updated content/language pertaining to unproven

indications: Spinal Fusion Added “pedicle screw

fixation” to list of unproven procedures/devices

Removed reference to

specific interbody cage

device/product name (“PEEK”)

Spinal Decompression Removed reference to

specific interspinous process decompression

(IPD) system device/product name (“X-STOP”)

Updated clinical evidence

for minimally invasive lumbar decompression (MILD®) to indicate:

- Clinical evidence is

limited to small, uncontrolled studies; additional randomized, controlled trials comparing these procedures to standard

This includes interbody cages, screws and pedicle screw fixation devices with any of the above procedures. Clinical evidence is limited primarily to retrospective studies and case series. Randomized, controlled trials comparing these procedures to

standard procedures are needed to determine impact on health outcomes

and long-term efficacy. B. Spinal Decompression and Interspinous Process Decompression

Systems 1. Interspinous process decompression (IPD) systems for the

treatment of spinal stenosis

2. Minimally invasive lumbar decompression (MILD®)

Current clinical evidence is insufficient to permit conclusions about whether any beneficial effect from minimally invasive lumbar decompression provides a significant advantage over surgical decompression. In addition, the complication rates and reoperation rates

for this procedure compared with those of decompression surgery is

unknown. C. Spinal Stabilization

1. Stabilization systems for the treatment of degenerative spondylolisthesis.

2. Total facet joint arthroplasty, including facetectomy, laminectomy, foraminotomy, vertebral column fixation

The current published evidence is insufficient to determine whether facet arthroplasty is as effective or as safe as spinal fusion, the current

standard for surgical treatment of degenerative disc disease. In addition, no devices have received approval from the U.S. Food and Drug Administration for use outside the clinical trial setting.

3. Percutaneous sacral augmentation (sacroplasty) with or without

a balloon or bone cement for the treatment of back pain. The available clinical evidence shows that percutaneous sacroplasty,

may alleviate the pain and functional impairment of sacral insufficiency fractures (SIF) in most patients with few and predominantly minor adverse effects, suggesting that this procedure may be relatively safe



REVISED



Mar. 1, 2016

procedures are needed to determine impact on health outcomes and long-term efficacy

Spinal Stabilization

Removed reference to

specific stabilization system device/product names (“Dynesys®”, “Dynamic Stabilization System” and “DSS Stabilization System”)

Added clinical evidence for total facet joint arthroplasty, including facetectomy, laminectomy, foraminotomy, vertebral column fixation to indicate:

- The current published

evidence is insufficient

to determine whether facet arthroplasty is as effective or as safe as spinal fusion, the current standard for surgical treatment of degenerative disc

disease

- In addition, no devices

have received approval from the U.S. Food and Drug Administration for use outside the clinical trial setting

Updated clinical evidence

for percutaneous sacral augmentation (sacroplasty) to indicate:

- The available clinical

and efficacious for treatment of SIF. Despite these promising findings, the overall quality of the body of evidence is low given that the available studies were limited by methodological flaws (e.g., retrospective design, small sample size, subjective outcome measures, lack of a control group, and inadequate follow-up). Before reliable

recommendations may be made, higher-quality studies are required

that entail large populations with sufficient statistical power.

D. Stand-alone facet fusion without an accompanying decompressive procedure. This includes procedures performed with or without bone grafting and/or the use of posterior intrafacet implants such as fixation systems, facet screw systems or anti-migration dowels. Clinical evidence is limited primarily to case series and nonrandomized studies.

Randomized, controlled trials comparing facet fusion to standard procedures are needed to determine impact on health outcomes and long-term efficacy.



