January 2025 Provider News
Date: 01/31/25
In this issue:
- General Updates - CP.MP.182 Short Inpatient Hospital Stay - National Marketplace, Child Blood Lead Screening Test, Eliminating Congenital Syphilis,
- Quality - January is Cervical Cancer Awareness Month - Cervical Cancer Screening (CCS), Asthma and 90 Day Medication Refills, (AIS-E) Adult Immunization Status, Oral Health Training For Healthcare Professionals, Well-Care Visits (WCV), Wellcare Quality
- Payment & Clinical Policy - Monthly Updates
- Pharmacy Updates - Additional January 1, 2025 Preferred Drug List Changes, January 1, 2025 Basaglar Formulary Removal, Wellcare Alternative Covered Drugs
- Apple Health Core Connections - Care Management
- Training/Education - Upcoming training/education opportunities
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General Updates
CP.MP.182 Short Inpatient Hospital Stay - National Marketplace
To bring ourselves into adherence with the CMS three-midnight rule we have changed the language of our Short Impatient Hospital Stay Clinical Policy (CP.MP.182). This changes language from “one to two days” to three midnights and allows inclusion of ED time in the timeframe.
Please reach out to your Provider Engagement Administrator with any questions or concerns.
Blood Lead Screening Test
Blood lead screening test results are a notifiable condition in Washington State. ALL blood lead screening test results (positive or negative) must be sent to the Department of Health (DOH) under chapter 246-01 WAC.
Blood lead screening tests must be done at ages 12 and 24 months. There are two methods for blood lead screen tests: venous and capillary (results must be confirmed by an additional test). Any child between 24 and 72 months with no record of a previous blood lead screening test must receive one. Perform a risk assessment at every visit as appropriate.
Note: Completion of a risk assessment questionnaire does not meet the Medicaid requirement for blood lead screening tests. The Medicaid requirement is met only when the blood lead screening tests (or a catch-up blood lead screening test) are conducted.
**Federal law mandates testing for all children covered by Medicaid.
Eliminating Congenital Syphilis
Congenital syphilis occurs when people pass syphilis to their babies during pregnancy. Congenital syphilis is preventable, yet the number of cases has more than tripled in recent years. Left untreated, congenital syphilis can result in infant death, developmental delays, skeletal abnormalities, deafness, meningitis, and ongoing adverse outcomes throughout the child’s life. Syphilis risks for the pregnant person include miscarriage, ongoing infection, and more.
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Quality
Medicaid Quality
January is Cervical Cancer Awareness Month - Cervical Cancer Screening (CCS)
The goal for CCS is to assess the following for your patients:
- Women 21 - 64 years of age who have had cervical cytology performed within last 3 yrs.
- Women 30 - 64 years of age who had cervical high risk human papillomavirus testing performed within the last 5 yrs.
- Women 30 - 64 years of age who had cervical/high risk human papillomavirus co-testing within the last 5 yrs.
For HEDIS measure information click here.
Asthma and 90 Day Medication Refills
Asthma is a treatable, manageable, condition that affects more than 25 million people in the United States. Managing this condition with appropriate medications could save the U.S. billions of dollars in medical costs.1 The prevalence and cost of asthma have increased over the past decade, demonstrating the need for better access to care and medication. Appropriate medication management for patients with asthma could reduce the need for rescue medication—as well as the costs associated with ER visits, inpatient admissions and missed days of work or school.
Moving members with asthma prescriptions to 90-day medication refills may increase their maintenance medication adherence.
(AIS-E) Adult Immunization Status
Measures percentage of members 19 years of age and older who are up to date on recommended routine vaccines for influenza, tetanus, and diphtheria (Td) or tetanus, diphtheria, and acellular pertussis (Tdap), zoster, and pneumococcal.
Tips:
- Schedule appointments within immunization timeframes.
- Discuss the importance of vaccinations during member appointments.
- Include immunization history from all sources in the member’s medical record.
- Use EMR (electronic medical record) system to set reminders flags.
| Description | Codes* |
|---|---|
| Adult Influenza Vaccine Procedure | CPT: 90630, 90653–90654, 90656, 90658, 90661–90662, 90673–90674, 90682, 90686, 90688–90689, 90694, 90756 |
| Adult Pneumoccocal Vaccine Procedure | CPT: 90670, HCPCS: G0009 |
| Td Vaccine Procedure | CPT: 90714 |
| Tdap Vaccine Procedure | CPT: 90715 |
| Herpes Zoster Vaccine Procedure | CPT: 90736, 90750 |
Oral Health Training For Healthcare Professionals
Smiles for Life is a comprehensive oral health curriculum for healthcare professionals and health educators. This American Dental Association endorsed curriculum is designed to enhance the role of primary care clinicians in the promotion of oral health for all age groups. This curriculum includes oral health training for all ages and offers free CME to healthcare providers.
Who can apply fluoride varnish?
Dental personnel working under the guidelines of WAC 246-814-020 and 246-815-260 may apply fluoride varnish in school settings.
Medical personnel working under the delegation of a licensed physician with documentation of completion of a training program on fluoride varnish are also qualified to apply fluoride varnish in health settings.
Well-Care Visits (WCV)
Child and Adolescent Well-Care Visits: Assesses children 3 - 21 years of age who received one or more well care visits from a primary care practitioner or OB/GYN practitioner during the measurement year.
Wellcare Quality
Healthy start in 2025 on managing Diabetes and associated conditions
Anyone with any kind of diabetes can get diabetic retinopathy — including DM type 1, type 2, and gestational diabetes.
Risk increases the longer a person has been diagnosed with diabetes. Over time, more than half of people with diabetes will develop diabetic retinopathy. Risk of developing diabetic retinopathy by controlling your diabetes.
- Cataracts - Having diabetes makes you 2 to 5 times more likely to develop cataracts. It also makes you more likely to get them at a younger age. Learn more about cataracts.
- Open-angle glaucoma - Having diabetes nearly doubles your risk of developing a type of glaucoma called open-angle glaucoma. Learn more about glaucoma.
The early stages of diabetic retinopathy usually don’t have any symptoms. Some people notice changes in their vision, like trouble reading or seeing faraway objects.
In later stages of the disease, blood vessels in the retina can start to bleed into the gel-like fluid that fills the eye. If this happens, a person may see dark, floating spots or streaks that look like cobwebs. It’s important to assess and implement treatment right away.
Diabetic retinopathy can lead to other serious eye conditions:
- Diabetic macular edema (DME) - Over time, about 1 in 15 people with diabetes will develop DME. DME happens when blood vessels in the retina leak fluid into the macula (a part of the retina needed for sharp, central vision). This causes blurry vision.
- Neovascular glaucoma - Diabetic retinopathy can cause abnormal blood vessels to grow out of the retina and block fluid from draining out of the eye. This causes a type of glaucoma (a group of eye diseases that can cause vision loss and blindness).
- Retinal detachment - Diabetic retinopathy can cause scars to form in the back of your eye. When the scars pull your retina away from the back of your eye, it’s called tractional retinal detachment.
Encourage your patients to attend their Annual Wellness Visit (AWV), get their A1C testing regularly, participate in a dilated Diabetic eye exam and have a healthy lifestyle that manages any associated condition with their diabetes.
