November 2024 Provider News

Date: 11/27/24

In this issue:

General Updates - Marketplace – PY 2025 Benefit Coverage Updates, Joint MCO Live Training Sessions for Apple Health (Medicaid) Providers, Ambetter from Coordinated Care introducing Availity Editing Services, Hepatitis C, Childhood Lead Poisoning Prevention, Syphilis Prevention, APC - after pregnancy coverage available
Quality - Influenza Vaccine Recommendation, Well Child Visits, CPT II coding
Tribal - Celebrating Native American Heritage Month
Payment & Clinical Policy - Monthly Updates
Pharmacy Updates - Synagis 2024/2025 Season, RSV Vaccines for Older Adults, January 1, 2025 Preferred Drug List (PDL) Changes
Wellcare - Wellcare Provider Guides Updated for 2025
Apple Health Core Connections - Interim Voucher Information
Training/Education - Monthly Training Opportunities

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General Updates

Marketplace – PY 2025 Benefit Coverage Updates

New Telehealth Vendor Partners: MD Live & Brightside
- Note: Our contract with Teladoc continues.
Prescription drug continuity of coverage for non-preferred drug prescription refill for an antipsychotic, antidepressant, antiepileptic or other drug prescribed to treat a serious mental illness aligns with Washington Senate Bill 5300.
In accordance with Washington Senate Bill 5986, balance billing is prohibited for ground ambulance services within Washington state. Until December 31, 2027, the allowed amount for out-of-network ground ambulance transports on of the following amounts:
- the locally set rate,
- where no local rate exists, the lesser of 325% of current Medicare rate or the ground ambulance’s billed charges.
In accordance with Washington Senate Bill 6127, benefits for prescribed HIV postexposure prophylaxis medication (at least one covered regimen recommended by the Centers for Disease and Prevention (CDC)) are covered without cost sharing and does not require prior authorization.
In accordance with Washington House Bill 1979, benefits for:
- Asthma inhalers (at least one covered inhaled corticosteroid and at least one inhaled corticosteroid combination product) are covered with a maximum Cost Share of $35 per 30-day supply, not subject to Deductible.
- Epinephrine autoinjectors (at least one covered epinephrine autoinjector product containing at least two autoinjectors) are covered with a maximum Cost Share of $35, not subject to Deductible.
In accordance with Washington Senate Bill 6228, coverage for inpatient and residential substance use disorder treatment will be provided for no less than 14 days from the date of admission for the initial authorization approved by us. Subsequent authorizations approved by us will be provided for no less than 7 days prior to requiring additional utilization review by our staff.
Inpatient and outpatient benefits will be provided for up to two months for Medically Necessary pasteurized donor human milk when prescribed by an infant’s pediatrician or licensed pediatric provider stating that the infant is medically or physically unable to receive maternal human milk or participate in breastfeeding or the infant’s mother is medically or physically unable to produce maternal human milk in sufficient quantities.
Allergy testing, injections and serum are covered.
Penile prostheses, when not medically necessary, is an excluded benefit.
Excluded Transplant Benefits (newly added or clarified):
- Trailer or truck rental (unless pre-approved by us).
- Parking (unless pre-approved by us).
- Loss of wages due to time off from work required for transplant for recipient, donor, or companion(s).
- Moving violations tickets or parking tickets.
- Any services related to pet care, boarding, lodging, food, and/or travel expenses.
- Expenses for persons other than the transplant recipient, donor or their respective companion(s).
- Expenses for lodging when the transplant recipient, donor or their respective companion(s) is staying with a relative, friend or otherwise have free lodging.
- Any fuel costs/charging station fees for any vehicle, not related to travel to and from the Center of Excellence or our approved facility when there is no network adequacy. (Note: Mileage is reimbursable.)
- Any tips, concierge, club level floors, and gratuities.
- Salon, barber, and spa services.
- Insurance premiums.
- Cost share amounts owed to the transplant surgeon or facility or other provider.
Private duty nursing is excluded from all places of treatment (i.e. inpatient, outpatient, and home locations).
Prior authorization is required for sick newborns with a complex health condition or when admitted to a Neonatal Intensive Care Unit (NICU).
Definitions for 'mental health disorder' and 'substance use disorder' were updated in the member’s Evidence of Coverage (EOC) to align with federal statutory requirements.

