Be Healthy/Medicaid Formulary Updates
Posted on May 30, 2017
The chart below defines the changes to the Be Healthy/Medicaid prescription drug coverage, effective 07/01/2017. These changes are included in the members’ coverage notice.
Be Healthy/Medicaid Prescription Drug Coverage
Step Therapy drug changes effective July 1, 2017:
For Health New England (HNE) to cover the Step Therapy drugs listed here, you first must try the corresponding First Line drugs. If HNE has paid a claim for the First Line drug within the previous 180 or 360 days (depending on the First Line drug), then you are eligible for coverage of the Step Therapy drug.
The use of samples does not satisfy the requirements of documented usage of a First Line drug or medical necessity for a Step Therapy drug.
If it is Medically Necessary for you to use a Step Therapy drug before trying a First Line drug, then your doctor can contact HNE to request a medical review.
All new Step Therapy requirements apply only to new prescriptions.
| You must try: | First Line Drug(s): | Serevent diskus |
| Before HNE will cover: | Step Therapy Drug(s): | Brovana
Perforomist |
| You must try: | First Line Drug(s): | Nasacort OTC and Azelastine 0.1% nasal spray |
| Before HNE will cover: | Step Therapy Drug(s): | Beconase AQ
Budesonide nasal spray RX Mometasone nasal spray Omnaris Qnasl Veramyst Zetonna Olopatadine nasal spray |
Quantity Limit Additions
Starting July 1, 2017, HNE will add Quantity Limits to the drugs below:
| Drug Name | Quantity Limit per 30 day supply
(unless otherwise specified) |
|
30 tablets/capsules |
|
250 strips |
|
1bottle |
|
1 therapy pack per lifetime |
New Prior Authorizations (PA) effective July 1, 2017
|
Prior Auth thru Optum |
| Aldurazyme, Cinqair, Darzalex, Empliciti, Imlygic, Kanuma, Naglazyme, Nucala, Onivyde, Portrazza, Supprelin LA, Yondelis |
Prior Auth thru Magellan |
| All hemophilia medications | Prior Auth thru Magellan |
Effective July 1, 2017, The following medications are Prior Authorized (PA) through Health New England:
|
Effective July 1, 2017, The following medications are not covered:
| · Xenical |
If you have any questions about the information in this notice, please contact Health New England Provider Relations at (800) 842-4464, extension 5000. A representative is available Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m.
