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May 2026 Provider News

Date: 05/29/26

In this issue: 

  • General Updates - Hepatitis C and Mayvret, Confidential Billing for School Based Health Center, Blood Lead Testing/Federal Medicaid Testing Requirement, After-Pregnancy Coverage (APC) Apple Health (Medicaid) After-Pregnancy Coverage (APC), Medicaid Member Access Distance & Drive Time standards
  • Quality - Medicaid Quality, Wellcare Quality
  • Tribal - Resources for Assistance
  • Clinical & Payment Policies and Prior Authorization Updates - Program Updates: DRG Audits, MPPR policy
  • Wellcare - Annual Wellness Visit and Routine Physical Exam coding refresher
  • Apple Health Core Connections  - Updated comprehensive healthcare guidance for youth in foster care (AAP)
  • Training/Education - Infant Early Childhood Mental Health Provider, MHAYC, Provider Travel Reimbursement Eligibility, HCA HR1 impact Webinar, Suicide Prevention in Youth, Trauma and Food: What is the connection?
  • Pharmacy Updates - Preferred Diabetic Supply Update: Accu-Chek® Added to Formulary, July 1, 2026 Preferred Drug List Changes, Blood Pressure Monitors and Cuffs Available at the Pharmacy Effective July 1, 2026, Pharmacy Clinical Policy Updates, Medical Oncology Update

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General Updates

Hepatitis C and Mavyret

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.
  • 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.
  • 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:


Confidential Billing Process for School-Based Health Centers

In Washington state, minor consent and confidentiality laws allow youth to receive certain services without involving a parent or guardian. School-Based Health Centers (SBHCs) follow the same state and federal confidentiality requirements as any other health care provider. Health information will not be shared without consent, except in very limited situations required by law. This document explains how confidentiality is maintained throughout the care and billing process, potential privacy risks, and how to report an issue. This process is focused on managed care organizations (MCO) Medicaid members and is specific to that company’s details.

My CCW health portal

  • Age 18 and older: can create their own portal account with Coordinated Care Washington (CCW).
  • Under age 18: do not have portal accounts. Information is not available through a parent/guardian’s account.

Potential confidentiality risk: A parent or guardian might create a portal account using their child’s personal information. This does not meet legal requirements. It should be corrected and reported to CCW for resolution.

Receiving confidential services at an SBHC

 

SBHCs follow minor consent laws (PDF) and HIPAA to ensure information is private and confidential, except in certain limited situations.

The patient may choose to sign a release of information (ROI) for certain information to be shared with a parent/guardian, school, school staff, or a trusted adult.

Eligibility and insurance verification

SBHCs must verify insurance coverage for each visit. Nothing from this step goes into a patient’s medical record.

Verification is completed through ProviderOne and includes:

  • MCO enrollment
  • Assigned provider
  • Whether the patient has other primary insurance

Good Cause Exemption: If the patient has other primary insurance, the provider will ask if there is Good Cause Exemption. This prevents billing of their primary insurance if confidentiality is preferred.

Billing, reimbursement, and medical records

 

CCW does not send Explanation of Benefits (EOB) for Medicaid clients. An EOB shows services received, provider charges, amount covered by insurance, remaining costs such as deductible and copay. An EOB is not a bill.

After a confidential appointment the provider sends a bill to CCW.

Potential confidentiality risk: If the patient has other primary health insurance, that plan may be billed, unless a Good Cause Exemption is applied.

  • CCW is not responsible for or involved in the billing processes of other insurance companies.
  • CCW processes the bill.
    • If approved:
      • CCW pays the health care provider.
      • CCW sends Evidence of Payment (EOP) to provider.
      • This does not affect the patient’s medical records.
    • If denied:
      • The provider can dispute the denial.
      • This does not affect the patient’s medical records.

 

Other considerations

Potential risks to maintaining confidentiality

Quality Assurance (QA) calls

CCW may call to follow up on care quality. QA calls are intended for the patient, but calls are made to the phone number on file, which could belong to a parent/guardian.

If a QA call or a QA email happens:

  • The CCW caller will ask to speak to the patient.
  • If the patient’s parent/guardian receives this call, the CCW caller should end the call without sharing information. 

CCW does not make calls for behavioral health services provided to people under 18.

Parent/guardian contacting CCW

If the parent/guardian contacts CCW about the patient or appointment, CCW will not share information unless the patient has signed an ROI.

Exceptions to confidentiality

  • Patient gives permission through a signed and dated ROI.
  • Patient indicates a risk of imminent harm to self or others.
  • Patient has a life-threatening health problem and is under age 18.
  • There is a reason to suspect abuse or neglect.
  • Certain communicable diseases must be reported to the public health department.

What is being done to address potential risks to maintaining your confidentiality at CCW

 

  • CCW is committed to maintaining confidentiality. We are taking additional measures to address these potential risks, including:
  • Adding training in confidentiality and billing to the required annual provider training.
  • Calls are not made for services to minors.
  • Providing this information regarding confidentiality and any potential risks and mitigation efforts.
  • Working with the Washington School-Based Health Alliance (WA SBHA) to continuously understand and address any areas of concern expressed by SBHCs to find ways to mitigate any potential risks to your confidentiality.

 

What to do if confidentiality is breached

If you experience any issues with confidential services email CCW and copy the HCA at hcamcprograms@hca.wa.gov with the following information:

  • Name of patient
  • Date of Birth of patient
  • P1 ID
  • Patient Phone Number
  • Provider Name & Contact Information
  • Brief description of the request/issue

HCA will identify the issues within confidential billing processes to address them with the MCO. We want providers to feel confident in billing, and this process will help to quickly identify and mitigate issues as they arise.


Background

About School-Based Health Centers

A School-Based Health Center (SBHC) is a health clinic located in or next to a school. Students can get medical care, mental health services, and sometimes other support all in one place.

SBHCs are different from school health staff, like the school nurse or a school-employed counselor. They are operated by a healthcare sponsor and follow the same healthcare laws and standards as community health clinics.

SBHCs are often placed in schools where students may have barriers to getting healthcare elsewhere, such as cost, distance, or lack of transportation.

Services at SBHCs are available to all students at the school. In some cases, SBHCs may also serve students from other schools in the district, as well as families, staff, or community members.

About Managed Care Organizations

Managed Care Organizations (MCOs) are health plans that provide healthcare coverage for physical health, mental health, and substance use treatment within one system. In Washington, most students who have Apple Health Medicaid get their care through an MCO.

The state has five MCOs. When someone becomes eligible for Apple Health, they choose or are assigned to one of these plans.