Joint MCO Live Training Sessions for Apple Health (Medicaid) Providers

Washington’s Managed Care Organizations (MCOs) request your participation in 2024 joint Apple Health Integrated Managed Care (IMC) & Medicare Advantage Provider Training. You will hear from Community Health Plan of Washington, Coordinated Care of Washington, Inc., Molina Healthcare of Washington, United Healthcare, and Wellpoint Washington about this training.

Joining one of the training sessions will satisfy your annual attendance requirement under 42 CFR 38.608(a)(1)iv.

Who: Providers servicing Medicaid and Medicare Advantage enrollees.

What is Covered:

Enrollee Rights & Responsibilities
Advanced Directives
Fraud, Waste and Abuse
False Claims Act
Cultural Awareness

Where: Webinar. To register, please use the date specific links below.

When: Please register for one of the below training sessions.

Date	Session	Time
Wednesday, December 11, 2024	Session 1	12:00 PM
Register Here
Thursday, December 12, 2024	Session 2	11:00 AM
Register Here
Friday, December 13, 2024	Session 3	10:00 AM
Register Here
Tuesday, December 17, 2024	Session 4	12:00 PM
Register Here
Wednesday, December 18, 2024	Session 5	11:00 AM
Register Here
Friday, December 20, 2024	Session 6	10:00 AM
Register Here

After the training, you will be asked to complete a short survey, which confirms your participation and provides an opportunity to submit feedback on this presentation.

If you have questions regarding this training requirement, please contact this email: aaron.moore@wellpoint.com

We appreciate your partnership in serving our patients and look forward to your attendance!

Ambetter from Coordinated Care introducing Availity Editing Services

In a continuous effort to make it easier to do business with us, Ambetter by Coordinated Care is introducing Availity Editing Services (AES). Starting Jan. 24, 2025, Centene is partnering with Availity to return rejection messages on its behalf via AES messages. These messages will show in your existing workflows. AES will give you an option, but not a requirement, to edit a claim.

AES can identify a claim error upfront and return a message to you for correction before sending the claim on to the plan to be adjudicated. You should review edit messages for potential corrections to the suggested claim line(s). If you make updates to the claim, this may help the claim process correctly the first time, preventing errors, improving payment accuracy, and claims adjudication turnaround time. If, after reviewing the message, you find it does not apply, please resubmit the claim as-is and this will allow a bypass of the edit in cases where it may not be applicable.

This is not intended as a new method to deny a claim, nor does it bypass or replace downstream edits. If you choose to bypass an edit, it is possible that other downstream edits will still function as normal in our claims systems. Remember to “submit” your claim regardless of your choice to edit or bypass. This action is required in order for the claim to be processed in our systems.

If you have a Practice Management System (PMS), you can locate your edits report within your claims workbasket or que reporting. If you submit claims via the Availity portal, any of these rejections will show on your normal reports.

If you submit claims via Availity, learn how to gather your reporting by joining one of Availity’s free webinars to learn additional tips for streamlining your workflow:

Send and Receive EDI Files – Training Demo
- Link
- This demo shows users where/how they can access reports in Availity Essentials. On these reports are where they would see edits. Please note: this demo does not say/call it AES however, this is the demo that would show the user how to locate the reports.
EDI Reporting Preferences – Training Demo
- Link
- This demo shows users how to setup their EDI Reporting Preferences which needs to be done first by the user’s organization’s Availity Administrator to access the reports in the Send and Receive EDI Files application.

