April 2025 Provider News
Date: 04/29/25
In this issue:
- General Updates - Ambetter Mid-level Reimbursement Alignment, Hepatitis C, Manual reminder
- Quality - Immunization, Mammogram, CMS Medicare Learning network, 2025 Prescribing Aid Medicare Advantage Part- D
- Tribal - Resource for Assistance
- Clinical & Payment Policy - Policy updates eff 05/01/2025
- Wellcare - Link to Medical Clinical Policy Updates
- Training/Education - Upcoming Training Opportunities
- Pharmacy Updates - Medical Oncology Update, Over the Counter (OTC) Birth Control
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General Updates
Medicaid Reminder: Providers must adhere to appointment availability and wait times found in the Provider Operations Manual on pages 27-28.
Ambetter Mid-level Reimbursement Alignment
To align with CMS guidance there will be changes to Ambetter/Marketplace mid-level reimbursement for the following provider types:
- Nutritionist
- Dietician
- Midwife
These changes will align with CMS guidelines outlined in the Calendar Year (CY) 2025 Medicare Physician Fee Schedule Final Rule, which can be found here.
Hepatitis C
Our provider partners are a key stakeholder in the fight to eliminate Hepatitis C in our state!
Coordinated Care would like to remind you that:
- Anti-viral MAVYRET can cure Hepatitis C.
- These daily pills are allowed for up to a 12-week supply at one time.
- Effective for claims on or after March 1, 2024, the Health Care Authority, Apple Health Fee-For-Service (FFS) has increased the maximum allowable days’ supply for Mavyret (glecaprevir/pibrentasvir).
- Pharmacies may dispense and submit claims for up to a 12-week (84 days) supply of Mavyret in a single fill.
- Mavyret is preferred and does not require prior authorization
- To ensure patients receive the full course of treatment, Mavyret prescriptions should be written in a manner to allow the pharmacy to dispense the entire 8-week or 12-week course of treatment.
- Other anti-viral medications will require review and be approved only if Mavyret is not clinically appropriate.
- CDC recommends that all adults 18 years and older be screened for Hep C at least once, as well as pregnant women during each pregnancy.
- Injection drug use is the primary risk for Hepatitis C. Any person requesting HCV screening should receive it.
- Direct-acting antiviral (DAA) medications can be prescribed for children aged 3 and up.
- Patients who have certain liver problems or are taking medicines (atazanavir or rifampin) are not eligible to take MAVYRET.
- Anyone licensed to prescribe direct acting anti-viral medications is allowed to screen and treat Apple Health members, including primary care doctors and pharmacists.
- Learn more at:
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Quality
Medicaid Quality
Vaccine guides: Vax Northwest • Immunity Community
Vaccine Clinic pop up guide (PDF)
Spokane region immunizations: Vaccines & Immunization | Spokane Regional Health District
Resources for health professionals, parents and other agencies to add brain building opportunities for children: Vroom in Healthcare | Vroom.org
Snippets from the Washington State Dept of Health’s Respiratory Illnesses Newsletter:
National Infant Immunization Week (April 21–28) – We highlight the importance of protecting children two years and younger from vaccine-preventable diseases and recommend that children stay on track with their well-child appointments and routine vaccinations.
National Infant Immunization Week (NIIW) is April 21–28, 2025
Don’t let diseases of the past become a part of their future.
In 2025, no parent should have to worry about their baby facing diseases like measles, rubella, diphtheria, or other illnesses we now have the power to prevent. But the ongoing measles outbreaks facing our nation today remind us that the progress we’ve made is fragile — and it’s up to all of us to protect it.
We’re fortunate to live in a time when we can protect babies from more than 16 dangerous diseases that once infected and even killed thousands of children. Today, 9 out of 10 parents in the U.S. choose to vaccinate. But with misinformation spreading and preventable diseases like measles making a comeback, it’s more important than ever to affirm why making the choice to vaccinate is so important.
Important information for parents:
- Learn more about the vaccines recommended for babies and young children.
- Find out how to access free or low-cost vaccines for babies and children, regardless of insurance or immigration status.
- Understand how we know vaccines are safe.
We all want to protect our children. But in a world full of conflicting information, knowing who to trust can be hard. The #VaxToTheFuture campaign helps explain how we can trust that vaccines are safe, while emphasizing that risking infection with diseases they protect against is not.
Vaccinate Your Family’s #VaxToTheFuture campaign is a bilingual initiative to remind parents, caregivers, and communities of a simple but powerful truth: a childhood free from vaccine-preventable diseases is possible, but only if we remember the lessons of the past and choose to vaccinate.