WA Health Care Privacy Toolkit (PDF)

Blood Lead Testing/Federal Medicaid Testing Requirement

Federal regulations require that all children enrolled in Medicaid receive a blood lead test at 12 and 24 months of age, or at 24 to 72 months of age if no record of a previous test exists. The Department of Health (DOH) recommends screening all children not covered by Medicaid at 12 and 24 months of age using this clinical algorithm (PDF).

Confirmatory Testing Timeframes if Initial Capillary Test Result ≥ 3.5 µg/dL:

Blood Lead Level Confirm blood lead level with a venous blood lead test:

  • 3.5-9 µg/dL Within 3 months to ensure the lead level is not rising.
  • 10-19 µg/dL Within 1 month to ensure the lead level is not rising.
  • 20-44 µg/dL Within 2 weeks. ≥45 µg/dL Within 48 hours.

Guidance for Medical Management of Blood Lead Levels: If blood lead level is ≥3.5 µg/dL: See PEHSU Recommendations on Medical Management of Childhood Lead Exposure.


After-Pregnancy Coverage (APC) Apple Health (Medicaid) After-Pregnancy Coverage (APC)

APC offers services to support your mental, physical, and emotional well-being for 12 months after pregnancy.

Benefits and services APC offer postpartum follow-up care and provides additional health care services at no cost to client. Benefits include dental care, contraception, preventive care, behavioral health, and other services covered by Apple Health.

Qualified coverage lasts up to 12 months after your pregnancy ends regardless of a change in income. Visit hca.wa.gov/apple-health-services to learn what services are covered under Apple Health.

To be eligible for the APC program client must:

  • Have been pregnant within the last 12 months.
  • Reside in Washington. 
  • Learn more here.


Apple Health - Medicaid - Member Access Distance & Drive Time Standards

Providers shall meet the distance and drive time standards in this subsection in every service area. HCA will designate a zip code in a service area as urban or non-urban for purposes of measurement. HCA will provide to the Contractor a list of service areas, zip codes and their designation. The Contractor’s ability to receive enrollment and/or assignment is based on the assignment provisions in this Contract. “Rural area” is defined as any area other than “urban area” as defined in 42 C.F.R. § 412.62(f)(1)(ii).

  • Distance Standards PCP
    • Urban: 2 within 10 miles.
    • Non-urban: 1 within 25 miles.
  • Obstetrics (including non-emergent birthing services)
    • Urban: 2 within 10 miles.
    • Non-urban: 1 within 25 miles.
  • Pediatrician or Family Practice Physician Qualified to Provide Pediatric Services
    • Urban: 2 within 10 miles.
    • Non-urban: 1 within 25 miles.
  • Hospital
    • Urban/Non-urban: 1 within 25 miles.
  • Pharmacy
    • Urban: 2 within 10 miles.
    • Non-urban: 1 within 25 miles.
  • Mental Health Professionals and SUDPs
    • Urban/non-urban: 1 within 25 miles.
  • Outpatient Behavioral Health Agency Providers
    • Urban/non-urban: 1 within 25 miles.

Drive Time Standards

The Contractor must ensure that when Enrollees travel to service sites, the drive time to the closest Provider of the service the Enrollee is seeking is within a standard of not more than:

In Urban Areas, a thirty-minute drive from the Enrollee’s primary residence to the service site or the service sites are accessible by public transportation with the total trip, including transfers, not to exceed ninety minutes each way;

Non-urban Areas, a sixty-minute drive from the Enrollee’s primary residence to the service site.

These travel standards do not apply under exceptional circumstances (e.g., inclement weather, hazardous road conditions due to accidents or road construction, public transportation shortages or delayed ferry service).

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Quality

Medicaid Quality


Use of Opioids at High Dosage (HDO) HEDIS Measure

The HEDIS Use of Opioids at High Dosage (HDO) measure tracks members age 18+ receiving ≥90 MME/day for ≥15 days. High dosages increase risk for overdose and adverse events.

For patients at ≥90 MME/day:

  • Reassess pain management and functional goals
  • Consider gradual dose reduction when appropriate
  • Use non-opioid and non-drug therapies when possible
  • Avoid concurrent opioid + benzodiazepine use
  • Check PDMP for overlapping prescriptions

WSAM Biennial Addition Medicine Summit

Date: Friday, June 12, 2026, 8:00 AM- Saturday, June 13, 2026, 5:00 PM

The Washington Society of Addiction Medicine (WSAM), in collaboration with the CHOICES, FIRST Clinic, and University of Washington (UW) Addictions, Drug & Alcohol Institute (ADAI), and representation from the UW Substance Use Research and Education (UW SURE) Unit, are excited to present the WSAM Addiction Medicine Summit: From Hospitalization to Recovery.

Event info

Improve Diabetes HEDIS Performance

Providers play a key role in improving outcomes for members with diabetes. Focus on closing care gaps for HbA1c control (<8.0%), annual HbA1c testing, blood pressure control (<140/90), retinal eye exams, and kidney health evaluation (eGFR and UACR). Timely documentation and coding of results are essential for HEDIS compliance. Encourage regular follow-up, medication adherence, and lab completion to support optimal disease management.

HEDIS measures

Chlamydia Screening (CHL) HEDIS Measure

Provider Actions:

  • Incorporate annual screening into routine care, including well-child, adolescent, and reproductive health visits.
  • Use urine-based testing when appropriate and ensure timely and accurate claim/encounter submission to capture screenings and close care gaps.

Chlamydia Screening (CHL)

Wellcare Quality

AIS-E (Adult Immunization Status)

Provider Actions:

  • Review immunization status at every visit and close gaps when possible.
  • Use IIS/EHR tools to verify and document vaccines from all sources.
  • Administer vaccines during visits or refer to in-network pharmacies.
  • Ensure accurate coding and timely documentation.

Adult Immunization Status (AIS-E)

OMW (Osteoporosis Management in Women Who Had a Fracture)

Provider Actions:

  • Ensure timely follow-up after any qualifying fracture by ordering BMD test or initiating osteoporosis therapy within 6 months.
  • Use discharge follow-up and post-acute visits as key opportunities to close care gaps.
  • Document services accurately.

Osteoporosis Management In Women Who Had a Fracture (OMW)

SPC (Statin Therapy for Patients with Cardiovascular Disease)

Provider Action:

  • Initiate appropriate statin therapy and reinforce medication adherence.
  • Use follow-up visits and medication reviews to address side effects, improve adherence, and ensure therapy is continued as prescribed.

Statin Therapy for Patients with Cardiovascular Disease (SPC)

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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 & Payment Policies and Prior Authorization Updates

Clinical Policy Updates 

The following policies are updated as of the listed Effective Date.