If you need assistance with registering for Availity Essentials, please call Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday, 8 a.m. – 8 p.m. ET. For general questions, please reach out to your Ambetter from Coordinated Care Provider Engagement Representative.

Hepatitis C

Our provider partners are a key stakeholder in the fight to eliminate Hepatitis C in our state!

Coordinated Care would like to remind you that:

Anti-viral MAVYRET can cure Hepatitis C.
These daily pills are allowed for up to a 12-week supply at one time.
- Effective for claims on or after March 1, 2024, the Health Care Authority, Apple Health Fee-For-Service (FFS) has increased the maximum allowable days’ supply for Mavyret (glecaprevir/pibrentasvir).
- Pharmacies may dispense and submit claims for up to a 12-week (84 days) supply of Mavyret in a single fill.
Mavyret is preferred and does not require prior authorization.
- To ensure patients receive the full course of treatment, Mavyret prescriptions should be written in a manner to allow the pharmacy to dispense the entire 8-week or 12-week course of treatment.
- Other anti-viral medications will require review and be approved only if Mavyret is not clinically appropriate.
CDC recommends that all adults 18 years and older be screened for Hep C at least once, as well as pregnant women during each pregnancy.
Injection drug use is the primary risk for Hepatitis C. Any person requesting HCV screening should receive it.
Direct-acting antiviral (DAA) medications can be prescribed for children aged 3 and up.
Patients who have certain liver problems or are taking medicines (atazanavir or rifampin) are not eligible to take MAVYRET.
Anyone licensed to prescribe direct acting anti-viral medications is allowed to screen and treat Apple Health members, including primary care doctors and pharmacists.

Learn more at:

Childhood Lead Poisoning Prevention Program WA DOH

Federal regulations require that all children enrolled in Medicaid receive a blood lead test at 12 and 24 months of age, or at 24 to 72 months of age if no record of a previous test exists. The Department of Health (DOH) recommends screening all children not covered by Medicaid at 12 and 24 months of age using this algorithm (PDF).

More information can be found here.

Reach out with questions here: lead@doh.wa.gov

Syphilis Prevention

What is already known about this topic?

Since 2012, U.S. congenital syphilis cases increased substantially. Syphilis during pregnancy can lead to stillbirth, miscarriage, infant death, and maternal and infant morbidity, which are preventable through appropriate screening and treatment.

What is added by this report?

In 2022, lack of timely testing and adequate treatment contributed to almost 90% of congenital syphilis cases in the United States, including substantial proportions of congenital syphilis cases in all U.S. Census Bureau regions and among all racial and ethnic groups.

What are the implications for public health practice?

Implementing tailored strategies addressing missed opportunities at the local and national levels could improve timeliness of testing and appropriateness of treatment for syphilis during pregnancy and thereby reduce the incidence of congenital syphilis and complications of syphilis during pregnancy.

After Pregnancy Care (APC)

Did you know for Pregnant members active on Apple Health there is 12 months of after pregnancy coverage available.

Individuals who are on an Apple Health program and pregnant must report their pregnancy to HCA and provide an estimated due date.
The transition into APC will be automatic as long as there is an estimated due date reported.
APC will begin the first day of the following month the pregnancy ends.
Coverage is for 12 months regardless of a change in income or household size.
Phone: Call the Washington Healthplanfinder Customer Support Center at 1-855-923-4633 please tell your patients report their pregnancy and Due date.

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Quality

Medicaid Quality

Influenza Vaccine Recommendation

It is important to remind members to get vaccinated and follow up to ensure it has been received. Repeat recommendations for those who are unvaccinated and answer any questions they may have. Strong professional recommendation plays a critical role in our members receiving their vaccination.

Well Child Visits

Educate parents on the importance of getting their children up to date on well child visits and routine vaccinations. Well child checkups are essential for their children’s growth and development and vaccines help protect their child’s health.