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Clinical & Payment Policy Updates
Clinical Policy Updates
The below policies were updated as part of our regular monthly review in December. The policy changes are effective February 1, 2025. You will find the policies, including a description of the revisions, posted on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
| WA.CP.MP.525 | Catheter Ablation for SVTA | Apple Health |
| WA.CP.MP.46 | Ventricular Assist Devices | Apple Health |
| CP.MP.46 | Ventricular Assist Devices | Ambetter |
| WA.CP.MP.70 | Proton and Neutron Beam Therapies | Apple Health |
| CP.MP.70 | Proton and Neutron Beam Therapies | Ambetter |
| CP.MP.87 | Therapeutic Utilization of Inhaled Nitric Oxide | Apple Health & Ambetter |
| CP.MP.91 | Obstetrical Home Health Care Programs | Ambetter |
| WA.CP.MP.117 | Peripheral and Percutaneous Electrical Nerve Stimulation | Apple Health & Ambetter |
| CP.MP.142 | Urinary Incontinence Devices and Treatments | Apple Health & Ambetter |
| CP.MP.168 | Biofeedback | Ambetter |
| CP.MP.186 | Burn Surgery | Apple Health & Ambetter |
| CP.MP.190 | Outpatient Oxygen Use | Ambetter |
| CP.MP.243 | Implantable Loop Recorder (Implantable Cardiac Monitor) | Apple Health & Ambetter |
| CP.MP.173 | Implantable Intrathecal or Epidural Pain Pump | Ambetter |
The below policies were updated as part of our regular monthly review in December. The policy changes are effective May 1, 2025. You will find the policies, including a description of the revisions, posted on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
| CP.MP.62 | Hyperhidrosis treatments | Apple Health & Ambetter |
| CP.MP.107 | Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines | Apple Health & Ambetter |
| CP.MP.180 | Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea | Ambetter |
The below policies are new effective February 1, 2025. You will find the policies posted on the policy Web site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
| WA.HIM.CP.MP.92 | Acupuncture | Ambetter |
| WA.CP.MP.173 | Implantable Intrathecal or Epidural Pain Pump | Apple Health |
The below genetic testing policies were updated as part of our regular monthly review in December. The policy changes are effective May 1, 2025. You will find the policies, including a description of the revisions, posted on the policy site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
| V1.2025 | CG Cardiac Disorders | Apple Health & Ambetter |
| V1.2025 | CG Dermatologic Conditions | Apple Health & Ambetter |
| V1.2025 | CG Epilepsy Neurodegenerative and Neuromuscular Conditions | Apple Health & Ambetter |
| V1.2025 | CG Exome and Genome Sequencing for the Diagnosis of Genetic Disorders | Ambetter |
| V1.2025 | CG Eye Disorders | Apple Health & Ambetter |
| V1.2025 | CG Gastroenterologic Disorders Non-cancerous | Apple Health & Ambetter |
| V1.2025 | CG General Approach to Genetic Testing | Apple Health & Ambetter |
| V1.2025 | CG Hearing Loss | Apple Health & Ambetter |
| V1.2025 | CG Hematologic Conditions Non-cancerous | Apple Health & Ambetter |
| V1.2025 | CG Hereditary Cancer Susceptibility | Apple Health & Ambetter |
| V1.2025 | CG Immune Autoimmune and Rheumatoid Disorders | Apple Health & Ambetter |
| V1.2025 | CG Kidney Disorders | Apple Health & Ambetter |
| V1.2025 | CG Lung Disorders | Apple Health & Ambetter |
| V1.2025 | CG Metabolic Endocrine Mitochondrial Disorders | Apple Health & Ambetter |
| WA.CP.MP.230 | CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Apple Health |
| V1.2025 | CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Ambetter |
| WA.CP.MP.231 | CG Prenatal Cell-Free DNA Testing | Apple Health |
| V1.2025 | CG Prenatal Cell-Free DNA Testing | Ambetter |
| V1.2025 | CG Oncology Algorithmic Testing | Ambetter |
| V1.2025 | CG Oncology Cancer Screening | Apple Health & Ambetter |
| V1.2025 | CG Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy | Apple Health & Ambetter |
| V1.2025 | CG Oncology Cytogenetic Testing | Apple Health & Ambetter |
| V1.2025 | CG Oncology Molecular Analysis Solid Tumors & Hematolgic Malignancies | Apple Health & Ambetter |
| WA.CP.MP.232 | CG Pharmacogenetics | Apple Health |
| V1.2025 v.A | CG Pharmacogenetics (Version A) | Ambetter |
| V1.2025 | CG Preimplantation Genetic Testing | Apple Health & Ambetter |
| V1.2025 | CG Prenatal and Preconception Carrier Screening | Apple Health & Ambetter |
| V1.2025 | CG Prenatal Diagnosis Pregnancy Loss | Apple Health & Ambetter |
| V1.2025 | CG Skeletal Dysplasia Rare Bone Disorders | Apple Health & Ambetter |
The below genetic testing policies are new effective May 1, 2025. You will find the policies posted on the policy Web site.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
| WA.CP.MP.219 | CG Exome and Genome Sequencing for the Diagnosis of Genetic Disorders | Apple Health |
| WA.CP.MP.237 | CG Oncology Algorithmic Testing | Apple Health |
The below policies will be archived effective January 31, 2025, and replaced with new policies.
| Policy Number | Policy Title | Line of Business |
|---|---|---|
| CP.MP.173 | Implantable Intrathecal or Epidural Pain Pump | Apple Health |
| CP.MP.92 | Acupuncture | Ambetter |
The below policies were previously announced as revised effective on the date noted. You will find the policies posted on the policy site.
| Policy Number | Policy Title | Effective Date | Line of Business |
|---|---|---|---|
| WA.CP.MP.54 | Hospice Services | 2/1/25 | Apple Health |
| CP.MP.54 | Hospice Services | 2/1/25 | Ambetter |
| CP.MP.51 | Reduction Mammoplasty and Gynecomastia Surgery | 2/1/25 | Apple Health & Ambetter |
| CP.BH.200 | Transcranial Magnetic Stimulation for Treatment Resistant Depression | 3/1/25 | Ambetter |
| CP.MP.145 | Electric Tumor Treating Fields | 4/1/25 | Ambetter |
| CP.MP.248 | Facility Based Sleep Studies for Obstructive Sleep Apnea | 4/1/25 | Apple Health & Ambetter |
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Pharmacy
Additional January 1, 2025 Preferred Drug List Changes - Medicaid
As of January 1, 2025, the additional drugs below will be non-preferred or require prior authorization. Suggested preferred alternatives are listed. Please note impacted members have been given a 3-month authorization.
