1199SEIU Benefit Funds
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1 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 of drug treatments. Register at If you have questions, please call (877) The symbol [] next to a drug name indicates that this medication is subject to the Prior orization. The symbol [C] next to a drug name indicates that this medication is subject to the orization. The symbol [evicore] next to a drug name indicates that this medication is subject to the evicore Comprehensive Oncology Management. Please contact (888) 910- () (C) ADAGEN PEGADEMASE BOVINE ENZYME DEFICIENCIES YES J2504 ADCIRCA ADCIRCA (TADALAFIL) PULMONARY HYPERTENSION YES J8499 ADEMS RIOCIGUAT CIRCULATION DISORDERS YES J8499 ADIPEX-P PHENTERMINE WEIGHT LOSS YES J8499 ADVATE FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7192 ADYNOVATE AFSTYLA FACTOR VIII (ANTIHEMOPHL FCTR) PEGYLATED ANTIHEMOPHL FCTR () SINGLE CHAIN HEMOPHILIA YES C9137, J7199, J7207 HEMOPHILIA YES C9140 ALDURAZYME LARONIDASE ENZYME DEFICIENCIES C NO J1931 ALPHANATE FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7186 ALPHANINE SD FACTOR IX COMPLEX (HUMAN) HEMOPHILIA YES J7193 ALPROLIX FACTOR IX Fc FUSION PROTEIN HEMOPHILIA YES J7201 AMPYRA DALFAMPRIDINE MULTIPLE SCLEROSIS YES J8499 APOKYN APOMORPHINE HCL MISCELLANEOUS CNS YES J0364 DISORDERS ARALAST NP ALPHA-1-PROTEINASE INHIBITOR RESPIRATORY YES J0256 ARCALYST RILONACEPT CRYOPYRIN-ASSOCIATED YES J2793 PERIODIC SYNDROMES ARISTADA ARIPIPRAZOLE LAUROXIL INJ MENTAL YES J1942
2 () (C) ARIXTRA FONDARINUX SODIUM ANTICOAGULANT YES J1652 ATGAM LYMPHOCYTE IMMUNE GLOBULIN TRANSPLANT YES J7504 AUBAGIO TERIFLUNOMIDE MULTIPLE SCLEROSIS YES J8499 AVEED TESTOSTERONE UNDECANOATE ENDOCRINE DISORDERS YES J3145 AVONEX INTERFERON BETA-1A MULTIPLE SCLEROSIS YES J1826, Q3027 BEBULIN FACTOR IX COMPLEX (HUMAN) HEMOPHILIA YES J7194 BELVIQ LORCASERIN WEIGHT LOSS YES J8499 BENEFIX FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7195 BENLYSTA BELIMUMAB INFLAMMATORY YES J0490 BERINERT C1 ESTERASE INHIBITOR HEREDITARY ANGIOEDEMA YES J0597 BETASERON INTERFERON BETA-1B MULTIPLE SCLEROSIS YES J1830 BIVIGAM IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1556 BONIVA (IV) IBANDRONATE OSTEOPOROSIS YES J1740 BOTOX BOTULINUM TOXIN A NEUROMUSCULAR YES J0585 /COSMETIC CARIMUNE NF IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1566 CELLCEPT MYCOPHENOLATE MOFETIL TRANSPLANT YES J7517, J7599 CEPROTIN PROTEIN C CONCENTRATE, HUMAN MISCELLANEOUS SPECIALTY YES J2724 CERDELGA ELIGLUSTAT ENZYME DEFICIENCIES C YES J8499 CEREDASE ALGLUCERASE ENZYME DEFICIENCIES