CPT II coding

Benefits of Providing CPT II Data

Better tracking of open and closed are gaps throughout the year.
Better reporting for providers; reduces burden on providers.
Potential to reduce the # of charts chased.
Fewer dropped codes by billing agencies.
Increases # of administrative claims submitted; improves members care outcomes-through accurate clinical data.

Wellcare Quality

Influenza Vaccine Recommendation

CPT II coding

Benefits of Providing CPT II Data

Better tracking of open and closed are gaps throughout the year.
Better reporting for providers; reduces burden on providers.
Potential to reduce the # of charts chased.
Fewer dropped codes by billing agencies
Increases # of administrative claims submitted; improves members care outcomes-through accurate clinical data.

Comprehensive Diabetes and Care

Assesses adults 18-75 years of age with diabetes (type 1 and type 2) who had each of the following:
Hemoglobin A1c (HbA1c) testing
HbA1c poor control (>9.0%)
HbA1c control (>8.0%)
Eye exam (retinal) performed.
Medical attention for nephropathy
BP control (>140/90 mmHg)

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Tribal

Celebrating Native American Heritage month - The Importance of Traditional Foods

In honor of #NativeAmericanHeritageMonth, we are exploring the importance of traditional foods in Indigenous cultures.

Long before Europeans colonized, Indigenous diets and life ways included wild game, fish, and many plants. These foods were an important part of cultural practices and ceremonies and contributed to the health of Indigenous Peoples. But colonization disrupted access to traditional foods, leading to government-issued rations for Indigenous Peoples which affected their health.

Traditional foods, as defined by The Assembly of First Nations, come from local plants and animal resources – they are not only healthy but environmentally friendly. These foods remain an important part to Native Americans cultural identity.

Take the huckleberry, known for its healing benefits such as having antioxidants, vitamin C & regulates blood sugar. The lessons of the huckleberry go beyond nutrition. It teaches us to live in harmony with the earth, adapt to different environments & respect other plant life.

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Clinical & Payment Policy Updates

Clinical Policy Updates

The below policies were updated as part of our regular monthly review in October. The policy changes are effective December 1, 2024. 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.527	Vitamin D Testing	Apple Health & Ambetter
CP.MP.12	Vagus Nerve Stimulation	Apple Health & Ambetter
CP.MP.182	Short Inpatient Hospital Stay	Apple Health & Ambetter

The below policies were updated as part of our regular monthly review in October. The policy changes are effective March 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.200	TMS for Treatment Resistant MDD	Ambetter

The below policies are new effective December 1, 2024. You will find the policies posted on the policy Web site.

Policy Number	Policy Title	Line of Business
WA.CP.MP.531	Imaging for Breast Cancer Screening	Apple Health
WA.CP.MP.532	Chronic Migraine and Tension-Type Headaches	Apple Health
WA.CP.MP.534	Upright Positional MRI	Apple Health
WA.CP.BH.522	Nonpharmacological Treatments for Depression	Apple Health

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.93	Bone-anchored hearing aid	12/1/24	Apple Health & Ambetter
CP.MP.129	Fetal Surgery in Utero for Prenatally Diagnosed Malformations	12/1/24	Apple Health & Ambetter
CP.MP.100	Allergy Testing and Therapy	1/1/25	Ambetter
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

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Pharmacy

Synagis 2024/2025 Season

A total of five (5) doses between December 1, 2024 – April 30, 2025 will be allowed for the 2024/2025 Synagis season.

For questions, please call 1-877-644-4613.

RSV Vaccines for older adults

Per updated August 2024 CDC guidance, RSV vaccination is recommended for the following:

All adults ages 75 and older
Adults ages 60–74 with risk factors including:
- Chronic heart or lung disease
- Weakened immune system
- Certain other medical conditions, including some people with diabetes and some people with obesity (body mass index ≥40 kg/m2)
- Living in a nursing home
- Visit the CDC's webpage for a complete list of risk factors.

*RSV vaccine is NOT currently an annual vaccine.
Some older adults may need additional counseling on which vaccines need annual dosing.