Policies are posted on the Coordinated Care of Washington Policy webpage. Evolent policies are available at https://www.radmd.com/solutions and will be accessible via the Evolent landing page found on the Coordinated Care Prior Authorization webpage. 

New to List?

Policy #

Policy Title

Line of Business

Change Type

Effective Date

 

CP.BH.124

ADHD Assessment and Treatment

Apple Health, Ambetter

Revised

6/1/2026

 

CP.MP.38

Ultrasound in Pregnancy

Apple Health

Revised

6/1/2026

 

WA.CP.MP.38

Ultrasound in Pregnancy

Ambetter

Revised

6/1/2026

 

ECG_7000

Evolent - Radiation Therapy Services

Ambetter

New

6/1/2026

 

ECG_7001

Evolent - Proton Beam Radiation Therapy and Neutron Beam Radiation Therapy Services

Ambetter

New

6/1/2026

X

WA.CP.MP.502

Cochlear Implants

Apple Health, Ambetter

Revised

6/1/2026

X

WA.CP.MP.503

Private Duty Nursing

Apple Health

Revised

6/1/2026

X

WA.CP.MP.504

Elective Delivery Prior to 39 Weeks

Apple Health

Revised

6/1/2026

X

WA.CP.MP.505

Microprocessor Controlled Lower Limb Prosthetics

Apple Health, Ambetter

Revised

6/1/2026

X

CP.MP.101

Donor lymphocyte infusion

Apple Health, Ambetter

Revised

6/1/2026

X

WA.CP.MP.69

Intensity-Modulated Radiotherapy

Apple Health, Ambetter

Revised

6/1/2026

X

CP.MP.160

Implantable Wireless Pulmonary Artery Pressure Monitoring

Ambetter

Revised

6/1/2026

X

CP.MP.170

Nerve Blocks for Pain Management

Apple Health, Ambetter

Revised

6/1/2026

X

CP.MP.176

Outpatient Cardiac Rehabilitation

Ambetter

Revised

6/1/2026

X

CP.MP.184

Home Ventilators

Apple Health, Ambetter

Revised

6/1/2026

X

CP.MP.246

Pediatric Kidney Transplant

Apple Health, Ambetter

Revised

6/1/2026

X

WA.CP.MP.237

CG Oncology Algorithmic  Testing

Apple Health, Ambetter

Revised

6/1/2026

X

WA.CP.MP.230

GC Multisystem Genetic Conditions

Apple Health, Ambetter

Revised

6/1/2026

X

ECG_7290

Evolent - Treatment of Varicose Veins

Apple Health, Ambetter

Revised

6/1/2026

X

CP.BH.201

Deep Transcranial Magnetic Stimulation (TMS) for OCD

Ambetter

Revised

6/1/2026

X

CP.MP.55

Assisted Reproductive Technology

Ambetter

Revised

6/1/2026

X

WA.CP.BH.200

Transcranial Magnetic Stimulation (TMS) for TRMD

Apple Health

Revised

6/1/2026

X

CP.BH.200

Transcranial Magnetic Stimulation (TMS) for TRMD

Ambetter

Revised

6/1/2026

X

CP.MP.132

Heart-Lung Transplant

Apple Health, Ambetter

Revised

6/1/2026

X

WA.CP.MP.37

Bariatric Surgery

Apple Health

Revised

6/1/2026

X

CP.MP.57

Lung Transplantation

Apple Health, Ambetter

Revised

6/1/2026

 

CC.PP.073

Sepsis Diagnosis

Apple Health, Ambetter

Revised

7/1/2026

 

CP.MP.102

Pancreas Transplantation

Apple Health, Ambetter

Revised

7/1/2026

 

CP.MP.162

Tandem Transplant

Apple Health, Ambetter

Revised

7/1/2026

X

WA.CP.MP.538

Frenotomy and Frenectomy with Breastfeeding Support

Apple Health

New

7/1/2026

X

CP.MP.252

Immobilized Lipase Cartridges (RELiZORB®)

Ambetter

New

8/1/2026

X

CP.MP.242

Pulmonary Function Testing

Apple Health, Ambetter

Revised

8/1/2026


Prior Authorization Updates

Future changes to Pre-Authorization requirements are noted below.

Utilize our Pre-Auth Check tool for real time response to pre-authorization requirements.

Code

Description

Line of Business

Effective Date

Notes

76965

Ultrasonic guidance for interstitial radioelement application

Ambetter

6/1/2026

 

77011

Computed tomography guidance for stereotactic localization

Ambetter

6/1/2026

 

77262

Therapeutic radiology treatment planning; simple

Ambetter

6/1/2026

 

77262

Therapeutic radiology treatment planning; intermediate

Ambetter

6/1/2026

 

77263

Therapeutic radiology treatment planning; complex

Ambetter

6/1/2026

 

77280

Therapeutic radiology simulation-aided field setting; simple

Ambetter

6/1/2026

 

77285

Therapeutic radiology simulation-aided field setting; intermediate

Ambetter

6/1/2026

 

77290

Therapeutic radiology simulation-aided field setting; complex

Ambetter

6/1/2026

 

77293

Respiratory motion management simulation (List separately in addition to code for primary procedure)

Ambetter

6/1/2026

 

77295

3-dimensional radiotherapy plan, including dose-volume histograms

Ambetter

6/1/2026

 

77299

Unlisted procedure, therapeutic radiology clinical treatment planning

Ambetter

6/1/2026

 

77300

Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician

Ambetter

6/1/2026

 

77301

Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications

Ambetter

6/1/2026

 

77306

Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s)

Ambetter

6/1/2026

 

77307

Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s)

Ambetter

6/1/2026

 

77316

Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s)

Ambetter

6/1/2026

 

77317

Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s)

Ambetter

6/1/2026

 

77318

Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s)

Ambetter

6/1/2026

 

77321

Special teletherapy port plan, particles, hemibody, total body

Ambetter

6/1/2026

 

77331

Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician

Ambetter

6/1/2026

 

77332

Treatment devices, design and construction; simple (simple block, simple bolus)

Ambetter

6/1/2026

 

77333

Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus)

Ambetter

6/1/2026

 

77334

Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts)

Ambetter

6/1/2026

 

77336

Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy

Ambetter

6/1/2026

 

77338

Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan

Ambetter

6/1/2026

 

77370

Special medical radiation physics consultation

Ambetter

6/1/2026

 

77387

Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed

Ambetter

6/1/2026

 

77399

Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services

Ambetter

6/1/2026

 

77402

Radiation treatment delivery; Level 1 (eg, single-electron field, multiple-electron fields, or 2D photons), including imaging guidance, when performed

Ambetter

6/1/2026

 

77407

Radiation treatment delivery; Level 2, single-isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed

Ambetter

6/1/2026

 