C NO J0205 CEREZYME IMIGLUCERASE ENZYME DEFICIENCIES C NO J1786 CHENODAL CHENODIOL MISCELLANEOUS SPECIALTY YES NO HCPC CHORIONIC GONADOTROPIN, CHORIONIC INFERTILITY YES J0725 GONADOTROPIN CIMZIA CERTOLIZUMAB PEGOL INFLAMMATORY YES J0717 CINQAIR RESLIZUMAB RESPIRATORY YES C9481, J2786 CINRYZE C1 ESTERASE INHIBITOR HEREDITARY ANGIOEDEMA YES J0598 COAGADEX FACTOR X HUMAN HEMOPHILIA YES J7175 CONTRAVE NALTREXONE/BUPROPRION WEIGHT LOSS YES J3490 COXONE GLATIRAMER ACETATE MULTIPLE SCLEROSIS YES J1595 COPEGUS RIBAVIRIN HETITIS C YES J8499 CORIFACT FACTOR XIII HEMOPHILIA YES J7180 COSENTYX SECUKINUMAB INFLAMMATORY YES C9399, J3590 CUVITRU IMMUNE GLOBULIN - SQ IMMUNE DEFICIENCY YES J3490 CYTOGAM CYTOMEGALOVIRUS IMMUNE GLOB IMMUNE DEFICIENCY YES 90291, J0850 DAKLINZA DACLATASVIR HETITIS C YES J8499 DDAVP DESMOPRESSIN ACETATE ENDOCRINE DISORDERS YES J2597 DEFEROXAMINE MESYLATE DEFEROXAMINE IRON TOXICITY YES J0895
3 () (C) DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE ENDOCRINE DISORDERS YES J1071 DESFERAL DEFEROXAMINE IRON TOXICITY YES J0895 DESMOPRESSIN DESMOPRESSIN ACETATE ENDOCRINE DISORDERS YES J2597 ACETATE DIDREX BENZPHETAMINE WEIGHT LOSS YES J3490 DIETHYLPROPRION DIETHYLPROPRION WEIGHT LOSS YES J3490 DYLOJECT DICLOFENAC SODIUM INJ IN MANAGEMENT YES J1130 DYSPORT ABOBOTULINUMTOXINA NEUROMUSCULAR YES J0586 /COSMETIC EGRIFTA TESAMORELIN ACETATE ENDOCRINE DISORDERS YES C9399, J3490 ELAPRASE IDURSULFASE ENZYME DEFICIENCIES C NO J1743 ELELYSO TALIGLUCERASE ALFA ENZYME DEFICIENCIES C NO J3060 ELOCTATE FACTOR IX Fc FUSION PROTEIN HEMOPHILIA YES J7205 EMFLAZA DEFLAZACORT MUSCULAR DYSTROPHY YES J8499 ENBREL ETANERCEPT INFLAMMATORY YES J1438 ENOXARIN SODIUM ENOXARIN ANTICOAGULANT YES J1650 ENTYVIO VEDOLIZUMAB INFLAMMATORY YES J3380 EPCLUSA SOFOSBUVIR/VELTASVIR HETITIS C YES J8499 EPOPROSTENOL EPOPROSTENOL NA PULMONARY HYPERTENSION YES J1325 SODIUM ESBRIET PIRFENIDONE IDIOTHIC PULMONARY YES J8499 FIBROSIS EUFLEXXA SODIUM HYALURONATE OSTEOARTHRITIS YES J7323 EXTAVIA INTERFERON BETA-1B MULTIPLE SCLEROSIS YES J1830 EYLEA AFLIBERCEPT OPHTHALMIC YES J0178 FABRAZYME AGALSIDASE ENZYME DEFICIENCIES C NO J0180 FEIBA NF ANTI-INHIBITOR COAGULANT COMP. HEMOPHILIA YES J7198 FIRAZYR ICATIBANT ACETATE HEREDITARY ANGIOEDEMA YES J1744 FLEBOGAMMA/ IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1572 FLEBOGAMMA DIF FLOLAN EPOPROSTENOL NA PULMONARY HYPERTENSION YES J1325 FOLLISTIM AQ FOLLITROPIN BETA, INFERTILITY YES S0128 FONDARINUX FONDARINUX SODIUM ANTICOAGULANT YES J1652 SODIUM FORTEO TERIRATIDE OSTEOPOROSIS YES J3110 FRAGMIN DALTERIN (PORCINE) ANTICOAGULANT YES J1645 FUZEON ENFUVIRTIDE HIV YES J1324 GAMASTAN S-D IMMUNE GLOBULIN - IM IMMUNE DEFICIENCY YES 90281, J1460, J1560 GAMMAGARD LIQUID IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, 90284,
4 () (C) J1569 GAMMAGARD S-D IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1566 GAMMAKED IMMUNE GLOBULIN - IV/SQ IMMUNE DEFICIENCY YES 90283, 90284, J1561 GAMMAPLEX IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1557 GAMUNEX-C IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, 90284, J1561 GEL-ONE HYALURONATE SODIUM OSTEOARTHRITIS YES J7326 GEL-SYN HYALURONATE SODIUM OSTEOARTHRITIS YES J7328 GENOTROPIN SOMATROPIN GROWTH DEFICIENCY YES J2941 GENVISC 850 HYALURONATE SODIUM OSTEOARTHRITIS YES Q9980, J7320 GILENYA FINGOLIMOD HYDROCHLORIDE MULTIPLE SCLEROSIS YES J8499 GLASSIA ALPHA-1-PROTEINASE INHIBITOR RESPIRATORY YES J0257 GLATO GLATIRAMER ACETATE MULTIPLE SCLEROSIS YES J1595 GRASTEK TIMOTHY GRASS POLLEN ASTHMA AND ALLERGY YES J3590, C9399 ALLERGEN EXTRACT H.P. ACTHAR GEL CORTICOTROPIN MISCELLANEOUS CNS YES J0800 DISORDERS HARVONI LEDISVIR/SOFOSBUVIR HETITIS C YES J8499 HELIXATE FS FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7192 HEMOFIL M FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7190 HEGAM B HEP.B IMMUNE GLOB/MALTOSE HETITIS B YES J1571, J1573 HETLIOZ TASIMELTEON MISC SPECIALTY YES J8499 HIZENTRA IMMUNE GLOBULIN- SQ IMMUNE DEFICIENCY YES 90284, J1559 HUMATE-P FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7187 HUMATROPE SOMATROPIN GROWTH DEFICIENCY YES J2941 HUMIRA ADALIMUMAB INFLAMMATORY YES J0135 HYALGAN SODIUM HYALURONATE OSTEOARTHRITIS YES J7321 HYMOVIS HYALURONIC ACID OSTEOARTHRITIS YES C9471, J7322 HYPERHEP B S-D HETITIS B IMMUNE GLOBULIN HETITIS B YES HYPERRAB S-D RABIES IMMUNE GLOBULIN IMMUNE DEFICIENCY YES HYPERRHO S-D RHO(D) IMMUNE GLOBULIN IMMUNE DEFICIENCY YES 90384, 90385, J2788, J2790 HYQVIA IMMUNE GLOBULIN - SQ IMMUNE DEFICIENCY YES J1575 IDELVION FACTOR IX ALBUMIN FUSION HEMOPHILIA YES C9139, J7202 PROTEIN ILARIS CANAKINUMAB CRYOPYRIN-ASSOCIATED YES J0638 PERIODIC SYNDROMES IMOGAM RABIES-HT RABIES IMMUNE GLOBULIN IMMUNE DEFICIENCY YES IMPLANON ETONOGESTREL CONTRACEPTIVE YES J7307 INCIVEK TELAPREVIR HETITIS C YES J8499
5 () (C) INCRELEX MECASERMIN GROWTH DEFICIENCY YES J2170 INFERGEN INTERFERON ALFACON-1 HETITIS C YES J9212 INFLECTRA INFLIXIMAB - DYYB INFLAMMATORY YES Q5102 IXINITY COAGULATION FACTOR IX HEMOPHILIA YES J7195 KALBITOR ECALLANTIDE HEREDITARY ANGIOEDEMA YES J1290 KALYDECO IVACAFTOR RESPIRATORY YES J8499 KANUMA SEBELISE ALFA ENZYME DEFICIENCIES C YES C9478, J2840 KCENTRA PROTHROMBIN COMPLEX HUMAN HEMOPHILIA YES C9132 KENALOG TRIAMCINOLONE ACETONIDE INFLAMMATORY YES J3301 KOATE-DVI FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7190 KOGENATE FS FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7192 KORLYM MIFEPRISTONE ENDOCRINE DISORDERS YES J8499 KOVALTRY FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA NO J7192 KRYSTEXXA PEGLOTICASE INFLAMMATORY YES J2507 KUVAN SAPROPTERIN DIHYDROCHLORIDE ENDOCRINE DISORDERS YES J8499 KYLEENA LEVONORGESTREL CONTRACEPTIVE YES S4989 LEMTRADA ALEMTUZUMAB MULTIPLE SCLEROSIS YES J0202 LETAIRIS AMBRISENTAN PULMONARY HYPERTENSION YES J8499 LILETTA LEVONORGESTREL CONTRACEPTIVE YES J7297 LOMAIRA PHENTERMINE WEIGHT LOSS YES J3490 LOVENOX ENOXARIN ANTICOAGULANT YES J1650 LUCENTIS RANIBIZUMAB OPHTHALMIC YES J2778 LUMIZYME ALGLUCOSIDASE ALFA ENZYME DEFICIENCIES C NO J0221 MACUGEN PEGAPTANIB SODIUM OPHTHALMIC YES J2503 MAKENA HYDROXYPROGEST CAPROATE MISC SPECIALTY YES J1725 MICRHOGAM PLUS RHO(D) IMMUNE GLOBULIN IMMUNE DEFICIENCY YES 90385, J2788 MIRENA LEVONORGESTREL CONTRACEPTIVE YES J7298 MODERIBA RIBAVIRIN HETITIS C YES J8499 MONOCLATE-P FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7190 MONONINE FACTOR IX COMPLEX (HUMAN) HEMOPHILIA YES J7193 MONOVISC SODIUM HYALURONATE OSTEOARTHRITIS YES C9399, J7327 MYALEPT METRELEPTIN LIPODYSTROPHY YES J3590, C9399 MYCOPHENOLATE MYCOPHENOLATE MOFETIL TRANSPLANT YES J7517 MOFETIL MYFORTIC MYCOPHENOLATE SODIUM TRANSPLANT YES J7518 MYOBLOC BOTULINUM TOXIN TYPE B NEUROMUSCULAR /COSMETIC YES J0587 MYOZYME ALGLUCOSIDASE ALFA ENZYME DEFICIENCIES C NO J0220 NABI-HB HETITIS B IMMUNE GLOBULIN HETITIS B YES 90371
6 () (C) NAGLAZYME GALSULFASE ENZYME DEFICIENCIES C NO J1458 NATRA RATHYROID HORMONE ENDOCRINE DISORDERS YES C9399, J3590 NEXPLANON ETONOGESTREL CONTRACEPTIVE YES J7307 NORDITROPIN SOMATROPIN GROWTH DEFICIENCY YES J2941 NOVAREL GONADOTROPIN, CHORIONIC INFERTILITY YES J0725 NOVOEIGHT FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7182 NOVOSEVEN RT FACTOR VIIA, (BHK CELLS) HEMOPHILIA YES J7189 NPLATE ROMIPLOSTIM BLOOD CELL DEFICIENCY YES J2796 NUCALA MEPOLIZUMAB RESPIRATORY YES C9473, J2182 NULOJIX BELATACEPT TRANSPLANT YES J0485 NUTROPIN SOMATROPIN GROWTH DEFICIENCY YES J2941 NUVARING ETONOGESTREL/ETHYINYL ESTRADIOL CONTRACEPTIVE YES J7303 NUWIQ FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES C9138, J7209 OBIZUR ANTIHEMOPHL FCTR () HEMOPHILIA YES J7194 PORCINE SEQUENCE OCTAGAM IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1568 OCTREOTIDE OCTREOTIDE ENDOCRINE DISORDERS YES J2354 ACETATE OFEV NINTEDANIB IDIOTHIC PULMONARY YES J8499 FIBROSIS