REVISED



Mar. 1, 2016

evidence shows that percutaneous sacroplasty, may alleviate the pain and functional impairment of

sacral insufficiency

fractures (SIF) in most patients with few and predominantly minor adverse effects, suggesting that this procedure may be

relatively safe and efficacious for treatment of SIF

- Despite these promising

findings, the overall

quality of the body of evidence is low given that the available

studies were limited by methodological flaws (e.g., retrospective design, small sample size, subjective outcome measures, lack of a control group, and

inadequate follow-up)

- Before reliable

recommendations may be made, higher-quality studies are required that entail large populations with sufficient statistical power

Reformatted lists of applicable CPT codes; updated table headers to clarify if listed codes are “proven” or “unproven”



REVISED



Mar. 1, 2016

Updated supporting information to reflect the most current description of services, clinical evidence, FDA information and references



REVISED

Policy Title Effective Date Summary of Changes Administrative Guidelines

Par Gastroenterologists Using Non-Par Anesthesiologists:

In-Office & Ambulatory

Surgery Centers

Mar. 1, 2016

Changed policy title; previously titled Par Gastroenterologists Using Non-Par Anesthesiologists: In-Office Services

Updated definitions: o Added definition of

“ambulatory surgery center (ASC)”

o Updated definition of “non-participating provider consent form” and “In-Office (IO)”

Revised language pertaining to applicable service settings; replaced references to “services performed in an office setting” with “services performed in office (IO) or an Ambulatory Surgery

Center (ASC)”

Participating gastroenterologists located in New York performing non-emergent procedures with anesthesia in office (IO) or in an Ambulatory Surgery Centers (ASC), must use an Oxford participating anesthesiologist unless:

1. The member explicitly agrees pre-service (no more than 90 days before

the scheduled date of the procedure) to receive services from a non-participating anesthesiologist by signing the Non-Participating Provider

Consent Form and understands that the use of this provider will be:

Out of Network: For members with out-of-network benefits, non-participating anesthesiologist claims will be paid at the Out of Network benefit level. Out of Network cost shares and deductibles will apply.

Denied: For Members without out-of-network benefits, non-

participating anesthesiologist claims will be denied as not covered because the member has no coverage for services provided by non-participating providers. Members will therefore be responsible for the entire cost of the service;

or

2. An In-network exception has been approved. Procedures and Responsibilities

The following procedures and responsibilities apply in non-emergent situations when the services are provided by a participating

gastroenterologist in New York:

1. Services performed IO or in an ASC by a participating gastroenterologist with anesthesia, must be performed in conjunction with an anesthesiologist who is participating with the Oxford network; or

2. If the participating gastroenterologists intends to utilize an

anesthesiologist that does not participate in the Oxford network, the provider must discuss referral options with the member prior (no more than 90 days before the scheduled date of the procedure) to making referrals to, or scheduling services on their behalf with, a non-participating anesthesiologist. Following the discussion, the member must indicate their choice to use a participating or non-participating

anesthesiologist by marking the appropriate box on the Non-Participating Provider Consent Form. The member must then sign and date the form.

3. Non-Participating Provider Consent Forms must be kept on file by a



REVISED


Par Gastroenterologists Using Non-Par Anesthesiologists: In-Office &

Ambulatory

Surgery Centers (continued)

Mar. 1, 2016

participating gastroenterologist. A separate Non-Participating Provider Consent Form is required for every service when the participating gastroenterologist wants to refer to or involve a non-participating anesthesiologist in a member’s care. The Non-Participating Provider Consent Form will only be valid for 90 days from the date of member

signature.

Oxford may request a copy of the completed Non-Participating Provider Consent Form from the participating gastroenterologist (who is required to keep the form on file) in order to conduct standard business. When requested, the participating gastroenterologist must provide a copy of the Non-Participating Provider Consent Form within 15 days of the

request. If a copy of the completed Non-Participating Provider Consent Form is not received within 15 days of the request, the participating gastroenterologist’s claim will be denied administratively for failure to comply with the protocol. In these instances, the participating provider is prohibited from balance billing the member.

4. Participating gastroenterologists must coordinate the procedure on behalf

of the member according to the arrangements agreed upon between the

participating gastroenterologist and the member within the Non-Participating Provider Consent Form including but not limited to supplying a participating anesthesiologist, In-Network Exceptions and/or claims appeals.

