Medical Benefit Updates

Post date: July 14, 2024/ Alerts

Date:	July 10, 2024
From:	Health Plan Pharmacy and Therapeutics Committee
To:	Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) Providers and Physicians
Type:	Regulatory
Subject:	Medical Benefit Updates
Business:	Medi-Cal Managed Care

Effective September 16, 2024, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.

Code J3358 – INJECTION, USTEKINUMAB, FOR IV INJECTION, (STELARA) 1 MG (For the treatment of Crohn’s Disease and Ulcerative Colitis): PA required. Reserved for treatment failure to tumor necrosis factor (TNF) inhibitors. Must be prescribed by gastroenterologist.
Code J2327 – INJECTION, RISANKIZUMAB-RZAA, IV (SKYRIZI) 1 MG (For the treatment of Crohn’s Disease only), Code J2267 – INJECTION, MIRIKIZUMAB-MRKZ, (OMVOH) 1 mg (For the treatment of Ulcerative Colitis): PA required. Reserved for treatment failure to tumor necrosis factor (TNF) inhibitors AND have tried and failed Stelara. Must be prescribed by gastroenterologist.
Code C9166 – INJECTION, SECUKINUMAB, IV, (COSENTYX) 1 MG:

For Psoriatic Arthritis: PA required. Must be prescribed by a rheumatologist or dermatologist. Reserved for patients who meet one of the following criteria:

(a) treatment failure/documented intolerance to Renflexis, Inflectra, Avsola, or Remicade OR

(b) patients with clinically relevant skin involvement defined as either having body surface area

>10% or negatively impacting quality of life (such as face or genital involvement) with treatment

failure to 12 weeks of dose-optimized oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, Sulfasalazine, and Leflunomide). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried.

For Axial Spondyloarthritis: PA required. Must be prescribed by a rheumatologist. Reserved for patients who meet one of the following criteria:

(a) documented symptomatic ankylosing spondylitis with treatment failure/documented

intolerance to Renflexis, Inflectra, Avsola, Remicade, Adalimumab, or Etanercept; OR

(b) diagnosed with non-radiographic axial spondyloarthritis (nr-axSpA) and tried and failed at least 2 different NSAIDs over 1 month; OR

(c) patients with clinically relevant skin involvement defined as either having body surface area >10% or negatively impacting quality of life (such as face or genital involvement) and tried and failed at least 2 different NSAIDs over 1 month.

Code Q5103 – INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG, Code Q5104 – INJECTION, INFLIXIMAB-ABDA, BIOSIMILAR, (RENFLEXIS), 10 MG, Code Q5121 – INJECTION, INFLIXIMAB-AXXQ, BIOSIMILAR, (AVSOLA), 10 MG, Code J1745 – INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, (REMICADE) 10 MG:

For Ankylosing Spondylitis: PA required. Reserved for documented symptomatic ankylosing spondylitis despite treatment with NSAIDs (unless NSAID-intolerant). An adequate trial is defined as at least 2 different NSAIDs tried over 1 month. Must be initiated by a rheumatologist.

For Rheumatoid Arthritis: PA required. Must be initiated by a rheumatologist. Reserved for treatment failure to either:

(a) 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Leflunomide, Hydroxychloroquine, Sulfasalazine, Azathioprine). (If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried) OR

(b) a previous biologic or its biosimilars (e.g. Adalimumab, Sarilumab, Anakinra) OR

Code J3262 – INJECTION, TOCILIZUMAB, (ACTEMRA) 1MG, Code J9312 – INJECTION, RITUXIMAB (RITUXAN) 10MG: PA required. Reserved for treatment of rheumatoid arthritis with treatment failure to Etanercept, Infliximab, Golimumab, or Rituximab biosimilars. Must be prescribed by a rheumatologist.
Code J0717 – INJECTION, CERTOLIZUMAB PEGOL, (CIMZIA) 1 MG: PA required. Must be prescribed by a rheumatologist or dermatologist. Reserved for treatment of rheumatoid arthritis and must meet one of the following:
(a) treatment failure/documented intolerance to Adalimumab, Etanercept, Infliximab, Golimumab, Rituximab (or biosimilars), Sarilumab, OR
(b) women that are currently pregnant or breastfeeding.
Code J0129 – INJECTION, ABATACEPT, (ORENCIA) 10 MG: Adjusted to 2^nd line agent. PA Must be initiated by a rheumatologist. Reserved for treatment of rheumatoid arthritis and must meet one of the following:

(a) treatment failure/documented intolerance to Adalimumab, Etanercept, Infliximab, Rituximab (or biosimilars), Sarilumab, OR

(b) patients with:

(1) nontuberculous mycobacterial lung disease OR contraindications to tumor necrosis factor (TNF) inhibitors, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease AND

(2) who have treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Leflunomide, Hydroxychloroquine, Sulfasalazine, Azathioprine).

Code Q5123 – INJECTION, RITUXIMAB-ARRX (RIABNI) 10MG, Code Q5119 – INJECTION, RITUXIMAB-PVVR (RUXIENCE) 10MG, Code Q5115 – INJECTION, RITUXIMAB-ABBS (TRUXIMA) 10MG, Code J1602 – INJECTION, GOLIMUMAB (SIMPONI, SIMPONI ARIA) 1MG: Adjusted to 1^st line agent. PA required. Must be initiated by a rheumatologist. Reserved for treatment failure to either:

(b) a previous biologic or its biosimilars (e.g. Adalimumab, Sarilumab, Anakinra) OR

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

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