March 2025 Provider News

Date: 03/28/25

In this issue: 

• HCA Announcement - Suspension of programs at Columbia River Mental Health Services
• General Updates - Autism Center of Excellence, Smoking and Tobacco Cessation, Apple Health (Medicaid) After-Pregnancy Coverage (APC), Childhood Lead Poisoning Prevention, RadMD Webinar
• Quality - Adult ASAM Criteria 4th Edition training opportunities
• Tribal - Resource for Assistance
• Clinical Policy - Monthly Updates
• Pharmacy Updates - Medical Oncology Update, April 1, 2025 Preferred Drug List Changes, Significant Change to Humira (adalimumab) Coverage Effective 04/01/2025, Implementation of Health Care Authority Quantity Limits Effective 04/01/2025 
• Apple Health Core Connections - Updated Mandated Reporter Training
• Training/Education - Upcoming Training Opportunities

______________________________________________________________________________________

HCA Announcement

Suspension of programs at Columbia River Mental Health Services

Columbia River Mental Health Services (CRMHS) is immediately suspending several outpatient programs at their Clark County sites. This is a developing situation. This announcement will be updated as new information becomes available.

Effective immediately, CRMHS has paused the following services:

• Adult outpatient
• Child outpatient
• Health Home
• Psychiatry
• Greater Access & Prevention (GAP) Medicine
• Case management services

The following programs remain operational:

• NorthStar (outpatient opioid treatment program)
• Program for Assertive Community Treatment (PACT)
• Behavioral health crisis services: Mobile Health Response & Night Crisis
• Forensic Housing and Recovery Peer Services (FHARPS)
• Trueblood

The Health Care Authority (HCA) encourages all impacted providers to support affected clients as capacity allows. Providers are also encouraged to contact the client’s Apple Health managed care organization to identify referral options for continued care.

We recognize the burden this sudden change places on the provider community and appreciate your commitment to ensuring continuity of care for those in need of behavioral health services.

Coordinated Care Provider Services phone number 1-877-644-4613.

Please contact your Provider Engagement Administrator with further questions. You can find more information about who your Provider Engagement Administrator is here.

Back to Top

______________________________________________________________________________________

General Updates

Autism Center of Excellence (COE) Certification Training

HCA is excited to forward an invitation for the Autism Center of Excellence (COE) Certification Training on Friday, May 16, 2025. 

***Reminder*** – Please provide the below announcement to eligible providers (ARNP’s, Physician Assistants, physicians, and naturopaths) who may be interested in becoming a Center of Excellence (COE) provider to assess individuals for autism or an intellectual disability and prescribe Applied Behavior Analysis (ABA), as well as to providers who are eligible as an ABA COE through their provider type credentials and may benefit from the COE training.

Eligible ABA COE providers by credentials:

• A developmental pediatrician
• A neurologist
• A pediatric neurologist
• A pediatric psychiatrist
• A psychiatrist
• A psychologist

Please report back to HCA that you have distributed this information to providers by responding through the inbox with Issue # 36114, by March 18, 2025.

Save the Date- Centers of Excellence Offers a One Day Training for providers interested in becoming an ABA COE on Friday, May 16, 2025, 8:30am-4:30pm

Autism Centers of Excellence Training is open to health care professionals who are pursuing diagnosis certification, and, to non-diagnosing professionals working in the health care industry such as registered nurses, care coordinators, case managers, claims staff, etc.

While the COE training certifies eligible providers to diagnose autism spectrum disorders for pediatric patients with Medicaid, it is the COE’s hope that non-diagnosing staff will join the training as it provides valuable insight and connections between those who work with our most vulnerable clients.

COE training focuses on current research and thinking regarding the evaluation, treatment, and continuing care for autistic individuals throughout the lifespan:

• Getting support from your administration
• Screening, evaluation, and diagnosis
• Differential diagnosis and co-occurring diagnoses
• Diagnostic evaluation models
• Treatment options including accessing Applied Behavior Analysis (ABA)
• Accessing community and state resources
• Documentation, billing codes, and orders
• Lived experience perspectives from autistic and family advocates
• Advice from current community COE clinicians
• ECHO Autism Washington and other follow up support
• Q & A and connect with regional partners

Non-diagnosing individuals do not need to complete the AAP online learning modules before the training. Simply register online and attend the one-day training.

Please also note that the COE has provided a link to the COE Quick Start Guide here (PDF).

Please click here for more information including registration and COE contacts for questions.

Smoking and Tobacco Cessation

Washington Apple Health (Medicaid) and Apple Health Core Connections (Foster Care) have Smoking and Tobacco Cessation Programs that have health coaches who will provide support to our members who are ready to quit smoking, vaping, or chewing tobacco which can be harmful to their health. AHCC (Foster Care) Tobacco Cessation Program also offers customized help for teens wanting to quit.

We accept referrals from our members and providers via phone or e-mail.

