DRUG COVERAGE GUIDELINES Policy Number: PHARMACY 098.175 T0 Effective Date: June 1, 2018
Total Page：16
File Type：pdf, Size：1020Kb
UnitedHealthcare® Oxford Clinical Policy DRUG COVERAGE GUIDELINES Policy Number: PHARMACY 098.175 T0 Effective Date: June 1, 2018 Table of Contents Page Related Policies INSTRUCTIONS FOR USE ......................................................................... 1 Refer to Payment Guidelines below CONDITIONS OF COVERAGE ..................................................................... 1 DESCRIPTION OF SERVICES ..................................................................... 2 DEFINITIONS ......................................................................................... 3 PAYMENT GUIDELINES ............................................................................. 3 POLICY HISTORY/REVISION INFORMATION ............................................ 161 INSTRUCTIONS FOR USE This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan upon which this Clinical Policy is based. In the event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Clinical Policy. Other Policies may apply. UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. CONDITIONS OF COVERAGE This policy applies to Oxford plan membership. Note: Not all Oxford groups have selected the same pharmacy benefits. Refer to the group's pharmacy plan number for specific exclusions, exceptions, and dispensing limitations. New Jersey Small group plan members should refer to their Certificate of Coverage for precertification and quantity limit guidelines. New Jersey members: Refer to the policy titled Supply Limits - New Jersey Benefit Maximum Limits. Drug Coverage Guidelines Page 1 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC DESCRIPTION OF SERVICES The Drug Coverage Guidelines table of medications contains medications that: o Have a quantity limit in place; and/or o Require precertification through Oxford's Pharmacy Benefit Manager (PBM); and/or o Require precertification through Oxford's Medical Management; and/or o Are standard exclusions (such as weight loss medications, fluorides, vitamins) Medications are listed alphabetically with an explanation of how precertification is obtained and under which benefit it is covered. While a medication by itself may not require precertification, Home Care for the administration of a medication does require precertification. Exception: The first seven days of therapy with low molecular weight heparin are an exception to the Home Care precertification requirement. Notes: Opioid Overutilization: The Center for Disease Control (CDC) recommends that clinicians should prescribe the lowest effective dosage when opioids are started. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 morphine equivalent doses (MED) or more per day, and should avoid increasing dosage to 90 MED or more per day or carefully justify a decision to titrate dosage to 90 MED or more per day. o This includes all salt forms, single and combination ingredient products, all long- and short-acting formulations, and all brand and generic formulations: codeine, dihydrocodeine, fentanyl, methadone, meperidine, morphine, hydrocodone, hydromorphone, levorphanol, oxycodone, oxymorphone, pentazocine, tapentadol, tramadol. o For additional coverage criteria for the above drugs, please refer to: Utilization Review Guideline: Opioid Overutilization Cumulative Drug Utilization Review Criteria Quantity duration (QD) and quantity level limitations (QLL) may be in place for certain medications. To request coverage for a greater quantity of a medication with a QLL, providers must call Oxford's Pharmacy Benefit Manager (PBM). For information regarding QD or QLL supply limits, refer to the following documents on UHCProvider.com > Drug Lists and Pharmacy > Supply Limits: o QD Supply Limits (defines the maximum quantity of medication that can be covered in a specified time period) o QLL Supply Limits (defines the maximum quantity of medication that is covered for one prescription or copayment) Oxford's PBM provides a nationwide network of participating pharmacies that administers prescription drugs on a retail level. Groups that purchase the Pharmacy Rider and Medicare Members with a Pharmacy benefit will have their retail pharmacy benefit administered by the PBM. For information regarding medication coverage related to the Member's pharmacy benefit, providers may contact Oxford's PBM. For issues of medication coverage unrelated to the Member's pharmacy benefit (Intravenous infusions, intramuscular injections, etc), Oxford may be contacted directly. Over-the-Counter (OTC) Medications: o New Jersey (NJ) Plans: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are not excluded from coverage. Refer to specific drug policies where applicable. o Connecticut (CT) and New York (NY) Plans: A prescription drug product that is therapeutically equivalent to an over-the-counter (OTC) drug may be covered if it is determined to be medically necessary. In order for a prescription drug to be deemed "medically necessary" when there is an equivalent OTC drug available, the physician must show that there is something about the prescription drug that is superior to the OTC drug, and likely to be more beneficial to the Member than the OTC drug. Documentation supporting medical necessity must be submitted by the provider. New FDA-approved drug products may require precertification immediately upon launch of the medication. For information on coverage of recent FDA-approved drug products for which drug-specific criteria are unavailable, please refer to Interim New Product Coverage Criteria. Review at Launch: The Review at Launch program provides Oxford the ability to review, evaluate, and implement programs for new to market medications. The medication may move to a covered status once the medication has been evaluated by the UnitedHealthcare Pharmacy and Therapeutics Committee and the appropriate system specifications have been implemented to ensure suitable utilization management strategies are in place. A medication will be subject to review at launch when the medication is listed on the Review at Launch Medication List. Please refer to the policy titled Review at Launch for New to Market Medications. Drug Coverage Guidelines Page 2 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC New Jersey Formulary Regulations: Members who are enrolled in a New Jersey group Product with a 3-Tier Prescription Drug Benefit and for whom the NJ Formulary Regulations apply should refer to Prior Authorization/Notification Non-Formulary (i.e., Tier 3 or higher) Copay Adjustment – New Jersey. DEFINITIONS For all of the definitions below, copayment/cost share will vary based on the Member’s plan design. Refer to the member's specific Certificate of Coverage, contract and/or Prescription Drug Rider as applicable. Mail Order Pharmacy: A network pharmacy contracted to provide up to a 90-day supply of certain prescription medications (new or refill) by mail. Retail Pharmacy: A network non-mail order pharmacy contracted to provide prescription medications (new or refill). Note: For Members enrolled in NY LOBs new and renewing on or after 01/12/12, if a retail pharmacy has contracted with the PBM, in advance, for the same rates and terms and conditions as the mail order or specialty pharmacy, covered prescriptions will be available at the same co-payment or other reimbursement level that would apply to the mail-order or non-retail specialty pharmacies (should any of these pharmacies be available in the service area). Specialty Pharmacy: A network pharmacy contracted to provide coverage for specialty medications at an in-network benefit level for members enrolled on NY and NJ LOBs. PAYMENT GUIDELINES The following list of procedure codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply