Aetna Better Health. Specialty Drug Program
|
|
|
- Elwin Gilmore
- 5 years ago
- Views:
Transcription
1 Aetna Better Health is managed through CVS Health Specialty Pharmacy. The Specialty pharmacies fill prescriptions and ship drugs for complex medical conditions, including multiple sclerosis, rheumatoid arthritis and most cancer drugs. Medications provided through CVS specialty pharmacy include injectable, oral and inhaled drugs. Due to the complexity of these drugs, they require a high level of support and care guidelines for shipment and storage. The provides care management services to your members, including: 24 hours a day, seven days a week access to a pharmacist Disease-specific education and counseling by the CareTeam TM. The CareTeam TM are clinical professionals who review dosing and medication schedules, identify injection issues, provide education of potential side effects and provide information to help your member to manage their medical condition. Care coordination with your member and you Delivery of Specialty drugs to your member s home and/or your office in temperaturecontrolled packaging with the required supplies, i.e. needles, syringes, and alcohol wipes Contact CVS Specialty Pharmacy at from 7:30 a.m. (EST) to 9:00 p.m. (EST) time, Monday Friday. CVS Specialty Pharmacy will assist you in filling your specialty drug. Prior Authorization (PA) still applies to specific specialty drugs that require a clinical review. You can check our health plan website at to confirm PA requirements on the below listed medications as well as review of the PA Guideline used in our clinical reviews. Last Update: 05/2017 Page 1
2 ALLERGEN IMMUNOTHERAPY Coagulation Disorders Cryopyrin Associated Periodic Syndromes Gastrointestinal Hematopoietics ORALAIR SAIZEN ARALAST NP GLASSIA ZEMAIRA CEPROTIN ILARIS GATTEX GENOTROPIN HUMATROPE INCRELEX NORDITROPIN NUTROPIN OMNITROPE SEROSTIM TEV-TROPIN ZORBTIVE MOZOBIL ADVATE ALPHANINE SD ALPHANATE ALPROLIX BEBULIN BENEFIX CORIFACT ELOCTATE FEIBA NF HELIXATE FS HEMOFIL M HUMATE-P KOATE-DVI MONOCLATE MONONINE NOVOSEVEN RT Last Update: 05/2017 Page 2
3 Hepatitis B Idiopathic Thrombocytopenic Purpura Idiopathic Thrombocytopenic Purpura Infectious Disease Iron Overload LIPID DISORDER PROFILNINE SD RECOMBINATE RIXUBIS TRETTEN WILATE XYNTHA XYNTHA SOLOFUSE BARACLUDE BERINERT CINRYZE FIRAZYR BIVIGAM CARIMUNE NF NANOFILTERED CYTOGAM FLEBOGAMMA GAMMAGARD LIQUID GAMMAKED HIZENTRA OCTAGAM PRIVIGEN GAMUNEX-C NPLATE PROMACTA ACTIMMUNE EXJADE KYNAMRO ALDURAZYME CEREZYME CYSTAGON ELAPRASE FABRAZYME LUMIZYME MYOZYME NAGLAZYME Last Update: 05/2017 Page 3
4 Movement disorders Neutropenia Neutropenia Oncology oral Oncology Oral Oncology-Oral VIMIZIM VPRIV Xenazine EXTAVIA MITOXANTRONE PLEGRIDY AUBAGIO GRANIX LEUKINE GAZYVA INTRON A ONCASPAR SYLATRON ERIVEDGE INLYTA JAKAFI MEKINIST NEXAVAR POMALYST REVLIMID STIVARGA SUTENT TAFINLAR THALOMID TYKERB VOTRIENT XALKORI ZELBORAF ZYKADIA ZYTIGA Afinitor Cabometyx TARGRETIN Brand Only ESBRIET HYQVIA RUCONEST SDV Last Update: 05/2017 Page 4