Dosing every year: Flu, COVID-19 (2024–2025 vaccine)

January 1, 2025 Preferred Drug List (PDL) Changes

Effective January 1, 2025, the following drugs below will no longer be preferred. The generic will be preferred.

EFFECTIVE DATE	DRUG NAME	Preferred Alternative(s)
01/01/2025	DENTA 5000 Plus 1.1% Cream (Brand) Sodium Fluoride 5000 Plus 1.1% Cream (Brand)	DENTA 5000 Plus 1.1% Cream (Generic) SodiumFluoride 1.1% Cream (Generic)
01/01/2025	Oralone Dental Paste 0.1% Paste (Brand)	Triamcinolone Acetonide 0.1% Paste (Generic)
01/01/2025	Sodium Fluoride 5000 PPM Dry Mouth 1.1% Paste (brand)	Dentagel 1.1% Gel (Generic) Sodium Fluoride 1.1% Gel (Generic)
01/01/2025	Toviaz ER Tablets (Brand)	Fesoterodine Fumarate ER Tablets (Generic)
01/01/2025	Imitrex Nasal Spray (Brand)	Sumatriptan Nasal Spray (Generic)
01/01/2025	Neuac Gel (Brand)	Clindamycin Phosph-Benzoyl Peroxide Gel (Generic)

Effective January 1, 2025, the following drugs will no longer be available as a 90-day supply. Members may still be able to obtain up to a 34-day supply at a time.