Washington Apple Health (Medicaid):
Toll-Free: 1-866-274-5791
E-mail: caremanagement@coordinatedcarehealth.com

Apple Health Core Connections (Foster Care):
Toll-Free: 1-844-882-3827
E-mail: ahccteam@coordinatedcarehealth.com

Puff Free Pregnancy Program - Start Smart for Your Baby:
Case Management and support for our member’s pregnancy includes smoking cessation assistance.
E-mail: WASSFB@centene.com
Resources to quit smoking:  Start Smart for Your Baby - Resources

Tobacco Cessation/Smoking Deterrent Medications:
Coordinated Care (Apple Health) Preferred Drug List (PDF)
Coordinated Care (Apple Health Expansion) Preferred Drug List (PDF)

Telehealth:
More information

Apple Health (Medicaid) After-Pregnancy Coverage (APC)

Apple Health (Medicaid) After-Pregnancy Coverage (APC) offers services to help your patient recover mentally, physically, and emotionally after a pregnancy that occurred in the last 12 months.

Benefits and Services

APC offers postpartum follow-up care and provides additional services including dental, contraception, preventive care, behavioral health, and other services covered by Apple Health up to 12 months after your pregnancy ends. Encourage your patient to visit this page to learn what services are covered under Apple Health and sign up for an extra 12 months of post-partum coverage.

Ask your patient: Are you pregnant and already have Apple Health coverage?

• If you have coverage through Washington Healthplanfinder, report your pregnancy at wahealthplanfinder.org for a smooth transition to APC coverage.
• If you are covered by Apple Health Classic Medicaid (age 65 or older, have blindness or a disability) report your pregnancy through Washington Connection.

Ask your Patient: Were you pregnant in the last 12 months and don’t have Apple Health coverage?

• Online: Go to wahealthplanfinder.org - select the "Apply Now" button.
• Phone: Call the Washington Healthplanfinder at 1-855-923-4633.
• Paper: Download the application here.

Childhood Lead Poisoning Prevention/Lead Poisoning Testing - EPSDT

All children 12 – 24 months of age should be tested for the risk of lead poisoning. This testing is a Federally mandated preventative health benefit.

For more information, please visit the Department of Health’s website.

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.

RadMD Webinar

Please join us on April 30th at 12pm PST

Coordinated Care is pleased to be hosting a RadMD webinar. Our partners with RadMD will be walking through the RadMD/Evolent portal and providing education on getting started and using the portal.

Register here.

Back to Top

______________________________________________________________________________________

Quality

Medicaid Quality

ASAM Criteria 4th Edition – Training Opportunities FAQ

The Adult ASAM Criteria 4th Edition has been released.  The ASAM Criteria is the most widely used and comprehensive set of guidelines for placement, continued stay, and transfer/discharge criteria for individuals with substance use disorder and co-occurring conditions.

From the Washington State Health Care Authority: Currently the updated ASAM is scheduled to be adopted in January of 2026. Our agency is aware and watching SB 5361 which would delay the adoption date.

Thanks to legislative support and State Opioid Response dollars, we have partnered and contracted with Train for Change to offer an array of free training opportunities virtually over the next 18 months.  Although many opportunities will be offered, we recognize that this training effort may not meet the need fully in our state. Individuals are welcome to seek out their own training if it meets their needs.

About the ASAM Criteria 4th Edition trainings

The trainings will be offered virtually, via Zoom between July 2024 and January 2026. While there is no cost for the trainings, participants must purchase The ASAM Criteria 4th Edition book or online version.

• NAADAC CEUs are offered for completing the trainings.

The trainings are offered in three tiers:

• Tier 1 is called The Evolution of The ASAM Criteria: What’s New in the Fourth Edition.  This is a great training for a broad audience who works in the field and wants a consolidated overview of the ASAM updates. The tier 1 training is for anyone and everyone in the behavioral health field.
• Tier 2 is a prerequisite for the tier 3 training and is called Two-day ASAM Criteria Fourth Edition Skill-building Training. The tier 2 training will benefit clinicians who are newer to the field or are SUDPTs who would benefit from an in-depth course.
• Tier 3 is called Implementation, Improvement, Sustainability and Coaching of the ASAM Criteria, A “How To,” Science Based Approach. The tier 3 training is designed for clinical supervisors, directors, administrators, and decision makers who play a key role in implementation and ongoing support of adopting the changes within their organization.

Who is eligible for training?

The following specialties are eligible for the new ASAM trainings:

• SUDPs/SUDPTs
• Licensed mental health counselors, marriage and family therapists, and social workers working in SUD BHA settings (including licensed associates level)
• Co-occurring enhanced specialists
• Payors (utilization management staff employed by MCOs, BH-ASOs, and fully insured plans)
• Tribal partners, tribal providers
• Prescribers (ARNPs, MDs, PAs)

How do I sign up for ASAM trainings?

• Check to make sure that you are registered on the same computer that you will attend the training on.
• Read through the 4th Edition ASAM training manual FAQ (PDF)
• Select the training that you want to attend.
• Click on the link for the training that you want to attend.
• Sign up using the email address for the location where you will attend the virtual training.
• Once registered, you will receive an email confirmation.

An important note about trainings:

ASAM Criteria 4th edition training will be ongoing.  More dates and times will be offered.

