Bydureon BCISE is not a preferred product. The PDL is still applicable for patients on Bydureon Pen (which has been discontinued):
Victoza and SGLT2s are preferred without prior authorization
Ozempic is allowed after 90 day trials of Victoza and an SLGT2 inhibitor
Bydureon BCISE is allowed after Ozempic
Antipsychotics:
Implementation of antipsychotic coverage rules will continue to be implemented. The following will be implemented May 11th. Grandfathering overrides will be allowed as clinically appropriate. Additional clinical review will be given for antipsychotics prescribed to children 5 years and younger and for children 20 years and younger receiving multiple antipsychotics. This is a continuation of a series of antipsychotic coverage rules implemented following a series of federal laws, guidance releases, and OIG findings relating to and requiring states to implement antipsychotic monitoring programs.
Diagnosis will be required for olanzapine, aripiprazole, and risperidone: FDA and compendia diagnoses will be accepted
Long acting injectable antipsychotic therapeutic duplication with oral antipsychotics
Therapeutic duplication of multiple oral antipsychotics (olanzapine, risperidone, and aripiprazole)
Dose optimization (e.g. using a 10mg tablet instead of 2 x 5mg tablets)
Changing of dose after dispensing prescription: Things you can try to avoid a phone call for an override.
You can reverse and rebill the corrected day supply accounting for the dose change. Note the new directions and date of change on the prescription. If the claim denies for plan limitations, an override will be needed (you will have to call us).
DUR Reject codes er, m0, 1b can be used when prescriptions are more than 61% or more utilized. This does not work for controlled substances.
Legislative Update: The following bills were passed and coverage will begin for dates of service July 1 and after. Coverage details will be shared as they are available.
HB1288 – Continuous Glucose Monitoring devices
SB2224 – Metabolic Supplements
Diagnosis will no longer be required for skeletal muscle relaxants and opioids as of May 11th.