5 Paroxysmal Nocturnal Hemoglobinuria Phenylketonuria Psoriasis Psoriasis Rheumatoid Arthritis RSV Seizure disorder Urea Cycle Disorders SIRTURO SOLIRIS KUVAN OTEZLA STELARA ADEMPAS LETAIRIS ORENITRAM ORENITRAM ER REMODULIN TRACLEER TYVASO VELETRI VENTAVIS SIMPONI SYNAGIS Sabril RAVICTI Last Update: 05/2017 Page 5
RAHF PFM ALPHANINE SD COAGULATION FACTOR IX J7193 COAGULATION FACTOR IX (RFIXFC)
INFECTIOUS DISEASE ACTIMMUNE INTERFERON GAMMA 1B J9216 ADVATE RAHF PFM ONCOLOGY ORAL AFINITOR EVEROLIMUS J7527 INFECTIOUS DISEASE ALFERON N INTERFERON ALFA N3 J9215 ALPHANATE VWF J7186 ALPHANINE SD J7193
Specialty Drugs. The following is a list of medications that are considered to be specialty drugs. Specialty drugs
Specialty Drugs The following is a list of medications that are considered to be specialty drugs. Specialty drugs include self-administered injectables, medications that are high cost, and/or medications
Specialty Drugs. The specialty drug list below is effective June 5, 2018 and is subject to change at any time.
Specialty Drugs The following is a list of medications that are considered specialty drugs. Specialty drugs include self-administered injectables, medications that are high cost, and/or medications that
LIMITED DISTRIBUTION MEDICATIONS
ACTEMRA IV (USSC can dispense 162 mg PFS) ACTHAR HP ACTIMMUNE ADAGEN ADCETRIS CVS Specialty 1-800-237-2767 1-800-237-2767 ADEMPAS ADVATE ALDURAZYME ALECENSA ALIQOPA ALUNBRIG AMPYRA APOKYN ARALAST NP ARCALYST
DRUGS REQUIRING PRIOR AUTHORIZATION
DRUGS REQUIRING PRIOR AUTHORIZATION Medication Abstral Actemra Acthar Gel Actiq* Adcirca Adderall Adderall XR Addyi Adempas Adipex* Adzenys XR-ODT Afinitor Afinitor Alecensa Alecensa Ampyra Androderm AndroGel
Medication Prior Authorization Form
Section I Member Information Name (Last, First, Middle Initial) Date of Birth WEA Trust Subscriber Number Diagnosis Page 2 1. MEDICATION 2. STRENGTH 3. DIRECTIONS 4. QUANTITY FEIBA NF NovoSeven RT HEMOFIL
Utilization Management
Abraxane Abraxane Actemra (IV) Inflammatory Conditions PA/Step Actemra (SQ) Inflammatory Conditions PA/Step Acthar HP Miscellaneous CNS Disorders PA Actimmune NF Adcetris Adcirca Adempas Advate (all forms)
2018 BCN Advantage Prior Authorization Criteria Last updated: November, 2017
Abstral Actemra Adcirca Adempas Afinitor Afinitor- Disperz Alecensa Alunbrig Amitiza Amitriptyline Ampyra Anadrol-50 Androgel Androderm Aralast NP Aranesp Arcalyst Armodafinil Aubagio Avonex Bavencio Beleodaq
2018 BCN Advantage Prior Authorization Criteria Last updated: April, 2018
Abstral Actemra Adcirca Adempas Aliqopa Afinitor Afinitor- Disperz Alecensa Alunbrig Amitiza Amitriptyline Ampyra Anadrol-50 Androgel Androderm Aralast NP Aranesp Arcalyst Armodafinil Aubagio Avonex Bavencio
Pulmonary Hypertension Weight Loss Skin Conditions. Skin Conditions Multiple Sclerosis Endocrine Disorder. Endocrine Disorder.