Join us in spreading the word about the importance of infant immunization. It has never been more important for each of us to speak up for the importance and safety of routine immunization for babies. Remember to use the #VaxToTheFuture hashtag when you share on social media and tag @vaccinateyourfamily (@vaxyourfam on X/Twitter) so we can amplify your posts!
World Immunization Week (April 24–30) – A global push for vaccine equity and access for all ages. Thank you for all you do to promote vaccines! Vaccines save lives!
Heads up! World Immunization Week (WIW) happens around the same time as NIIW. WIW is April 24-30, 2025. It’s time to show the world that Immunization for All is Humanly Possible. Hashtags: #VaccinesWork, #Humanly Possible Check out the World Health Organization's Campaign!
Mammograms (HEDIS Measure)
The HEDIS measure assesses women ages 50-74 who had at least one mammogram to screen for breast cancer in the past 2 years.
Does your patient have any of these risk factors? They may need to be assessed for early onset Breast Cancer:
* Reproductive history- menstrual history of starting periods before age 12 and menopause after 55
* Having dense breasts
* Breast/ ovarian cancer personal/family history orpersonal/family history of genetic mutations
Spread the word about the importance of getting regular colorectal cancer screenings, starting at age 45 years. Share the National Cancer Institute’s colorectal cancer resources to help people learn about prevention, treatment, and more. Colorectal Cancer—Health Professional Version - NCI Share awareness resources from the Centers for Disease Control and Prevention (CDC) with your networks.
Wellcare Quality
Check out CMS Medicare Learning network here: 2025-04-17-MLNC | CMS
Raise Awareness & Understanding of Alcohol Use and Misuse
Excessive alcohol use is a leading preventable cause of death in the U.S. During Alcohol Awareness Month, talk with your patients who drink alcohol about potential risks.
Medicare pays for alcohol misuse screening and counseling for Medicare Part B patients who qualify.
Encourage your patients who are at risk to get an annual screening. Find out when your patient is eligible for these screenings and counseling. If you need help, contact your eligibility service provider.
More Information:
- Substance Use Screenings & Treatment (PDF) booklet
- For your patients:
2025 Prescribing Aid Medicare Advantage Part- D
- subject to evidence of coverage
- Tiers 3-5 Deductible will apply
- Tier 6: initial coverage
- $0-$10 monthly for C-snp plan,
- $0 copay for all other plants
- D-Snp plans: $0 copays across all phases of coverage
- No coverage gap (donut hole) 2025
- Max $35 monthly for insulin products
2025 Preferred Blood Glucose Meter Strips
- One touch Verio Reflect or Verio felx meter & One Touch Verio test strips, One Touch Ultra 2 meter & One Touch ultra test strips
- Quantity Limits: 1 meter kit per 365 days (1 per calendar year) 100 test strips per 25 days (4 per day)
Continuous Glucose (CGM) Systems: FreeStyle Libre or DexCom a re preferred -PAR. PA-Criteria (ALL1-4)
- DM diagnosis
- Insulin-treated, OR had problematic hypoglycemia documented by ONE (a. OR b.) of the following
- More than one level 2 hypoglycemic event (BG <54 mg/dL) that persist despite more than one attempt to adjust medications and/ or modify diabetes treatment plan.
OR
- One level 3 hypoglycemic even (BG<54 mg/dL) characterized by altered mental and/ or physical state requiring third-party assistance for treatment,
- Seen by providing in last 6 months
- Will have follow-up appointments ever 6 months to document adherence to both the CGM regimen and diabetes treatment plan. The Coverage Determination form for PAR requests is available on the Wellcare website.