| Drug Class | Drug Name | Preferred Alternative(s) |
|---|---|---|
| ADHD / ANTI-NARCOLEPSY : STIMULANTS - LONG ACTING | VYVANSE CHEWABLE TABLETS | • GENERIC LISDEXAMFETAMINE CHEWABLE TABLETS
|
| ADHD / ANTI-NARCOLEPSY : STIMULANTS - SHORT ACTING | FOCALIN TABLETS | • GENERIC DEXMETHYLPHENIDATE TABLETS
|
| ADHD / ANTI-NARCOLEPSY : STIMULANTS - SHORT ACTING | METHYLIN HCL SOLN | • GENERIC METHYLPHENIDATE HCL SOLUTION
|
| ALLERGY : ANAPHYLAXIS - VASOPRESSOR SELF-ADMINISTERED | EPINEPHRINE AUTO-INJECTOR | • EPINEPHRINE AUTO-INJECTOR (NDCS 49502-0101-01 OR 49502-0101-02)
• EPIPEN JR 2-PAK |
| ALLERGY : ANTIHISTAMINE - DECONGESTANTS COMBINATIONS | FT ALL DAY ALLERGY-D | • ALLERGY RELIEF D • CETIRIZINE-PSEUDOEPHEDRINE ER • GNP ALL DAY ALLERGY-D • GOODSENSE ALL DAY ALLERGY-D |
| ALLERGY : ANTIHISTAMINE - DECONGESTANTS COMBINATIONS | FT ALLERGY D-12 HOUR | • ALLERGY RELIEF D-12 • ALLERGY/CONGESTION RELIEF • LORATADINE-D 12HR |
| ALLERGY : ANTIHISTAMINE - DECONGESTANTS COMBINATIONS | FT ALLERGY RELIEF-D | • ALLERGY RELIEF D-24 • ALLERGY RELIEF/NASAL DECONGEST • GNP ALLERGY & CONGESTION • GNP ALLERGY/CONGESTION RELIEF • HM ALLERGY RELIEF/NASAL DECONG • LORATADINE-D 24HR |
| ALLERGY : ANTIHISTAMINES | FT ALLERGY RELIEF CHLORPHENIRAMINE TABLET | • ALLER-CHLOR • ALLERGY • ALLERGY RELIEFGNP • GNP ALLERGY RELIEF • HM ALLERGY RELIEF |
| ALLERGY : ANTIHISTAMINES | FT ALLERGY RELIEF DIPHENHYDRAMINE CAPSULE | • ALLERGY • ALLERGY RELIEF • BANOPHEN • DIPHENHYDRAMINE HCL • GNP ALLERGY RELIEF • HM ALLERGY RELIEF |
| ALLERGY : ANTIHISTAMINES | FT ALLERGY RELIEF DIPHENHYDRAMINE TABLET | • ALLERGY RELIEF • BANOPHEN • DIPHENHYDRAMINE HCL • GNP ALLERGY • GNP ALLERGY RELIEF • HM ALLERGY RELIEF |
| ALLERGY : ANTIHISTAMINES | FT ALLERGY RELIEF CHILDRENS DIPHENHYDRAMINE LIQUID | • ALLERGY RELIEF CHILDRENS • DIPHENHYDRAMINE HCL • DIPHENHYDRAMINE HCL CHILDRENS • GNP ALLERGY CHILDRENS • GNP ALLERGY RELIEF MAX ST • GNP CHILDRENS ALLERGY • LIQUID ALLERGY • M-DRYL |
| ALLERGY : ANTIHISTAMINES | FT ALL DAY ALLERGY | • ALL DAY ALLERGY • ALLERGY RELIEF CETIRIZINE • ALLERGY RELIEF/INDOOR/OUTDOOR • CETIRIZINE HCL • GNP ALL DAY ALLERGY • GOODSENSE ALL DAY ALLERGY • HM ALLERGY RELIEF (CETIRIZINE) • HM CETIRIZINE HCL |
| ALLERGY : ANTIHISTAMINES | FT ALLERGY RELIEF CHILDRENS CETIRIZINE HCL SOLUTION | • ALL DAY ALLERGY CHILDRENS • ALLERGY RELIEF CHILDRENS • CETIRIZINE HCL • CETIRIZINE HCL ALLERGY CHILD • CETIRIZINE HCL CHILDRENS ALRGY • GNP ALL DAY ALLERGY CHILDRENS • GOODSENSE ALL DAY ALLERGY • HM ALL DAY ALLERGY CHILDRENS |
| ALLERGY : ANTIHISTAMINES | FT ALL DAY ALLERGY RELIEF | • ALLERGY RELIEF • ALLERGY RELIEF (LORATADINE) • GNP LORATADINE • GOODSENSE ALLERGY RELIEF • HM LORATADINE • LORATADINE |
| ALLERGY : ANTIHISTAMINES | FT ALLERGY CHILDRENS | • ALLERGY CHILDRENS • ALLERGY REL CHILD (LORATADINE) • CHILDRENS LORATADINE • GNP LORATADINE • GNP LORATADINE CHILDRENS • GOODSENSE ALLERGY RELIEF CHILD • LORATADINE • LORATADINE CHILDRENS • SM LORATADINE |
| ALLERGY : NASAL STEROIDS | FT ALLERGY RELIEF 24 HR | • ALLERGY RELIEF • FLUTICASONE PROPIONATE • GNP FLUTICASONE PROPIONATE • GOODSENSE 24-HR ALLERGY NASAL • HM ALLERGY RELIEF |
| ANALGESICS : MISC - TOPICAL | GLYDO LIDOCAINE HCL URETHRAL/MUCOSAL GEL PREFILLED SYRINGE | GENERIC LIDOCAINE HCL URETHRAL/MUCOSAL GEL PREFILLED SYRINGE |
| ANALGESICS : NON-NARCOTIC - ORAL | FEVERALL CHILDRENS SUPPOSITORY | ACETAMINOPHEN SUPPOSITORIES |
| ANALGESICS : NON-NARCOTIC - ORAL | FEVERALL INFANTS SUPPOSITORY | • INFANTS’ PAIN-FEVER • INFANTS’ ACETAMINOPHEN • INFANT’S FEVER-PAIN RELIEVER |
| ANALGESICS : NON-NARCOTIC - ORAL | FT 8 HOUR PAIN RELIEF | • ACETAMINOPHEN ER • ARTHRITIS PAIN RELIEF • GNP 8 HOUR ARTHRITIS RELIEF • GNP 8 HOUR PAIN RELIEF • GNP 8 HOUR PAIN RELIEVER • GOODSENSE ARTHRITIS PAIN |
| ANALGESICS : NON-NARCOTIC - ORAL | FT PAIN & FEVER CHILDRENS | • ACETAMINOPHEN • ACETAMINOPHEN CHILDRENS • ACETAMINOPHEN INFANTS • CHILDRENS ACETAMINOPHEN • GNP INFANTS PAIN/FEVER • GNP PAIN & FEVER CHILDRENS • GOODSENSE PAIN & FEVER CHILD • GOODSENSE PAIN & FEVER INFANTS • PAIN & FEVER CHILDRENS • PAIN & FEVER INFANTS |
| ANALGESICS : NON-NARCOTIC - ORAL | FT PAIN RELIEF ADULT EXTRA ST | • ACETAMINOPHEN • ACETAMINOPHEN EXTRA STRENGTH • GNP PAIN RELIEF EXTRA STRENGTH • GOODSENSE PAIN RELIEF EXTRA ST |
| ANALGESICS : NON-STEROIDAL ANTIINFLAMMATORY | FT ALL DAY PAIN RELIEF | • ALL DAY PAIN RELIEF • ALL DAY RELIEF • GNP NAPROXEN SODIUM • GOODSENSE NAPROXEN SODIUM • NAPROXEN SODIUM • SM NAPROXEN SODIUM |
| ANALGESICS : OPIOID AGONISTS - SHORT ACTING | ENDOCET TABLETS | • GENERIC OXYCODONE W/ ACETAMINOPHEN TABLETS |
| ANALGESICS : OPIOID AGONISTS - SHORT ACTING | ASCOMP-CODEINE CAPSULES | • GENERIC BUTALBITAL-ASPIRIN-CAFF W/ CODEINE CAPSULES |
| ANORECTAL AGENTS : RECTAL ANESTHETIC / STEROID COMBINATIONS | LIDOCAINE-HYDROCORT (PERIANAL) | • PROCTOFOAM-HC FOAM • HYDROCORTISONE-PRAMOXINE |
| ANORECTAL AGENTS : RECTAL STEROIDS | PROCTOSOL HC RECTAL CREAM | • GENERIC HYDROCORTISONE (PERIANAL) CREAM |
| ANTIANXIETY AGENTS : MISC | · HYDROXYZINE HCL VIAL | • PRODUCT REQUIRES AUTHORIZATION TO VERIFY IT IS BEING PROFESSIONALLY ADMINISTERED, OR OTHER JUSTIFICATION FOR USE OF A PRODUCT THAT WOULD BE EXPECTED TO BE PROFESSIONALLY ADMINISTERED. |