Cultural Humility Training

Provider reminder to please take Annual Cultural Humility Training:

There are multiple cultures interacting in every clinical encounter, including:

• Physician’s culture
• Patient’s culture
• Culture of each person that interacts with the patient from the office staff to nurses to the health plan

Cultural Humility May Improve Patient Care By:

• Improving health outcome of the patient when healthcare beliefs and cultural background are taken into consideration
• Building trust
• Increasing confidence, satisfaction, and follow-up
• Increasing patient and health plan retention

Access Free Accredited On-Demand Cultural Humility and Unconscious Bias in Healthcare Training at Centene Institute: 

After Completion, Participants will be able to:

• Define unconscious bias and its impact on patient health outcome 
• Analyze how cultural humility can improve patient care, safety, and experience
• Explore the intersectionality between unconscious bias, cultural humility, and health equity
• Obtain Free Credit:
• Attendance Credit 0.50 Credit (0 hour and 30 minutes)
• ANCC 0.50 Credit (0 hour and 30 minutes)
• IPCE 0.50 Credit (0 hour and 30 minutes)
• AMA PRA Category 1 Credit(s)™ 0.50 Credit (0 hour and 30 minutes)

How to Access Free Accredited On-Demand Training at Centene Institute:

1. Visit CenteneInstititute.com
2. Create New Account
3. Start Your Learning

How to Enroll in Courses:

• Click on “Enroll Now” to access the course of your choice.
• Complete the course and receive attendance credit for free.
• For Help with Courses, Email: Centene_Institute@centene.com
• View the complete Catalog

About our new NOP Report

The Notification of Pregnancy (NOP) is an essential component of complete prenatal care for patients, helping to identify risk factors as early in pregnancy as possible, and establishing a relationship between the patient, provider, and health plan team.

By collating NOPs completed by our care management team, claims and lab data, we can identify members who are pregnant or likely pregnant and could benefit from a prenatal visit. To support our providers, we have established a real-time NOP reporting process through our Provider Analytics Portal.

Benefits of Using the New Report for Patients and Providers

Patients who complete the NOP are three times more likely to be compliant with prenatal care and are less likely to have low-birth-weight babies.

Helps providers and payers to meet the HEDIS^® Prenatal Postpartum Care (PPC) Timeliness measure, which tracks the percentage of deliveries where patients had a prenatal care visit in the first trimester, on or before the enrollment start date or within 42 days of enrollment with their health plan.

What’s included in the Report

The Provider Analytics NOP report provides the following information when available:  Date the member was identified as pregnant.

Estimated date the member is due to give birth.

Member’s name, date of birth, address, phone number, race, ethnicity and primary language. Member’s Care Manager, the identified PCP and OBGYN, including their contact information.

This new report is updated daily within Provider Analytics, and your health plan partners can help address any questions you may have.

Key Features:

• Immediate access from the secure portal home page
• Simple user interface
• Daily updates
• Last refresh date is shown
• Links to communications and educational materials

How to access the Provider Analytics Notification of Pregnancy (NOP) Report

• Begin by logging in to our secure Provider Portal
• Next, click on the Provider Analytics link: From the Provider Analytics page, select Notice of Pregnancy to access the report. See Reference Materials and Data Dictionary for additional information.

Upper Respiratory Infection Resources

According to the CDC 30% of outpatient antibiotic prescriptions in the US are unnecessary.  Approximately half of outpatient antibiotic prescribing in humans may be inappropriate.  Patients who are unnecessarily exposed to antibiotics are placed at risk for those adverse events with no benefit. By reducing unnecessary antibiotic prescribing, antimicrobial stewardship programs can prevent avoidable adverse events resulting from antibiotics.

Clinician Checklist for Outpatient Antibiotic Stewardship (PDF)

Facility Checklist for Outpatient Antibiotic Stewardship PDF

Core Elements of Antibiotic Stewardship for Nursing Homes PDF

Source

Lead Poisoning Screening

Federal law mandates that all children enrolled in Medicaid are required to get blood lead tests at ages 12 and 24 months.

For more information, visit doh.wa.gov/lead

Asthma and 90 Day Refills

Moving members with asthma prescriptions to 90-day medication refills may increase their maintenance medication adherence.

The Importance of Depression Screening

Depression is one of the leading causes of disability across the world. ¹ The earlier depression is detected, the earlier it can be treated. Research shows when collaboration occurs between primary, OB/GYN and behavioral health care to screen for depression, monitor symptoms, and provide or refer for treatment, patient outcomes improve. Perinatal depression refers to minor and major depression episodes during pregnancy and/or the first 12 months after childbirth and is a common condition that affects functional outcomes both for affected women and for their families. ²

Provider Tips

Ensure all staff understand the importance of and are well versed in strategies to engage patients on completing and understanding the screening tools. Offer to assist patients with low health literacy on completing the questionnaire. Whenever possible, ensure depression screening and treatment are culturally appropriate and offered in the patient’s first language. Screen patients at new visits, on an annual basis at well care visits, or when clinically indicated. Discuss the results and address any questions or concerns during the appointment and work with a care team to coordinate follow-up care for members with a positive screening.