77412

Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (eg, 2D, 3D, or IMRT) or a single-isocenter photon therapy (eg, 3D or IMRT) with active motion management, or total skin electrons, or mixed-electron/photon field(s), including imaging guidance, when performed

Ambetter

6/1/2026

 

77417

Therapeutic radiology port image(s)

Ambetter

6/1/2026

 

77427

Radiation treatment management, 5 treatments

Ambetter

6/1/2026

 

77431

Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only

Ambetter

6/1/2026

 

77432

Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)

Ambetter

6/1/2026

 

77435

Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions

Ambetter

6/1/2026

 

77470

Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation)

Ambetter

6/1/2026

 

77499

Unlisted procedure, therapeutic radiology treatment management

Ambetter

6/1/2026

 

77750

Infusion or instillation of radioelement solution (includes 3-month follow-up care)

Ambetter

6/1/2026

 

77761

Intracavitary radiation source application; simple

Ambetter

6/1/2026

 

77762

Intracavitary radiation source application; intermediate

Ambetter

6/1/2026

 

77763

Intracavitary radiation source application; complex

Ambetter

6/1/2026

 

77767

Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel

Ambetter

6/1/2026

 

77768

Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions

Ambetter

6/1/2026

 

77770

Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel

Ambetter

6/1/2026

 

77771

Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels

Ambetter

6/1/2026

 

77772

Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels

Ambetter

6/1/2026

 

77778

Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed

Ambetter

6/1/2026

 

77789

Surface application of low dose rate radionuclide source

Ambetter

6/1/2026

 

77790

Supervision, handling, loading of radiation source

Ambetter

6/1/2026

 

77799

Unlisted procedure, clinical brachytherapy

Ambetter

6/1/2026

 

G0458

Services, low dose rate (LDR) prostate brachytherapy (insertion of radioactive seeds)

Ambetter

6/1/2026

 

E1399

Durable Medical Equipment (DME), miscellaneous

Apple Health, Ambetter

8/1/2026

Prior authorization is required for all requests, regardless of billed amount. Previous billed amount thresholds removed.

 

Program Updates

Coordinated Care is committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. Please see below information on DRG and ACA marketplace updates.

DRG validation program

Description

Lines of Business

Coordinated Care will begin auditing selected claims and associated medical records to ensure payments were applied in accordance with national correct coding standards and DRG payment rules.  

Medical records will be requested for selected claims by both our internal review team (update/change) and our contracted partner Cotiviti. Please ensure medical records are sent according to the instructions on the request correspondence. 

Medicare, Medicaid, Marketplace 

 

 

New policy for ACA Marketplace that will go into effect on or after 9/1/2026.

Description of Changes

Lines of Business

CC.PP.068 – Multiple Procedure Payment Reduction for Therapeutic Service:

When multiple (two or more) ‘always therapy’ procedures with an MPI of 5 are performed by the same provider, or by providers within the same group practice, on the same day, the policy will allow 100% of the maximum allowance for the therapeutic procedure with the highest cost per until and 90% of the allowance for each subsequent therapeutic procedure.

Marketplace

 

 

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    Wellcare

    Please visit the Wellcare Provider Bulletins for the latest on Annual Wellness Visit and Routine Physical Exam Coding Refresher.

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    Apple Health Core Connections 

    The American Academy of Pediatrics published an updated edition of Fostering Health: Health Care for Children and Adolescents in Foster Care. This resource if for pediatrics health care professionals and serves as a comprehensive guide to health care for this population. This edition incorporates principles of trauma-informed relational health care with an equity lens and has been reviewed by people with lived experience in the foster care system. It is available as a paperback or eBook.

    Coordinated Care is the single managed care organization to administer the Integrated Managed Care Apple Health Foster Care program in collaboration with the Health Care Authority and Department of Children Youth and Families. Our program, Apple Health Core Connections, serves children and youth in foster care, adoption support, alumni of foster care (ages 18-26), children reunified with their parents, and youth in the Unaccompanied Refugee Minor program. To learn more about our foster care health plan, please contact katherine.ferguson@coordinatedcarehealth.com.  

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    Training/Education

    Infant Early Childhood Mental Health Provider Technical Assistance

    Opportunity for providers to connect with all five MCOs to discuss Infant Early Childhood Mental Health

    Topics will cover:

    • Review of changes to reimbursement (up to 5 sessions for assessment)
    • Eligible Travel reimbursement
    • Review of billing guidance resources and DC 0-5 crosswalk
    • Review of resources

    Technical Assistance Sessions Available:

    Each session will cover the same topics so please attend the session that works best for your schedule.

    Reminder: Resources and Supports Available

    Washington State has expanded mental health assessment resources for children from birth through age five. This initiative is referred to as Mental Health Assessment for Young Children (MHAYC).

    Key policy changes include:

    • Enhanced reimbursement, including:
      • Coverage for up to five assessment sessions, if needed
      • Reimbursement for provider travel costs when assessments occur in the home or community
    • Required use of the DC:0–5™ diagnostic classification system

    Provider Travel Reimbursement Eligibility

    Travel reimbursement is available only when all of the following conditions are met:

    • Travel is for the purpose of conducting a mental health assessment (CPT codes 90791, 90792, or H0031 only)
    • The child is between birth and their 6th birthday
    • The session occurs in the child/family home or a community setting (POS 03 – School; POS 04 – Homeless Shelter; POS 12 – Home; POS 99 – Other)

    Submitting MHAYC Travel Reimbursement: Coordinated Care of Washington

    Providers should use the MHAYC Provider A-19 Form (Provider Training | Coordinated Care Health Plan)  

    Each A-19 entry must include:

    • Service date of the diagnostic assessment
    • ProviderOne client ID
    • Starting and ending addresses
    • Miles traveled
    • Mileage rate (prepopulated on the form)

    Submit invoices to: CoordinatedCareFinance@coordinatedcarehealth.com

    All invoices must match adjudicated claims and meet eligibility requirements. Invoices are due within 60 days of the adjudicated supporting claim.

    Additional Information & Resources

    Upcoming HCA webinar on H.R. 1 impact

    The HCA is hosting an  H.R. 1 impacts series. These webinars are held quarterly and provide an overview of H.R. 1 changes.  Please visit the HCA link.

    Suicide Prevention in Youth

    Provides an overview of the topic of suicide, signs and symptoms in youth, and how professionals and 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. Will include a discussion on self-harm and social media. This training has many resources to utilize, as well as being useful for concerns of suicidal ideation in adults as well. This training will be held in person at Excelsior Wellness in Spokane, WA from 11:30am to 2pm on June 5 and is open to the public. Snacks will be provided and a brief presentation on the beneficial programs offered for foster care youth by Excelsior will be included.  No RSVP needed.

