PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
|
|
|
- Gertrude Dinah Sutton
- 5 years ago
- Views:
Transcription
1 Abstral fentanyl citrate oral tablet Controlled Dangerous Substance Accu-Chek Test Strips blood glucose test strips Blood Glucose Test Strips Actemra tocilizumab Monoclonal Antibody Acthar corticotropin Hormone Actimmune interferon gamma 1b Interferon Actiq fentanyl citrate OTFC Controlled Dangerous Substance Adcirca tadalafil Pulmonary Vasodilator Adempas riociguat Pulmonary Vasodilator Adlyxin lixisenatide Type 2 Diabetes Advocate Test Strips blood glucose test strips Blood Glucose Test Strips Aerospan** flunisolide Corticosteroids (Inhaled) Afrezza insulin Insulin (inhaled) Ampyra dalfampridine Multiple Sclerosis Agent Altoprev** lovastatin Cholesterol Alvesco** ciclesonide Corticosteroids (Inhaled) Amrix** cyclobenzaprine Skeletal Muscle Relaxant Androderm testosterone Topical Testosterone Drug Androgel testosterone Topical Testosterone Drug Apidra insulin glulisine [rdna origin] Human Insulin Analog Aplenzin** bupropion Antidepressant Aranesp darbepoetin alfa Red Blood Cell Progenitor Arcapta Neohaler** indacaterol Beta Adrenergic (Inhaled) Asmanex HFA/Twisthaler** mometasone Corticosteroid (Inhaled) Atralin tretinoin Anti-Acne Auryxia ferric citrate Phosphate Binder Avita tretinoin Anti-Acne Axiron testosterone Topical Testosterone Drug Benlysta belimumab Lupus Berinert C1 esterase inhibitor Hereditary Angioedema Betaseron interferon beta-1b Multiple Sclerosis Agent Bethkis** tobramycin Cystic Fibrosis Bevespi Aerosphere glycopyrrolate/formoterol fumarate Beta Adrenergic/Anticholinergic (inhaled) Bivigam immune globulin-intravenous Intravenous Immune Globulin Boniva Syringe ibandronate Osteoporosis/Bones
2 Botox onabotulinumtoxina Specialty Drug Briviact brivaracetam Anticonvulsant Brovana** aformoterol tartrate Beta Adrenergic (Nebulized) Bunavail buprenorphine/naloxone Controlled Dangerous Substance Bydureon exenatide ER Incretin Mimetic Agent Byetta exenatide Incretin Mimetic Agent Carimune NF immune globulin-intravenous Intravenous Immune Globulin Cayston** aztreonam Cystic Fibrosis Cholbam cholic acid Bile Acid Cialis tadalafil Benign Prostatic Hyperplasia Cimzia certolizumab pegol Anti-Tumor Necrosis Factor Drug Cinryze C1 esterase inhibitor Hereditary Angioedema Cinqair reslizumab Monoclonal Antibody Cosentyx secukinumab Interleukin-17 Receptor Antagonist Crestor** rosuvastatin Cholesterol Cuprimine** penicillamine Wilson s Disease/Cystinuria/Rheumatoid Arthritis Cuvitru immune globulin-subcutaneous Subcutaneous Immune Globulin Daklinza daclatasvir dihydrochloride Hepatitis C Daraprim** pyrimethamine Antimalarial Denavir** penciclovir Antiviral/Herpes Dulera** mometasone/formoterol Beta Adrenergic/Corticosteroid (Inhaled) Durlaza aspirin ER Antiplatelet Dysport onabotulinumtoxina Specialty Drug Ecoza** econazole Antifungal Edarbi azilsartan Hypertension Edarbyclor azilsartan/chlorthalidone Hypertension Egrifta tesamorelin HIV Associated Lipodystrophy Embrace Pro Test Strips blood glucose test strips Blood Glucose Test Strips Elidel** tacrolimus Immunomodulator Enbrel etanercept Anti-Tumor Necrosis Factor Drug Entyvio vedolizumab Monoclonal Antibody Epclusa sofosbuvir/velpatasvir Hepatitis C Epogen epoetin alfa Red Blood Cell Progenitor Ertaczo** sertaconazole Antifungal