Develop a workflow to identify the PHQ-9 score that requires intervention in your setting. Question nine on the screening tool needs special consideration as it is a screening for suicidal symptoms. Have a standard workflow in place for patients answering yes regarding suicidal ideation. Have staff and treatment plans in place for these patients. Ensure all services conducted during the visit are coded appropriately, including the depression screening LOINC codes. All primary care, maternity care, allied health, and public health professionals seeing individuals in the perinatal period should use the Edinburgh Postnatal Depression Scale (EPDS) to screen for depression. Scores 13 and above indicate an 80% chance that the mother has depression. 3

Measures

• Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E)
• Depression Screening and Follow-Up for Adolescents and Adults (DSF-E)
• Depression Remission or Response for Adolescents and Adults (DRR-E)
• Prenatal and Postpartum Depression Screening and Follow-Up (PND-E and PDS-E)

Additional Support:

• Substance Abuse and Mental Health Services Administration (SAMHSA): www. samhsa.gov
• National Institute for Mental Health: www.nimh.nih.gov/
  

Sources:

¹ WHO Depressive disorder (depression)

² NCQA Depression Screening and Follow-Up for Adolescents and Adults (DSF-E)*

³ Edinburgh Postnatal Depression Scale

This document is an informational resource designed to assist licensed healthcare practitioners in caring for their patients. Healthcare practitioners should use their professional judgment in using the information provided. HEDIS® measures are not a substitute for the care provided by licensed healthcare practitioners and patients are urged to consult with their healthcare practitioner for appropriate treatment. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

This document is an informational resource designed to assist licensed healthcare practitioners in caring for their patients. Healthcare practitioners should use their professional judgment in using the information provided. HEDIS® measures are not a substitute for the care provided by licensed healthcare practitioners and patients are urged to consult with their healthcare practitioner for appropriate treatment. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Closing the Gap on Follow-up Care After Discharge

Help patients get mental health services within 7 days after discharge

Primary care and mental health providers play an important role and can help patients receive appropriate follow-up care after discharge from an emergency room or acute hospitalization for a mental health (MH) diagnosis.

How Outpatient providers can help:

• Complete comprehensive assessments and evidence-based screening tools (i.e., PHQ-9, GAD-7) and know when to refer the patient to a behavioral health specialist.
• Ensure flexibility and appointment availability for patients who are being discharged from ED and acute hospital stays; the appointment should be scheduled within seven days of discharge. If a situation arises where a patient is unable to be seen within 7 days, you can schedule an appointment within 30 days of discharge.
• Reminder calls to members prior to appointment and after a missed appointment to reschedule.
• Review medications with patients to ensure they understand the purpose, appropriate frequency, and method of administration.
• Educate office staff on local resources to assist with barriers such as lack of food, housing, and transportation needs.
• Educate patients and family on the signs and symptoms of anxiety and when to call you, the nurse advice line, or go to the emergency room.
• Establish communication pathways with inpatient discharge coordinators at local facilities.
• Submit claims in a timely manner with appropriate diagnoses, procedure and place of service codes.
• Offer psychiatric collaborative care, peer services and telehealth visits.

 Example of aftercare services:

• Medication Management with a Psychiatrist/ARNP/PA with a mental health license or certificate
• Individual Therapy in the home or office in accordance with program specifications
• Electroconvulsive Therapy (ECT)
• Intensive Outpatient Program (IOP) or Partial Hospitalization Program (PHP)
• Mental Health and/or Substance Use Assessments, Screenings, Treatment Planning
• Community-Based Wrap-Around and/or Day Treatment Services
• Telehealth Services with a mental health provider or with any diagnosis of mental health disorder
• Psychiatric Collaborative Care Management
• Psychiatric Residential Treatment
• Peer Services with any diagnosis of mental health disorder

Outpatient visits with any diagnosis of mental health disorder. In previous years, the visit had to be done with a mental health provider, beginning in 2025, only a mental health diagnosis is required for the outpatient visit.

What’s new for 2025:

After discharge from inpatient mental health stays:

• Follow-up appointment focus is now on mental health services rather than on the specialty of the provider delivering the service
• Mental health services conducted by medical providers and mental health providers count toward adherence using qualified billing and diagnostic codes
• Mental health condition diagnosis is required

After discharge from inpatient or emergency room stays

• Peer support and residential treatment services are now included

Wellcare Quality

The Office of Disease Prevention and Health Promotion (ODPHP) deems March 2025 as National Nutrition Month^®. OASH has collected a variety of resources professionals can use to help older adults build and sustain healthy eating habits.

Dietary Guidelines for Americans: Build a Healthy Eating Routine

ODPHP’s healthy eating fact sheet for older adults, Build a Healthy Eating Routine as You Get Older, is a great place to start. Based on the latest edition of the Dietary Guidelines for Americans, this resource features practical tips to help older adults choose a mix of healthy foods, find out how many calories they need, and more. Check out the Build a Healthy Eating Routine fact sheet in English here (PDF) and Spanish here (PDF).