• ACARBOSE TABLETS
• ACIPHEX TABLETS
• ADDAPRIN TABLETS
• ADDERALL TABLETS
• ADDERALL XR CAPSULES
• AGRYLIN CAPSULES
• ALENDRONATE SODIUM TABLETS
• ALEVE TABLETS
• ALIVE DAILY SUPPORT PRENATAL GUMMIES TABLETS
• ALIVE PREMIUM PRENATAL DAILY SUPPORT TABLETS
• ANAGRELIDE HYDROCHLORIDE CAPSULES
• ANAPROX DS TABLETS
• CELEBREX CAPSULES
• CENTRUM SPECIALIST PRENATAL CAPSULES
• CHILDRENS ADVIL SUSPENSION
• CILOSTAZOL TABLETS
• CIMETIDINE HCL SOLUTION
• CINQAIR SOLUTION
• CITRANATAL B-CALM TABLETS
• CITRANATAL MEDLEY CAPSULES
• CLONAZEPAM TABLETS
• CLONIDINE HCL ER TABLETS
• CLOPIDOGREL TABLETS
• C-NATE DHA CAPSULES
• CONCEPT DHA CAPSULES
• CONCEPT OB CAPSULES
• CONCERTA TABLETS
• CONSTULOSE SOLUTION
• CREON CAPSULES
• CVS ESOMEPRAZOLE MAGNESIUM CAPSULES
• CVS IBUPROFEN INFANTS SUSPENSION
• CVS LANSOPRAZOLE CAPSULES
• CVS PRENATAL GUMMIES TABLETS
• CVS PRENATAL MULTI+DHA CAPSULES
• CVS WOMENS PRENATAL+DHA CAPSULES
• CYCLOGYL OPHTH SOLN
• CYCLOMYDRIL OPHTH SOLN
• CYSTARAN OPHTH SOLN
• CYTOTEC TABLETS
• DABIGATRAN ETEXILATE CAPSULES
• DAPSONE TABLETS
• DARUNAVIR TABLETS
• DAYPRO TABLETS
• DEFERASIROX TABLETS
• DEFERIPRONE TABLETS
• DENTA 5000 PLUS CREAM
• DENTAGELGEL
• DERMACINRX PRETRATE TABLETS
• DEXEDRINE CAPSULES
• DEXILANT CAPSULES
• DEXMETHYLPHENIDATE HCL TABLETS
• DEXMETHYLPHENIDATE HYDROCHLORIDE TABLETS
• DEXTROAMPHETAMINE SULFATE ER CAPSULES
• DICLOFENAC SODIUM DR TABLETS
• DICLOFENAC SODIUM ER TABLETS
• DIFLUNISAL TABLETS
• DIPYRIDAMOLE TABLETS
• DUET DHA 400 CAPSULES
• EC-NAPROSYN TABLETS
• ELITE-OB TABLETS
• ENBRACE HR CAPSULES
• NAPROXEN SODIUM TABLETS
• NATACHEW TABLETS
• NATAL PNV TABLETS
• NEEVO DHA CAPSULES
• NEONATAL FE TABLETS
• NEONATAL/DHA CAPSULES
• NESTABS TABLETS
• NESTABS DHA CAPSULES
• NESTABS ONE CAPSULES
• NOXAFIL TABLETS
• NUCALA INJ
• NUEDEXTA CAPSULES
• OB COMPLETE ONE CAPSULES
• OB COMPLETE PETITE CAPSULES
• OB COMPLETE PREMIER TABLETS
• OB COMPLETE/DHA CAPSULES
• OBSTETRIX DHA CAPSULES
• OBSTETRIX ONE CAPSULES
• OMEPRAZOLE CAPSULES
• ONE A DAY WOMENS PRENATAL/DHA CAPSULES
• ONE A DAY WOMENS PRENATAL1 CAPSULES
• ONE-A-DAY WOMENS PRENATAL CAPSULES
• PANTOPRAZOLE SODIUM TABLETS
• PENTOXIFYLLINE ER TABLETS
• PIMOZIDE TABLETS
• PNV PRENATAL PLUS MULTIVITAMIN + DHA CAPSULES
• PNV TABS 20-1 TABLETS
• PNV-DHA CAPSULES
• PNV-OMEGA CAPSULES
• PNV-SELECT TABLETS
• PREGEN DHA CAPSULES
• PREMESISRX TABLETS
• PRENA 1 TRUE CAPSULES
• PRENA1 PEARL CAPSULES
• PRENATAL TABLETS
• PRENATAL COMPLETE TABLETS
• PRENATAL ESSENTIALS CAPSULES
• PRENATAL FORMULA CAPSULES
• PRENATAL FORMULA A-FREE TABLETS
• PRENATAL GUMMIES/DHA & FOLIC ACID TABLETS
• PRENATAL MULTI + DHA CAPSULES
• PRENATAL MULTI +DHA CAPSULES
• PRENATAL-U CAPSULES
• PRENATE TABLETS
• PRENATE DHA CAPSULES
• PRENATE ELITE TABLETS
• PRENATE ENHANCE CAPSULES
• PRENATE MINI CAPSULES
• PRENATE PIXIE CAPSULES
• PRENATE RESTORE CAPSULES

