Pharm Prior Authorization Updates

Change in Prior Authorization Requirements

Effective December 1, 2021, Buckeye Health Plan (Buckeye) and Ambetter are making changes to services requiring prior authorization for Medicaid and Marketplace (Ambetter) members.  Below is notification of the changes and resource information related to the specific services that will be impacted.

Please note the following important changes:

• Ruxience (Rituximab-pvvr), Q5119 (preferred)
• Truxima (Rituximab-abbs), Q5115 (preferred)
• Riabni (Rituximab-arrx), J3590 no medication specific code at this time ( 2^nd preferred)
• Rituxan (Rituximab), J9312 (non-preferred)
• Rituxan Hycela  (Rituximab-Hyaluronidase), J9311 (non-preferred)
• Ogivri (Trastuzumab-dkst), Q5114 (preferred)
• Trazimera (Trastuzumab-qyyp), Q5116 (preferred)
• Kanjinti (trastuzumab-anns), Q5117 (preferred)
• Herzuma (trastuzumab-pkrb), Q5113 ( 2nd preferred)
• Ontruzant (trastuzumab-dttb), Q5112 ( 2nd preferred)
• Herceptin (Trastuzumab), J9355 (non-preferred)
• Herceptin Hylecta (Trastuzumab-hyaluronidase-oysk), J9356 (non-preferred)
• Evrysdi (risdiplam), (preferred)
• Spinraza (nusinersen), J2326 (non-preferred)

On December 1, 2021, the following changes will take effect.

1. Ruxience (Rituximab-pvvr), Q5119 and Truxima (Rituximab-abbs), Q5115 will be the preferred rituximab, then Riabni (Rituximab-arrx), J3590 will be the next preferred agent initial and continuation therapy.  .
2. Ogivri (Trastuzumab-dkst), Q5114, Trazimera (Trastuzumab-qyyp), Q5116, and Kanjinti (trastuzumab-anns), Q5117 will be the preferred trastuzumab., then Herzuma (trastuzumab-pkrb), Q5113 and Ontruzant (trastuzumab-dttb), Q5112 will be the next preferred agents initial and continuation therapy.  .
3. Evrysdi (risdiplam) will be the preferred medication for the treatment of spinal muscular atrophy for initial therapy.
4. These changes effect the following site of care settings: provider-administered, outpatient hospital or ambulatory care center. 

To further assist you in this transition, you may access forms and updated materials on our website at www.buckeyehealthplan.com/providers/resources/forms-resources.html.

Please contact Buckeye’s Provider Services Department at 1-866-296-8731 with any questions. 

Medicaid PA List as of June 1, 2021 (PDF)

Ambetter PA List as of June 1, 2021 (PDF)

NCH PA Partnership - FAQs (PDF) 

In our ongoing efforts to make working with us as easy as possible, Buckeye Health Plan is pleased to announce a partnership with New Century Health (NCH). This partnership allows us to expand our BHP Oncology Pathway Solutions pre-approval program to include all members of all ages in our Medicaid and Exchange plans.

NCH brings many years of experience in oncology management expertise which will simplify the administrative process for providers, while supporting effective delivery of quality patient care.

Beginning June 1, 2021, all oncology-related infused, oral chemotherapeutic drugs and supportive agents will require authorization from NCH before being administered in a:

• Physician’s office
• Outpatient hospital
• Ambulatory setting
• Infusion center

This authorization requirement applies to all Buckeye Health Plan’s Medicaid and Exchange members of all ages. 

BHP Oncology Pathway Solutions program benefits include:

• The use of clinical criteria, based on nationally recognized guidelines, to promote evidence-based cancer care.
• Increased collaboration with physician offices to foster a team approach. 
• Physician discussions with medical oncologists who can understand and discuss treatment plans.
• A  provider web portal to:
  • Obtain real-time approvals when selecting evidence-based NCH treatment care pathways.
  • Determine which clinical documentation is necessary for medical necessity review.
  • View all submitted requests for authorization in one location.
  • Check member eligibility.

Prior Authorization Process

The requesting physician must complete an authorization request using one of the following methods:

1. Logging into the NCH Provider Web Portal
2. Calling 1-888-999-7713 Monday–Friday (8 a.m. - 8 p.m. ET) Medical Oncology- Option 1

Timeframe for Approval

Real-time approval is given for NCH recommended treatments. Timeframes for authorization of treatment regimens not auto approved by NCH are as follows:

        Medicaid Requests:

• Pharmacy: 24 hours
• Office Administered:
  • 24 hours if all needed information is sent with the request.
  • If more information is needed, BHP will send a request to provider to obtain the necessary information for a final review.