Prior Authorization PricewaterhouseCoopers The following medications may require prior authorization prior to dispensing at a participating retail pharmacy or through the Express Scripts Pharmacy home
Prior Authorization Program
Prescription Drug List January 2011 Prior Authorization Program The prior authorization program helps us offer broad prescription drug coverage and promotes safe, clinically appropriate drug usage. Under
Quarterly Pharmacy Formulary Change Notice
Quarterly Pharmacy Formulary Change Notice Summary of Change: The formulary changes listed in the table below were reviewed and approved at our December 18, 2014 Value Assessment Committee (VAC) meeting.
METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE ALPHA-1 PROTEINASE INHIBITORS ARANESP BLOOD CELL DEFICIENCY ARANESP ARCALYST
PRIOR AUTHORIZATION LIST (SUBJECT TO CHANGE) MEDICATION THERAPEUTIC CATEGORY MODULE ACTEMRA INFLAMMATORY CONDITIONS ACTEMRA ADCIRCA PULMONARY HYPERTENSION PDE-5 INHIBITORS FOR PAH ADDYI SEXUAL DISORDERS
LDI integrated pharmacy services
8 ARRANON CARIMUNE NF Immunodeficiency 8-MOP Psoriasis ARZERRA CAYSTON Cystic Fibrosis A ASTAGRAF XL Antirejection CERDELGA Gaucher's Disease abacavir ATRIPLA CEREZYME Gaucher's Disease abacavir/lamivudine/
Specialty Drug List - Sorted by Therapeutic Class Developed for the Mississippi Division of Medicaid by Mercer
ANTI-INFECTIVE ABELCET 100 MG/20 ML VIAL 4/1/2017 ANTI-INFECTIVE AMBISOME 50 MG VIAL 4/1/2017 ANTI-INFECTIVE ANCOBON 250 MG CAPSULE 4/1/2017 ANTI-INFECTIVE ANCOBON 500 MG CAPSULE 4/1/2017 ANTI-INFECTIVE
BCBS AZ ADV PLUS * CLASSIC * PREMIER For use with members associated with the BHN Network Prior Authorization List 2015
Prior Authorization List 2015 Participating providers are responsible to furnish or arrange health care services with other participating healthcare facilities or providers. Prior authorization requests
acromegaly Drugs Covered Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Coverage Duration
acromegaly SIGNIFOR, SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML, SOMAVERT SUBCUTANEOUS RECON SOLN 15 MG, 20 MG, 25 MG, 30 MG All medically accepted indications not
MedStar Medicare Choice Pharmacy Services
Pharmacy Services 1 MedStar Medicare Choice Pharmacy Services Table of Contents At a Glance..page 2 Pharmacy Policies..page 4 Medicare Choice Pharmacy Programs..page 6 Where to Obtain Prescriptions..page
SPECIALTY PHARMACY Master Clinical Drug List
Abraxane J9264 Provider ONCOLOGY None NO Actemra J3262 Provider ARTHRITIS PA - all YES Acthar HP Gel J0800 Prov/Self Med/Pharm ENDOCRINE/METABOLIC PA - all YES Adagen J2504 Provider ENZYME DISORDERS None
PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate
J-Code Trade Name Drug Name Required Medical Information
FIDELIS CARE NEW YORK DEPARTMENT OF PHARMACY SERVICES Updated: 10/31/2017 J-Code Prior Authorizations & Required Clinical Information Medicaid, Child Health Plus, HealthierLife, Metal-Level J-Code Trade
Prescription Drug Benefit Rider
Prescription Drug Benefit Rider Your Certificate of Coverage is amended as described in this document. This Rider becomes a part of your Certificate of Coverage and is subject to all provisions of your
Canada s Rare Disease Strategy: Pathway to Timely Sustainable Access. CADTH Conference
Canada s Rare Disease Strategy: Pathway to Timely Sustainable Access CADTH Conference Durhane Wong-Rieger, PhD Canadian Organization for Rare Disorders President & CEO Getting to Sustainable Access What
Positively Affecting the Lives of Members Each and Every Day. Volume 14 May Specialty Drug News
Positively Affecting the Lives of Members Each and Every Day LDI Volume 14 May 2008 Specialty Drug News 2008 Medications to Watch 1. Respiratory syncytial virus (RSV) Numax (motavizumab) Respiratory syncytial
PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
Abstral fentanyl citrate oral tablet Controlled Dangerous substance Actemra tocilizumab Monoclonal antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate
Prescription Drug Benefit Rider V
Prescription Drug Benefit Rider V Your Certificate of Coverage is amended as described in this document. This Rider becomes a part of your Certificate of Coverage and is subject to all provisions of your
Lista de medicamentos especializados
Lista de medicamentos especializados Vigencia: 1o. de enero de 2016 A continuación se listan, en orden alfabético, los medicamentos de especialidad recetados más frecuentemente. Los medicamentos de especialidad
Texas Prior Authorization Program Clinical Edit Criteria
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document - Oral Drugs requiring prior authorization: the list of drugs requiring prior
Medication Prior Authorization Form
Policy Number: 1041 FEIBA NF Novoeight Mononine NovoSeven RT RECOMBINATE BEBULIN HEMOFIL M Xyntha Profilnine SD Koate-DVI Obizur BeneFix Monoclate-P Alphanate RIXUBIS ADVATE HUMATE-P Corifact Helixate
1199SEIU Benefit Funds
1199SEIU Benefit Funds MEDICAL BENEFIT MANAGEMENT PROGRAM SPECIALTY DRUG LIST Effective April 1, 2017 As of April 1, 2015, providers must use the web-based Expressth platform to obtain prior authorization
Pharmacy and Medical Guideline Updates
STAT Bulletin PO Box 15013 Albany, New York 12212 August 2, 2010 Volume 8: Issue 19 To: All PCPs and Specialists Contracts Affected: All Lines of Business Pharmacy and ical Guideline Updates As a result
1199SEIU Benefit Funds
1199SEIU Benefit Funds MEDICAL BENEFIT MANAGEMENT PROGRAM SPECIALTY DRUG LIST Effective October 1, 2016 As of April 1, 2015, providers must use the web-based Expressth platform to obtain prior authorization
Section I contains changes to the Highmark Select/Choice Formulary.
March 2008 1 st Quarter Update: Highmark Drug Formulary Enclosed is the 1 st Quarter 2008 update to the Highmark Drug Formulary and pharmaceutical management procedures. The Formulary and pharmaceutical
Cigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Clotting Factors and Antithrombin Effective Date... 4/15/2018 Next Review Date... 3/15/2019 Coverage Policy Number... 8007 Table of Contents Coverage Policy...
FLU COAGULATIO ON PRODUCTS IVIG VACCINES HYPERIMM. the products you. when you need h COAGULA PRODU IGIM ASMA PROT ALBUMIN PROTEI GLOBUL
VACCINES FLU VACCINE VACCINES HYPERIMMUNE GLOBULINS SCIG HYPERIMMUNE GLOBULINS IGIM COAGULATIO ON PRODUCTS ALBUMIN/PLASMA PROTEIN FRACTION IVIG the products you when you need h SC CIG COAGULA PRODU ALBUMIN/PLA
FIDELIS CARE NEW YORK DEPARTMENT OF PHARMACY SERVICES J Code Prior Authorizations & Required Clinical Information 2011 (Updated 3/14/11)
FIDELIS CARE NEW YORK DEPARTMENT OF PHARMACY SERVICES J Code Prior Authorizations & Required Clinical Information 2011 (Updated 3/14/11) Brand Generic J Code Covered Uses Required Medical Information and
STAT Bulletin. Drug Therapy Guideline Updates. To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business
STAT Bulletin November 28, 2011 Volume 9: Issue 27 To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business Drug Therapy Guideline Updates Why you re receiving this Stat
Original Policy Date
MP 5.01.17 Specialty Drugs Medical Policy Section Prescription Drug Issue 12:2013 Original Policy Date 12:2013 Last Review Status/ Date Local policy Last updated/12:2013 Return to Medical Policy Index
Pharmacy Services Request Types
FOR DRUG REQUESTS, ONLY-- * NOTE: Only those drugs administered by a healthcare provider and billed medically would be entered via CareAffiliate. * Oral drugs would not be administered by a healthcare