5. If requesting an In-Network Exception to have a non-participating anesthesiologist covered as if they were participating with the Oxford

network, the participating gastroenterologist must make the exception request. The exception request will not be accepted from the non-participating anesthesiologist. o The participating gastroenterologist must make the In-Network

Exception request no less than 14 days in advance of the scheduled procedure in order to avoid delays in care and alleviate potential complications with the patient’s required preparations for the

procedure. o If the participating gastroenterologist requests an In-Network

Exception less than 14 days in advance of the scheduled procedure, the In-Network Exception request will be processed per Oxford’s standard guidelines, however the participating gastroenterologist will receive an administrative denial for their claim for failure to follow protocol.



REVISED


Par Gastroenterologists Using Non-Par Anesthesiologists: In-Office &

Ambulatory

Surgery Centers (continued)

Mar. 1, 2016

o The participating gastroenterologist may be asked to provide information regarding their New York State Office Based Surgery Accreditation status, which they should have available when making the In-Network Exception request.

6. When a participating gastroenterologist performs non-emergent services

IO or in an ASC using a participating anesthesiologist, there will be no

additional requirements to fulfill. A Non-Participating Provider Consent Form is not required.

Non-compliance with this policy:

Providers are required to keep a signed copy of the Non-Participating Provider Consent Form on file. Oxford may request a copy of the signed Non-

Participating Provider Consent Form at any time, including when responding to a member appeal. Providers are not required to submit this form with their initial claim. If the participating gastroenterologist cannot provide the signed Non-Participating Provider Consent Form, within 15 days of the request, as proof

that they discussed the member’s options for selecting a participating or

non-participating anesthesiologist in advance of the service, Oxford will administratively deny the participating gastroenterologist claim. Any payment previously made for the gastroenterology service will be subject to recovery. The participating gastroenterologist cannot balance bill the member for claims denied for administrative reasons.



NEW

Policy Title Effective Date Reimbursement Guidelines

Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction Policy

Apr. 1, 2016*

*Notice of Implementation Delay: The following reimbursement guidelines will not be effective on Mar. 1, 2016

as previously announced; implementation of the new policy has been postponed until Apr. 1, 2016. Reimbursement

Consistent with CMS, Oxford ranks all reimbursable procedures from the Multiple Therapy Reducible Codes list

(procedures with indicator 5 in the Multiple Procedure Payment Reduction [MPPR] field on the CMS National Physician Fee Schedule) that are provided on a single date of service. The primary procedure is reimbursed without reduction and the PE portions of all secondary and subsequent procedures from this list performed by the Same Group Physician and/or Other Health Care Professional on the same date are reduced by 50%.

The multiple therapy procedure reduction applies when more than one procedure, or more than one unit of the same procedure, from the Multiple Therapy Reducible Codes list is provided to the same patient on the same day, i.e., the

reduction applies to multiple units as well as to multiple procedures.

These reductions apply to the Same Group Physician and/or Other Health Care Professional, regardless of specialty. These reductions do not apply to flat rate per diem contract providers.

Procedure Ranking

The CMS Non-Facility PE RVU assigned to each code on the Multiple Therapy Reducible Codes list is used to

determine the primary procedure. The primary procedure is identified as the procedure having the highest PE RVU on a given date of service. The PE portion of the charge for the primary procedure will not be reduced.

For the remaining Multiple Therapy Reducible Codes reported on the same date of service by the Same Group Physician and/or Other Health Care Professional, an amount representing the PE for each code will be reduced by 50%. The PE amount is determined by calculating the ratio of CMS PE RVU to Total RVU assigned to each secondary and subsequent procedure on the same date of service. When procedures share the same PE RVU, the Total RVU is used to further rank those codes.

Example

The following table shows an example of how reimbursement is determined for services subject to this policy when

services are furnished to a patient on a single date of service by the Same Group Physicians and/or Other Health Care Professionals.