    Trauma and Food: What is the connection?

    This training will discuss the reasons behind food related issues such as eating too fast or too much, hiding and stealing food, arguing over meal selections, etc. It is designed for those treating, supporting and caring for children 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 in regard to this common concern. Jun 12, 12:30 – 02:30pm.

    Register.

    Back to Top

    ______________________________________________________________________________________

    Pharmacy Updates

    Preferred Diabetic Supply Update: Accu-Chek® Added to Formulary- Medicaid

    Important Notice

    Due to a recent recall affecting certain True Metrix® diabetic testing supplies, Coordinated Care is implementing an immediate formulary update to support continuity of care and maintain member access to reliable glucose monitoring products.

    In addition to continuing coverage of True Metrix® products, Accu-Chek® products are being added to the formulary as preferred diabetic testing supplies. Newly preferred products include the Accu-Chek Guide® meter, Accu-Chek Guide Me® meter, and Accu-Chek® test strips.

    For additional details about the True Metrix® recall, including a list of affected products, please visit this page.

    July 1, 2026 Preferred Drug List Changes- Medicaid

    Effective July 1, 2026, the drugs listed below will be non-preferred. Impacted members will be notified prior to this change. Preferred alternatives are listed in the last column.

    Drug Name

    Drug Class

    Preferred Alternative(s)

    Copaxone Syringe (Glatiramer Acetate) SYRINGE

    Multiple Sclerosis Agents

    Glatiramer Acetate Syringe (generic for Copaxone)

    Farxiga Tabs (Dapagliflozin Propanediol)

    Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

    Dapagliflozin Propanediol TABS (generic for Farxiga)

    Tobramycin AMPUL-NEB

    Aminoglycosides- Drugs to Treat Bacterial Infections

    Bethkis or Kitabis PAK AMPUL-NEB

     

    Blood Pressure Monitors and Cuffs Available at the Pharmacy Effective July 1, 2026- Medicaid

    Effective July 1, 2026, blood pressure monitors and cuffs will be available at the pharmacy with a prescription*.  Some limitations will apply.

    Some covered manufacturers will include:

    • Advocate 
    • BD (Becton Dickinson) 
    • CareTouch 
    • Clever Choice (Simple Diagnostics) 
    • CVS Health 
    • Equate (Walmart) 
    • Essential 
    • FondCircle 
    • ForaCare 
    • Fred's/Fred Meyer 
    • GNP (Good Neighbor Pharmacy) 
    • Health Mart (HM) 
    • Health Sense 
    • HealthSmart 
    • H-E-B 
    • Kroger 
    • Microlife 
    • Omron 
    • Pro Health 
    • ProCare 
    • Quality Choice (QC) 
    • ReliOn (Walmart) 
    • Rite Aid (RA) 
    • Safeway (SM) 
    • SureLife (Home Aide) 
    • Talking Sense 
    • Target (TGT) 
    • True Health Sense

    *Not applicable for Apple Health Expansion

    Pharmacy Clinical Policy Updates- Medicaid & Ambetter

    The following pharmacy policies have been updated or will be new. Policies will be posted on the policy site, including a description of revisions.

    Policy Number

    Policy Title

    Effective Date

    Line of Business

    CP.PHAR.103

    Immune Globulins

    6/1/2026

    Medicaid

    CP.PHAR.105

    Bosutinib (Bosulif)

    6/1/2026

    Ambetter

    CP.PHAR.107

    Regorafenib (Stivarga)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.112

    Ponatinib (Iclusig)

    6/1/2026

    Ambetter

    CP.PHAR.116

    Pomalidomide (Pomalyst)

    6/1/2026

    Ambetter

    CP.PHAR.127

    Encorafenib (Braftovi)

    6/1/2026

    Ambetter

    CP.PHAR.140

    Pegvaliase-pqpz (Palynziq)

    6/1/2026

    Ambetter

    CP.PHAR.152

    Laronidase (Aldurazyme)

    6/1/2026

    Ambetter

    CP.PHAR.153

    Eliglustat (Cerdelga)

    6/1/2026

    Ambetter

    CP.PHAR.154

    Imiglucerase (Cerezyme)

    6/1/2026

    Ambetter

    CP.PHAR.155

    Cysteamine oral (Cystagon, Procysbi)

    6/1/2026

    Ambetter

    CP.PHAR.156

    Idursulfase (Elaprase)

    6/1/2026

    Ambetter

    CP.PHAR.157

    Taliglucerase Alfa (Elelyso)

    6/1/2026

    Ambetter

    CP.PHAR.158

    Agalsidase Beta (Fabrazyme)

    6/1/2026

    Ambetter

    CP.PHAR.159

    Sebelipase Alfa (Kanuma)

    6/1/2026

    Ambetter

    CP.PHAR.16

    Palivizumab (Synagis)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.161

    Galsulfase (Naglazyme)

    6/1/2026

    Ambetter

    CP.PHAR.162

    Elosulfase Alfa (Vimizim)

    6/1/2026

    Ambetter

    CP.PHAR.163

    Velaglucerase Alfa (VPRIV)

    6/1/2026

    Ambetter

    CP.PHAR.164

    Miglustat (Zavesca)

    6/1/2026

    Ambetter

    CP.PHAR.168

    Repository Corticotropin Injection (Acthar Gel, Purified Cortrophin Gel)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.174

    Nafarelin Acetate (Synarel)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.176

    Paclitaxel, Protein-Bound (Abraxane)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.227

    Pertuzumab (Perjeta), Pertuzumab-dpzb (Poherdy)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.228

    Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.229

    Ado-Trastuzumab Emtansine (Kadcyla)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.230

    AbobotulinumtoxinA (Dysport)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.231

    IncobotulinumtoxinA (Xeomin)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.232

    OnabotulinumtoxinA (Botox)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.233

    RimabotulinumtoxinB (Myobloc)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.236

    Darbepoetin Alfa (Aranesp)

    6/1/2026

    Ambetter

    CP.PHAR.237

    Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit)

    6/1/2026

    Ambetter

    CP.PHAR.238

    Methoxy Polyethylene Glycol-Epoetin Beta (Mircera)

    6/1/2026

    Ambetter

    CP.PHAR.239

    Dabrafenib (Tafinlar)

    6/1/2026

    Ambetter

    CP.PHAR.240

    Trametinib (Mekinist)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.243

    Alemtuzumab (Lemtrada)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.246

    Canakinumab (Ilaris)

    6/1/2026

    Ambetter

    CP.PHAR.248

    Dalfampridine (Ampyra)

    6/1/2026

    Ambetter

    CP.PHAR.249

    Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity), Monomethyl Fumarate (Bafiertam)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.251