        Ambetter Requests:

• Pharmacy: 24 hours for expedited requests and 72 hours for standard requests.
• Office Administered: 48 hours for expedited requests and 10 days for standard requests.

Authorizations issued by Buckeye Health Plan or Envolve Pharmacy Solutions before June 1, 2021 for Medicaid and Exchange members are effective until the authorization end date. Subsequent authorization requests must be submitted to NCH. If continued authorization is not obtained from NCH, drug-related claims may be denied.

Please note:

NCH may approve chemotherapeutic and supporting agents, including hematology drugs, for a period up to 90 days.

• Medicaid IP chemotherapy should continue to be submitted:
  • Buckeye’s Secure Provider Portal    
  • Buckeye’s Secure Fax at 1-866-529-0290
  • Pharmacy dispensed chemotherapeutic and supportive agents that were previously submitted to Envolve Pharmacy Solutions or CoverMyMeds, should be submitted directly to NCH.
  • Failure to obtain prior authorization may result in denial of payment.
     
• Ambetter IP chemotherapy should continue to be submitted to fax# 1-888.241.0664.
  • Pharmacy dispensed chemotherapeutic and supportive agents that were previously submitted to Envolve Pharmacy Solutions or CoverMyMeds, should be submitted directly to NCH.

Next Step

An NCH representative will contact you soon to schedule an introductory meeting and training. Should you have any questions prior to the introductory meeting, please call NCH at 1-888-999-7713, Option 6 or by email to providertraining@newcenturyhealth.com. You may also contact Buckeye Health Plan at 1-866-296-8731.

For Your Reference 

• You will find a list of medications that need prior authorization for the medical benefit starting 06/01/2021 at BHP Health Plan/Pharmacy/Latest News website.
• There are no changes to the pharmacy benefit. For pharmacy benefit questions, please refer to Buckeye Health Plan’s preferred drug list at BHP Health Plan/Pharmacy website.
• Any request using a generic J code (examples: J3490, J8499, J9999) will need a single case agreement to ensure proper payment.

We look forward to offering you this program and hope that it will enhance your experience with oncology service authorizations.    

Change in Prior Authorization Requirements

Effective November 21, 2020, Buckeye Health Plan (Buckeye) is making changes to services requiring prior authorization for Medicaid members.  This letter is provided as notification of the changes and resource information related to the specific services that will be impacted.

Please note the following important changes:

• Epoetin alfa-epbx, Retacrit, Q5105 and Q5106 (preferred)
• Darbepoetin alfa, Aranesp, J0881 and J0882
• Epoetin Alfa, Epogen, Q4081 and J0885
• Epoetin Alfa, Procrit, Q4081 and J0885
• Methoxy polyethylene glycol-epoetin beta, Mircera, J0887 and J0088

On November 21, 2020, the following changes will take effect.

1. Epoetin alfa-epbx, Retacrit, Q5105 and Q5106 will be the preferred erythropoiesis-stimulating agent (ESA) for new and continuation therapy.  

These changes effect the following site of care settings: provider-administered, outpatient hospital or ambulatory care center. These changes do not effect dialysis centers.

To further assist you in this transition, you may access forms and updated materials on our website at our Forms-Resources page. 

Please contact Buckeye’s Provider Services Department at 1-866-296-8731 with any questions. Thank you for your partnership and for the quality care you provider to Buckeye members.

Change in PA Requirements for Preferred Botulinum Toxins

Effective December 16, 2020, Buckeye Health Plan (Buckeye) is making changes to services requiring prior authorization for Medicaid members.  This letter is provided as notification of the changes and resource information related to the specific services that will be impacted.

Please note the following important changes:

• IncobotulinumtoxinA, Xeomin, J0588 (preferred)
• AbobotulinumtoxinA, Dysport, J0586 (preferred)
• OnabotulinumtoxinA, Botox, J0585

On December 16, 2020, the following changes will take effect.

1.    IncobotulinumtoxinA, Xeomin, J0588 will be the preferred botulinum toxin for limb spasticity (ages 18 and older), cervical dystonia, blepharospasm, and chronic sialorrhea.

2.    AbobotulinumtoxinA, Dysport, J0586 will be the preferred botulinum toxin for limb spasticity (ages 2 and older) and cervical dystonia.

These changes effect the following site of care settings: provider-administered, outpatient hospital or ambulatory care center. To obtain forms and more detailed information, please visit Buckeye’s website at Provider Home Page or contact Provider Services at 866-296-8731.

To further assist you in this transition, you may access forms and updated materials on our website at in the forms and resources section.  

Please contact Buckeye’s Provider Services Department at 1-866-296-8731 with any questions. Thank you for your partnership and for the quality care you provider to Buckeye members.