New mail order pharmacy options and formulary/quantity updates for Medicare
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Describes addition of Froedtert Home Delivery (and mentions Cost Plus Drugs) as preferred mail order pharmacy options for Medicare members and summarizes multiple Medicare and commercial formulary, quantity limit, and prior authorization updates that affect pharmacy benefits and vaccine guidance.
Froedtert Home Delivery has been added as a preferred mail order option for Medicare members.
Mark Cuban Cost Plus Drug Company (Cost Plus Drugs) is listed as a preferred low-cost mail order option available online for Medicare members.
Multiple Medicare and commercial quantity level limits and policy criteria have been updated (additions/changes to quantity limits, PA criteria, and indications across many drugs and policies).
Removed body surface area (BSA) requirement for plaque psoriasis diagnosis in multiple product criteria.
Removed methotrexate as a pre-requisite therapy for atopic dermatitis for selected products.
Removed language requiring 'adequate dose/duration' for pre-requisite medication trials in select dermatologic and psoriatic arthritis criteria.
Removed certain clinical measurement or documentation requirements not supported by FDA labeling (e.g., NT proBNP requirement, exclusions for biliary/pancreatic disease, eGFR <30 exclusion).
Updated pediatric/adolescent-specific criteria such as FEV1 requirements and weight thresholds for certain agents.
Removed cystic fibrosis indication criteria for a liposomal nebulized amikacin product due to lack of compendial support.
Coverage and Prior Authorization Criteria
Oxervate prior authorization flow
Covered when ALL of the following are met:
ALL of the following
ALL of the following
- Left: Proceed to Question 2 and subsequent left-eye branch.
- Right: Proceed to Question 2 and subsequent right-eye branch.
- Both: Proceed to Question 2 and follow both-eye branching.
ALL of the following
- Yes: Documentation attached (e.g., chart notes, prescription refill history) — proceed to next branch.
- No: Deny — documentation not submitted.
ALL of the following
Left-eye branch
- Confirm provider requested treatment for LEFT eye in the prior authorization.
ALL of the following
- Yes — Deny.
- No — Approve up to 16 weeks for the LEFT eye.
Right-eye branch
- Confirm provider requested treatment for RIGHT eye in the prior authorization.
ALL of the following
- Yes — Deny.
- No — Approve up to 16 weeks for the RIGHT eye.
- Both-eyes branch: Follow respective checks for each eye per the left and right branches (assess lifetime weeks and approve/deny per eye).
Quantity limit rules
Apply the updated quantity/supply limits as listed below; limits reflect the quantity and days' supply changes indicated in the document.
ALL of the following
Examples
- Adbry 300 mg/2 ml autoinjector — add 6 ml per 28 days.
- Entresto 6 mg-6 mg tablet and Entresto 15 mg-16 mg pellets in dispensing capsule — change from 60/30 to 240/30 (per specified formulations).
- Otezla 10 mg-20 mg tablet dose pack — add 55 per 28 days; Otezla 20 mg tablet — add 60 per 30 days.
- Retevmo (various strengths) — add 60/30 days (120 mg, 160 mg effective 2025); other Retevmo strengths per table (40 mg = 180/30 days; 80 mg = 120/30 days).
- Dasatinib formulations — apply the listed additions/changes to 30/30, 60/30, or 90/30 days as specified for each strength.
- Taltz and Tremfya and Tremfya injector forms — apply the specified ml/28 days updates (e.g., Taltz 20 mg/0.25 ml = 0.25 ml/28 days; Tremfya 200 mg/2 ml = 4 ml/28 days).
Updated prior authorization and coverage criteria
Coverage and prior authorization criteria have been updated for select therapies. Apply the changes below where applicable.
Formulary Status, Codes, and Quantity Details
| Formulary status indicators (C = commercial preferred drug list (PDL) status; M = Medicare PDL status) and footnote indicators for Non-Preferred Specialty, prior authorization (PA), quantity limit (QL), and step therapy (ST). |
| PAR-483 | Risankizumab (Skyrizi) |
| PAR-491 | Tafamidis |
| PAR-499 | Upadacitinib (Rinvoq) |
| PAR-524 | Basal Insulin |
| PAR-529 | Sandostatin (Octreotide acetate) |
| PAR-534 | Arikayce (amikacin sulfate liposomal with nebulizer accessories) |
| PAR-570 | Benlysta (belimumab) |
| PAR-574 | Sifnifor (pasireotide) |
| PAR-615 | Cibinqo (Abrocitinib) |
| PAR-617 | Adbry (tralokinumab-ldrm) |
How Providers Should Send Prescriptions and Updated Prescriber/Documentation Rules
Send prescriptions to Froedtert Home Delivery
Providers may e-prescribe to Froedtert Home Delivery by selecting the e-prescribe destination 'Froedtert Hospital - 87th Street entrance'. Alternatively, prescriptions can be faxed to 414-805-6513 or arrangements made by calling the Medication Management Team at 414-805-5690.
Send prescriptions to Cost Plus Drugs
To send prescriptions to Mark Cuban Cost Plus Drug Company (Cost Plus Drugs), follow the instructions at costplusdrugs.com/contact-your-doctor/ and be sure the prescription includes the patient’s email address.
Oxervate prior authorization criteria flow
Oxervate prior authorization requires documentation of which eye(s) are being treated, lifetime weeks of Oxervate treatment for the affected eye(s), and the review uses a 16-week per‑eye lifetime limit to determine approval or denial.
- Confirm laterality: left, right, or both (question 1).
- Attach documentation of lifetime weeks of Oxervate treatment for the affected eye(s) (question 2); chart notes or refill history are acceptable.
- If lifetime weeks for the specific eye are <16 weeks, approve up to 16 weeks; if ≥16 weeks, deny (questions 5 and 7).
- When prior active PA exists, follow branching logic comparing requested eye(s) to the active PA per the policy flow (questions 3–8).
Add hepatologist as allowable prescriber
Hepatologist has been added as an allowable prescriber option for applicable commercial and Medicare therapies—include hepatologist as a valid prescriber when submitting requests for the affected products.
Remove specified treatment/therapy and medication history documentation requirements
Per CMS updates, remove certain historical treatment/therapy and medication history documentation requirements from specified Medicare and Commercial prior authorization reviews as noted in the policy updates.
- Do not require listing of prior treatments/therapies as mandatory documentation where CMS-directed removals apply.
- Do not require medication history as part of required medical information for the products updated per CMS guidance.
Definitions and Guidance
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