Code

Allowable

Amount

Prior to

Reduction

PE

RVU

Total

RVU

Portion of charge

attributable to

Practice Expense (PE RVU/

Total RVU)

Ranking Comments Final Allowable Amount

Multiple Therapy

Reducible Code A

$31.60 .45 .79 56% 3 PE value = 56% of $31.60 or $17.70. $17.70 is reduced by 50% or $8.85.



NEW

Policy Title Effective Date Reimbursement Guidelines

Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction Policy

(continued)

Apr. 1, 2016 Allowable Amount = $31.60 - $8.85 or $22.75.

Multiple Therapy

Reducible Code B

$40.40 .36 1.01 35% 4 PE value = 35% of $40.40 or $14.14. $14.14 is reduced by 50% or $7.07. Allowable Amount = $40.40 - $7.07 or $33.33.

Multiple Therapy

Reducible Code C

$36.40 .45 .91 49% 2 Because Codes A and C have the same PE

RVUs, the Total RVUs are used to further rank

these two procedures.

PE value = 49% of $36.40 or $17.84. $17.84 is reduced by 50% or $8.92. Allowable Amount = $36.40 - $8.92 or $27.48.

Multiple Therapy

Reducible Code D

$96.80 1.05 2.42 43% 1 Primary procedure (highest PE value) is not subject to reduction

$96.80

For a list of codes that are subject to the Multiple Therapy Reduction policy (including the assigned Practice Expense RVU, Total RVU and ratio of Practice Expense to Total RVU for each code) refer to the Multiple Therapy Reducible Codes list.

\

UPDATED

Policy Title Effective Date Summary of Changes Reimbursement Guidelines

Microsurgery

Feb. 1, 2016

Revised list of Services Allowed with CPT 69990 (attachment file listing CPT codes for services that are reimbursed when submitted with CPT code 69990); added 61645, 61650 and 61651

CPT Code 64727

Consistent with the CPT book coding guidelines for CPT code 64727, Oxford

will only reimburse CPT code 64727 when submitted with internal neurolysis codes on the list of Services Allowed with CPT 64627. The Centers for Medicare and Medicaid Services (CMS) Medicare Claims Processing Manual and the Correct Coding Initiative (CCI) state that CPT code 69990 is not to be reported in addition to CPT code 64727.



UPDATED


Microsurgery (continued)

Feb. 1, 2016 CPT Code 69990

CMS reimbursement guidelines differ from the CPT book coding guidelines.

Oxford follows CMS reimbursement guidelines for reimbursement of 69990 with certain nervous system surgeries.

Oxford will reimburse CPT code 69990 when billed in conjunction with services described in the List of Services Allowed with CPT 69990.

The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the Member’s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive.

Applicable CPT Codes

CPT® Code Description

64727 Internal neurolysis, requiring use of operating microscope (List separately in addition to code for

neuroplasty) (Neuroplasty includes external neurolysis)

69990 Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)

CPT® is a registered trademark of the American Medical Association.

Multiple Imaging Rules

Feb. 1, 2016 Reformatted and rebranded Multiple Imaging Rules (attachment file detailing bundling rules); replaced

references to “CareCore National” with “eviCore Healthcare”

When two or more procedures within a similar body part (refer to Multiple Imaging Rules) are performed on the same patient by the same provider at the same session, Oxford will reduce the Global or Technical Component (TC) of the second and subsequent procedure.

The Professional Component (PC) will not be reduced.

Wrong Surgical or Other Invasive Procedures

Feb. 1, 2016

Updated lists of applicable codes: o Added list of applicable ICD-

10 diagnosis codes (effective for dates of service on or after 10/01/2015): Y65.51, Y65.52 and Y65.53

o Added language to indicate

Similar to any other patient population, Oxford members experience serious injury and/or death if wrong surgeries are performed and may require additional healthcare in order to correct adverse outcomes resulting from such errors. This Oxford reimbursement policy is based on information stated by CMS in

its National Coverage Decision (NCD) 140.6 for Wrong Surgical or Other



UPDATED


Wrong Surgical or Other Invasive Procedures (continued)

Feb. 1, 2016

ICD-9 codes should be used to report services provided prior to 10/01/2015

Invasive Procedure Performed on a Patient and is in alignment with the Leapfrog Group and the National Quality Forum (NQF) position on Serious Reportable Events in Healthcare. For more information see the NQF and Leapfrog Group websites in the References section of the policy.