| ANTIBIOTICS : AMINOPENICILLINS - INJECTABLE | AMPICILLIN SODIUM | • PRODUCT REQUIRES AUTHORIZATION TO VERIFY IT IS BEING PROFESSIONALLY ADMINISTERED, OR OTHER JUSTIFICATION FOR USE OF A PRODUCT THAT WOULD BE EXPECTED TO BE PROFESSIONALLY ADMINISTERED. |
| ANTIBIOTICS : ANTI-INFECTIVE AGENTS - MISC - ORAL | METRONIDAZOLE CAPSULES | • METRONIDAZOLE TABLETS |
| ANTIBIOTICS : FLUOROQUINOLONES - ORAL | MOXIFLOXACIN HCL TABLETS | • CIPROFLOXACIN TABLETS • LEVOFLOXACIN TABLETS |
| ANTIBIOTICS : FLUOROQUINOLONES - ORAL | CIPRO ORAL SUSPENSION | • GENERIC CIPROFLOXACIN FOR ORAL SUSPENSION |
| ANTIBIOTICS : GLYCOPEPTIDES - ORAL | FIRVANQ ORAL SOLN | • GENERIC VANCOMYCIN HCL FOR ORAL SOLUTION |
| ANTIBIOTICS : SULFONAMIDES - ORAL | SULFATRIM PEDIATRIC SUSPENSION | • GENERIC SULFAMETHOXAZOLE-TRIMETHOPRIM SUSPENSION |
| ANTIBIOTICS : TOPICAL | FT DOUBLE ANTIBIOTIC | • DOUBLE ANTIBIOTIC • HM DOUBLE ANTIBIOTIC • POLY BACITRACIN |
| ANTIBIOTICS : VAGINAL | NUVESSA VAGINAL GEL | • METRONIDAZOLE GEL |
| ANTICONVULSANTS : HYDANTOINS | PHENYTEK EXTENDED CAPSULES | • GENERIC PHENYTOIN SODIUM EXTENDED CAPSULES |
| ANTICONVULSANTS : MISC | SUBVENITE TABLETS | • GENERIC LAMOTRIGINE TABLETS |
| ANTICONVULSANTS : MISC | ROWEEPRA TABLETS | • GENERIC LEVETIRACETAM TABLETS |
| ANTICONVULSANTS : MISC | TRILEPTAL SUSPENSION | • GENERIC OXCARBAZEPINE SUSPENSION |
| ANTICONVULSANTS : VALPROIC ACID | DEPAKOTE SPRINKLES DELAYED RELEASE CAPSULES | • GENERIC DIVALPROEX SODIUM CAPSULE DELAYED RELEASE SPRINKLES |
| ANTIDEMENTIA AGENTS : | EXELON TD PATCH | • GENERIC RIVASTIGMINE TD PATCH 24HR |
| ANTIDIABETICS : DIABETIC OTHER | PROGLYCEM SUSPENSION | • GENERIC DIAZOXIDE SUSPENSION |
| ANTIDIABETICS : DPP4 INHIBITORS | SITAGLIPTIN BASE-METFORMIN HCL TABLET | • JANUMET |
| ANTIDIABETICS : INSULIN - RAPID ACTING | HUMALOG KWIKPEN | • INSULIN LISPRO SOLN PEN-INJECTOR |
| ANTIDOTES AND SPECIFIC ANTAGONISTS : CHELATING AGENTS | CHEMET | • DEFERASIROX GRAN TABLETS • DEFERASIROX GRAN PACK • DEFERASIROX TABLETS DISPERSABLE |
| ANTIEMETICS / ANTIVERTIGO AGENTS : OTHER | FT MOTION SICKNESS | • GNP MOTION SICKNESS RELIEF • MECLIZINE HCL • MOTION SICKNESS RELIEF |
| ANTIEMETICS / ANTIVERTIGO AGENTS : OTHER | PROMETHEGAN HCL SUPPOSITORY | • GENERIC PROMETHAZINE HCL SUPPOSITORY |
| ANTIFUNGALS : TOPICAL | FT ANTIFUNGAL CREAM | • GNP TOLNAFTATE CREAM • TOLNAFTATE CREAM |
| ANTIFUNGALS : TOPICAL | FT ATHLETES FOOT (CLOTRIMAZ) | • ANTIFUNGAL (CLOTRIMAZOLE) • ATHLETES FOOT (CLOTRIMAZOLE) • CLOTRIMAZOLE • CLOTRIMAZOLE ANTI-FUNGAL • GNP ATHLETES FOOT • MICOTRIN AC • MYCOZYL AC • TM-CLOTRIMAZOLE |
| ANTIFUNGALS : TOPICAL | FT ANTIFUNGAL | • ANTIFUNGAL • MICONAZOLE NITRATE • SM ANTIFUNGAL MICONAZOLE |
| ANTIFUNGALS : TOPICAL | NYSTOP TOPICAL POWDER | • GENERIC NYSTATIN TOPICAL POWDER |
| ANTIFUNGALS : VAGINAL | 3 DAY VAGINAL CREAM | • FT CLOTRIMAZOLE 3 • GNP CLOTRIMAZOLE 3 |
| ANTIHYPERLIPIDEMICS : BILE ACID SEQUESTRANTS | PREVALITE POWDER PACKETS | • GENERIC CHOLESTYRAMINE LIGHT POWDER PACKET |
| ANTIHYPERTENSIVES : CALCIUM CHANNEL BLOCKERS | DILT-XR CAPSULES EXTENDED RELEASE | • GENERIC DILTIAZEM HCL CAPSULE EXTENDED RELEASE |
| ANTIHYPERTENSIVES : CALCIUM CHANNEL BLOCKERS | TIADYLT ER EXTENDED RELEASE BEADS CAPSULES | • GENERIC DILTIAZEM HCL EXTENDED RELEASE BEADS CAPSULES |
| ANTIPARASITICS : ANTIMALARIALS | SOVUNA TABLETS | • GENERIC HYDROXYCHLOROQUINE SULFATE TABLETS |
| ANTIPARASITICS : SCABICIDES AND PEDICULICIDES | NATROBA SUSPENSION | • GENERIC SPINOSAD SUSPENSION |
| ANTIPARKINSON AGENTS : ANTICHOLINERGICS | BENZTROPINE MESYLATE 2MG/2ML AMPUL INJECTION | • PRODUCT REQUIRES AUTHORIZATION TO VERIFY IT IS BEING PROFESSIONALLY ADMINISTERED, OR OTHER JUSTIFICATION FOR USE OF A PRODUCT THAT WOULD BE EXPECTED TO BE PROFESSIONALLY ADMINISTERED. |
| ANTIPSYCHOTICS / ANTIMANIC AGENTS : ANTIPSYCHOTICS - 2ND GENERATION | GEODON INJECTION | • GENERIC ZIPRASIDONE MESYLATE FOR INJECTION |
| ANTIVIRALS : RESPIRATORY SYNCYTIAL VIRUS (RSV) AGENTS | AREXVY | • PRIOR AUTHORIZATION REQUIRED |
| ASTHMA AND COPD AGENTS : LONG ACTING MUSCARINIC AGENT / LONG ACTING BETA AGONIST COMBINATIONS | ANORO ELLIPTA | • PRIOR AUTHORIZATION REQUIRED |
| BONE DENSITY REGULATORS : CALCITONINS | CALCITONIN (SALMON) | • PRIOR AUTHORIZATION REQUIRED |
| CARDIOVASCULAR AGENTS : ANTIANGINAL AGENTS - NITRATES | NITROGLYCERIN IN D5W | • NOT COVERED THROUGH RETAIL PHARMACY, MUST BE BILLED AS A MEDICAL CLAIM |
| CARDIOVASCULAR AGENTS : ANTIANGINAL AGENTS - NITRATES | ISORDIL TITRADOSE TABLETS | • GENERIC ISOSORBIDE DINITRATE TABLETS |
| CARDIOVASCULAR AGENTS : ANTIARRHYTHMICS | • AMIODARONE HCL • LIDOCAINE IN D5 • LIDOCAINE HCL (CARDIAC) • LIDOCAINE HCL (CARDIAC) PF • NEXTERONE • PROCAINAMIDE HCL | • NOT COVERED THROUGH RETAIL PHARMACY, MUST BE BILLED AS A MEDICAL CLAIM |
| CARDIOVASCULAR AGENTS : CARDIAC GLYCOSIDES | DIGOXIN | • PRODUCT REQUIRES AUTHORIZATION TO VERIFY IT IS BEING PROFESSIONALLY ADMINISTERED, OR OTHER JUSTIFICATION FOR USE OF A PRODUCT THAT WOULD BE EXPECTED TO BE PROFESSIONALLY ADMINISTERED. |
| CARDIOVASCULAR AGENTS : PERIPHERAL VASODILATORS - ORAL | NIAVASC | • ENDUR-ACIN NIACIN ER SLO-NIACIN |
