July 2020: New Drugs Requiring Utilization Management
Date:06/30/20
Superior HealthPlan is committed to keeping providers updated on prescription drugs as they enter the market, whether or not they will need prior authorization, as well as how these drugs may be billed. Upon approval from the U.S. Food and Drug Administration (FDA) and/or availability onto the market, and if determined by Superior that the drug will be a covered benefit, these drugs will be subjected to utilization management. This can include, but is not limited to clinical prior authorization, quantity limit and age limit or specialty pharmacy.
Depending on the formulation/route of administration of the drug, the drug may be billed under the pharmacy benefit or medical benefit as a Clinician Administered Drug (CAD). CADs are billed using a Healthcare Common Procedure Coding System (HCPCS) J Code. Most CAD drugs, upon FDA approval, will not have a specific J Code assigned. Instead, they will fall under the miscellaneous J Code (J3590) until they are officially assigned their own J Code.
For July, the following drugs will be subjected to utilization management:
| DRUG NAME BRAND (GENERIC) | ROUTE OF ADMINISTRATION | INDICATION |
|---|
| 1 | Fensolvi (leuprolide acetate) | Subcutaneous | Central Precocious Puberty |
|---|
| 2 | Retevmo (selpercatinib) | Oral | Cancer |
|---|
| 3 | Qinlock (ripretinib) | Oral | Gastrointestinal Stromal Tumor |
|---|
| 4 | artesunate | Intravenous | Malaria |
|---|
| 5 | naxitamab | Intravenous | Cancer |
|---|
| 6 | givinostat | Oral | Duchene’s Muscular Dystrophy |
|---|
| 7 | Nyvepria (pegfilgrastim-apgf) | Subcutaneous | Neutropenia |
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| 8 | Recarbrio (imipenem/cilastin/relebactam) | Intravenous | Antibiotic |
|---|
| 9 | Revascor (rexlemestrocel-L) | Intramyocardial Injection | Chronic Heart Failure |
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| 10 | valoctocogene roxaparvovec | Intravenous | Hemophilia A |
|---|
| 11 | Ryoncil (remestemcel-L) | Intravenous | Acute graft vs. host disease |
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| 12 | KTE-X19 | Intravenous | Mantle Cell Lymphoma |
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| 13 | lisocabtagene maraleucel | Intravenous | Non-Hodgkin's Lymphoma |
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| 14 | oxymetazoline | Ophthalmic Solution | Blepharoptosis
|
|---|
| 15 | Viaskin Peanut | Transdermal Patch | Peanut Allergy |
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| 16 | veverimer | Oral | Chronic Kidney Disease (CKD) |
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| 17 | Winlevi (clascoterone) | Topical | Acne |
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| 18 | viloxazine | Oral | ADHD |
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| 19 | cantharidin | Topical | Molluscum Contagiosum |
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| 20 | Gimoti (metoclopramide) | Nasal Spray | Diabetic Gastroparesis |
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| 21 | Fintelpa (fenfluramine) | Oral | Dravet Syndrome |
|---|
| 22 | Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf) | Subuctaneous | Breast Cancer |
|---|
Please note:Some of the drugs listed above are billed under the medical benefit. To determine which of these drugs under the medical benefit will need prior authorization, please utilizeSuperior’s Pre-Auth Needed Tool.
For detailed information regarding utilization management, including prior authorization criteria and quantity limits, please visitSuperior’s Pharmacy webpage. For information regarding utilization management for Ambetter from Superior HealthPlan, please referenceAmbetter’s 2020 Prescription Drug List.
For questions regarding any of the drugs listed above and utilization management or prior authorization for these drugs, please contact the Superior Pharmacy Department at 1-800-218-7453, ext. 22080.
(20min delay)