Oxford will not reimburse for a Wrong Surgical l or Other Invasive Procedure

Performed on a Patient when the physician or other healthcare professional erroneously performs: 1) a different procedure altogether; 2) the correct procedure but on the wrong body part; or 3) the correct procedure but on the wrong patient. Oxford will not reimburse for related services associated with these Wrong Surgical or Other Invasive Procedures Performed on a Patient.

Related services which will not be reimbursed include: All services provided in the operating room related to the error. All providers in the operating room when the error occurs, who could bill

individually for their services. All related services provided during the same hospitalization in which the

error occurred.

The rendering physician and all other providers performing services related to the erroneously performed procedure are expected to waive all costs associated with the Wrong Surgical or Other Invasive procedure. Participating providers may not bill or collect payment from Oxford members for any amounts not paid due to the application of this reimbursement policy.

Related services do not include: Services provided following hospital discharge, regardless of whether they

are related to the surgical error.

Performance of the correct procedure. Submission of Claims

Consistent with CMS billing requirements, Oxford requires the reporting of these Wrong Surgery or Other Invasive Procedures Performed on a Patient in

the manner described below. Hospital Inpatient Claims

Hospitals are required to submit a no-pay claim (Type of Bill 110) to report all charges associated with the erroneous surgery. However, if



UPDATED


Wrong Surgical or Other Invasive Procedures (continued)

Feb. 1, 2016 there are also non-related services/procedures provided during the same stay as the erroneous surgery, hospitals are then required to submit two claims, one claim with services or procedures unrelated to the erroneous surgery and the other claim with the erroneous services/procedures as a no-pay claim.

The non-covered Type of Bill 110 must have one of the following ICD-9-CM or ICD-10-CM diagnosis codes reported in diagnosis position 2-9 on the hospital claim to identify the type of erroneous surgery performed. These codes shall not be reported in the External Cause of Injury (E-code) field.

ICD-9-CM codes for a date of service prior to 10/01/2015: o E876.5 - Performance of wrong operation (procedure) on correct

patient (existing code) o E876.6 - Performance of operation (procedure) on patient not

scheduled for surgery o E876.7- Performance of correct operation (procedure) on wrong

side/body part

ICD-10-CM codes for a date of service 10/01/2015 and after: o Y65.51 - Performance of wrong procedure (operation) on correct

patient o Y65.52 - Performance of procedure (operation) on patient not

scheduled for surgery

o Y65.53 - Performance of correct procedure (operation) on wrong side of body parts

Hospital Outpatient, Ambulatory Surgery Center (ASC), and

Professional/1500 Claims Outpatient, ASCs and physicians or other health care professionals must report the applicable HCPCS modifier(s) with the associated charges on

all lines related to the surgical error: o PA - Surgery Wrong Body Part o PB - Surgery Wrong Patient o PC - Wrong Surgery on Patient



REVISED


Injection and Infusion Services

Feb. 1, 2016

Revised list of E&M Codes for Injection Codes 96372-96379 (attachment file listing evaluation and management codes that apply when reported with injection

codes 96372-96379):

o Added 99415 and 99416 o Removed M0064

Injections (96372-96379) and Evaluation and Management Services by Place of Service