    Fingolimod (Gilenya, Tascenso ODT)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.252

    Glatiramer Acetate (Copaxone, Glatopa)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.255

    Interferon Beta-1a (Avonex, Rebif)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.256

    Interferon Beta-1b (Betaseron, Extavia)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.258

    Mitoxantrone

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.259

    Natalizumab (Tysabri), Natalizumab-sztn (Tyruko)

    6/1/2026

    Ambetter

    CP.PHAR.260

    Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab/Hyaluronidase (Rituxan Hycela)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.262

    Teriflunomide (Aubagio)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.266

    Rilonacept (Arcalyst)

    6/1/2026

    Ambetter

    CP.PHAR.271

    Peginterferon Beta-1a (Plegridy)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.272

    Sonidegib (Odomzo)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.273

    Vismodegib (Erivedge)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.28

    Immunization coverage

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.294

    Osimertinib (Tagrisso)

    6/1/2026

    Ambetter

    CP.PHAR.298

    Afatinib (Gilotrif)

    6/1/2026

    Ambetter

    CP.PHAR.306

    Ofatumumab (Arzerra, Kesimpta)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.316

    Cabazitaxel (Jevtana)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.319

    Ipilimumab (Yervoy)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.327

    Nusinersen (Spinraza)

    6/1/2026

    Ambetter

    CP.PHAR.335

    Ocrelizumab (Ocrevus), Ocrelizumab/Hyaluronidase-ocsq (Ocrevus Zunovo)

    6/1/2026

    Ambetter

    CP.PHAR.337

    Telotristat Ethyl (Xermelo)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.339

    Durvalumab (Imfinzi)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.340

    Valbenazine (Ingrezza, Ingrezza Sprinkle)

    6/1/2026

    Ambetter

    CP.PHAR.342

    Brigatinib (Alunbrig)

    6/1/2026

    Ambetter

    CP.PHAR.343

    Edaravone (Radicava, Radivaca ORS)

    6/1/2026

    Ambetter

    CP.PHAR.344

    Midostaurin (Rydapt)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.349

    Ceritinib (Zykadia)

    6/1/2026

    Ambetter

    CP.PHAR.369

    Alectinib (Alecensa)

    6/1/2026

    Ambetter

    CP.PHAR.374

    Vestronidase Alfa-vjbk (Mepsevii)

    6/1/2026

    Ambetter

    CP.PHAR.378

    Ibalizumab-uiyk (Trogarzo)

    6/1/2026

    Ambetter

    CP.PHAR.380

    Cobimetinib (Cotellic)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.394

    Migalastat (Galafold)

    6/1/2026

    Ambetter

    CP.PHAR.395

    Patisiran (Onpattro)

    6/1/2026

    Ambetter

    CP.PHAR.405

    Inotersen (Tegsedi)

    6/1/2026

    Ambetter

    CP.PHAR.406

    Lorlatinib (Lorbrena)

    6/1/2026

    Ambetter

    CP.PHAR.416

    Caplacizumab-yhdp (Cablivi)

    6/1/2026

    Ambetter

    CP.PHAR.417

    Brexanolone (Zulresso)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.418

    Dexrazoxane (Totect)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.419

    Elapegademase-lvlr (Revcovi)

    6/1/2026

    Ambetter

    CP.PHAR.421

    Onasemnogene Abeparvovec (Zolgensma)

    6/1/2026

    Ambetter

    CP.PHAR.422

    Cladribine (Mavenclad)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.427

    Siponimod (Mayzent)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.43

    Sapropterin Dihydrochloride (Kuvan, Javygtor)

    6/1/2026

    Ambetter

    CP.PHAR.447

    Mercaptopurine (Purixan)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.461

    Nadofaragene firadenovec-vncg (Adstiladrin)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.462

    Ozanimod (Zeposia)

    6/1/2026

    Ambetter

    CP.PHAR.468

    Aducanumab-avwa (Aduhelm)

    6/1/2026

    Ambetter

    CP.PHAR.471

    Fosdenopterin (Nulibry)

    6/1/2026

    Ambetter

    CP.PHAR.474

    Remestemcel-L-rknd (Ryoncil)

    6/1/2026

    Ambetter

    CP.PHAR.475

    Sacituzumab Govitecan-hziy (Trodelvy)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.477

    Risdiplam (Evrysdi)

    6/1/2026

    Ambetter

    CP.PHAR.478

    Selpercatinib (Retevmo)

    6/1/2026

    Ambetter

    CP.PHAR.479

    Decitabine/Cedazuridine (Inqovi)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.480

    Ferric Derisomaltose (Monoferric)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.481

    Idecabtagene Vicleucel (Abecma)

    6/1/2026

    Ambetter

    CP.PHAR.482

    Isatuximab-irfc (Sarclisa)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.483

    Lisocabtagene Maraleucel (Breyanzi)

    6/1/2026

    Ambetter

    CP.PHAR.486

    Bimatoprost Implant (Durysta)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.50

    Binimetinib (Mektovi)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.503

    Sutimlimab-jome (Enjaymo)

    6/1/2026

    Ambetter

    CP.PHAR.504

    Voclosporin (Lupkynis)

    6/1/2026

    Ambetter

    CP.PHAR.512

    Pegunigalsidase Alfa-iwxj (Elfabrio)

    6/1/2026

    Ambetter

    CP.PHAR.514

    Pralsetinib (Gavreto)

    6/1/2026

    Ambetter

    CP.PHAR.516

    Fostemsavir (Rukobia)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.526

    Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP)

    6/1/2026

    Ambetter

    CP.PHAR.527

    Narsoplimab (Yartemlea)

    6/1/2026

    Ambetter

    CP.PHAR.528

    Odevixibat (Bylvay)

    6/1/2026

    Ambetter

    CP.PHAR.529

    Relugolix (Orgovyx), Relugolix/Estradiol/Norethinedrone (Myfembree)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.530

    Tepotinib (Tepmetko)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.533

    Ciltacabtagene Autoleucel (Carvykti)

    6/1/2026

    Ambetter

    CP.PHAR.534

    Insulin Delivery Systems (V-Go, Omnipod, InPen)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.536

    Ophthalmic Riboflavin (Photrexa, Photrexa Viscous)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.537

    Ponesimod (Ponvory)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.538

    Tivozanib (Fotivda)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.550

    Vutrisiran (Amvuttra)

    6/1/2026

    Ambetter

    CP.PHAR.558

    Mitapivat (Pyrukynd, Aqvesme)

    6/1/2026

    Ambetter

    CP.PHAR.573

    Cabotegravir, Cabotegravir-Rilpivirine (Apretude, Cabenuva)

