In this issue
- Injectable medication updates
- Enhanced VBC reporting coming soon
- Medical necessity criteria updates
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Injectable medication updates
The following prior authorization updates have been made to the injectable medications currently in the Magellan Rx program. Magellan Rx will review all prior authorization requests for these specialty injectable medications, along with other specialty medications that are already part of the program when administered in:
- An outpatient facility
- A patient's home
- A physician's office
Policy Changes
Effective September 10, 2020
Keytruda (J9271):
- Cutaneous Melanoma: To adjuvant treatment, limited use to patients with stage 3 disease who have undergone complete resection.
- Gastric Cancer: Specified prior therapy must have included fluoropyrimidine- and platinum-containing chemotherapy, and patients with HER2-positive disease must have previously failed HER2- directed therapy.
- Esophageal Cancer: Specified prior therapy must have included fluoropyrimidine- and platinum-containing chemotherapy.
- Merkel Cell Carcinoma: Limited use to first-line therapy.
- SCCHN: In first-line therapy, specified use is for non-nasopharyngeal disease. To subsequent therapy, limited use as a single-agent to patients with PD-L1- expressing tumors and removed use in combination with fluorouracil and platinum chemotherapy.
- Classic Hodgkin Lymphoma: To relapsed or refractory disease, specified must be used after three or more prior lines of therapy and removed use in patients who are transplant ineligible or have failed second-line chemotherapy. Also removed use as palliative therapy in patients more than 60 years old and post-allogeneic transplant.
- PMBCL: Added patient must have progressed after autologous stem cell transplant or if ineligible for autologous stem cell transplant, after two or more prior lines of therapy.
- MSI-H Cancer: To CRC, limited use to unresectable advanced or metastatic disease that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and/or irinotecan, and primary treatment in patients with unresectable metastatic disease who have received previous adjuvant treatment with FOLFOX or CAPOX within the past 12 months, and removed all other NCCN-recommended indications (e.g., primary and adjuvant treatment). To Pancreatic Adenocarcinoma, removed use in recurrent disease after resection and first-line therapy. To Bone Cancer, removed use in Ewing Sarcoma. To Hepatobiliary Adenocarcinoma, removed Gallbladder Cancer, revised use to subsequent therapy, and removed use in resected Gross Residual Disease. Removed Penile Cancer, Testicular Cancer, Vulvar Squamous Cell Carcinoma, and Occult Primary Cancer of Unknown Primary.
- SCLC: Limited use to metastatic disease with progression on or after platinum-based treatment and at least one other line of therapy, and removed NCCN recommendation for relapsed or primary progressive disease.
- MF/SS: Removed use in primary therapy. RCC: Limited use to first-line therapy.
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EOP announcement
We are excited to announce that our redesigned EOPs are now available in Benefit Tracker. For any claims paid after June 17, the corresponding EOP can be viewed and downloaded in Benefit Tracker. EOPs will be available for a period of 24 months.
For claims paid prior to June 17, please contact Customer Service at 877-605-3229 for assistance. We hope that our redesigned EOPs will make obtaining and reading payment information easier. We welcome your feedback about this enhancement at
providerrelations@modahealth.com
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Enhanced VBC reporting coming soon!
Moda’s Value-Based Care programs were created to reward providers that meet cost and quality benchmarks, and our suite of reports is designed to help providers work toward earning as much incentive as possible.
Our Provider Reports portal was recently redesigned to improve the navigation experience for users. New reports, which will continue to be released throughout the summer, include:
- Total Cost of Care Incentive report
- Member roster, including all members enrolled in a Moda Value-Based Care program
- Member outreach priority summary
- Practitioner demographic report
- Value-Based Care quality metric performance report
- Pharmacy opportunity report
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Medical necessity criteria updates
Effective April 1, 2020
- New technologies
- Criteria changes: Genesight genetic test was requested to be covered by Myriad. This request has been discussed with our Healthcare Services and Pharmacy teams. Coverage will not be provided at this time as there is no evidence indicating clinical advantage to using this new technology.
Effective May 1, 2020
- Continuous glucose monitoring
- Criteria change: : To ensure clarity, member education requirement for coverage of long-term glucose monitoring was reviewed. Updated the information that’s submitted with the prior authorization request. Updated non-coverage guidelines.
- Electrical stimulation devices
- Criteria change:
- Removed indications for TENS (Transcutaneous Electrical Nerve Stimulation). This procedure is currently NOT being medically reviewed
- Added missing criteria indications that are considered experimental and investigational
- Grammar changes and formatting
- Electrical stimulation devices
- Criteria change: Guideline updated to indicate a total of four or more weeks of failed conservative therapy. Added CPT code 64451 as not covered. Removed trigger point injections guidelines, currently not being reviewed.
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Moda Medical Customer Service
For claims review, adjustment requests and/or billing policies, please call 888-217-2363 or email
medical@modahealth.com
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Moda Provider Relations
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Provider Updates
Credentialing Department
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