Medical Benefit Update
| Date: | April 10, 2024 |
| From: | Health Plan |
| To: | All Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) Physicians, Providers, and Facilities |
| Type: | Formulary |
| Subject: | Medical Benefit Update |
| Business: | Medi-Cal Managed Care |
Effective June 13, 2024, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.
- Code 91304 – SARSCOV2 VACC SAPONIN-BSD ADJT 5MCG/0.5ML IM USE; Code 90678 – RESPIRATORY SYNCYTIAL VIRUS VACCINE, PREF, SUBUNIT, BIVALENT, (ABRYSVO) FOR INTRAMUSCULAR USE; Code 90679 – RSV VACC PREF RECOMBINANT ADJUVANTED (AREXVY) FOR IM USE; Code 90623 – MENINGOCOCCAL PENTAVALENT VACCINE, CONJUGATED MEN A, C, W, Y-TETANUS TOXOID CARRIER, AND MEN B-FHBP, FOR INTRAMUSCULAR USE: Authorization not required.
- 2. Code J2778 – INJECTION, RANIBIZUMAB, (LUCENTIS), 0.1 MG; Code Q5124 – INJECTION, RANIBIZUMAB-NUNA, BIOSIMILAR, (BYOOVIZ), 0.1 MG; Code Q5128 – INJECTION, RANIBIZUMAB-EQRN BS, (CIMERLI), 0.1 MG; CODE J2779 – INJECTION, RANIBIZUMAB VIA IVT IMPLANT, (SUSVIMO), 0.1 MG: PA required. Must meet ALL of the following: Eye condition appropriate for treatment, including:
- Diabetic macular edema
- Diabetic retinopathy
- Macular edema following retinal vein occlusion
- Myopic choroidal neovascularization
- Neovascular wet or exudative age-related macular degeneration
- Polypoid choroidal vasculopathy with active juxtafoveal or subfoveal lesions,
- Indication approved by FDA or society guidelines
Must have no concurrent ocular or periocular infection. Limited to ages 18 years or older AND must have failed or had clinically significant adverse effects to bevacizumab. Limited to one dose per eye every four weeks for ranibizumab injection and every 24 weeks (6 months) for SUSVIMO implant.
- Code J0178 – INJECTION, AFLIBERCEPT, (EYLEA) 1 MG; Code J0177- INJECTION, AFLIBERCEPT HD, (EYLEA HD) 1 MG: PA required. Must meet ALL of the following: Eye condition appropriate for treatment, including:
- Diabetic macular edema, with or without diabetic retinopathy
- Macular edema following retinal vein occlusion
- Neovascular (wet or exudative) age-related macular degeneration
- Indication approved by FDA or society guidelines
Must have no concurrent ocular or periocular infection.
Limited to ages 18 years or older AND must have failed or had clinically significant adverse effects to bevacizumab unless patient’s baseline visual acuity is 20/50 or worse.
For EYLEA: Limit to standard dosing of one 2 mg dose per eye every 4 weeks.
For EYLEA HD: Limit to standard dosing of one 8 mg dose every 4 weeks for the first three (3) doses, followed by 8 mg once every 8 to 16 weeks (±1 week).
- Code J2781 – INJECTION, PEGCETACOPLAN, INTRAVITREAL, (SYFOVRE), 1 MG: PA required. Indicated for ALL of the following: Eye condition appropriate for treatment, including:
- Geographic atrophy (GA) secondary to age-related macular degeneration (AMD).
- Indication approved by FDA or society guidelines.
Must have no concurrent ocular or periocular infection, or active intraocular inflammation.
Limited to ages 60 years or older.
Does not exceed standard dosing per FDA package insert, including dosing frequency no more often than every 25 days per affected eye.
- Code C9162 – INJECTION, AVACINCAPTAD PEGOL, (IZERVAY), 0.1 MG: PA required. Indicated for ALL of the following: Eye condition appropriate for treatment, including:
- Geographic atrophy (GA) secondary to age-related macular degeneration (AMD).
- Indication approved by FDA or society guidelines.
Must have no concurrent ocular or periocular infection, or active intraocular inflammation.
Limited to ages 50 years or older.
Does not exceed standard dosing per FDA package insert, including no more than 12 months total duration.
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG
