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Announcement: Pharmacy Benefit Coverage Update – Effective May 1, 2020 & July 1, 2020 – UnitedHealthcare Commercial Plans

Posted on by KR2Medical Billing

The original pharmacy formulary for UHC Commercial Pharmacy Benefits Plans was scheduled to take place on May 1,2020.

However, due to the current circumstances UHC revised their Pharmacy Benefits update and pushed it to become effective on July 1,2020.

According to UHC statement the change was done: “…to allow additional time for you and your patient to discuss alternative therapies when appropriate…”

This change applies to the following medications:

1. Diabetes-Insulin: Basaglar KwikPen, Levemir, Levemir FlexTouch and Tr

a. Lantus, Lantus SoloSTAR, Toujeo Max SoloSTAR and Toujeo SoloSTAR are currently excluded but will be added to the coverage on July 1,2020

2. Diabetes- Non-Insulin: Janumet, Janumet XR and Januvia

3. Neuromuscular Disorders: Firdapse

Step Therapy for Zomig will be required effective July 1,2020

Asthma- Arnuity Ellipta, Flovent Disus, Flovent HFA and Pulmicort Flexhaler will be covered at this time until further notice. However, these medications are still on tier 3 for UHC commercial Plans pharmacy benefit plans.

Since there are multiple prescription drug lists exist, please feel free to refer to patient-specific information received through e-prescribing or UHC PreCheck MyScript tool on Link.

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Empire Plan (NYSHIP) coverage of HPV vaccine (updated)

Posted on by KR2Medical Billing

 

Referring to the updated CDC ACIP reccomendations publication, the coverage for Empire Plan (NY State) memebers as follows:

-Only HPV (Gardasil 9) Human Papillomavirus 9-valent Vaccine, Recombiant) is covered for individuals through age 45 years

-There is no co-pay


Coverage for other HPV vaccines is still only limited to members under 26 years.

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1199SEIU- Avastin injection with age-related macular degenaration-updated for 2019

Posted on by KR2Medical Billing

As of 4/9/2019- 1199 has published the updated information, regarding the drug bevacizumab (Avastin)

The following is the new information:

If the patient is seen in the hospital or a facility setting then the proper code is C9257.

If the patient is receiving the injection in the private office, then the proper HCPCS code is J7999.

The HCPCS codes J3490 and J3590 will be denied as invalid codes.

1199SEIU also increased its reimbursement for the injection: “The standard dosage reimbursement is now 0.25mg (6)×5 units, equaling $30 per standard dosage”. However, manufacturer does not package or prepare it in that way. According to 1199, there are single-dose (1.25 mg/eye) compound syringes that can be made in the pharmacy, to minimize the conramination risk of the injection drug. Pharmacy needs to be a qualified 1199 pharmacy.