    6/1/2026

    Ambetter

    CP.PHAR.575

    Tebentafusp-tebn (Kimmtrak)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.582

    Lutetium Lu 177 vipivotide tetraxetan (Pluvicto)

    6/1/2026

    Ambetter

    CP.PHAR.583

    Pacritinib (Vonjo)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.584

    Sodium Phenylbutyrate/Taurursodiol (Relyvrio)

    6/1/2026

    Ambetter

    CP.PHAR.590

    Omaveloxolone (Skyclarys)

    6/1/2026

    Ambetter

    CP.PHAR.592

    Beremagene Geperpavec (Vyjuvek)

    6/1/2026

    Ambetter

    CP.PHAR.594

    Donanemab-azbt (Kisunla)

    6/1/2026

    Ambetter

    CP.PHAR.596

    Lecanemab-irmb (Leqembi)

    6/1/2026

    Ambetter

    CP.PHAR.599

    Marnetegragene autotemcel (Kresladi)_PEPP

    6/1/2026

    Ambetter

    CP.PHAR.60

    Capecitabine (Xeloda)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.600

    Trofinetide (Daybue)

    6/1/2026

    Ambetter

    CP.PHAR.601

    Velmanase Alfa-tycv (Lamzede)

    6/1/2026

    Ambetter

    CP.PHAR.606

    Spesolimab-sbzo (Spevigo)

    6/1/2026

    Ambetter

    CP.PHAR.609

    Prademagene Zamikeracel (Zevaskyn)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.616

    Zilucoplan (Zilbrysq)

    6/1/2026

    Ambetter

    CP.PHAR.620

    Pirtobrutinib (Jaypirca)

    6/1/2026

    Ambetter

    CP.PHAR.621

    Ublituximab-xiiy (Briumvi)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.622

    Lenacapavir (Sunlenca, Yeztugo)

    6/1/2026

    Ambetter

    CP.PHAR.623

    Elacestrant (Orserdu)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.625

    Concizumab-mtci (Alhemo)

    6/1/2026

    Ambetter

    CP.PHAR.626

    Pozelimab-bbfg (Veopoz)

    6/1/2026

    Ambetter

    CP.PHAR.629

    Retifanlimab-dlwr (Zynyz)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.631

    Sparsentan (Filspari)

    6/1/2026

    Ambetter

    CP.PHAR.633

    Eplontersen (Wainua)

    6/1/2026

    Ambetter

    CP.PHAR.639_PEPP

    Troriluzole (BHV-4157)_PEPP

    6/1/2026

    Ambetter

    CP.PHAR.64

    Topotecan (Hycamtin)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.65

    Imatinib (Gleevec, Imkeldi)

    6/1/2026

    Ambetter

    CP.PHAR.650

    Zuranolone (Zurzuvae)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.669

    Birch Triterpenes (Filsuvez)

    6/1/2026

    Ambetter

    CP.PHAR.673

    Garadacimab-gxii (Andembry)

    6/1/2026

    Ambetter

    CP.PHAR.676

    Aprocitentan (Tryvio)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.677

    Vadadustat (Vafseo)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.679

    Mavorixafor (Xolremdi)

    6/1/2026

    Ambetter

    CP.PHAR.68

    Gefitinib (Iressa)

    6/1/2026

    Ambetter

    CP.PHAR.689

    Olezarsen (Tryngolza)

    6/1/2026

    Ambetter

    CP.PHAR.69

    Sorafenib (Nexavar)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.708

    Sepiapterin (Sephience)

    6/1/2026

    Ambetter

    CP.PHAR.71

    Lenalidomide (Revlimid)

    6/1/2026

    Ambetter

    CP.PHAR.714

    Copper Histidinate (Zycubo)

    6/1/2026

    Ambetter

    CP.PHAR.715

    Datopotamab Deruxtecan-dlnk (Datroway)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.716_PEPP

    Deramiocel (CAP-1002)_PEPP

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.717

    Donidalorsen (Dawnzera)

    6/1/2026

    Ambetter

    CP.PHAR.718

    Mirdametinib(Gomekli)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.719_PEPP

    Mozafancogene Autotemcel (RP-L102)_PEPP

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.72

    Dasatinib (Sprycel, Phyrago)

    6/1/2026

    Ambetter

    CP.PHAR.720

    Nipocalimab-aahu (Imaavy)

    6/1/2026

    Ambetter

    CP.PHAR.721

    Plozasiran (Redemplo)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.722_PEPP

    Rebisufligene Etisparvovec (UX111)_PEPP

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.723

    Sebetralstat (Ekterly)

    6/1/2026

    Ambetter

    CP.PHAR.724_PEPP

    Sodium Dichloroacetate (SL-1009)_PEPP

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.725

    Tiopronin Delayed-Release (Thiola EC)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.726

    Vimseltinib (Romvimza)

    6/1/2026

    Ambetter

    CP.PHAR.727

    Atrasentan (Vanrafia)

    6/1/2026

    Ambetter

    CP.PHAR.728_PEPP

    Rexlemestrocel-L (Revascor)_PEPP

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.729_PEPP

    Vatiquinone (PTC743)_PEPP

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.73

    Sunitinib (Sutent)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.736

    Relacorilant (Lifyorli)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.74

    Erlotinib (Tarceva)

    6/1/2026

    Ambetter

    CP.PHAR.746

    Navepegritide (Yuviwel)

    6/1/2026

    Ambetter

    CP.PHAR.75

    Bexarotene (Targretin Capsules, Gel)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.759

    Nerandomilast (Jascayd)

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.76

    Nilotinib (Tasigna, Danziten)

    6/1/2026

    Ambetter

    CP.PHAR.77

    Temozolomide (Temodar)

    6/1/2026

    Ambetter

    CP.PHAR.771_PEPP

    Dalnacogene Ponparvovec (BBM-H901)_PEPP

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.772_PEPP

    Doruxapapogene Ralaplasmid (INO-3107)_PEPP

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.773_PEPP

    Veligrotug (VRDN-001)_PEPP

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.774_PEPP

    Vusolimogene Oderparepvec (RP1)_PEPP

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.775

    Sibeprenlimab-szsi (Voyxact)

    6/1/2026

    Ambetter

    CP.PHAR.776_PEPP

    Gefurulimab (ALXN1720)_PEPP

    6/1/2026

    Ambetter & Medicaid

    CP.PHAR.777_PEPP

    Adrabetadex (VTS-270)6_PEPP

    6/1/2026 (Medicaid), 08/01/2026 (Ambetter)

    Ambetter & Medicaid (New Policy)

    CP.PHAR.778_PEPP

    Garetosmab (REGN2477)_PEPP

    6/1/2026 (Medicaid), 08/01/2026 (Ambetter)