OLYSIO SIMEPREVIR HETITIS C YES J8499 OMNITROPE SOMATROPIN GROWTH DEFICIENCY YES J2941 ONSOLIS FENTANYL CITRATE IN MANAGEMENT YES J8499 OPSUMIT MACITENTAN PULMONARY HYPERTENSION YES J8499 ORALAIR MIXED GRASS POLLENS ASTHMA AND ALLERGY YES J3590, C9399 ALLERGENS EXTRACT ORENCIA ABATACEPT/MALTOSE INFLAMMATORY YES J0129 ORENITRAM TREPROSTINIL PULMONARY HYPERTENSION YES J8499 ORKAMBI LUMACAFTOR/IVACAFTOR CYSTIC FIBROSIS YES J8499 ORTHO EVRA NORELGESTROMIN/ETHINYL CONTRACEPTIVE YES J7304 ESTRADIOL ORTHOVISC HYALURONATE SODIUM OSTEOARTHRITIS YES J7324 OTEZLA APREMILAST INFLAMMATORY YES J8499 OTIPRIO CIPROFLOXACIN ANTI-INFECTIVE YES J7342 PHENDIMETRAZINE PHENDIMETRAZINE WEIGHT LOSS YES J3490 PLEGRIDY PEGINTERFERON BETA-1A MULTIPLE SCLEROSIS YES J3590, C9399 PRALUENT ALIROCUMAB HYPERCHOLESTEROLEMIA YES C9399, J3590 PREGNYL GONADOTROPIN,CHORIONIC INFERTILITY YES J0725
7 () (C) PRIALT ZICONOTIDE ACETATE IN MANAGEMENT YES J2278 PRIVIGEN IMMUNE GLOBULIN - IV IMMUNE DEFICIENCY YES 90283, J1459 PROBUPHINE IMPLANT PROFILNINE/ PROFILNINE SD BUPRENORPHINE HCL MISCELLANEOUS SPECIALTY YES J0570 FACTOR IX COMPLEX (HUMAN) HEMOPHILIA YES J7194 PROGESTERONE PROGESTERONE ENDOCRINE DISORDERS YES J2675 PROGRAF TACROLIMUS TRANSPLANT YES J7507, J7525 PROLASTIN/ ALPHA-1-PROTEINASE INHIBITOR RESPIRATORY YES J0256 PROLASTIN-C PROMACTA ELTROMBOG OLAMINE BLOOD CELL DEFICIENCY YES J8499 PULMOZYME DEOXYRIBONUCLEASE RESPIRATORY YES J7639 RAMUNE SIROLIMUS TRANSPLANT YES J7520 REBETOL RIBAVIRIN HETITIS C YES J8499 REBIF INTERFERON BETA-1A/ALBUMIN MULTIPLE SCLEROSIS YES Q3028 INATE FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7192 REGIMEX BENZPHETAMINE WEIGHT LOSS YES J3490 REMICADE INFLIXIMAB INFLAMMATORY YES J1745 REMODULIN TREPROSTINIL SODIUM PULMONARY HYPERTENSION YES J3285 RETHA EVOLOCUMAB HYPERCHOLESTEROLEMIA YES C9399, J3590 REVATIO SILDENAFIL CITRATE PULMONARY HYPERTENSION YES J3490, J8499 RHOGAM PLUS RHO(D) IMMUNE GLOBULIN IMMUNE DEFICIENCY YES 90384, J2790 RHOPHYLAC RHO(D) IMMUNE GLOBULIN IMMUNE DEFICIENCY YES 90384, 90386, J2791 RIBAK RIBAVIRIN HETITIS C YES J8499 RIBASPHERE RIBAVIRIN HETITIS C YES J8499 RIBATAB RIBAVIRIN HETITIS C YES J8499 RIBAVIRIN RIBAVIRIN HETITIS C YES J8499 RITUXAN RITUXIMAB INFLAMMATORY / CANCER / evicore RUCONEST C1 ESTERASE INHIBITOR HEREDITARY ANGIOEDEMA YES J0596 SAIZEN SOMATROPIN GROWTH DEFICIENCY YES J2941 SANDOSTATIN OCTREOTIDE ENDOCRINE DISORDERS YES J2354 SANDOSTATIN LAR OCTREOTIDE ENDOCRINE DISORDERS YES J2353 SAXENDA LIRAGLUTIDE WEIGHT LOSS YES J3490 SEROSTIM SOMATROPIN GROWTH DEFICIENCY YES J2941 SIGNIFOR SIREOTIDE DIASRTATE ENDOCRINE DISORDERS YES C9399, J3490 SIGNIFOR LAR SIREOTIDE DIASRTATE INJ ENDOCRINE DISORDERS YES C9454, J2502 SILDENAFIL CITRATE SILDENAFIL CITRATE PULMONARY HYPERTENSION YES J3490, J8499 SILIQ BRODALUMAB INFLAMMATORY YES J3590 YES J9310