after reconstitution No Yes Refrigerate; do Not freeze. Discard unused portions; do Not save for further Immune Deficiencies & Related
Store at room temp. Protect from bright light. Freezing or refrigerating do not adversely affect the stability of intact vials. Different standards apply Abraxane Oncology- Injectable IV No No Yes after
2019 Prior Authorization
2019 Prior Authorization FID 19148 Prior Authorization ACTEMRA Products Affected Actemra INJ 162MG/0.9ML PA Details Age Other 1 ACTIMMUNE Products Affected Actimmune PA Details Age Other 2 ADEMPAS Products
2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization
2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services
Prior Authorization Program Information (Effective April 1st, 2018)
Prior Authorization Program Information (Effective April 1st, 2018) Prior Authorization Certain drugs require prior authorization to help promote safe, quality and affordable pharmacy care. Your doctor
BCN Advantage SM requirements for drugs covered under the medical benefit
J0586 ABOBOTULINUMTOXINA Dysport X X X the medication is being used to treat J0178 AFLIBERCEPT Eylea X X X X X of Neovascular (Wet) -Related Macular Degeneration of Macular Edema following either central
2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization
2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services
2019 Prior Authorization
2019 Prior Authorization FID 19148 Prior Authorization ACTEMRA Products Affected Actemra INJ 162MG/0.9ML Actemra Actpen Other 1 ACTIMMUNE Products Affected Actimmune Other 2 ADEMPAS Products Affected Adempas
Drug Name Generic Name J-Code Unclassified Drugs in excess of $10,000
Unclassified Drugs in excess of $10,000 J3490 Unclassified Biologics in excess of $10,000 J3590 Revenue Codes in excess of $10,000 R250 - R259 ABRAXANE paclitaxel protein-bound J9264 & J9267 ACTEMRA tocilizumab
2017 MDwise HIP Medical Services that Require Prior Authorization
2017 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
Method of Viral Inactivation or Depletion. Generation/ Human or Animal Protein in Culture. Third/ None 1. Immunoaffinity
TABLE I. Products Licensed in the U.S. to Treat HEMOPHILIA A A. Recombinant FACTOR VIII Concentrates The table includes bioengineered recombinant factor concentrates with altered properties such as extended
Specialty conditions overview
Specialty conditions overview Prevalence and cost Click on the vials to learn more about these specialty conditions. 1. Approximate annual AWP cost per patient of top utilized drugs for UHC calendar year
Ally Rx D-SNP Current as of r 1, 2017
Ally Rx D-SNP Current as of r 1, 2017 AMPYRA AMPYRA PA Moderate to severe renal impairment (CrCL less than or equal to 50ml/min), patient not able to walk 25 feet in 8-45 seconds. Documentation of diagnosis,
2018 MDwise HIP Medical Services that Require Prior Authorization
2018 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
2010 Drugs Requiring Prior Authorization
2010 Drugs Requiring Prior Authorization Drugs Covered Uses Exclusion Criteria Actemra (tocilizumab) Adcirca (tadalafil) Alfa Interferons - Alferon N - Infergen - PEG-Intron - PEG-Intron Redipen - Pegasys
Percent Brand Name Generic Name Strength How Supplied NDC from AWP/SWP Adcetris. Amprya dalfampridine 10 mg 60 count bottle
Department of General Services Procurement Division Contract # 01-14- 65-57 Pharmaceutical Acquisitions Section Exhibit G-1 April 30, 2015 Walgreens Specialty Pharmacy LLC, Products Pricing Crescent Healthcare,
2018 MDwise HIP Medical Services that Require Prior Authorization
2018 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
Specialty Overview by Prior Authorization Approval or Denial 4th Quarter 2016
Specialty Overview by Prior Authorization Approval or 4th Quarter 2016 Carrier Physician Specialty Drug Drug Class Decision Comments Reporting Year Reporting Month 3961 GASTROENTEROLOGY Humira RHEUMATOID
of our members each and
s p e c i a l t y d r u g n e w s Positively affecting the lives of our members each and every day Efalizumab (Raptiva ) Withdrawn from US Market On April 9, 2009 Genentech, Inc. announced that it is undergoing
1199SEIU Benefit Funds
1199SEIU Benefit Funds MEDICAL BENEFIT MANAGEMENT PROGRAM SPECIALTY DRUG LIST Effective October 1, 2017 As of April 1, 2015, providers must use the web-based ExpressPAth platform to obtain prior authorization
STAT Bulletin. Drug Therapy Guideline Updates. To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business
STAT Bulletin November 28, 2011 Volume 17: Issue 34 To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business Drug Therapy Guideline Updates Why you re receiving this Stat
2018 MDwise HIP Medical Services that Require Prior Authorization
2018 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
IVIG IGIM FLU FLU PRODUCTS GLOBULINS GLOBULINS SCIG SCIG HYPERIMMUNE COAGULATION COAGULATION HYPERIMMUNE VACCINE PRODUCT CATALOG SPRING2018
PRODUCT CATALOG SPRING2018 VACCINES FLU VACCINE VACCINES HYPERIMMUNE GLOBULINS SCIG HYPERIMMUNE GLOBULINS SCIG COAGULATION IGIM COAGULATION PRODUCTS the products you need when you need them ALBUMIN/PLASMA
2018 INJECTABLE DRUG PRIOR AUTHORIZATION CRITERIA
2018 INJECTABLE DRUG PRIOR AUTHORIZATION CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+) These drugs require authorization before dispensing
Specialty Overview by Prior Authorization Approval or Denial 2nd Quarter 2016
Specialty Overview by Prior Authorization Approval or 2nd Quarter 2016 3961 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/13/2016 thru 04/13/2018 3961 DERMATOLOGY Stelara PSORIASIS
Prior Authorization Approval Guidelines. May, 2017
Prior Authorization Approval Guidelines May, 2017 Prior Authorization Approval Guidelines Please be advised that in order to be considered for approval, all applicable prior therapies must be listed on
BDI Pharma, LLC 2018 Product Reference Charts
BDI Pharma, LLC 2018 Product Reference Charts Protein Therapies Intravenous Immune Globulin (10%) 800.948.9834 www.bdipharma.com BIVIGAM NF ADMA Biologics Flebogamma 10% DIF GAMMAGARD LIQUID Gammaked Kedrion
Medi-Cal DHCS Carve Out Medication List
Medi-Cal DHCS Carve Out Medication List The drugs shown below are non-capitated or carved-out of Managed Care Plans (MCPs). IE H P i s a man ag ed c a r e p l a n. T his means they are not reimbursed by
ALPHA1-PROTEINASE INHIBITOR
Ally Rx D-SNP Current as of Nov. 1, 2018 ALPHA1-PROTEINASE INHIBITOR ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG GLASSIA PROLASTIN-C INTRAVENOUS RECON SOLN ZEMAIRA PA Documentation of diagnosis, lab results,
Quick Reference: Plasma Protein Products
All plasma protein products a contraindicated in patients with any of the following: Hypersensitivity to the product or any ingdient in the formulation or component of the container. Pvious anaphylactic
Essential Health Benefits Standard Specialty PA and QL List July 2016
Anti-infectives Antiretrovirals, HIV SELZENTRY (maraviroc) Cardiology Antilipemic Pulmonary Arterial Hypertension Central Nervous System Anticonvulsants Depressant Neurotoxins Parkinson's Sleep Disorder
ACAMPROSATE (CAMPRAL)
ACAMPROSATE (CAMPRAL) ACAMPROSATE CALCIUM Creatinine clearance less than 30 PAGE 1 LAST UPDATED 06/2016 ADALIMUMAB (HUMIRA) HUMIRA, HUMIRA PEDIATRIC CROHN'S, HUMIRA PEN, HUMIRA PEN CROHN'S-UC-HS, HUMIRA
Prior January 2016 Authorization What Is Prior Authorization? What Happens at a Retail Pharmacy? Please Note: Which Medications Are Included?