Facility, Emergency Room, and Ambulatory Surgical Center Services

Per CPT and the CMS National Correct Coding Initiative (NCCI) Policy Manual, CPT codes 96372-96379 are not intended to be reported by the physician in

the facility setting. Thus, when an E/M service and a therapeutic and diagnostic injection service are submitted with CMS Place of Service (POS) codes 21, 22, 23, 24, 26, 51, 52, and 61 for the same patient by the Same Individual Physician or Other Health Care Professional on the same date of service, only the E/M service will be reimbursed and the therapeutic and

diagnostic Injection(s) are not separately reimbursed, regardless of whether a modifier is reported with the injection(s). Non-Facility Injection Services E/M services provided in a non-facility setting are considered an inherent component for providing an injection service. CPT indicates these services typically require direct supervision for any or all purposes of patient

assessment, provision of consent, safety oversight, and intra-service supervision of staff. When a diagnostic and therapeutic Injection procedure is performed in a POS other than 21, 22, 23, 24, 26, 51, 52, and 61 and an E/M service is provided on the same date of service, by the Same Individual Physician or Other Health Care Professional only the appropriate therapeutic and diagnostic injection(s) will be reimbursed and the EM service is not

separately reimbursed. If a significant, separately identifiable EM service is performed unrelated to the physician work (injection preparation and disposal, patient assessment, provision of consent, safety oversight, supervision of staff, etc.) required for the injection service, modifier 25 may be reported for the E/M service in

addition to 96372-96379. If the E/M service does not meet the requirement

for a significant separately identifiable service, then modifier 25 would not be reported and a separate E/M service would not be reimbursed. Exceptions

CPT 99211: E/M service code 99211 will not be reimbursed when submitted

with a diagnostic or therapeutic Injection code, with or without modifier 25. This very low service level code does not meet the requirement for "significant" as defined by CPT, and therefore should not be submitted in



REVISED


Injection and Infusion Services (continued)

Feb. 1, 2016

addition to the procedure code for the injection. CPT 99381-99429: The Preventive Medicine codes (99381-99429) do not need modifier 25 to indicate a significant, separately identifiable service when reported in addition to the diagnostic and therapeutic injection service.

The Preventive Medicine codes include routine services such as the ordering

of immunizations or diagnostic procedures. The performance of these services is to be reported in addition to the Preventive Medicine E/M code. Therefore, diagnostic and therapeutic Injections can be reported at the same time as a Preventive Medicine code without appending modifier 25. CMS POS Database

E&M Codes for Injection Codes 96372-96379 Injection and Infusion Services (96360-96549) and HCPCS Supplies Consistent with CPT guidelines, HCPCS codes identified by code description as standard tubing, syringes, and supplies are considered included when

reported with Injection and Infusion services, CPT codes 96360-96549, and

will not be separately reimbursed. Injection and Infusion Inclusive Supplies Note: Additional editing may be applicable to CPT codes 96360-96549 under the T Status Codes Policy.

Drug Codes Oxford reimbursement policy is aligned with CMS and will separately reimburse for the HCPCS drug code when submitted with Injection or

Infusion codes (CPT 96360-96549) by the Same Individual Physician or Other Health Care Professional on the same date of service under the guidelines of this policy.



REVISED


Time Span Codes

Mar. 1, 2016

Revised reimbursement guidelines: o Updated example/illustration

language (provided to help clarify how “time span” is

determined)

o Added language to indicate: In order to consider

reimbursement for services that may be repeated following a month with fewer than 31 days, Oxford

may allow reimbursement of monthly time span codes when reported with dates of service at least 28 days apart

Revised definitions; modified

definition of “calendar month” to

specify it is the time period that corresponds with an individually named month of the year (e.g., January, February, March)

Revised Questions and Answers (Q&A); added language to Q&A

#1 to clarify how the “time span” is determined for codes with a description of “calendar month” or “per month/monthly”

Revised Time Span Codes List (attachment file listing time span codes with corresponding

designations): updated time span designations for 0378T, 0379T, 0383T, 0384T, 90963, 90964, 90965, 90966, 93228, 93229, 93268, 93270, 93271, 93272, 93297, 93298, 93299, 94014, 94015, 94016, 94774, 94775,

Time Span Codes

Oxford will reimburse a CPT or HCPCS Level II code that specifies a time

period for which it should be reported (e.g., weekly, monthly), once during that time period. The time period is based on sourcing from the AMA or CMS including: the CPT or HCPCS code description, CPT book parentheticals and

other coding guidance in the CPT book, other AMA publications or CMS publications.