| CARDIOVASCULAR AGENTS : PERIPHERAL VASODILATORS - ORAL | NIAVASC 750 | • ENDUR-ACIN |
| CONTRACEPTIVES : NON-HORMONAL - VAGINAL | PHEXXI | • PRIOR AUTHORIZATION REQUIRED |
| CORTICOSTEROIDS : GLUCOCORTICOSTEROIDS - INJECTABLE | • METHYLPREDNISOLONE SODIUM SUCC • TRIAMCINOLONE ACETONIDE | • PRODUCT REQUIRES AUTHORIZATION TO VERIFY IT IS BEING PROFESSIONALLY ADMINISTERED, OR OTHER JUSTIFICATION FOR USE OF A PRODUCT THAT WOULD BE EXPECTED TO BE PROFESSIONALLY ADMINISTERED. |
| CORTICOSTEROIDS : GLUCOCORTICOSTEROIDS - ORAL | UCERIS TABLETS EXTENDED RELEASE | • GENERIC BUDESONIDE TABLETS EXTENDED RELEASE |
| COUGH / COLD : ANTITUSSIVES / EXPECTORANTS / MISC COMBINATIONS | SM TUSSIN MUCUS+CHEST CONGEST | • CHEST CONGESTION RELIEF • GNP TUSSIN MUCUS & CHEST CONG • GUAIFENESIN • TUSNEL-EX • TUSSIN MUCUS & CHEST CONGEST • TUSSIN MUCUS+CHEST CONGESTION |
| COUGH / COLD : DECONGESTANTS - SYSTEMIC | FT NASAL DECONGESTANT MAX STR | • GNP NASAL DECONGESTANT • HM NASAL DECONGESTANT • NASAL DECONGESTANT • PSEUDOEPHEDRINE HCL • SUDOGEST • SUDOGEST MAXIMUM STRENGTH |
| COUGH / COLD : DECONGESTANTS - SYSTEMIC | FT NASAL DECONGESTANT PE | • GNP NASAL DECONGESTANT PE • NASAL DECONGESTANT PE • NASAL DECONGESTANT PE MAX ST • PHENYLEPHRINE HCL |
| COUGH / COLD : DECONGESTANTS - SYSTEMIC | FT PAIN RELIEF ACETAMINOPHEN TABLET | • ACETAMINOPHEN TABLET (DIFFERENT NDCS) • GNP ACETAMINOPHEN • GNP PAIN RELIEF • GOODSENSE PAIN RELIEF • HM PAIN RELIEVER |
| COUGH / COLD : DECONGESTANTS - SYSTEMIC | FT PAIN RELIEF IBUPROFEN TABLET | • FT IBUPROFEN • GNP IBUPROFEN • GOODSENSE IBUPROFEN • IBUPROFEN • SM IBUPROFEN |
| DERMATOLOGICS : BURN PRODUCTS | SSD CREAM | • GENERIC SILVER SULFADIAZINE CREAM |
| DERMATOLOGICS : KERATOLYTIC / ANTIMITOTIC AGENTS | PODOFILOX SOLUTION | • PRIOR AUTHORIZATION REQUIRED |
| DERMATOLOGICS : KERATOLYTIC / ANTIMITOTIC AGENTS | PODOFILOX GEL | • PODOFILOX SOLUTION (PA REQUIRED) |
| DERMATOLOGICS : KERATOLYTIC / ANTIMITOTIC AGENTS | • SALYCIM • SALICYLIC ACID | • PRIOR AUTHORIZATION REQUIRED |
| DERMATOLOGICS : ROSACEA AGENTS | FINACEA FOAM | • GENERIC AZELAIC ACID FOAM |
| DERMATOLOGICS : ROSACEA AGENTS | FINACEA GEL | • GENERIC AZELAIC ACID GEL |
| DERMATOLOGICS : TOPICAL STEROIDS - LOW POTENCY | FT ITCH RELIEF MAX STRENGTH CREAM | • ANTI-ITCH MAXIMUM STRENGTH • GNP HYDROCORTISONE PLUS • GNP HYDROCORTISONE/ALOE • HM HYDROCORTISONE PLUS • HM HYDROCORTISONE-ALOE MAX ST • HYDROCORTISONE (Preferred NDCs) • HYDROCORTISONE MAX ST • HYDROCORTISONE MAX ST/12 MOIST |
| DERMATOLOGICS : TOPICAL STEROIDS - LOW POTENCY | FT ITCH RELIEF MAX STRENGTH OINTMENT | • GNP HYDROCORTISONE MAX ST • HYDROCORTISONE • SM HYDROCORTISONE MAX ST |
| ENDOCRINE AND METABOLIC AGENTS : CALCIMIMETIC AGENTS - ORAL | SENSIPAR TABLETS | • GENERIC CINACALCET TABLETS |
| ENDOCRINE AND METABOLIC AGENTS : ESTROGEN / PROGESTIN COMBINATIONS | • AMABELZ TABLETS • MIMVEY TABLETS | • GENERIC ESTRADIOL & NORETHINDRONE ACETATE TABLETS |
| ENDOCRINE AND METABOLIC AGENTS : ESTROGEN / PROGESTIN COMBINATIONS | • FYAVOLV TABLETS • JINTELI TABLETS | • GENERIC NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TABLETS |
| ENDOCRINE AND METABOLIC AGENTS : ESTROGENS - INJECTABLE | ESTRADIOL VALERATE 10MG/ML VIAL | • DEPO-ESTRADIOL • ESTRADIOL VALERATE 20MG/ML or 40MG/ML STRENGTH |
| ENDOCRINE AND METABOLIC AGENTS : ESTROGENS - VAGINAL | YUVAFEM VAGINAL TABLETS | • GENERIC ESTRADIOL VAGINAL TABLETS |
| ENDOCRINE AND METABOLIC AGENTS : THYROID HORMONE - ORAL | THYROID | • ADTHYZA • ARMOUR THYROID • NIVA • NP THYROID |
| ENDOCRINE AND METABOLIC AGENTS : THYROID HORMONE - ORAL | • EUTHYROX TABLETS • LEVO-T TABLETS • LEVOXYL TABLETS • UNITHROID TABLETS | • GENERIC LEVOTHYROXINE SODIUM TABLETS |
| GASTROINTESTINAL AGENTS - ULCER DRUGS : H-2 ANTAGONISTS | FT ACID REDUCER | • ACID REDUCER • FAMOTIDINE • FAMOTIDINE ORIG ST • GNP ACID REDUCER • HEARTBURN RELIEF |
| GASTROINTESTINAL AGENTS - ULCER DRUGS : H-2 ANTAGONISTS | FT ACID REDUCER MAX STRENGTH | • ACID REDUCER MAXIMUM STRENGTH • FAMOTIDINE • FAMOTIDINE MAXIMUM STRENGTH • GNP ACID REDUCER MAX ST • HEARTBURN RELIEF MAX ST |
| GASTROINTESTINAL AGENTS : ANTIDIARRHEAL | FT ANTI-DIARRHEAL | • ANTI-DIARRHEAL • GNP ANTI-DIARRHEAL • LOPERAMIDE HCL |
| GASTROINTESTINAL AGENTS : ANTISPASMODICS - OTHER | OSCIMIN TABLET SUBLINGUAL | • GENERIC HYOSCYAMINE SULFATE TABLETS SUBLINGUAL |
| GASTROINTESTINAL AGENTS : ANTISPASMODICS - OTHER | NULEV TABLES DISP | • GENERIC HYOSCYAMINE SULFATE TABLETS DISP |
| GASTROINTESTINAL AGENTS : INFLAMMATORY BOWEL AGENTS | MESALAMINE ENEMA 4GM | • MESALAMINE SUPPOSITORY 1,000 MG • HYDROCORTISONE ENEMA |
