July 21, 2021 Pharmacy Updates

Maine Department of Health & Human Services sent this bulletin at 07/21/2021 07:36 AM EDT

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Important Updates to MaineCare Coverage and Prior Authorization Criteria for Buprenorphine for Treatment of Opioid Use Disorder  

 

Effective July 15, 2021, and in partnership with the Maine Opioid Response Clinical Advisory Committee, MaineCare is updating its coverage criteria and Prior Authorization (PA) process for buprenorphine for the treatment of Opioid Use Disorder (OUD). The Maine Opioid Response Clinical Advisory Committee is a group of approximately 30 leaders in Substance Use Disorder (SUD) prevention, treatment and harm reduction in Maine and includes both prescribers and pharmacists. With their input, MaineCare has made these updates to its coverage criteria to reflect best clinical practice in the use of Medications for Addiction Treatment (MAT) for OUD and to further its efforts to reduce barriers to care and increase access to life-saving medications for the treatment of OUD. 

 

Key changes to the MaineCare coverage criteria and PA processes include the following:

  • Buprenorphine induction period changes:
    • Induction period is now considered to be 30 days (previously was 60 days) 
    • Max buprenorphine dose is 24 mg/day for up to 30 days of induction period (previously was 32 mg/day) 
    • Buprenorphine induction doses of up to 24mg/day will be allowed for multiple induction periods per year, during which prescribers can write for a maximum of 24 mg daily for up to 30 days without requiring a PA. 
    • For members who are pregnant, a Prior Authorization (PA) will not be required for buprenorphine monotherapy in doses up to 16 mg/day when the prescriber notes a pregnancy diagnosis noted on the prescription  
  • PAs for buprenorphine will no longer be required when a provider prescribes a concomitant opioid medication for the treatment of acute pain.    
  • The “SC” (Strength Change) override code can be used with an active PA to titrate a member’s dose from once daily to twice daily dosing. This new override eliminates the need to submit a new PA request. 

Reminders of current coverage criteria: 

  • MaineCare preferred products for buprenorphine include brand name Suboxone films and generic buprenorphine/naloxone combination tablets or films. The prescriber must note a diagnosis of either Opioid Use Disorder (OUD) or Substance Use Disorder (SUD) on the prescription, and the pharmacy must submit the claim with either “62” or “OA” codes. 
  • MaineCare covers maximum maintenance dose of buprenorphine up to 16 mg/day; requests for dosing higher than 16mg outside of the 30D induction period will require a PA. 

 

For questions, contact the Change Healthcare Pharmacy Help Desk at 1-888-420-9711. MaineCare providers can also send inquiries via email to PBA_helpdesk@changehealthcare.com.  

 

MaineCare Provider Drug List (PDL) Update for June 25, 2021

The following medication(s) have recently been added to the MaineCare PDL as preferred and with new PDL criteria:

  • Tysabri will require a clinical PA to establish diagnosis and medical necessity. Providers must be enrolled in the TOUCH Prescribing program, a restricted distribution program.

The following medication(s) have been recently added/changed to the MaineCare PDL as non-preferred and will require prior authorization.

  • Abecma
  • Acyclvir Oint
  • Breyanzi
  • Cabenuva
  • Fotivda
  • Gimoti Spray
  • Margenza
  • Nextstellis
  • Orgovyx
  • Pepaxto
  • Qdolo Soln
  • Tepmetko
  • Ukoniq

The following medication(s) have recently been added to the MaineCare PDL as non-preferred and with new PDL criteria:

  • Amondy 45: Clinical prior authorization to verify diagnosis and use of stable dose of corticosteroid for at least 6 months. The prescriber is, or has consulted with, a neuromuscular disorder specialist AND The dose does not exceed 30mg/kg once weekly AND The patient is currently on a stable corticosteroid dose for at least 6 months. The patient must be ambulatory (able to walk with or without assistance, not wheelchair bound).
  • Bronchitol for the treatment of patients ≥18 years of age with CF. It will be considered as add-on maintenance therapy to improve pulmonary function in adult patients 18 years and older with cystic fibrosis (CF). Use Bronchitol® only for adults who have passed the Bronchitol® Tolerance Test (BTT). (see Recommended Dosage section for further information.
  • Evkeeza requires a clinical PA for appropriate diagnosis and is for patients ≥ 12 years of age.
  • Gemtesa use a preferred long acting antispasmodic.
  • Vesicare LS is for the treatment of patients ≥ 2 years of age.
  • Lupkynis is a sensitive CYP3A4 substrate. Co-administration with strong or moderate CYP3A4 inhibitors increases voclosporin exposure, which may increase the risk of Lupkynis® adverse reactions. Co-administration of Lupkynis® with strong CYP3A4 inhibitors (e.g. ketoconazole, itraconazole, clarithromycin) is contraindicated. Reduce Lupkynis® dosage when co-administered with moderate CYP3A4 inhibitors (e.g. verapamil, fluconazole, diltiazem).
  • Ponvory requires a clinical PA to establish diagnosis and medical necessity. Before initiation of Ponvory® treatment, assess the following: Complete Blood Count (CBC)- Obtain a recent (i.e. within the last 6 months) CBC, including lymphocyte count. Cardiac Evaluation- Obtain an electrocardiogram (ECG) to determine whether pre-existing conduction abnormalities are present. In patients with certain pre-existing conditions, advice from a cardiologist should be sought and first-dose monitoring is recommended. Determine whether patients are taking drugs that could slow heart rate of atrioventricular (AV) conduction. Liver Function Tests- Obtain recent (i.e. within the last 6 months) transaminase and bilirubin levels. Ophthalmic Evaluation- Obtain an evaluation of the fundus, including the macula. Current or prior medications with immune system effects- If patients are taking anti-neoplastic, immunosuppressive, or immune-modulating therapies, or if there is a history of prior use of these drugs, consider possible unintended additive immunosuppressive effects before starting treatment with Ponvory®.
  • Qelbree is for pediatric patients 6 to 17 years of age. Concomitant use of Qelbree® with an MAO inhibitor or within 2 weeks after discontinuing an MAO inhibitor is contraindicated. Concomitant use of Qelbree® significantly increases the total exposure, but not peak exposure, of sensitive CYP1A2 substates, which may increase the risk of adverse reactions associated with these CYP1A2 substrates. Coadministration of Qelbree® with sensitive CYP1A2 substrates or CYP1A2 substrates with a narrow therapeutic range (e.g. alosetron, duloxetine, ramelteon, tasimelteon, tizanidine, theophylline), is contraindicated.
  • Santyl Oint and Desowen have been removed from the PDL.

If you have any questions, please contact Change Healthcare at 1-888-420-9711.