Prior January 2016 Authorization What Is Prior Authorization? It s a quality and safety program that promotes the proper use of certain medications. If your doctor prescribes a medication that is included
Drug Class Prior Authorization Criteria Immune Globulins
Drug Class Prior Authorization Criteria Immune Globulins Line of Business: Medicaid P & T Approval Date: August 16, 2017 Effective Date: August 16, 2017 This policy has been developed through review of
Cleveland Clinic EHP Total Care/ SummaCare EPO
Cleveland Clinic Cleveland Clinic EHP Total Care/ SummaCare EPO Prescription Drug Benefit and Formulary Handbook Calendar Year 2014 Your Guide to Quality Healthcare Services and Healthier Living Welcome
2013 Prior Authorization (PA) Criteria
2013 Prior Authorization (PA) Criteria Certain drugs require prior authorization from EmblemHealth Medicare HMO/PPO Medicare Plans. This means that your doctor must contact us to get approval before prescribing
March 2017 P&T Updates
March 2017 P&T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth DICLEGIS 3 No 2 No Yes EMVERM 2 No 2 Yes Yes Detailed s 4 tablets per day, 9 month supply per year Pinworms: 1 tablet
2019 INJECTABLE DRUG PRIOR AUTHORIZATION CRITERIA
2019 INJECTABLE DRUG PRIOR AUTHORIZATION CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+) These drugs require authorization before dispensing
Actemra. Products Affected ACTEMRA INTRAVENOUS. Covered Uses
Actemra ACTEMRA INTRAVENOUS All medically accepted indications not otherwise excluded plus patients already started on tocilizumab for a covered use. Castleman's disease. Still's disease. Concurrent use
Brand Generic J-Code 1 Billable. Exclusion Criteria. Information and Criteria. Unit
Affinity Health Plan Department Of Pharmacy (Medicaid, Child Health Plus, Family Health Plus, Medicare Part B) **Medications Requiring Authorization under Medical Benefit** Click Here For Medication Authorization
Descriptor Brand Name. Alprostadil, Caverject, Edex, Prostin VR Pediatric. Calcimar, Miacalcin
Self-Administered Drug Exclusion List R2 This article from Medicare A News, Issue 2106 dated January 23, 2013 and Medicare B News, Issue 283 dated January 23, 2013 is being revised to add Acthar ACTH gel
Cleveland Clinic Employee Health Plan/ SummaCare EPO. Prescription Drug Benefit
Cleveland Clinic Employee Health Plan/ SummaCare EPO Prescription Drug Benefit Table of Contents PRESCRIPTION DRUG BENEFIT Cleveland Clinic Pharmacies Enhanced Benefit.............................................................
Injectable Drugs Requiring Pre-Service Approval
Abatacept Orencia J0129, 10 mg 1500 FL LCD- L29051 1) For patients with rheumatoid arthritis with failure, intolerance or contraindications to methotrexate. Limit dosing to 40 mg Q 2 weeks. 2) For patients
Texas Prior Authorization Program Clinical Edit Criteria
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Oral Drugs requiring prior authorization: the list of drugs requiring prior
2016 MDwise HIP Medical Services that Require Prior Authorization
2016 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
The Effect of Current Managed Care Trends on Patient Access in 3 Specialty Classes MS, Hepatitis C & Pulmonary Arterial Hypertension
The Effect of Current Managed Care Trends on Patient Access in 3 Specialty Classes MS, Hepatitis C & Pulmonary Arterial Hypertension DISCLAIMER The information within this CME/CE activity is for continuing
LIST OF DRUGS THAT MAY BE COVERED UNDER YOUR MEDICAL BENEFIT
LIST OF DRUGS THAT MAY BE COVERED UNDER YOUR MEDICAL BENEFIT The following medications may be covered under your medical benefit if they are provided to you in your doctor s office or outpatient infusion
2014 Prior Authorization (PA) Criteria
2014 Prior Authorization (PA) Certain drugs require prior authorization from EmblemHealth Medicare HMO/PPO Medicare Plans. This means that your doctor must contact us to get approval before prescribing
Clinical Therapeutic Intelligence Report: Year in Review
Clinical Therapeutic Intelligence Report: Year in Review Last year marked a productive year for oncology drug research and development with ten new oncology drugs coming to market two of which were granted
IVIG FLU SCIG IMIG HYPERIMMUNES COAGULATION ANTIVIRALS PEDIATRIC VACCINES ALBUMIN BIOSURGICALS. The products you need, when you need them.
