Category: Pharmacy (Various Insurance Payers)

Find the latest Pharmacy/Formulary Updates (Various Insurance Payers)

Posted in MVP (NY/VT) Insurance Payer, Pharmacy (Various Insurance Payers), Prior Authorization Insurance Carrier Updates, Training, Updates

MVP NY Medicaid Patients: coverage for Farxiga tablets

Posted on by KR2Medical Billing

If you are a physician prescribing Farxiga for any of your patients that have NY MVP Medicaid Coverage, this blog post is for you!

Farxiga may be considered for coverage when used for one of the applicable FDA-approved indications including:

  1. For the reduction of heart failure hospitalizations in adults with Type 2 diabetes mellitus and
    established cardiovascular (CV) disease or multiple CV risk factors
  2. For the treatment of heart failure with reduced ejection fraction (NYHA classes II to IV) to
    reduce the risk of cardiovascular death and hospitalization for heart failure
  3. For the treatment of chronic kidney disease to reduce the risk of sustained eGFR decline, endstage kidney disease, cardiovascular death, and hospitalization for heart failure in those at-risk
    of disease progression

There are 2 other medications that are on the MVP Formulary that do not require prior authorization (such as Segluromet and Steglatro).

If the patient requires Farxiga then the physician needs to obtain a prior authorization.

Please follow the steps: (ALL requests have to have documentation submitted to support the use of Farxiga)

A. Visit mvphealthcare.com/Providers and Sign In to your Provider online account to use the new electronic prior authorization tool powered by Novologix®.
B. Complete the appropriate MVP prior authorization form, which can be accessed at
mvphealthcare.com/Providers, then select Forms, then under Prior Authorization, select the appropriate form in the Pharmacy section. Then, fax completed request form to MVP at 1-800-376-6373.
C. Submit a request through Surescripts.com or CoverMyMeds.com. ( covermymeds is also available on NAVINET)

Find this type of information useful? Follow my blog for more medical billing and coding guideline updates, medical policy/reimbursement changes and anything else related to healthcare!

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Posted in Pharmacy (Various Insurance Payers), Training, Updates

NY/CA UHC CommunityHealthPlan: updated info for Xolair and Synagis auth, 04/01/2021

Posted on by KR2Medical Billing

Starting 04/01/2021- the providers will need to request an authorization for Xolair and Synagris if they plan on billing through patient medical benefit. (Community Health Plan)

This change applies to providers in CA and NY (community health plans).

These requirements will apply whether members are new to therapy or have already been receiving these medications.

UHC will honor existing authorizations for Xolair until the end date on the authorization or the date the member’s eligibility changes.

Providers don’t need to submit a new prior authorization request for members who already have an authorization for Xolair on April 1, 2021.

You can submit prior authorization requests in the following ways:

  • Online: Use the Prior Authorization and Notification tool on Link. Go to UHCprovider.com/paan.
  • Call: Use the Provider Services phone number on the member’s health care identification card.
Posted in MVP (NY/VT) Insurance Payer, Pharmacy (Various Insurance Payers), Training, Updates

NY Managed Medicaid Plans Reimbursement Update: Pharmacies 05/01/2021

Posted on by KR2Medical Billing

Starting 05/01/2021– The prescriptions will no longer be covered and paid under the Managed Medicaid Plans (ei. MVP). Instead the prescriptions will be covered under NY Medicaid Fee for Service Fee Schedule.

Where can I find the list of covered medications?

  1. Medicaid Fee for Service has a list of covered medications. OTC (over the counter medications and most other medications are on that list. The list can be found on emdNY website.
  2. Medicaid Fee for Services also has a preferred medication list. This list can be found by clicking here.

Do I have to participate in NY Medicaid Fee for Service?

As a pharmacy (provider) you will need to participate in NY Medicaid Fee for Service, in order to fulfill the Managed Medicaid Patient RXs.

What else do I need, in order to process claims?

A Managed Medicaid Member has to show you their NY Medicaid Card or your Health Plan Card. As a Participating Pharmacy Provider you will need the CIN number in order to file your claims.

For General Information and Updates please click here.