For example: Within the CPT book, the code description for CPT code 95250 states, “Ambulatory continuous glucose monitoring of interstitial tissue fluid via subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording”. In addition to that code description, there is also a parenthetical that provides further instructions with regard to the frequency

the code can be reported. The parenthetical states, “Do not report 95250 more than once per month”. Oxford will reimburse CPT Code 95250 only once per month for the same member, for services provided by the Same

Group Physician and/or Other Health Care Professional. In order to consider reimbursement for these services that may be repeated following a month with fewer than 31 days, Oxford may allow reimbursement of monthly time span codes when these codes are reported with dates of service at least 28

days apart. CPT coding guidelines specify for physicians or other qualified health care professionals to select the name of the procedure or service that accurately identifies the services performed.

External Electrocardiographic Recording Services - CPT codes 93224, 93225, 93226, and 93227 Reported with Modifier 52

CPT codes 93224 – 93227 are reported for external electrocardiographic

recording services up to 48 hours by continuous rhythm recording and storage. CPT coding guidelines for codes 93224 – 93227 specify that when there are less than 12 hours of continuous recording modifier 52 (Reduced Services) should be used. When modifier 52 is appended to CPT code 93224, 93225, 93226, or 93227,

Oxford does not apply the Time Span Codes Policy for reimbursement of these codes. Instead, Oxford applies the “Reduced Services Policy” which



REVISED


Time Span Codes (continued)

Mar. 1, 2016

94776, 94777, 95250, 95251, A4595, E0441, E0442, E0443, E0444, H0042, H0044, Q0513, S0197, S0320, S4040, S5141, S5146, S5161, S5185, S9110,

T2022, T2023, T2030, and T2032

addresses reimbursement for codes appended with modifier 52. End-Stage Renal Disease Services (ESRD) 90951-90962

CPT codes 90951-90962 are grouped by age of the patient and the number

of face-to-face physician or other qualified health care professional visits

provided per month (i.e., 1, 2-3, or 4 or more). Oxford will reimburse the single most comprehensive outpatient ESRD code submitted per age

category (i.e., under 2 years of age, 2-11 years of age, 11-19 years of age, and 20 years of age and older) once per month. This aligns with CPT coding guidance which states to report the age-specific ESRD codes should be reported once per month for all physician or other health care professional face-to-face outpatient services. Time Span Comprehensive and Component Codes

When related Time Span Codes which share a common portion of a code description are both reported during the same time span period by the Same

Group Physicians and/or Other Health Care Professional for the same patient,

the code with the most comprehensive description is the reimbursable service. The other code is considered inclusive and is not a separately reimbursable service. No modifiers will override this denial. The following example illustrates how the CPT book lists code 93268 first as it is the comprehensive code. CPT codes 93270, 93271, and 93272 are

indented and each share a common component of their code description with CPT code 93268.

CPT® Code Description

93268

External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with

symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; includes transmission, physician review and interpretation

93270 recording (includes connection, recording, and

disconnection)

93271 transmission and analysis

93272 review and interpretation by a physician or other qualified health care professional

CPT® is a registered trademark of the American Medical Association.



REVISED


Time Span Codes (continued)

Mar. 1, 2016 When CPT code 93270, 93271, or 93272 are reported with CPT 93268 during the same 30 day period by the Same Group Physician and/or Other Health Care Professional for the same patient, only CPT code 93268 is the reimbursable service.

The Time Span Comprehensive and Component Codes list includes applicable

comprehensive and related component Time Span Codes.

february 2016 update bulletin - oxhp · 2 oxford® policy update bulletin: february 2016 oxford...

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