| GASTROINTESTINAL AGENTS : INFLAMMATORY BOWEL AGENTS | • APRISO CAPSULE EXTENDED RELEASE • DELZICOL CAPSULE DELAYED RELEASE • LIALDA TABLET DELAYED RELEASE • PENTASA CAPSULE CONTROLLED RELEASE | • GENERIC MESALAMINE CAPSULES EXTENDED RELEASE |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT CLEARLAX | • CLEARLAX • GNP CLEARLAX • GOODSENSE CLEARLAX • HM CLEARLAX • PEG 3350 • POLYETHYLENE GLYCOL 3350 |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT ENEMA SALINE | • ENEMA • ENEMA READY-TO-USE • HM ENEMA |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT FIBER PSYLLIUM HUSK (WITH SUGAR) POWDER 3 G/12 G | • CLEARLAX • KONSYL • POLYETHYLENE GLYCOL 3350 • REGULOID • FIBER • PSYLLIUM FIBER POWDER • SMOOTH TEXTURE FIBER • DAILY FIBER • HEALTHYLAX |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT FIBER PSYLLIUM HUSK (WITH SUGAR) 3 G/7 G | • QC PSYLLIUM FIBER |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT FIBER PSYLLIUM HUSH/ASPARTAME POWDER | • DAILY FIBER • EQL SMOOTH TEXTURE FIBER • REGULOID |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT LAXATIVE | • BISACODYL EC • GENTLE LAXATIVE • GNP GENTLE LAXATIVE • GNP WOMENS GENTLE LAXATIVE • HM LAXATIVE |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT LUBRICANT EYE DROPS | • GOODSENSE LUBRICATING EYE DROP • LUBRICANT EYE DROPS PF |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT SENNA LAXATIVE | • GNP SENNA LAX • HM SENNA • SENNA • SENNA-LAX • SENNA-TIME |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT STOMACH RELIEF BISMUTH SUBSALICYLATE TABLET | • GNP PINK BISMUTH • STOMACH RELIEF |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT STOMACH RELIEF BISMUTH SUBSALICYLATE TAB CHEWABLE | • BISMUTH SUBSALICYLATE • GNP PINK BISMUTH • HM STOMACH RELIEF • STOMACH RELIEF |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT STOMACH RELIEF BISMUTH SUBSALICYLATE ORAL SUSP | • GNP STOMACH RELIEF |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT STOOL SOFTENER DOCUSATE CAPSULE | • DOCUSATE SODIUM • GNP STOOL SOFTENER • HM STOOL SOFTENER • STOOL SOFTENER |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT STOOL SOFTENER DOCUSATE TABLET | • DOK SODIUM TABLETS |
| GASTROINTESTINAL AGENTS : LAXATIVES | FT TUSSIN ADULT | • GNP TUSSIN MUCUS & CHEST CONG • GUAIFENESIN • TUSNEL-EX • TUSSIN MUCUS & CHEST CONGEST • TUSSIN MUCUS+CHEST CONGESTION |
| GASTROINTESTINAL AGENTS : LAXATIVES | GLYCERIN (ADULT) | • GLYCERIN (ADULT) (NDCs 57237032521, 57237032552, & 70000057201) |
| GASTROINTESTINAL AGENTS : LAXATIVES | SENOKOT EXTRA STRENGTH | • SENNA • DOK • SENNA LAX • DOCUSATE SODIUM • LAXATIVE |
| GASTROINTESTINAL AGENTS : LAXATIVES | CONSTULOSE SOLUTION | • GENERIC LACTULOSE SOLUTION |
| GASTROINTESTINAL AGENTS : LAXATIVES | ENULOSE SOLUTION | • GENERIC LACTULOSE (ENCEPHALOPATHY) SOLUTION |
| GASTROINTESTINAL AGENTS : OTHER | FT GAS RELIEF | • GAS RELIEF • GNP GAS RELIEF • HM GAS RELIEF • SIMETHICONE |
| GASTROINTESTINAL AGENTS : OTHER | FT GAS RELIEF EXTRA STRENGTH SIMETHICONE CAPSULE | • GAS RELIEF EXTRA STRENGTH • GNP GAS RELIEF EXTRA STRENGTH • HM GAS RELIEF |
| GASTROINTESTINAL AGENTS : OTHER | FT GAS RELIEF EXTRA STRENGTH SIMETHICONE TAB CHEW | • GAS RELIEF EXTRA STRENGTH • GOODSENSE GAS RELIEF EXTRA ST |
| GASTROINTESTINAL AGENTS : OTHER | FT GAS RELIEF INFANTS | • GAS RELIEF INFANTS • GNP INFANT GAS RELIEF • SIMETHICONE DROPS INFANTS |
| GASTROINTESTINAL AGENTS : OTHER | FT GENTLE LAXATIVE | • BISACODYL • GENTLE LAXATIVE • GNP GENTLE LAXATIVE • HM GENTLE LAXATIVE |
| GASTROINTESTINAL AGENTS: ANTACIDS | FT ANTACID REGULAR STRENGTH | • ANTACID CALCIUM • CALCIUM ANTACID • CAL-GEST ANTACID • HM ANTACID |
| GASTROINTESTINAL AGENTS: ANTACIDS | FT ANTACID EXTRA STRENGTH | • ANTACID • ANTACID EXTRA STRENGTH • CALCIUM ANTACID EXTRA STRENGTH • GNP ANTACID EXTRA STRENGTH • HM CALCIUM ANTACID EX ST • SMOOTH ANTACID EXTRA STRENGTH |
| GI ULCER AGENTS : H. PYLORI ANTIBIOTICS | BIS SUBCIT-METRONID-TETRACYC | JUSTIFICATION REQUIRED WHY COMBINATION PRODUCT IS REQUIRED RATHER THAN SEPARATE INGREDIENT PRODUCTS |
| GI ULCER AGENTS : MISC | CARAFATE SUSPENSION | • GENERIC SUCRALFATE SUSPENSION |
| GLAUCOMA AGENTS : MIOTICS | PHOSPHOLINE IODIDE OPHTH FOR SOLN 0.125% | • PILOCARPINE HCL OPHTH 1 % • PILOCARPINE HCL OPHTH 2 % • PILOCARPINE HCL OPHTH 4 % |
| HEMATOPOIETIC AGENTS : COBALAMINS / COBALAMIN COMBINATIONS | DODEX INJECTION | DODEX INJECTION |
| HIV : ANTIVIRALS - ORAL | INTELENCE | • GENERIC ETRAVIRINE TABLETS |
| HIV : ANTIVIRALS - ORAL | KALETRA | • GENERIC LOPINAVIR-RITONAVIR TABLETS |
| HIV : ANTIVIRALS - ORAL | ATRIPLA | • GENERIC EFAVIRENZ-EMTRICITABINE-TENOFOVIR DF TABLETS |
| MINERALS AND ELECTROLYTES : PHOSPHATE - ORAL | PHOSPHO-TRIN 250 NEUTRAL | • PHOSPHA 250 NEUTRAL • PHOSPHOROUS • WES-PHOS 250 NEUTRAL |
| MINERALS AND ELECTROLYTES : POTASSIUM | KLOR-CON EXTENDED RELEASE TABLETS | • GENERIC POTASSIUM CHLORIDE TABLETS CONTROLLED RELEASE |
| MINERALS AND ELECTROLYTES : POTASSIUM | KLOR-CON M10 AND M20 CRYS CONTROLLED RELEASE TABLETS | • GENERIC POTASSIUM CHLORIDE MICROENCAPSULATED CRYS TABLETS CONTROLLED RELEASE |
| ONCOLOGY AGENTS : MULTIKINASE INHIBITORS - ORAL | SUTENT | • GENERIC SUNITINIB MALATE CAPSULES |
| ONCOLOGY AGENTS : TYROSINE KINASE INHIBITORS - ORAL | FRUZAQLA | • PREFERRED TYROSINE KINASE INHIBITORS PRODUCTS. PRIOR AUTHORIZATION WILL BE REQUIRED. PLEASE SEE PREFERRED DRUG LIST AT COORDINATEDCAREHEALTH.COM FOR PREFERRED PRODUCTS. |
| ONCOLOGY AGENTS : TYROSINE KINASE INHIBITORS - ORAL | TYKERB | • GENERIC LAPATINIB DITOSYLATE TABLETS |
| OPHTHALMIC AGENTS : ANTIALLERGIC | ALAWAY | • KETOTIFEN FUMARATE |
| OPHTHALMIC AGENTS : ARTIFICIAL TEARS AND LUBRICANTS | REFRESH TEARS | • CARBOXYMETHYLCELLULOSE SODIUM • VENTIVA TEARS |
