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New Pharmacy Benefit Manager beginning January 2022

Effective January 1, 2022, Buckeye Health Plan will transition their Pharmacy Benefit Manager (PBM) from Envolve Pharmacy Solutions to CVS Caremark for their Medicaid and MyCare Opt Out members.

As part of this transition, the prior authorization fax number will change. Please update your fax system and prior authorization system to reflect this change:   

Buckeye Health Plan Medicaid and MyCare Opt Out new prior authorization fax number: 1- 844-205-3383.

The pharmacy benefits for Buckeye Medicaid and Mycare Opt Out members will remain the same.

We appreciate your careful attention to this new information. Please contact Buckeye Provider Services at 1–866–296-8731 with any questions.

Buckeye Health Plan has a clinical policy in place for Medicaid members who meet the criteria for a Continuous Glucose Monitor. Product availability varies based upon whether the monitor is reviewed and approved through the pharmacy benefit or the medical DME benefit.

Examples of CGM System Continuous Glucose Monitor Models (this is not an exhaustive list):

  • Freestyle Libre 10 day **Pharmacy benefit**
  • Freestyle Libre 14 day **Pharmacy benefit**
  • Dexcom G4 **DME – medical benefit**
  • Dexcom G5 **DME – medical benefit**
  • Dexcom G6 **DME – medical benefit**
  • Medtronic MiniMed Guardian Connect **DME – medical benefit**

See the complete policy with clinical criteria that are required for review of medical necessity.

As a Buckeye Health Plan provider you know that quality health care is a high priority for the Centers for Medicare & Medicaid Services (CMS). CMS considers statin use in patients with cardiovascular disease and statin therapy in members with diabetes very important quality measures that should be appropriately managed and monitored. Buckeye has put in place the following initiatives to improve our measures and the success of Buckeye Health Plan quality efforts and the quality care of the members that we serve relies on each provider’s attention to these initiatives.

  1. Working with our data analytics team a monthly report is generated that identifies BHP members that fall into each of these measures.
  2. Our pharmacy team will make up to 2 fax attempts to each provider for each member identified.
  3. If no response from our fax outreach then a BHP clinical Pharmacist will attempt to contact the provider to review and resolve each opportunity.

Please consider the following for members that fall into these measures:

  • Evaluate and consider if member would benefit from the use of statin therapy (either during annual wellness exam or by responding to BHP outreach)  
  • Consider prescribing the medication electronically to the patient’s pharmacy of choice.
  • Make it easier for the patient to adhere to treatment by prescribing a 90-day supply, mail order or auto-refills – especially for patients stable on therapy.
  • Assess health literacy to determine need for additional support in medication management.
  • Educate the member on the role the medication plays in their disease process and what to do if they experience a side effect.

Measures For Your Reference:

SUPD Statin Use in Persons with Diabetes (Medicare)
Definition: 
Percentage of patients 40-75 years of age during the measurement year with at least 2 diabetes medications dispensed, and who also received a statin medication fill during the measurement year.

*STAR Weight: Currently 1 Star and will be 3 Star for 2020

The SPC and SPD CMS Quality measures can be found on the NCQA website. 

What is changing?

  • CGMs: Dexcom G6 is now available thru the pharmacy benefit, but requires PA. This means the following CGMs can be obtained thru the pharmacy benefit with an approved PA:
    • Freestyle Libre 10
    • Freestyle Libre 14
    • Freestyle Libre 2
    • Dexcom G6
  • CGMs: Upon approval, the following quantity limits apply to CGMs and associated products:
    • 1 receiver every 4 years, 1 transmitter every three months, 4 sensors per month.
  • Diabetic Supplies: Below are the new quantity limits for diabetic supplies:

Diabetic Supplies

Product

Previous Quantity Limits

New Quantity Limits

Blood Ketone Strips

QL: 100 per 30 days

QL: 100 per 30 days

Insulin Syringes

QL: 5 per day

QL: 7 per day

Pen Needles

QL: 5 per day

QL: 7 per day

Alcohol Swabs

QL: 400 per 30 days

 

QL: 10 per day

Blood Glucose Test Strips

(Preferred test strips are listed in the table below)

QL for insulin users or pregnant members: 150 per 30 days

QL for non-insulin users: 100 per 90 days

 

QL for Insulin users or pregnant: 250 per 30 days

QL for Non-insulin users: 200 per 90 days

Blood Glucose Meters

(Preferred meters are listed in the table below)

QL: 1 per 720 days

QL: 1 per 720 days

 

Blood Glucose

TEST STRIPS:
Manufacturer

NDC

Product Description

LifeScan, Inc.

53885-0244-50

ONETOUCH ULTRA BLUE

LifeScan, Inc.

53885-0245-10

ONETOUCH ULTRA BLUE

LifeScan, Inc.

53885-0270-25

ONETOUCH VERIO

LifeScan, Inc.

53885-0271-50

ONETOUCH VERIO

LifeScan, Inc.

53885-0272-10

ONETOUCH VERIO

LifeScan, Inc.

53885-0994-25

ONETOUCH ULTRA BLUE

Trividia Health, Inc.

56151-1460-01

TRUE METRIX

Trividia Health, Inc.

56151-1460-04

TRUE METRIX

 

METERS:
Manufacturer

NDC

Product Description

LifeScan, Inc.

53885-0044-01

ONETOUCH VERIO FLEX

LifeScan, Inc.

53885-0046-01

ONETOUCH ULTRA 2

LifeScan, Inc.

53885-0194-01

ONETOUCH VERIO FLEX

LifeScan, Inc.

53885-0208-01

ONETOUCH ULTRA MINI

LifeScan, Inc.

53885-0267-01

ONETOUCH VERIO IQ

LifeScan, Inc.

53885-0448-01

ONETOUCH ULTRA 2

LifeScan, Inc.

53885-0657-01

ONETOUCH VERIO

LifeScan, Inc.

53885-0927-01

ONETOUCH VERIO REFLECT

Trividia Health, Inc.

56151-1470-02

TRUE METRIX

Trividia Health, Inc.

56151-1490-02

TRUE METRIX AIR

  • The new QLs for blood glucose test strips were implemented on 7/31/21, and the implementation of the other QLs and adding Dexcom G6 is TBD.

 

Why are these changes being implemented?

  • ODM and the Medicaid Managed Care Plans (MCPs) have been discussing coverage of CGMs and diabetic supplies for some time, primarily related to the ongoing Diabetes Quality Improvement Project (QIP). ODM gathered information from all the MCPs around each plan’s coverage of CGMs (medical vs pharmacy benefit, PA requirements, etc) and quantity limits for diabetic supplies. After gathering all this information, ODM decided that they would remove PA from CGMs and cover Freestyle Libre and Dexcom via their pharmacy benefit. ODM allowed each MCP to determine if they would remove PA or not.