MyPlate Resources for Older Adults

MyPlate’s Older Adults webpage highlights the unique nutrition needs of people age 60 years and older. Topics like healthy eating on a budget, dietary supplements, and food safety are included. Use of the MyPlate’s interactive resources, older adults can build their own healthy eating plans, set personalized goals with the Start Simple with MyPlate app, or even program their smart home devices to share healthy eating tips with MyPlate on Alexa. Explore MyPlate’s Older Adults webpage here.

Explore more healthy eating resources

If you’re a health professional who works with older adults, don’t miss out on these resources — based on the Dietary Guidelines for Americans — that cover topics relevant to older adults’ nutritional needs:

• Talk to Your Patients and Clients About Healthy Eating Routines: This fact sheet (PDF) offers simple questions that you can use to start the conversation about healthy eating routines, along with strategies to address common barriers that people of all ages may experience.
• Make Healthy Drink Choices: Fact sheet here (PDF) Taking in too many calories from drinks can make it hard to stay at a healthy weight — even more so as we age. Share this fact sheet to help older adults make healthy drink choices.
• Cut Down on Added Sugars, Sodium, and Saturated Fat: (resources found here) You can share these materials to help older adults lower the amount of added sugars, sodium, and saturated fat in their diet.  

Food Assistance Resources for Older Adults

Access to nutritious foods is a key social determinant of health — and a major area of focus for Healthy People 2030.   Authorized under the Older Americans Act (OAA), Congregate Nutrition Services and Home-Delivered Nutrition Services provide meals to people age 60 years and older and their spouses of any age. Congregate Nutrition Services also offers opportunities for older adults to socialize in community settings like senior centers, schools, and churches as they enjoy a meal together. Learn more about Congregate Nutrition Services and Home-Delivered Nutrition Services here.

The U.S. Department of Agriculture (USDA) offers several programs that can help people age 60 years and older access a variety of healthy foods. For example, the Senior Farmers’ Market Nutrition Program (SFMNP) helps older adults with lower incomes afford locally grown fruits and vegetables. Learn more about USDA food assistance programs for older adults here.

For many people experiencing food insecurity — including older adults — the process of enrolling in food assistance programs can be a barrier to access. The National Council on Aging (NCOA) created the Senior SNAP Enrollment Initiative to help older adults enroll in the Supplemental Nutrition Access Program (SNAP), the largest food assistance program in the U.S. Get the details about the Senior SNAP Enrollment Initiative here.

Back to Top

______________________________________________________________________________________

Tribal

Resource for Assistance

IHCPs have access to a dedicated email inbox for inquires regarding all lines of business at Coordinated Care (Medicaid, Marketplace/Exchange, and Medicare Advantage). Please don’t hesitate to reach out to IndianHealthCareProviderAssistance@coordinatedcarehealth.com and the team monitoring the inbox will assist or connect you with the appropriate contacts to resolve your questions.

Back to Top

______________________________________________________________________________________

Clinical Policy Updates

The below policies were updated as part of our regular monthly review in
February. The policy changes are effective April 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.36	Experimental Technologies	Ambetter
WA.CP.MP.36	Experimental Technologies	Apple Health
CP.MP.130	Fertility Preservation	Ambetter
CP.MP.40	Gastric Electrical Stimulation	Apple Health & Ambetter
CP.MP.113	Holter Monitors	Apple Health & Ambetter
CP.MP.86	Neonatal Abstinence Syndrome Guidelines	Apple Health & Ambetter
CP.MP.85	Neonatal Sepsis Management Guidelines	Apple Health & Ambetter
CP.MP.141	Non-Myeloablative Allogenic Stem Cell Transplants	Apple Health & Ambetter
CP.MP.102	Pancreas Transplantation	Apple Health & Ambetter

The below policies were updated as part of our regular monthly review in December. The policy changes are effective July 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.BH.104	Applied Behavior Analysis	Apple Health & Ambetter
CP.BH.105	Applied Behavioral Analysis Documentation Requirements	Apple Health & Ambetter
WA.CP.MP.515	Fecal Microbiota Transplantation	Apple Health
CP.MP.121	Homocysteine Testing	Apple Health & Ambetter
CP.MP.82	NICU Apnea Bradycardia Guidelines	Apple Health & Ambetter
CP.MP.81	NICU Discharge Guidelines	Apple Health & Ambetter
WA.CP.MP.526	Stem Cell Therapy for Musculoskeletal Conditions	Apple Health
CP.MP.162	Tandem Transplant	Apple Health & Ambetter
WA.CP.MP.510	Tinnitus Treatment	Apple Health
CP.MP.163	Total Parenteral Nutrition and Intradialytic Parenteral Nutrition	Apple Health & Ambetter

The below policies are new effective July 1, 2025. You will find the policies posted on the policy Web site.

Policy Number	Policy Title	Line of Business
WA.CP.MP.510	Tinnitus Treatment	Ambetter
WA.CP.MP.526	Stem Cell Therapy for Musculoskeletal Conditions	Ambetter
WA.CP.MP.515	Fecal Microbiota Transplantation	Ambetter

The below policies will be archived effective March 31, 2025.