Drug Class |
Medications |
Wellcare Dual Liberty
Wellcare Dual Access
Wellcare Dual Reserve (HMO-POS D- SNP) | Wellcare Giveback,
Wellcare Simple (HMO-POS) | Wellcare Dual Liberty Open, Wellcare Dual Access Open (PPO D-SNP) | Wellcare Mutual of Omaha Simple Open, Wellcare Mutual of Omaha Premium Enhanced Open (PPO) |
Insulins | Fast Acting: Insulin Aspart | Tier 1 | Tier 3 | Tier 1 | Tier 3 |
| Short Acting: Novolin R U100 | Tier 1 | Tier 3 | Tier 1 | Tier 3 |
| Intermediate: Novolin N U-100, Humulin R U-500 | Tier 1 | Tier 3 | Tier 1 | Tier 3 |
| Long Acting: Insulin Degludec U-100 AND U-200, Insulin Glargine YFGN U-100, Insulin Glargine U-300 |
Tier 1 |
Tier 3 |
Tier 1 |
Tier 3 |
| Combinations: Novolin 70/30, Insulin Aspart Protamine-Insulin Aspart Mix 70/30 |
Tier 1 |
Tier 3 |
Tier 1 |
Tier 3 |
| Other Insulin Combinations: Xultophy, Soliqua | Tier 1 | Tier 3 | Tier 1 | Tier 3 |
Orals | Biguanide: Metformin, Metformin ER (generic for Glucophage XR only) 2nd Generation Sulfonylure: Glipizide, Glipizide XR, Glimepiride Thiazolidinedione: Pioglitazone Alpha-Glucosidase inhibitor: Acarbose Meglitinide analogue: Nateglinide, Repaglinide Combinations: Glipizide/ Metformin, Pioglitazone/ Metformin, Pioglitazone/ Glimepiride | Tier 1 |
Tier 6 Tier 2: Metformin ER (generic for Fortamet) | Tier 1 |
Tier 6 Tier 2: Metformin ER (generic for Fortamet) |
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Tribal
Resource for Assistance
IHCPs have access to a dedicated email inbox for inquires regarding all lines of business at Coordinated Care (Medicaid, Marketplace/Exchange, and Medicare Advantage). Please don’t hesitate to reach out to IndianHealthCareProviderAssistance@coordinatedcarehealth.com and the team monitoring the inbox will assist or connect you with the appropriate contacts to resolve your questions.
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Clinical Policy Updates
The below policies were updated as part of our regular monthly review in March. The policy changes are effective May 1, 2025. You will find the policies, including a description of the revisions, posted on the policy site.
Policy Number | Policy Title | Line of Business |
WA.CP.MP.37 | Bariatric Surgery | Apple Health |
WA.CP.BH.521 | Behavioral Health Wraparound Support | Apple Health |
CP.MP.101 | Donor Lymphocyte Infusion | Apple Health & Ambetter |
WA.CP.BH.528 | HRSN – Intensive Behavioral Supportive Supervision | Apple Health |
CP.MP.160 | Implantable Wireless Pulmonary Artery Pressure Monitoring | Ambetter |
CP.MP.170 | Nerve Blocks for Pain Management | Apple Health & Ambetter |
CP.MP.176 | Outpatient Cardiac Rehabilitation | Ambetter |
CP.MP.246 | Pediatric Kidney Transplant | Apple Health & Ambetter |
CP.MP.182 | Short Inpatient Hospital Stay (only change is from 2024 to 2025 CMS Inpatient Only List) | Apple Health & Ambetter |
The below policies were updated as part of our regular monthly review in March. The policy changes are effective August 1, 2025. You will find the policies, including a description of the revisions, posted on the policy site.
Policy Number | Policy Title | Line of Business |
CP.MP.55 | Assisted Reproductive Technology | Ambetter |
CP.BH.201 | Deep Transcranial Magnetic Stimulation (TMS) for OCD | Ambetter |
CP.MP.132 | Heart-Lung Transplant | Apple Health & Ambetter |
WA.CP.MP.69 | Intensity-Modulated Radiotherapy | Apple Health |
CP.MP.57 | Lung Transplant | Apple Health & Ambetter |
WA.CP.MP.517 | Testosterone Testing | Apple Health |
WA.CP.MP.520 | Tympanostomy Tubes | Apple Health |
The below policies are new effective August 1, 2025. You will find the policies posted on the policy Web site.
Policy Number | Policy Title | Line of Business |
WA.CP.MP.69 | Intensity-Modulated Radiotherapy | Ambetter |
WA.CP.MP.517 | Testosterone Testing | Ambetter |
WA.CP.MP.520 | Tympanostomy Tubes | Ambetter |
The below policy will be archived effective July 31, 2025.
Policy Number | Policy Title | Line of Business |
CP.MP.69 | Intensity-Modulated Radiotherapy | Ambetter |
The policies below were previously announced as revised effective on the date noted. You will find the policies posted on the policy site.
