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Provider eNews - June edition
Outpatient formulary changes cont.
The proposed revisions shall:
- Add reimbursement for the sustained release gabapentin agents Gabapentin (Gralise®) and Gabapentin Encarbil (Horizant®). Reimbursement for these agents will require a prior authorization
that reflects a 30-day trial and clinical failure (as defined by Ohio Administrative Code (OAC) 4123-6-21(J)(2)) of the immediate release forms of gabapentin. Reimbursement shall be restricted
to a single form of gabapentin at any one time.
- Add reimbursement for ziconotide (Prialt®). Reimbursement requires previous approval of the use of an implanted pain pump. We will approve and reimburse for the combination of ziconitide
with any other medication results in a compounded sterile parenteral product as described in OAC 4123-6-21 (E)(1)(a)(b).
- Limit reimbursement for all testosterone products (oral, topical, injections) to only those claims that have medical allowances involving the genitourinary or endocrine systems.
- Allow reimbursement for treatment with transdermal forms of the drugs Fentanyl and Buprenorphine (Butrans®) as initial sustained release opiates in claims with clinical documentation
of an inability to swallow or absorb oral medications. We will also allow reimbursement for either transdermal agent in claims with documentation of a therapeutic failure,
demonstrated unacceptable side effects or systemic allergic reaction (as defined in OAC 4123-6-21 paragraphs (J)(1) and (J)(2) to any oral sustained release opiate.
Reimbursement for all sustained release opiate medications is limited to the use of a single sustained release agent at any one time.
- Limit reimbursement for each strength of buprenorphine patch (Butrans®) to a prescription for four patches per 28 days. Reimbursement for (Butrans®) is further limited to claims
requiring a daily morphine equivalent dose of 90 mg or less per day. The maximum daily dose covered will be 20 mcg/day.
- Limit coverage for prescriptions of fentanyl patches to a maximum of 10 patches per 30 days. Reimbursement for all strengths of these products shall be restricted to not more than every 72 hours.
Dosing at every 48 hours may be reimbursed with prior authorization upon submitting documentation that supports clinical failure, as defined in OAC 4123-6-21(J)(2), of a 72 hours dosing interval
and evidence of an escalation of the dose before a reduction in frequency.
- Limit coverage of all formulary products containing acetaminophen to only those products that contain 325 mg or less of acetaminophen per dosage unit.
- Revise the language that describes the coverage of the proton pump inhibitor drug class to clarify specifically what over the counter products and prescription products we would cover.
The current language states:
Proton Pump Inhibitor Class Specific Restrictions Effective July 1, 2012, reimbursement is restricted to only the following drugs in this class: omeprazole, Prilosec OTC®, Prevacid OTC®, Prevacid Solutab (lansoprazole).
This coverage restriction shall apply effective Aug. 31, 2012, for claims in which non-covered drugs in this class were reimbursed by BWC prior to July 1, 2012, and July 1, 2012, for all other claims. Reimbursement for
covered drugs in this class is only permitted when they are prescribed as gastrointestinal protectants during non-steroidal anti-inflammatory drug therapy or to treat an allowed condition that involves a gastrointestinal
disorder such as ulcer or GERD (gastrointestional esophageal reflux disease).
The new language would state:
Proton Pump Inhibitor Class-Specific Restrictions: Reimbursement for covered drugs in this class is only permitted when they are prescribed as gastrointestinal protectants during chronic oral steroid or non-steroidal
anti-inflammatory drug therapy or to treat an allowed condition that involves a gastrointestinal disorder such as ulcer or GERD (gastrointestinal esophageal reflux disease). Effective with the date of this revision,
reimbursement is limited to only the following drugs in this class:
- Prescription Strength Delayed Release Product: Omeprazole(10mg, 20mg, 40mg) products;
- Prescription Strength Dispersible Tablet: Prevacid Solutab® (15mg, 30mg) (Requires Prior Authorization to document inability to utilize the standard oral product);
- Over-The-Counter (OTC) Product: Omeprazole OTC 20mg products only.
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