Policy Number	Policy Title	Line of Business
WA.CP.MP.130	Fertility Preservation	Apple Health
CP.MP.209	Gastrointestinal Pathogen Nucleic Acid Panel Testing	Apple Health & Ambetter
CP.MP.136	Home Births	Apple Health & Ambetter
CP.MP.150	Phototherapy for Neonatal Hyperbilirubinemia	Apple Health & Ambetter
CP.MP.181	Polymerase Chain Reaction Respiratory Viral Panel Testing	Apple Health & Ambetter
CP.MP.97	Testing for Select Genitourinary Conditions / Diagnosis of Vaginitis	Apple Health & 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
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
CP.MP.62	Hyperhidrosis treatments	5/1/25	Apple Health & Ambetter
CP.MP.107	Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines	5/1/25	Apple Health & Ambetter
CP.MP.180	Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea	5/1/25	Ambetter
WA.CP.MP.237	CG Oncology Algorithmic Testing	5/1/25	Apple Health
WA.CP.MP.219	CG Genetic Testing Exome and Genome Sequencing	5/1/25	Apple Health
V1.2025	Concert Genetics Policies	5/1/25	Apple Health & Ambetter

 

Back to Top

______________________________________________________________________________________

Pharmacy

Medical Oncology Update- Ambetter

Prior Authorization requests for the following HCPCS codes need to be verified by Evolent.

HCPCS	Generic Name	Brand Name	Medical PA	Pharmacy PA	Impact Description
J9181	ETOPOSIDE PHOSPHATE INJECTION	ETOPOPHOS	Yes	n/a	New brand added 2/11/2025
J9999	NIVOLUMAB AND HYALURONIDASENVHY INJECTION	OPDIVO QVANTIG	Yes	Yes	Effective 7/1/25

Participating providers should submit oncology/supportive drug authorization for members through Evolent.

April 1, 2025 Preferred Drug List Changes- Medicaid

Effective April 1, 2025, the drugs listed below will be non-preferred. Suggested preferred alternatives are listed in the last column. Please note that impacted members will be notified prior to the change.

Drug Class	Drug Name	Preferred Alternative(s)
ANTIDIABETICS : INSULIN - LONG ACTING	BASAGLAR KWIKPEN U-100 BASAGLAR TEMPO PEN U-100	INSULIN GLARGINE-YFGN OR LANTUS SOLOSTAR
ANTIDIABETICS : INSULIN - LONG ACTING	LEVEMIR	INSULIN GLARGINE-YFGN OR LANTUS
ANTIDIABETICS : INSULIN - LONG ACTING	LEVEMIR FLEXPEN	INSULIN GLARGINE-YFGN OR LANTUS SOLOSTAR
ANTIDEPRESSANTS : TRICYCLIC AGENTS	AMOXAPINE TABLETS	AMITRIPTYLINE HCL TABLETS, CLOMIPRAMINE HCL CAPSULES, DESIPRAMINE HCL TABLETS, DOXEPIN CAPSULES, IMIPRAMINE HCL TABLETS, OR NORTRIPTYLINE HCL CAPSULES

Significant Change to Humira (adalimumab) Coverage Effective 04/01/2025-Medicaid

Effective  April 1, 2025 Washington Apple Health (Medicaid) will make a significant change to the preferred products in the Cytokine and CAM Antagonist drug class. Brand name Humira products will no longer be preferred. Select adalimumab biosimilars (see included list for specific products), Enbrel, Enbrel Sureclick and Spevigo will be the preferred products in this class.

This change will apply to all agency-contracted managed care organizations (MCOs) and the fee-for-service (FFS) program per the Apple Health PDL. For questions about the Apple Health PDL, please email applehealthpharmacypolicy@hca.wa.gov.