Policy Number | Policy Title | Effective Date | Line of Business |
CP.MP.62 | Hyperhidrosis treatments | 5/1/25 | Apple Health & Ambetter |
CP.MP.107 | Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines | 5/1/25 | Apple Health & Ambetter |
CP.MP.180 | Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea | 5/1/25 | Ambetter |
WA.CP.MP.237 | CG Oncology Algorithmic Testing | 5/1/25 | Apple Health |
WA.CP.MP.219 | CG Genetic Testing Exome and Genome Sequencing | 5/1/25 | Apple Health |
V1.2025 | Concert Genetics Policies | 5/1/25 | Apple Health & Ambetter |
CP.BH.104 | Applied Behavior Analysis | 7/1/25 | Apple Health & Ambetter |
CP.BH.105 | Applied Behavioral Analysis Documentation Requirements | 7/1/25 | Apple Health & Ambetter |
WA.CP.MP.515 | Fecal Microbiota Transplantation | 7/1/25 | Apple Health |
CP.MP.121 | Homocysteine Testing | 7/1/25 | Apple Health & Ambetter |
CP.MP.82 | NICU Apnea Bradycardia Guidelines | 7/1/25 | Apple Health & Ambetter |
CP.MP.81 | NICU Discharge Guidelines | 7/1/25 | Apple Health & Ambetter |
WA.CP.MP.526 | Stem Cell Therapy for Musculoskeletal Conditions | 7/1/25 | Apple Health |
CP.MP.162 | Tandem Transplant | 7/1/25 | Apple Health & Ambetter |
WA.CP.MP.510 | Tinnitus Treatment | 7/1/25 | Apple Health |
CP.MP.163 | Total Parenteral Nutrition and Intradialytic Parenteral Nutrition | 7/1/25 | Apple Health & Ambetter |
The below genetic testing policies were previously announced to be updated effective May 1, 2025. You will find the policies, including a description of the revisions, posted on the policy site.
Policy Number | Policy Title | Line of Business |
V1.2025 | CG Aortopathies and Connective Tissue Disorders | Apple Health & Ambetter |
V1.2025 | CG Cardiac Disorders | Apple Health & Ambetter |
V1.2025 | CG Dermatologic Conditions | Apple Health & Ambetter |
V1.2025 | CG Epilepsy Neurodegenerative and Neuromuscular Conditions | Apple Health & Ambetter |
V1.2025 | CG Exome and Genome Sequencing for the Diagnosis of Genetic Disorders | Ambetter |
V1.2025 | CG Eye Disorders | Apple Health & Ambetter |
V1.2025 | CG Gastroenterologic Disorders Non-cancerous | Apple Health & Ambetter |
V1.2025 | CG General Approach to Genetic Testing | Apple Health & Ambetter |
V1.2025 | CG Hearing Loss | Apple Health & Ambetter |
V1.2025 | CG Hematologic Conditions Non-cancerous | Apple Health & Ambetter |
V1.2025 | CG Hereditary Cancer Susceptibility | Apple Health & Ambetter |
V1.2025 | CG Immune Autoimmune and Rheumatoid Disorders | Apple Health & Ambetter |
V1.2025 | CG Kidney Disorders | Apple Health & Ambetter |
V1.2025 | CG Lung Disorders | Apple Health & Ambetter |
V1.2025 | CG Metabolic Endocrine Mitochondrial Disorders | Apple Health & Ambetter |
WA.CP.MP.230 | CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Apple Health |
V1.2025 | CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | Ambetter |
WA.CP.MP.231 | CG Prenatal Cell-Free DNA Testing | Apple Health |
V1.2025 | CG Prenatal Cell-Free DNA Testing | Ambetter |
V1.2025 | CG Oncology Algorithmic Testing | Ambetter |
V1.2025 | CG Oncology Cancer Screening | Apple Health & Ambetter |
V1.2025 | CG Oncology Circulating Tumor DNA Tumor Cells Liquid Biopsy | Apple Health & Ambetter |
V1.2025 | CG Oncology Cytogenetic Testing | Apple Health & Ambetter |
V1.2025 | CG Oncology Molecular Analysis Solid Tumors & Hematolgic Malignancies | Apple Health & Ambetter |
WA.CP.MP.232 | CG Pharmacogenetics | Apple Health |
V1.2025 v.A | CG Pharmacogenetics (Version A) | Ambetter |
V1.2025 | CG Preimplantation Genetic Testing | Apple Health & Ambetter |
V1.2025 | CG Prenatal and Preconception Carrier Screening | Apple Health & Ambetter |
V1.2025 | CG Prenatal Diagnosis Pregnancy Loss | Apple Health & Ambetter |
V1.2025 | CG Skeletal Dysplasia Rare Bone Disorders | Apple Health & Ambetter |
The below new policies were previously announced effective on the dates noted. You will find the policies posted on the policy site.