• ANASPAZ TABLETS
• ANORO ELLIPTA AERO POWD
• APTENSIO XR CAPSULES
• ARAVA TABLETS
• ARMODAFINIL TABLETS
• ASPIRIN/DIPYRIDAMOLE CAPSULES
• ATOMOXETINE CAPSULES
• ATROPINE SULFATE OPHTH SOLN
• AZESCO TABLETS
• BACLOFEN TABLETS
• BRILINTA TABLETS
• CADEAU DHA CAPSULES
• CALCIUM ACETATE CAPSULES
• CARAFATE TABLETS
• CATAFLAM TABLETS
• ENULOSE SOLN
• ERGOLOID MESYLATES TABLETS
• ETHAMBUTOL HYDROCHLORIDE TABLETS
• ETODOLAC ER CAPSULES
• ETODOLAC ER TABLETS
• FASENRA SOLN
• FELDENE CAPSULES
• FENOPROFEN CALCIUM CAPSULES
• FERRIPROX SOLN
• FLUDROCORTISONE ACETATE TABLETS
• FLUORIDEX DAILY RENEWAL CONC
• FLURBIPROFEN TABLETS
• FOLIVANE-OB CAPSULES
• FORTEO SOLN PEN-INJ
• FOSRENOL TABLETS
• GUANFACINE HYDROCHLORIDEER TABLETS
• HYOSCYAMINE SULFATE TABLETS
• HYOSCYAMINE SULFATE ER TABLETS
• IBU TABLETS
• INDOMETHACIN CAPSULES
• INDOMETHACIN ER CAPSULES
• IPRATROPIUM BROMIDE NASAL SOLN
• ISONIAZID TABLETS
• JENLIVA PRENATAL/POSTNATAL CAPSULES
• JUXTAPID CAPSULES
• KETOPROFEN CAPSULES
• KETOPROFEN ER CAPSULES
• KOSHER PRENATAL PLUS IRON TABLETS
• K-PHOS NEUTRAL TABLETS
• KPN PRENATAL TABLETS
• LATUDA TABLETS
• LISDEXAMFETAMINE DIMESYLATE CAPSULES
• MECLOFENAMATE SODIUM CAPSULES
• MEFENAMIC ACID CAPSULES
• MEFLOQUINE HCL TABLETS
• MEGESTROL ACETATE SUSPENSION
• MELOXICAM TABLETS
• METADATE CD CAPSULES
• METHYLIN SOLN
• METHYLPHENIDATE HYDROCHLORIDE TABLETS
• METHYLPHENIDATE HYDROCHLORIDE ER TABLETS
• METHYLPHENIDATE HYDROCHLORIDE ER (LA) CAPSULES
• MODAFINIL TABLETS
• MYDRIACYL OPHTH SOLN
• NABUMETONE TABLETS
• NAPROSYN TABLETS
• NAPROXEN TABLETS
• PREVIDENT RINSE
• PRIMACARE CAPSULES
• PROCHLORPERAZINE MALEATE TABLETS
• PROMACTA TABLETS
• PROVIDA OB CAPSULES
• QUETIAPINE FUMARATE TABLETS
• QUETIAPINE FUMARATE ER TABLETS
• QUILLICHEW ER TABLETS
• QUILLIVANT XR SUSPENSION
• RAMELTEON TABLETS
• RENAGEL TABLETS
• RENVELA TABLETS
• RIDAURA CAPSULES
• SALSALATE TABLETS
• SAVELLA TABLETS
• SELECT-OB TABLETS
• SELECT-OB+DHA CAPSULES
• SEVELAMER HYDROCHLORIDE TABLETS
• STAVUDINE CAPSULES
• STUART ONE CAPSULES
• SULINDAC TABLETS
• TARON-C DHA CAPSULES
• THALOMID CAPSULES
• THERANATAL COMPLETE CAPSULES
• THERANATAL ONE CAPSULES
• THERANATAL OVAVITE CAPSULES
• TIZANIDINE HCL TABLETS
• TOLECTIN 600 TABLETS
• TOLMETIN SODIUM CAPSULES
• TOPIRAMATE ER CAPSULES
• TRISTART DHA CAPSULES
• TROPICAMIDE SOLUTION
• ULTRA PRENATAL VITAMINS & MINERALS + DHA CAPSULES
• VITAFOL FE+ CAPSULES
• VITAFOL GUMMIES TABLETS
• VITAFOL ULTRA CAPSULES
• VITAFOL-OB TABLETS
• VITAFOL-OB+DHA CAPSULES
• VITAFOL-ONE CAPSULES
• VITAMEDMD ONE RX/QUATREFOLIC CAPSULES
• XIFAXAN TABLETS
• ZENPEP CAPSULES

Effective January 1, 2025, the following additional drugs will need to be billed to the Health Care Authority (HCA) for more information, please contact the HCA at 800-562-3022.