Preferred adalimumab biosimilars

Product ID	Label Name	Generic Name	Strength	Dosage Form
72606002206	ADALIMUMAB-AATY(CF)	ADALIMUMAB-AATY	40MG/0.4ML	SYRINGEKIT
72606004101	ADALIMUMAB-AATY(CF)	ADALIMUMAB-AATY	20MG/0.2ML	SYRINGEKIT
72606002210	ADALIMUMAB-AATY(CF) AUTOINJ(2)	ADALIMUMAB-AATY	40MG/0.4ML	AUTOINJKIT
72606002209	ADALIMUMAB-AATY(CF) AUTOINJECT	ADALIMUMAB-AATY	40MG/0.4ML	AUTOINJKIT
72606004004	ADALIMUMAB-AATY(CF) AUTOINJECT	ADALIMUMAB-AATY	80MG/0.8ML	AUTOINJKIT
61314032764	ADALIMUMAB-ADAZ(CF)	ADALIMUMAB-ADAZ	40MG/0.4ML	SYRINGE
61314032720	ADALIMUMAB-ADAZ(CF) PEN	ADALIMUMAB-ADAZ	40MG/0.4ML	PEN INJCTR
00597055580	ADALIMUMAB-ADBM(CF)	ADALIMUMAB-ADBM	20MG/0.4ML	SYRINGEKIT
00597056520	ADALIMUMAB-ADBM(CF)	ADALIMUMAB-ADBM	40MG/0.4ML	SYRINGEKIT
00597058589	ADALIMUMAB-ADBM(CF)	ADALIMUMAB-ADBM	10MG/0.2ML	SYRINGEKIT
00597059520	ADALIMUMAB-ADBM(CF)	ADALIMUMAB-ADBM	40MG/0.8ML	SYRINGEKIT
00597057550	ADALIMUMAB-ADBM(CF) PEN	ADALIMUMAB-ADBM	40MG/0.4ML	PEN IJ KIT
00597054566	ADALIMUMAB-ADBM(CF) PEN CROHNS	ADALIMUMAB-ADBM	40MG/0.8ML	PEN IJ KIT
00597057560	ADALIMUMAB-ADBM(CF) PEN CROHNS	ADALIMUMAB-ADBM	40MG/0.4ML	PEN IJ KIT
00597054544	ADALIMUMAB-ADBM(CF) PEN PS-UV	ADALIMUMAB-ADBM	40MG/0.8ML	PEN IJ KIT
00597057540	ADALIMUMAB-ADBM(CF) PEN PS-UV	ADALIMUMAB-ADBM	40MG/0.4ML	PEN IJ KIT
00597054522	ADALIMUMAB-ADBM(CF)PEN	ADALIMUMAB-ADBM	40MG/0.8ML	PEN IJ KIT
00597037082	CYLTEZO(CF)	ADALIMUMAB-ADBM	40MG/0.8ML	SYRINGEKIT
00597040089	CYLTEZO(CF)	ADALIMUMAB-ADBM	10MG/0.2ML	SYRINGEKIT
00597040580	CYLTEZO(CF)	ADALIMUMAB-ADBM	20MG/0.4ML	SYRINGEKIT
00597048520	CYLTEZO(CF)	ADALIMUMAB-ADBM	40MG/0.4ML	SYRINGEKIT
00597037597	CYLTEZO(CF) PEN	ADALIMUMAB-ADBM	40MG/0.8ML	PEN IJ KIT
00597049550	CYLTEZO(CF) PEN	ADALIMUMAB-ADBM	40MG/0.4ML	PEN IJ KIT
00597037516	CYLTEZO(CF) PEN CROHN'S-UC-HS	ADALIMUMAB-ADBM	40MG/0.8ML	PEN IJ KIT
00597049560	CYLTEZO(CF) PEN CROHN'S-UC-HS	ADALIMUMAB-ADBM	40MG/0.4ML	PEN IJ KIT
00597037523	CYLTEZO(CF) PEN PSORIASIS-UV	ADALIMUMAB-ADBM	40MG/0.8ML	PEN IJ KIT
00597049540	CYLTEZO(CF) PEN PSORIASIS-UV	ADALIMUMAB-ADBM	40MG/0.4ML	PEN IJ KIT

Implementation of Health Care Authority Quantity Limits Effective 04/01/2025- Medicaid

Effective April 1, 2025, Coordinated Care will be implementing the Health Care Authorities’ quantity limits which will include daily dose, quantity vs time, and fill limits. Below are the drugs that will have the highest impact related to quantity limit updates. Quantity limits effective 04/01, will be posted on the Coordinated Care (Apple Health) Preferred Drug List (PDF).

Top 10 Impacted Drugs for Daily Dose Updates

Drug Name	New Daily Dose
Methocarbamol Tablet 500MG	8 Tablets
Methocarbamol Tablet 750MG	6 Tablets
Tizanidine Tablet 2MG	4 Tablets
Sumatriptan Tablet 50MG	2 Tablets
Baclofen Tablet 5MG	4 Tablets
Baclofen Tablet 10MG	4 Tablets
Azathioprine Tablet 50MG	1 Tablet
Duloxetine Capsule 20MG	2 Capsules
Duloxetine Capsule 30MG	2 Capsules
Clobazam Tablet 10MG	2 Tablets

Top 5 Impacted Drugs for Quantity vs Time (QVT) Updates

Drug Name	Quantity vs Time Updates
Estradiol TD Patch Biweekly 0.1 MG/24HR	8 per 28 days
Estradiol TD Patch Biweekly 0.075 MG/24HR	8 per 28 days
Estradiol TD Patch Weekly 0.1 MG/24HR	4 per 28 days
Estradiol TD Patch Weekly 0.025 MG/24HR	4 per 28 days
Scopolamine TD Patch 72HR 1 MG/3DAYS	10 per 30 days

Top 10 Impacted Drugs for Fill Limit Updates

Drug Name	Fill Limit
Fluconazole Tablet 150mg	2 Fills per 30 Days
Methocarbamol Tablet 750mg	2 Fills per 30 Days
Ondansetron Tablet 4mg ODT	2 Fills per 30 Days
Gabapentin Capsule 300mg	2 Fills per 30 Days
Colchicine Tablet 0.6mg	2 Fills per 30 Days
Hydroxyzine HCL Tablet 25mg	2 Fills per 30 Days
Hydroxyzine Pam Capsule 50mg	2 Fills per 30 Days
Oxycodone Tablet 5mg	4 Fills per 30 Days
Cyclobenzaprine Tablet 10mg	2 Fills per 30 Days
Acetaminophen Tablet 500mg	2 Fills per 30 Days

Fill Limits Exceeded Additional Information

If a fill limit is exceeded, the medication may be overridden at point of sale for more fills than the allowable fill limit under the following circumstances: 

• The prescription is written for a short days-supply because the prescriber is monitoring the member’s supply 
• The member needs a take-home supply of medication for school, camp, or skilled nursing facility.

For any other circumstance, the provider must acknowledge monitoring and provide justification that it is medically necessary for needing more than the allowable fill limit.  

Back to Top
______________________________________________________________________________________

Apple Health Core Connections (AHCC)

The Washington State Department of Children, Youth, and Families (DCYF) has updated its Mandatory Reporter training to help distinguish between families needing support vs. child abuse and neglect. This training was updated with input from a wide variety of community stakeholders, including the medical community. 

What is a mandated reporter? Mandated Reporters are people who are legally required to report child abuse or neglect. This includes medical practitioners, nurses, dentists, psychologists, medical examiners, pharmacists, social service counselors/therapists, and more. Visit the DCYF Mandated Reporter webpage here for more info.

Additional trainings and resources regarding mandated reporting:

1. The Alliance for Professional Development, Training, and Caregiver Excellence through the University of Washington (Free)
2. Build Initiative (Free)

 

Back to Top
______________________________________________________________________________________

Training/Education

Trauma-Focused Cognitive Behavioral Therapy

Coordinated Care is providing a no-cost Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) training for contracted, in-network providers and Indian Health Care Providers. This training will be held on Wednesday, May 14 and Thursday, May 15, 2025, from 8:30 a.m. to 5:00 p.m. each day at Spokane Falls Community College, 3410 W Whistalks Wy, Spokane WA 99224 in the Multipurpose Conference Room #102/3/4.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based treatment for children and adolescents impacted by trauma that includes participation by their parents or caregivers. Research shows that TF-CBT successfully resolves a broad array of emotional and behavioral difficulties associated with single, multiple and complex trauma experiences.

There are two pre-training requirements which will need to be completed by Friday, May 2nd in order to participate in this training. Register here.

Cultural Care & Connection - 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. Host by Alliance CaRES April 2, 2025 6:00 PM. Register here.

Supporting LGBTQIA+ Youth in Foster Care - This curriculum was developed through Amara with input from Coordinated Care and guidance from many community organizations. This training is for caregivers and professionals who work in the child welfare setting. April 16, 2025 10:00 AM. Register here.

Suicide Prevention - Provides an overview of the topic of suicide, signs and symptoms, and how caregivers should respond in times of crisis. The training will dive into the rates of youth suicide, risk factors, and proactive steps to take for prevention. April 17, 2025 10:00 AM. Register here.

Secondary Traumatic Stress and Self-Care - Caring for children who have experienced trauma can be difficult, draining, exhausting, and frustrating. This training will help caregivers and service providers to understand the differences between Secondary Traumatic Stress, Compassion fatigue and Vicarious trauma. Participants will also be able to recognize warning signs and personal triggers, as well as understand why self-care is important and develop a personal self-care plan. April 22, 2025 11:00 AM. Register here.

Working with Families of Origin - The relationship between foster parents and birth parents can play a key role in successful reunification. In 2013, 57% of youth in foster care in Washington State were reunified. It is critical that foster parents have the skills to communicate effectively with birth parents. This training will focus on building communication skills and enhance the participants’ understanding of the impact of trauma on parenting, and the birth parent grief process. April 24, 2025 3:00 PM. Register here.

Cultural Care & Connections - This presentation addresses the need to keep children connected to their culture of origin while in foster and adoptive care. It covers the importance of acknowledging cultural differences when working or living with a child of a different race or family background. This training strives to provide insight on how attendees can recognize different values, beliefs, behaviors, communication variations and potential barriers within themselves and youth. April 3, 2025 1:00-2:35 PM. Register here.

TIC: 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 connection and even placement disruption. This training offers a Trauma refresher overview and ideas into helping the child manage their reactions and behaviors. Developed by the National Child Traumatic Stress Network (NCTSN).  April 7, 2025 6:00–8:00 PM. Register here.

Attachment: Beyond Infancy - This is an in-person training event sponsored by Excelsior and Coordinated Care on April 9, from 5:30 to 8:00pm (includes free dinner) in Spokane, WA at the Excelsior Wellness Campus.  It is open to providers, caregivers and anyone who may be interested in the topic, or who works with youth with a background of trauma. Training certificate is available if needed.  Please contact Zia.Freeman@coordinatedcarehealth.com for the full flyer and more information, or register here.

Attachment: Beyond Infancy - Attachment is the foundation of all relationships, and when caring for children with a history of trauma and trust issues, it does not always occur easily. Attachment issues are often a core reason why caretakers and children have challenges in placement and/or disrupt from the home. This training addresses the need for Attachment-Focused care, including some practical tips on how to strengthen bonding to children. April 10, 2025 6:00–8:00 PM. Register here. 

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. April 15, 2025 12:30–2:05 PM. Register here.

Back to Top