| OPHTHALMIC AGENTS : ARTIFICIAL TEARS AND LUBRICANTS | LACRISERT | • SYSTANE • GENTEAL TEARS SEVERE • LUBRICATING PLUS • LUBRICATING EYE • CARBOXYMETHYLCELLULOSE SODIUM • LUBRICANT EYE DROP • POLYVINYL ALCOHOL • LUBRIFRESH PM • ARTIFICIAL TEARS • LUBRICANT EYE • LUBRICATING TEARS • LUBRICANT EYE DROPS • ULTRA LUBRICANT EYE • DRY EYE RELIEF • VENTIVA TEARS • SENTIA |
| OPHTHALMIC AGENTS : ARTIFICIAL TEARS AND LUBRICANTS | REFRESH LACRI-LUBE | • GENTEAL TEARS NIGHT-TIME • LUBRICANT EYE NIGHTTIME • LUBRIFRESH P.M. • SYSTANE NIGHTTIME |
| OPHTHALMIC AGENTS : CYCLOPLEGIC MYDRIATICS | CYCLOMYDRIL OPTH SOLUTION | • ATROPINE SULFATE OPHTH DROPS • TROPICAMIDE OPHTH DROPS |
| OPHTHALMIC AGENTS : CYCLOPLEGIC MYDRIATICS | • CYCLOPENTOLATE HC • PHENYLEPHRINE HCL • TROPICAMIDE | • PRIOR AUTHORIZATION REQUIRED |
| OPHTHALMIC AGENTS : CYCLOPLEGIC MYDRIATICS | CYCLOGYL OPTH SOLUTION | • GENERIC CYCLOPENTOLATE HCL OPHTH SOLUTION |
| OPHTHALMIC AGENTS : LOCAL ANESTHETICS | • PROPARACAINE HCL • TETRACAINE HCL | • PRIOR AUTHORIZATION REQUIRED |
| OTIC AGENTS : MISC | FT EARWAX REMOVAL | • EAR DROPS • EARWAX REMOVAL • GNP EARWAX REMOVAL DROPS • GNP EARWAX REMOVAL KIT • HM EARWAX REMOVAL • HM EARWAX REMOVAL KIT |
| SLEEP DISORDER AGENTS : BENZODIAZEPINE HYPNOTICS - INJECTABLE | MIDAZOLAM-SODIUM CHLORIDE | • NOT COVERED THROUGH RETAIL PHARMACY, MUST BE BILLED AS A MEDICAL CLAIM |
| SUBSTANCE USE DISORDER : OPIOID ANTAGONISTS | • NARCAN NASAL SPRAY • REXTOVY NASAL SPRAY | • GENERIC NALOXONE HCL NASAL SPRAY |
| VITAMINS : PRENATAL VITAMINS | PRENATRYL | • M-NATAL PLUS • NEONATAL PLUS • NIVA-PLUS • PRENATAL • PRENATAL PLUS VITAMIN/MINERAL • PRENATAL VITAMIN PLUS LOW IRON • THERANATAL CORE NUTRITION • WESTAB PLUS |
| VITAMINS : VITAMIN K | PHYTONADIONE | • Over-the-Counter |
January 1, 2025 Basaglar Formulary Removal - Ambetter
Starting January 1, 2025, Basaglar will be removed from the formulary and Semglee will be the preferred alternative. Basaglar and Semglee are both insulin glargine, but they are not interchangeable with one another (i.e. a new prescription is needed). Semglee is an interchangeable biosimilar of Lantus. Basaglar and Semglee are expected to have similar safety and efficacy as they both reference Lantus as the originator product.
Patients currently on Basaglar will need to have a new prescription for Semglee sent to their pharmacy for use starting January 1, 2025.
FAQs
- What are Biosimilars?
- A biosimilar is a biologic drug that is highly similar to the original biologic or “reference product” and has no clinically meaningful differences in terms of safety and efficacy with the reference product. For more information on biosimilars, visit this page.
- Are there clinical differences between Basaglar and Semglee
- Semglee is an interchangeable biosimilar of Lantus whereas Basaglar is an insulin glargine product that was created before the FDA’s biosimilar pathway was established. However, both Semglee and Basaglar used Lantus as the reference product. As such, the clinical safety and efficacy profile is expected to be similar for Basaglar and Semglee.
- When should I send in the new Semglee prescription to the pharmacy?
- Please send in the new prescription to your patient’s pharmacy anytime between now and January 1st with the note “DO NOT FILL UNTIL AFTER 1/1/2025” on the prescription.
The next time the patient is due for their refill after January 1st, the pharmacy will substitute Basaglar with the Semglee prescription that is on file.
- Please send in the new prescription to your patient’s pharmacy anytime between now and January 1st with the note “DO NOT FILL UNTIL AFTER 1/1/2025” on the prescription.
- What if my patient need to remain on Basaglar?
- If there’s a medical reason for why your patient should remain on Basaglar, formulary exception requests can be submitted AFTER January 1, 2025 here.
- Will my patient’s out-of-pocket cost increase because of this formulary change?
- Semglee will be on the Preferred Brand Tier, the same formulary tier as previous preferred drug, Basaglar so switching from Basaglar to Semglee should not lead to increased patient cost. However, your patient’s cost-share may also depend on other factors like their deductible phase, out-of-pocket maximum, and plan design.
- Where can I find the full formulary? What are the other formulary changes for the upcoming plan year?
- The complete list of formulary changes, 2025 formulary, and other pharmacy resources are published online. Please visit www.ambetterhealth.com. Select your “State,” go to “For Providers,” and then “Drug Coverage” to access the pharmacy resources webpage.
2025 Alternative Covered Drugs- Wellcare
Wellcare covers over 40,000 Drugs. We strive to cover the most common drugs across all conditions. Below are some common drugs not covered by the plan, along with alternative drugs that are covered. If your patient is currently on a drug that is not covered, please see if the formulary alternatives listed below would work for your patient.
You can also check our plan’s formulary (drug list) for a comprehensive listing of all drugs that are covered and any formulary restrictions that may apply.
