Medicaid Managed Care Florida Healthy Kids

Provider Bulletin September 2020 Medical drug benefit Clinical Criteria updates

This communication applies to the Medicaid programs for Simply Healthcare Plans, Inc. (Simply) and Clear Health Alliance (CHA), as well as the Florida Healthy Kids program for Simply.

On February 21, 2020, May 15, 2020, and June 18, 2020, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Simply and CHA. These policies were developed, revised or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:  New: newly published criteria  Revised: addition or removal of medical necessity requirements, new document number  Annual review: minor wording and formatting updates, new document number  Updates marked with an asterisk (*): criteria may be perceived as more restrictive

Please share this notice with other members of your practice and office staff.

Please note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical plan. This does not apply to pharmacy services.

Effective date Document Clinical Criteria title New, revised, number annual review 10/30/2020 ING-CC-0164* Jelmyto (mitomycin gel) New 10/30/2020 ING-CC-0165* Trodelvy () New 10/30/2020 ING-CC-0029 Dupixent (dupilumab) Revised 10/30/2020 ING-CC-0107 for Non-Ophthalmologic Indications Revised 10/30/2020 Darzalex () and Darzalex Faspro ING-CC-0127* Revised (daratumumab and hyaluronidase-fihj) 10/30/2020 ING-CC-0128 Tecentriq () Revised 10/30/2020 ING-CC-0125 Opdivo () Revised 10/30/2020 ING-CC-0119 Yervoy () Revised 10/30/2020 ING-CC-0051* Enzyme Replacement Therapy for Gaucher Disease Revised 10/30/2020 GnRH Analogs for the Treatment of Non-Oncologic ING-CC-0061* Revised Indications

https://provider.simplyhealthcareplans.com/florida-provider https://provider.clearhealthalliance.com/florida-provider Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Medicaid contract. Simply Healthcare Plans, Inc. dba Clear Health Alliance is a Managed Care Plan with a Florida Medicaid contract. Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Healthy Kids contract. SFLCARE-0311-20 September 2020 512909MUPENMUB Simply Healthcare Plans, Inc. Clear Health Alliance Medical drug benefit Clinical Criteria updates Page 2 of 2

10/30/2020 ING-CC-0042 Monoclonal Antibodies to Interleukin-17 Revised 10/30/2020 ING-CC-0011* Ocrevus (ocrelizumab) Revised 10/30/2020 ING-CC-0072* Selective VEGF Antagonists Revised 10/30/2020 ING-CC-0002* Colony Stimulating Factor Agents Revised