8 () (C) SIMPONI GOLIMUMAB INFLAMMATORY YES C9399, J3590 SIMPONI ARIA GOLIMUMAB INFLAMMATORY YES J1602 SIMULECT BASILIXIMAB TRANSPLANT YES J0480 SKYLA LEVONORGESTREL CONTRACEPTIVE YES J7301 SOLESTA DEXTRANOMER/HYALURONATE/ SOD MISCELLANEOUS SPECIALTY SOLIRIS ECULIZUMAB MISCELLANEOUS SPECIALTY YES J1300 SOMATULINE DEPOT LANREOTIDE ACETATE ENDOCRINE DISORDERS YES J1930 SOVALDI SOFOSBUVIR HETITIS C YES J8499 SPINRAZA NUSINERSEN NEUROMUSCULAR YES C9399, J3490 STELARA USTEKINUMAB INFLAMMATORY YES J3357 STELARA IV USTEKINUMAB INFLAMMATORY YES C9487, J3590 SURTZ HYALURONATE SODIUM OSTEOARTHRITIS YES J7321 SUPRENZA PHENTERMINE WEIGHT LOSS YES J3490 SYNAGIS LIVIZUMAB RSV PREVENTION YES SYNVISC HYALURONATE SODIUM OSTEOARTHRITIS YES J7325 SYNVISC-ONE HYALURONATE SODIUM OSTEOARTHRITIS YES J7325 TACROLIMUS TACROLIMUS TRANSPLANT YES J7507 TALTZ IXEKIZUMAB RESPIRATORY YES J3490 TECFIDERA DIMETHYL FUMARATE MULTIPLE SCLEROSIS YES J8499 TECHNIVIE OMBITASVIR, RITAPREVIR, AND HETITIS C YES J8499 RITONAVIR TESTOPEL TESTOSTERONE PELLET ENDOCRINE DISORDERS YES S0189 TESTOSTERONE ENANTHATE TESTOSTERONE ENANTHATE ENDOCRINE DISORDERS YES J3121 THYMOGLOBULIN LYMPHOCYTE IMMUNE GLOBULIN TRANSPLANT YES J7511 TOBI TOBRAMYCIN/SODIUM CHLORIDE RESPIRATORY YES J7682 TRACLEER BOSENTAN PULMONARY HYPERTENSION YES J8499 TYSABRI NATALIZUMAB MULTIPLE SCLEROSIS YES J2323 TYVASO TREPROSTINIL (TYVASO) PULMONARY HYPERTENSION YES J7686 UPTRAVI SELEXIG PULMONARY HYPERTENSION YES J8499 VAPRISOL CONIVAPTAN MISCELLANEOUS SPECIALTY YES C9488 VELETRI EPOPROSTENOL NA PULMONARY HYPERTENSION YES J1325 VENTAVIS ILOPROST PULMONARY HYPERTENSION YES Q4074 VIEKIRA K OMBITASVIR, RITAPREVIR AND HETITIS C YES J8499 RITONAVIR; DASABUVIR VIEKIRA XR OMBITASVIR, RITAPREVIR AND RITONAVIR; DASABUVIR HETITIS C YES J8499 YES L8605
9 () (C) VIMIZIM ELOSULFASE ALFA ENZYME DEFICIENCIES C NO C9022, J1322 VISUDYNE VERTEPORFIN OPHTHALMIC YES J3396 VIVITROL NALTREXONE MICROSPHERES MISCELLANEOUS CNS YES J2315 DISORDERS VONVENDI VON WILLEBRAND FACTOR HEMOPHILIA YES J7179 (INANT) VPRIV VELAGLUCERASE ALFA ENZYME DEFICIENCIES C NO J3385 WINRHO SDF RHO(D) IMMUNE GLOBULIN IMMUNE DEFICIENCY YES 90384, 90386, J2792 XELJANZ TOFACITINIB INFLAMMATORY YES J8499 XENAZINE TETRABENAZINE MISCELLANEOUS CNS YES J8499 DISORDERS XENICAL ORLISTAT WEIGHT LOSS YES J3490 XEOMIN INCOBOTULINUMTOXINA NEUROMUSCULAR YES J0588 /COSMETIC XIAFLEX COLLAGENASE CLOSTRIDIUM HIST. MISCELLANEOUS SPECIALTY YES J0775 XOLAIR OMALIZUMAB RESPIRATORY YES J2357 XULANE NORELGESTROMIN/ETHINYL ESTRADIOL CONTRACEPTIVE YES J7304 XYNTHA/XYNTHA SOLOFUSE FACTOR VIII (ANTIHEMOPHL FCTR) HEMOPHILIA YES J7185 ZAVESCA MIGLUSTAT ENZYME DEFICIENCIES C YES J8499 ZEMAIRA ALPHA-1-PROTEINASE INHIBITOR RESPIRATORY YES J0256 ZETIER ELBASVIR/GRAZOPREVIR HETITIS C YES J8499 ZINBRYTA DACLIZUMAB MULTIPLE SCLEROSIS YES C9399, J3590 ZOMACTON SOMATROPIN GROWTH DEFICIENCY YES J2941 ZORBTIVE SOMATROPIN GROWTH DEFICIENCY YES J2941
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
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
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
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
Aetna Better Health. Specialty Drug Program
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
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
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
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
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
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
1199SEIU Benefit Funds
1199SEIU Benefit Funds MEDICAL BENEFIT MANAGEMENT PROGRAM SPECIALTY DRUG LIST Effective January 1, 2019 As of April 1, 2015, providers must use the web-based ExpressPAth platform to obtain prior authorization
Client Prior Authorization Program (CPA) PA Required (PA) Reimb Code. Reimb Code CLAIM EDIT. Reimb Code. Reimb Code. Reimb Code
Medical Benefit Management Specialty Drug List Effective October 1, 2015 The symbol [] next to a drug name indicates that this medication is subject to the Prior. The symbol [C] next to a drug name indicates
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
Drug Name. J0129 Injection, abatacept (Orencia ), 10 mg Effective 01/01/2014. J0178 Injection, aflibercept (Eylea ), 1 mg Effective 04/01/2015
J0129 Injection, abatacept (Orencia ), 10 J0178 Injection, aflibercept (Eylea ), 1 J0256 J0257 J0585 J0586 J0587 J0588 J0597 J0641 J0717 J0800 Injection, alpha 1-proteinase inhibitor, human (Aralast NP,
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
LIMITED DISTRIBUTION MEDICATIONS
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after reconstitution No Yes Refrigerate; do Not freeze. Discard unused portions; do Not save for further Immune Deficiencies & Related
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ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0364T 0365T 0366T 0367T 0373T 0374T H2020 96116
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