BRAND PHARMACEUTICALS IVIG FLU PEDIATRIC VACCINES BIOSURGICALS HYPERIMMUNES IMIG SCIG OTHER PHARMACEUTICALS ONCOLOGY ANTITHROMBIN The products you need, when you need them. ALBUMIN COAGULATION ADULT VACCINES
List of Designated High-Cost Drugs
List of Designated High-Cost Drugs UPDATED APRIL 25, 2018 For details on the High-Cost Drug policy, see Section 5.8 of the PharmaCare Policy Manual. Recent updates appear in red. Deletions are listed at
GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Prior Authorization (PA) Criteria
GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP 2014 Prior Authorization (PA) Certain drugs require prior authorization from GuildNet Gold and GuildNet Health Advantage Medicare Plans.
Medical Prior Authorization List Rosen Employee Plans For prescription drug requirements, contact EHIM toll-free at
For prescription drug requirements, contact EHIM toll-free at 1.800.311.3446. General Information These requirements are administered by Health First Health Plans ( Health Plan ). Benefits are determined
DATE OF LICENSURE (mo/day/yr) Plasbumin-5; Plasbumin-20; Plasbumin-25; Albuked 10/21/1942 NA NA
125296 Adenovirus Type 4 and Type 7 Vaccine Live Oral 3/16/2011 101138 Albumin (Human) Plasbumin-5; Plasbumin-20; Plasbumin-25; Albuked 10/21/1942 101452 Albumin (Human) Buminate; Buminate 25%; Buminate
ACNE AGENTS_NVT Chinese Community Health Plan Senior Select Program (HMO SNP)
ACNE AGENTS_NVT adapalene topical cream adapalene topical gel Avita tretinoin tretinoin microspheres topical gel Age Other 1 ADAGEN_NVT Adagen Age Other 2 ADCIRCA_NVT 2017 Adcirca Diagnosis confirmed by
ACNE AGENTS_NVT Chinese Community Health Plan Senior Select Program (HMO SNP)
ACNE AGENTS_NVT adapalene 0.3% gel pump adapalene topical cream adapalene topical gel avita tretinoin tretinoin microspheres topical gel Age Other 1 ADAGEN_NVT ADAGEN Age Other 2 ADCIRCA_NVT 2017 ADCIRCA
ACROMEGALY THERAPY. Products Affected Somatuline Depot subcutaneous syringe 120 mg/0.5 ml, 60 mg/0.2 ml, 90 mg/0.3 ml
Prior Authorization Requirements Effective January 1, 2019 ACROMEGALY THERAPY Somatuline Depot subcutaneous syringe 120 mg/0.5 ml, 60 mg/0.2 ml, 90 mg/0.3 ml Somavert PA Age Other PATIENT PROGRESS NOTES,
Geisinger Health Plan Prior Authorization Requirements
ACTIQ FENTANYL CITRATE DOCUMENTATION OF USE TO MANAGE BREAKTHROUGH CANCER PAIN IN PATIENTS WITH CANCER CONCOMITANT MORPHINE 60 MG/DAY OR MORE, TRANSDERMAL FENTANYL 25 MCG/H, OXYCODONE 30 MG/DAY, ORAL HYDROMORPHONE