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The purpose of this bulletin is to inform providers that DMAS fee-for-service (FFS) and all contracted managed care organizations (MCOs) will ensure coverage of the following oral antiviral agents for full benefit Medicaid and FAMIS members: 1) Paxlovid (nirmatrelvir and ritonavir), and 2) molnupiravir. This is consistent with recent FDA Emergency Use Authorizations (EUAs), in accordance with Section 6008(b)(4) of the Families First Coronavirus Response Act. For further information on COVID-19 treatment coverage, please reference previous DMAS memos here: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/MedicaidMemostoProviders.

Coverage of Paxlovid

Paxlovid will be covered for members who meet the criteria outlined in the FDA EUA (https://www.fda.gov/media/155049/download). At the time of this memo’s publication, these criteria for members include, but are not limited to:

• 12 years of age and older and weighing at least 40 kg; and
• Diagnosed with confirmed SARS-CoV-2 infection within 5 days prior to treatment; and
• Diagnosed with mild-to-moderate COVID-19 infection; and
• At high risk for progression to severe COVID-19, including hospitalization or death.

Providers are encouraged to be aware of the current guidelines regarding persons who should not be considered for Paxlovid (see FDA EUA above) and interactions of Paxlovid with other medications, notably those highly dependent on CYP3A4 metabolism (i.e. alfuzosin, amiodarone, flecainide, colchicine, lovastatin, simvastatin, sildenafil, carbamazepine, buprenorphine, methadone, fentanyl, fluoxetine, paroxetine, and sertraline). Information for patients can be found here: https://www.fda.gov/media/155051/download.

Billing

Prior authorization is not required on the first two (2) treatment courses per patient per year. Prior authorization for additional courses will require proof of a positive COVID-19 test. Patient eligibility, per FDA criteria, must be documented in the medical record. Pharmacy providers should submit claims through the pharmacy point of sale system. Paxlovid MCO and FFS claims will be covered retroactively for claims with dates of service on and after December 22, 2021. MCOs and FFS will work to ensure pharmacy point of sale systems reflect this coverage in coming weeks. Reimbursement will not be provided for medications that pharmacies receive for free, however MCOs and FFS will pay a dispensing fee when Paxlovid is covered and dispensed for eligible members.

Coverage of Molnupiravir

Molnupiravir will be covered for members who meet the criteria outlined in the FDA EUA (https://www.fda.gov/media/155054/download).  At the time of this memo’s publication, these criteria for members include, but are not limited to:

• 18 years of age and older; and
• Diagnosed with confirmed SARS-CoV-2 infection within 5 days prior to treatment; and
• Diagnosed with mild-to-moderate COVID-19; and
• At high risk for progression to severe COVID-19, including hospitalization or death;  and
• Clinically inappropriate for, or unable to access, alternative COVID-19 treatment options authorized by the FDA.

Providers are strongly encouraged to be aware of the current risks and exclusion criteria associated with molnupiravir. Per the FDA EUA, providers should strongly consider other authorized/approved alternative treatments in light of known side effects of molnupiravir and the relative effectiveness of other available treatments. Information for patients can be found here: https://www.fda.gov/media/155055/download.

Billing

Prior authorization is not required for the first two (2) treatment courses per patient per year. Prior authorization for additional courses will require proof of a positive COVID-19 test. Patient eligibility, per FDA criteria, must be documented in the medical record. Pharmacy providers should submit claims through the pharmacy point of sale system. Molnupiravir MCO and FFS claims will be covered retroactively for claims with dates of service on and after December 23, 2021. MCOs and FFS will work to ensure pharmacy point of sale systems reflect this coverage in coming weeks. Reimbursement will not be provided for medications that pharmacies receive for free, however MCOs and FFS will pay a dispensing fee when molnupiravir is covered and dispensed for eligible members.

Any questions regarding FFS pharmacy claims processing may be directed to the Magellan pharmacy call center 7 days a week 24 hours per day at 800-932-6648. Any questions regarding MCO pharmacy claims processing, or medical coverage for members enrolled in managed care organizations, may be directed to managed care points of contact summarized below.

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