Policy Number | Policy Title | Effective Date | Line of Business |
WA.CP.MP.510 | Tinnitus Treatment | 7/1/25 | Ambetter |
WA.CP.MP.526 | Stem Cell Therapy for Musculoskeletal Conditions | 7/1/25 | Ambetter |
WA.CP.MP.515 | Fecal Microbiota Transplantation | 7/1/25 | Ambetter |
Prior Authorization Updates
The following services will require prior authorization effective July 1, 2025
Line of Business | Code | Description |
Ambetter | J1439 | Injection, ferric carboxymaltose, 1 mg |
Apple Health | 37229 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy |
Apple Health | 37227 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral, with transluminal stent placement(s) and atherectomy |
Apple Health | 42145 | Palatopharyngoplasty |
Apple Health | E2402 | Negative pressure wound therapy electrical pump, stationary or portable |
Apple Health | L1833 | Knee orthosis, adjustable knee joints, positional orthosis, rigid support, off-the-shelf |
Apple Health | L0650 | Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panel(s), lateral strength provided by rigid lateral frame/panel(s), off-the-shelf |
Apple Health | L0648 | Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, off-the-shelf |
Apple Health | L0637 | Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, prefabricated item, customized to fit |
Due to changes in reimbursement and benefit limitations for Apple Health members which were effective April 1, 2025, we will no longer require prior authorization for G0481 (Definitive Drug Testing, 8-14 Drug Classes) effective July 1, 2025. Please remember that the benefit limit for definitive drug testing is now 12 total services per year.
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Wellcare
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Training/Education
Suicide Prevention Provides an overview of the topic of suicide, signs, and symptoms, and how caregivers should respond in times of crisis. The training will dive into the rates of youth suicide, risk factors, and proactive steps to take for prevention. May 8th 2pm – 3:30pm Registration link
Supporting LGBTQIA+ Youth in Foster Care This training was developed through Amara with input from Coordinated Care and other community organizations. It is for caregivers and professionals who work in the child welfare setting. May 9th 11am – 12:30pm Registration link
Trauma and Food This training will discuss the reasons behind food-related issues such as eating too fast, hiding and stealing food, arguing over meal selections, etc. It is designed for those treating, supporting and caring for youth who have experienced trauma and may now have "quirky" behaviors around food. We will discuss how trauma affects childhood development, as well as offer practical and easy ideas to help regarding food. May 13th 10am – 11:30am Registration link
Understanding Behavioral Health Stigma A historical and current look at why mental health concerns can often meet with bias or stigma. This training provides a chance for open discussion on what has happened historically and the current barriers that may continue to get in the way of behavioral health solutions. May 21st 2pm – 3:30pm Registration Link
ACE's (Adverse Childhood Experiences): This training explains the Adverse Childhood Experiences (ACEs) study and identifies all 10 ACEs. All childhood experiences, especially traumatic events, have an impact on people as they mature. This training explores the long-term effects that adverse childhood experiences have on physical and mental health. Preventative measures, resiliency, and how to address the needs of children with a high ACEs score are all discussed. Personal ACE's test provided. May 8, 2025, 12:01 - 01:30 Register
Trauma Informed Care & Discipline: We all need discipline in our lives to function well in society. For youth especially, boundaries and consistency help provide safety and security. How does a caregiver or professional provide that understanding to a child, and then possibly consequences for inappropriate behavior, who is not attached to the foster family and has significant trauma in their lives? This training discusses this topic with ideas and tips, as well as an overview of why children with traumatic history can be so challenging. May 20, 2025 12:01 - 01:30 Register
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Pharmacy
Medical Oncology Update- Ambetter
Prior Authorization requests for the following HCPCS codes need to be verified by Evolent.
HCPCS | Generic Name | Brand Name | Medical PA | Pharmacy PA | Impact Description |
J3590 | DENOSUMAB-DSSB INJECTION | OSPOMYV | Yes | Yes | FDA new release approval 2/13/25 (biosimilar to Prolia) Effective date 10/1/25 |
J3590 | DENOSUMAB-DSSB INJECTION | XBRYK | Yes | Yes | FDA new release approval 2/13/25 (biosimilar to Xgeva) Effective date 10/1/25 |
Over the Counter (OTC) Birth Control - Medicaid
- Contraceptive FAQ
- WA DOH Teen Health Hub
- WA HCA Over the counter contraception for Apple Health clients FAQ (PDF)
- WA DOH Emergency Contraception