Axatilimab (SNDX-6352)- Date to Market
Crinecerfont (NBI-74778)- Date to Market
Deutivacaftor-Tezacaftor-Vanzacaftor (VX-121/TEZ/VX-561)- Date to Market *
Dornase Alfa (Pulmozyme)
Eculizumab (Bkemv)- Date to Market
Elexacaftor-Tezacaftor-Ivacaftor (Trikafta)
Ensartinib (X-396)- Date to Market *
Garadacimab (CSL312)- Date to Market
Govorestat (AT-007)- Date to Market
Inavolisib (RG6114)- Date to Market *
Ivacaftor (Kalydeco)
Lazertinib (YH25448)- Date to Market *
Lumacaftor-Ivacaftor (Orkambi)
Mannitol (Cystic Fibrosis) (Bronchitol Tolerance Test)
Mannitol (Cystic Fibrosis) (Bronchitol)
Marnetegragene (Kresladi)- Date to Market
Marstacimab (PF-06741086)- Date to Market
Mirdametinib (PD-0325901)- Date to Market *
N-Acetyl-L-Leucine (IB1001)- Date to Market
Nipocalimab (Nipocalimab)- Date to Market
Obecabtagene Autoleucel (Auto1)- Date to Market
Olezarsen (AKCEA-APOCIII-LRx)- Date to Market
RemestemceL-L (Ryoncil)- Date to Market
Revumenib (SNDX-5613)- Date to Market *
Setmelanotide Acetate (Imcivree)
TBD (SH-201)- Date to Market *
Tezacaftor-Ivacaftor (Symdeko)
Tolvaptan (Jynarque)
Tolvaptan (Samsca)
Tolvaptan (Tolvaptan)
Vorasidenib (Vorasidenib)- Date to Market *

*Apple Health Expansion Only

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Wellcare

Wellcare Provider Guides Updated for 2025

Updates include:

Prior Authorization Guide
Quick Reference Guide
Appeals-Reconsiderations Guide
Claim Disputes and Recovery Guide

Access the guide here.

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Apple Health Core Connections (AHCC)

When a child first enters foster care, their foster care health coverage may not immediately be reflected in Provider One. During this time, caseworkers or caregivers may present providers with Coordinated Care’s Interim Voucher. This lets you know that the child is in state custody and will likely be coming onto Coordinated Care’s Apple Health Core Connections insurance plan.

Please do not withhold health care services, including filling prescriptions, based on lack of verified eligibility in ProviderOne or Coordinated Care’s Provider Portal for a youth in foster care. There are some cases where the child will not ultimately end up on Coordinated Care’s AHCC plan. Instead, they may be enrolled in Apple Health without Managed Care (aka Fee-for-Service). If that’s the case, our team will inform you on how to submit for payment to the Health Care Authority for services provided.

View the Interim Voucher on our website.

Training/Education

Secondary Trauma 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. December 3rd 10am – 11:30am Register here.

Coping with Holiday Stress with Youth All of us can feel stressed around the holidays. This stress can be amplified by feelings of grief and loss for youth in foster care, kinship and early adoption. This training will help participants identify holiday concerns that children in new homes feel, create a healthy environment for the holidays, and how to help youth, caregivers & professionals cope. When: Dec 3, 2024 06:00 – 07:45 PM 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. December 4th 10am – 11:30am Register here.

Understanding Stigmas in Behavioral Health A historical and current look at why mental health concerns can often meet with bias or stigma. This training provides a chance for open discussion on what has happened historically and the current barriers in our society. Dec 5, 2024 12:01 – 1:30 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 care and even placement disruption. This training offers a Trauma refresher overview and ideas to help the child manage their reactions and behaviors. Dec 11, 2024 12:30 – 02:00 PM Register here.

Coping with Holiday Stress All of us can feel stressed around the holidays. This stress can be amplified by feelings of grief and loss for children and youth in foster care. This training will help participants identify holiday stress that children in foster care feel, create a healthy environment for the holidays, and how to help children and youth cope. December 12th 10am – 11:30am Register here.