    Ambetter & Medicaid (New Policy)

    CP.PHAR.779_PEPP

    Imlifidase (IdeS)_PEPP

    6/1/2026 (Medicaid), 08/01/2026 (Ambetter)

    Ambetter & Medicaid (New Policy)

    CP.PHAR.78

    Thalidomide (Thalomid)

    6/1/2026

    Ambetter

    CP.PHAR.780_PEPP

    Isaralgagene Civaparvovec (ST-920)_PEPP

    6/1/2026 (Medicaid), 08/01/2026 (Ambetter)

    Ambetter & Medicaid (New Policy)

    CP.PHAR.88

    Belimumab (Benlysta)

    6/1/2026

    Ambetter

    CP.PHAR.90

    Crizotinib (Xalkori)

    6/1/2026

    Ambetter

    CP.PHAR.92

    Tetrabenazine (Xenazine)

    6/1/2026

    Ambetter

    CP.PMN.110

    Crisaborole (Eucrisa)

    6/1/2026

    Ambetter

    CP.PMN.117

    Naproxen/Esomeprazole (Vimovo)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.119

    Ozenoxacin (Xepi)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.120

    Ibuprofen/Famotidine (Duexis)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.122

    Celecoxib (Celebrex, Elyxyb)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.124

    Itraconazole (Sporanox, Tolsura)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.125

    Milnacipran (Savella)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.126

    Toremifene (Fareston)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.128

    Dutasteride (Avodart), Dutasteride/Tamsulosin (Jalyn)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.130

    Cysteamine Ophthalmic (Cystaran, Cystadrops)

    6/1/2026

    Ambetter

    CP.PMN.136

    Mecamylamine (Vecamyl)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.137

    Carbamazepine ER (Equetro)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.138

    Age Limit Override (Codeine, Tramadol, Hydrocodone)

    6/1/2026

    Ambetter

    CP.PMN.154

    Isavuconazonium (Cresemba)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.191

    Age Limit for Topical Tretinoin

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.192

    Brimonidine Tartrate (Mirvaso)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.193

    Hydroxyurea (Siklos, Xromi)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.196

    Rifamycin (Aemcolo)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.197

    Clomipramine (Anafranil)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.198

    Overactive Bladder Agents

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.199

    Esketamine (Spravato)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.209

    Solriamfetol (Sunosi)

    6/1/2026

    Ambetter

    CP.PMN.221

    Pitolisant (Wakix)

    6/1/2026

    Ambetter

    CP.PMN.235

    Emtricitabine/Tenofovir Alafenamide (Descovy)

    6/1/2026

    Ambetter

    CP.PMN.262

    Quinine Sulfate (Qualaquin)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.264

    Viloxazine (Qelbree)

    6/1/2026

    Ambetter

    CP.PMN.275

    Levoketoconazole (Recorlev)

    6/1/2026

    Ambetter

    CP.PMN.276

    Pentosan Polysulfate Sodium (Elmiron)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.277

    Ulcer Therapy Products

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.278

    Ganaxolone (Ztalmy)

    6/1/2026

    Ambetter

    CP.PMN.287

    Nabumetone Double-Strength (Relafen DS)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.293

    Berdazimer (Zelsuvmi)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.294

    Budesonide (Eohilia, Uceris)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.295

    Semaglutide (Wegovy)

    6/1/2026

    Ambetter

    CP.PMN.298

    Tirzepatide (Zepbound)

    6/1/2026

    Ambetter

    CP.PMN.301

    Suzetrigine (Journavx)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.305

    GLP-1 RA Weight Management Benefit for Pediatric Members

    6/1/2026

    Ambetter

    CP.PMN.307

    Tradipitant (Nereus)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.308

    Difamilast (Adquey)

    6/1/2026 (Medicaid), 08/01/2026 (Ambetter)

    Ambetter & Medicaid (New Policy)

    CP.PMN.309

    Insulin Icodec-abae (Awiqli)

    6/1/2026

    Medicaid (New Policy)

    CP.PMN.33

    Pregabalin (Lyrica*, Lyrica CR)

    6/1/2026

    Ambetter

    CP.PMN.35

    Armodafinil (Nuvigil)

    6/1/2026

    Ambetter

    CP.PMN.39

    Modafinil (Provigil)

    6/1/2026

    Ambetter

    CP.PMN.42

    Sodium Oxybate (Xyrem, Lumryz) and Calcium, Magnesium, Potassium, and Sodium Oxybate (Xywav)

    6/1/2026

    Ambetter

    CP.PMN.48

    Cyclosporine (Cequa, Restasis, Verkazia, Vevye, Klarity-C)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.58

    Propranolol HCl Oral Solution (Hemangeol)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.61

    ACEI and ARB Duplicate Therapy

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.79

    Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.80

    Minocycline ER (Emrosi, Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi)

    6/1/2026

    Ambetter & Medicaid

    CP.PMN.86

    Oxymetazoline (Rhofade, Upneeq)

    6/1/2026

    Ambetter & Medicaid

    HIM.PA.180

    Insulin Icodec-abae (Awiqli)

    8/1/2026

    Ambetter (New Policy)

    HIM.PA.SP60

    Biologic and Non-biologic DMARDs

    6/1/2026

    Ambetter

    WA.PHAR.122

    Antidiabetics- GLP-1 Agonists

    6/1/2026

    Medicaid

    WA.PHAR.139

    Movement Disorder Agents Valbenazine (Ingrezza)

    6/1/2026

    Medicaid

    WA.PHAR.140

    Immune Modulators- Thalidomide Analogs

    6/1/2026

    Medicaid

    WA.PHAR.157

    Oncology Agents Antimetabolites- Oral

    8/1/2026

    Medicaid  (New Policy)

    WA.PHAR.158

    Asthma and COPD Agents Monoclonal Antibodies

    8/1/2026

    Medicaid (New Policy)

    WA.PHAR.20

    Methadone

    8/1/2026

    Medicaid

    WA.PHAR.23

    Analgesics- Opioid Agonists

    8/1/2026

    Medicaid

    WA.PHAR.80

    Transmucosal Fentanyl Products

    8/1/2026

    Medicaid

     

    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-ADET PONLIMSI
    INJECTION

    PONLIMSI

    Yes

    Yes

    • FDA new release/approval 3/30/26 Biosimilar to Prolia (already in-scope, has PA)
    • Centene PA effective date 10/1/26

    J8999

    RELACORILANT ORAL

    LIFYORLI

    Yes

    Yes

    • FDA new release/approval 3/25/26
    • Centene PA effective date 10/1/26


    Participating providers should submit oncology/supportive drug authorization for members through Evolent.   


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