Generics and authorized generics listed in the table below with the double asterisk (**) have the same active ingredients as the drug not covered on the formulary. If your patient has an active prescription for a drug not covered, they will still be able to access the listed double-asterisked drug without needing a new prescription.
| Drug (s) not covered on the Formulary | Drug (s) covered on the Formulary | Formulary Restrictions |
|---|---|---|
| NovoLog® | Insulin Aspart** | None |
| NovoLog Mix 70/30® | Insulin Aspart Mix 70/30** | None |
| Humalog® , Fiasp®, Insulin Lispro | Insulin Aspart | None |
| Semglee® | Insulin Glargine-YFGN Pen** | None |
| Basaglar KwikPen® , Lantus® , Levemir® | Insulin Glargine-YFGN Pen | None |
| Toujeo® | Insulin Glargine U-300 Solostar® & Max SoloStar® ** | None |
| Tresiba® | Insulin Degludec** | None |
| Victoza® , Byetta® | Bydureon BCISE ®, Mounjaro ®, Ozempic ®, Rybelsus ®, Trulicity ® | PA, QL |
| Advair Diskus®, Wixela Inhub® | Fluticason-Salmeterol Diskus**, Breyna ®, Breo Ellipta ®, Advair HFA ® | QL |
| Symbicort® Budesonide-Formoterol HFA | Breyna®**, Fluticasone-Salmeterol Diskus, Breo Ellipta® , Advair HFA® | QL |
| Dulera® | Breyna®, Fluticasone-Salmeterol Diskus, Breo Ellipta® , Advair HFA® | QL |
| Pulmicort Flexhaler®, Fluticasone Propionate Diskus & HFA | Arnuity Ellipta® | QL |
| Levalbuterol HFA | Albuterol HFA, Ventolin HFA® | QL |
| Spiriva Handihaler® , Spiriva Respimat® | Incruse Ellipta® | QL |
| Gemtesa®, Fesoterodine | Tolterodine, Solifenacin, Oxybutynin, Myrbetriq® | QL |
| Silodosin | Tamsulosin, Alfuzosin, Finasteride Dutasteride | None QL |
| Emgality® | Aimovig® | PA, QL |
| Repatha® | Praluent® | PA |
| Omega-3 Acid Ethyl Esters | Vascepa® | None |
| Veltassa® | Sodium Polystyrene Sulfate, Lokelma® | None |
| Vyzulta® | Latanoprost, Travoprost, Lumigan® | None |
| Simbrinza® | Alphagan P® 0.1%, Brimonidine 0.2%, Brimonidine 0.15%, Combigan® , Dorzolamide HCl, Dorzolamide-Timolol, Brinzolamide | None |
| Restasis® | Cyclosporine 0.05% eye drops** | QL |
| Forteo® | Teriparatide Prolia® | PA,QL QL |
| Procrit® | Procrit® | PA |
| Xeljanz® , Xeljanz XR® | Cyltezo® 40mg/0.8ml, Yuflyma® , Humira® , Enbrel® , Rinvoq® , Skyrizi® , Stelara® , Cosentyx® , Tremfya® , Otezla® , Actemra® | PA, QL |
- Bold type= Brand name drug
- Plan (not bolded) type= Generic Drug
- **Therapeutically equivalent generic
- PA= Prior Authorization
- QL= Quantity
Please note: Alternative drugs are suggestions only and may not be right for every patient or their condition. This information is correct as of October 1, 2024, but is subject to change. Please check the drug list for details on which drugs are covered, as this drug list can change at any time.
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Apple Health Core Connections (AHCC)
Did you know that Apple Health Core Connections has a dedicated care management team? The AHCC team has expertise in providing trauma-informed care for youth impacted by the child welfare system. Our care management team is here to support you and our members.
Top reasons to refer to care management:
- History of recent Inpatient Admissions or ED visits
- Three (3) or more inpatient admissions within the last 6 months for same/similar diagnosis o A NICU stay with Length of Stay greater than 7 days within the last 6 months
- Three (3) or more ED visits in the last 3 months for same/similar diagnosis
- Placement Disruptions
- One or more placement changes in the last 3 months related to a health condition
- Two or more placement changes in the last 3 months for any reason
- Unmanaged or high intensity Behavioral Health needs
- Suicide or homicide attempts within the last 6 months that resulted in ED Visit or hospitalization
- Suicide or homicide ideation with no behaviors and/or attempts in the past 3 months
- Patient actively engaging in self-harming behaviors within the last 6 months
- Substance Use Disorder diagnosis and ED visit for substance use in past 30-days
- Enrollment in WISe, CLIP, or a BRS placement
- Behavioral or Medical diagnoses that are not well managed, that impact school/work/daycare/home, or that require additional resources to manage well.
- Enrollment in other high intensity mental health services
- Complex medical conditions/multiple co-morbidities, including but not limited to:
- Chronic or non-healing wounds / Stage 3 burns that require extensive wound care or skin grafts
- Requires life sustaining device – ventilator, tracheostomy, oxygen, CPAP / BIPAP, tracheostomy care or suctioning
- TPN (Total Parenteral Nutrition) or continuous tube feedings
- Recent functional decline within 90 days
- Skilled Nursing Visits greater than 3 visits / week
- Multiple co-morbidities that require 4 or more specialists
- Diabetes with Lower Extremity (LEX) episode or HgbA1c greater than 7
- Pregnancy
- Post-transplant within 6 months
- Catastrophic illness or injury, e.g. transplants, HIV/AIDS, cancer, serious motor vehicle accidents
- End Stage Renal Disease (ESRD)
- Dual diagnosis –patients with serious, chronic behavioral health and physical health diagnoses
- Non-compliance with medication, outpatient follow up, treatment recommendations, or routine provider visits
- General Care Coordination needs
- Primarily psychosocial issues such as housing, financial, transportation, etc. with need for referrals to community resources
- Need for assistance with accessing health care services
- Need for assistance to connect with in-network providers
How to make a referral:
- Use the provider portal, send us a secure email to AHCCTeam@CoordinatedCareHealth.com with the member’s name, DOB, Medicaid number, and current need in the body of the email, or call 1-844-354-9876.
What to expect after making a referral:
- The patient will be assigned either a Complex Care Manager (CCM) or Care Coordinator (CC) depending on the patient’s level of need. Patient will be assigned within 14 days of the initial referral, and email will be sent to the Provider & Care Team with name and contact number of CCM or CC.
- CCM or CC will reach out to provider within 14 days of receiving referral for a medical consult.
- CCM or CC will work with the patient, caregivers, caseworker and providers to complete a 20-minute health assessment with the member (if not already on file). They will then connect the member with appropriate services, ensure follow-up appointments are kept, provide health education, and partner with the member for identified needs.
- Once the patient’s case has been identified for closure, the CCM or CC will reach out to the Provider and Care Team for a final medical consult before closing case (no time frame).
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Training/Education
Childhood Development & The Impact of Trauma - This training provides information on key areas of childhood development; social, cognitive, and physical development are all explored. The training focuses on how complex trauma affects development in infants and toddlers, school aged children, and adolescents. Feb 3, 2025, 10:00 AM Register here.
Cultural Care & Connections - This training explains the importance of cultural differences when caring for a child of a different race or culture. It provides insight on how the caregiver can recognize different values, beliefs, behaviors, communication variations and potential barriers, including personal care. Additionally, this training addresses the need to keep children connected to their culture of origin. Feb 4, 2025, 10:00 AM Register here.
Resiliency - Coordinated Care’s Resilience Training provides information on how to foster resilience in children. It reviews research from Ann Masten and Laurence Gonzales to guide discussion. This training looks at factors that effect resilience, the human adaptive process, ways to successfully cope with trauma, and the 12 steps of successful survivors. The training ends with a discussion around how caregivers can help their children feel safe, capable and loveable. Feb 5, 2025 10:00 AM Register here.
Trauma Informed Care: Understand & Reduce Traumatic Reactions in youth - Children who have experienced trauma often bring challenging behaviors to their environment. Professionals & caregivers do not know what to do, which can lead to frustration, lack of care and even placement disruption. This training offers a Trauma refresher overview and ideas into helping the child manage their reactions and behaviors. Feb 25, 2025, 1:00 PM Register here.