Category: Prior Authorization Insurance Carrier Updates

Posted in #unitedhealthcare, Prior Authorization Insurance Carrier Updates, Training, Updates

UHC Exchange Plans: diabetes medications coverage.

Posted on by KR2Medical Billing

This change applies to members that have Individual and Family (Exchange Plans)1 and are on diabetes medication.

As of September 1,2022 and thereafter UHC will no longer cover diabetes medications: Invokana® and Invokamet® 

Current Medication Coverage:

UHC will cover these medications for patients that are currently have an authorization, until Dec 31,2022.

New covered medications
Effective for DOS 09/01/2022 and thereafter, we’re covering diabetes medications Farxiga® and Xigduo® XR for Individual Exchange plans.²

Members also have access to alternative diabetes medications:

  • Farxiga
  • Xigduo XR
  • Jardiance®
  • Synjardy®
¹For these plans in Louisiana and Texas, we’ll no longer cover Invokana and Invokamet as of Jan. 1, 2023.
²For these plans in Louisiana and Texas, we’ll cover Farxiga and Xigduo XR as of Jan. 1, 2023.

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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)

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Posted in #unitedhealthcare, Prior Authorization Insurance Carrier Updates, Training, Updates

UHC Commercial Plans: some radiotherapies do not require prior auth

Posted on by KR2Medical Billing

This policy change applies to UHC Commercial Plans:

  • UnitedHealthcare Plan of the River Valley, Inc.
  • UnitedHealthcare Insurance Company of the River Valley
  • UnitedHealthcare of the Mid-Atlantic, Inc.
  • MAHP Life and Health Insurance Company
  • Neighborhood Health Partners
  • UHOne
  • All Savers (fractionation prior authorization requirement for All Savers will be delayed)
  • Rhode Island and Oxford Health Plan members will be excluded

If you are a provider seeing any of the patients with the above mentioned plans and refer them for some outpatient radiotherapies, then this change applies to you.

There are 8 Radiotherapy codes, when performed in outpatient setting will no longer require a prior authorization.

These codes are:

  • 37243-Vascular embolization or occlusion, for tumors, organ ischemia, or infarction
  • 61796-Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion
  • 61797-Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion
  • 61798-Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 complex cranial lesion
  • 61799-Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional cranial lesion, complex
  • 61800-Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)
  • 63620-Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion
  • 63621-Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure)

If you would like to read the full coverage of determination, please click here.

If you are a provider that is ordering other types of outpatient radiotherapy, please ubmit an online prior authorization request, sign in to Link to access the Prior Authorization and Notification tool. Select the “Radiology, Cardiology, Oncology and Radiation Therapy” box. After selecting “commercial” as the product type, you’ll be directed to another website to process the authorization requests.

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