3 Esbriet pirfenidone Pulmonary Fibrosis Evencare Mini Glucose Test Strips blood glucose test strips Blood Glucose Test Strips Euflexxa sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection Evzio** naloxone hcl injection Opiate Reversal Agent Exelderm** sulconazole Antifungal Exondyx 51 eteplirsen Duchenne Muscular Dystrophy Extina** ketoconazole Antifungal Farxiga** dapagliflozin Type 2 Diabetes Fentora fentanyl buccal tablet Controlled Dangerous Substance Fexmid** cyclobenzaprine Skeletal Muscle Relaxant Firazyr icatibant Hereditary Angioedema Flexeril** cyclobenzaprine Skeletal Muscle Relaxant Flolan epoprostenol sodium Pulmonary Vasodilator Flebogamma immune globulin-intravenous Intravenous Immune Globulin Foradil Aerolizer** formoterol Beta Adrenergic (Inhaled) Forfivo XL** bupropion Antidepressant Fortamet** metformin Type 2 Diabetes Forteo teriparatide Osteoporosis/Bones Fortesta testosterone Topical Testosterone Drug Fosrenol lanthanum carbonate Phosphate Binder FreeStyle Test Strips blood glucose test strips Blood Glucose Test Strips Gamimune N immune globulin-intravenous Intravenous Immune Globulin Gammagard Liquid immune globulin-intravenous Intravenous Immune Globulin Gammagard S/D immune globulin-intravenous Intravenous Immune Globulin Gammaked immune globulin-intravenous Intravenous Immune Globulin Gammaplex immune globulin-intravenous Intravenous Immune Globulin Gammar-P IV immune globulin-intravenous Intravenous Immune Globulin Gamunex immune globulin-intravenous Intravenous Immune Globulin Gamunex-C immune globulinintravenous/subcutaneous Intravenous/Subcutaneous Immune Globulin Gattex teduglitide [rdna origin] Short Bowel Syndrome Gel-One sodium hyaluronate Hyaluronic Acid Derivative for Joint Injection Gel-Syn sodium hyaluronate Hyaluronic Acid Derivative for Joint Injection Genotropin somatropin Growth Hormone
4 Genstrip Test Strips blood glucose test strips Blood Glucose Test Strips GenVisc 850 sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection Glucose Test Strip blood glucose test strips Blood Glucose Test Strips Glucophage XR** metformin Type 2 Diabetes Glumetza** metformin Type 2 Diabetes Gralise** gabapentin Postherpetic Neuralgia Agent Grastek timothy grass pollen allergen extract Allergy Immunotherapy Harvoni ledipasvir/sofosbuvir Hepatitis C NS5A/Polymerase Inhibitor Hetlioz tasimelteon Non-24-Hour Sleep-Wake Disorder Hizentra immune globulin-subcutaneous Subcutaneous Immune Globulin Horizant** gabapentin enacarbil Restless Legs Syndrome/Postherpetic Neuralgia Humalog insulin lispro [rdna origin] Human Insulin Analog Humatrope somatropin Growth Hormone Humira adalimumab Monoclonal Antibody Humulin insulin human [rdna origin] Human Insulin Hyalgan sodium hyaluronate Hyaluronic Acid Derivative for Joint Injection Hymovis sodium hyaluronate Hyaluronic Acid Derivative for Joint Injection Hyqvia immune globulin-subcutaneous Subcutaneous Immune Globulin Impavido miltefosine Antileishmanial Increlex mecasermin Growth Hormone Iveegam EN immune globulin-intravenous Intravenous Immune Globulin IVIG or IGIV immune globulin-intravenous Intravenous Immune Globulin Jentadueto/XR* linagliptin/metformin Type 2 Diabetes Jublia** efinaconazole Antifungal Juxtapid lomitapide Homozygous Familial Hypercholesterolemia Kalbitor ecallantide Hereditary Angioedema Kalydeco ivacaftor Cystic Fibrosis Kanuma selbelipase alfa Enzyme Kazano alogliptin/metformin Type 2 Diabetes Kerydin** tavaborole Antifungal Keveyis diclorphenamide Carbonic Anhydrase Inhibitor Kombiglyze XR** saxagliptin/metformin Type 2 Diabetes Korlym mifepristone Endocrine/Cushing s Disease
5 Krystexxa pegloticase Gout Kuvan sapropterin Phenylketonuria Kynamro mipomersen Homozygous Familial Hypercholesterolemia Lazanda Nasal Spray fentanyl citrate Controlled Dangerous Substance Lemtrada alemtuzumab Multiple Sclerosis Letairis ambrisentan Pulmonary Vasodilator Liberty Test Strip blood glucose test strips Blood Glucose Test Strips Lidoderm lidocaine Topical Anesthetic Livalo** pitavastatin calcium Cholesterol Lovaza omega-3-acid ethyl esters Omega-3 Fatty Acid Lumigan bimatoprost Anti-Glaucoma Luzu** luliconazole Antifungal Makena hydroxyprogesterone Hormone Mentax** butenafine Antifungal Mircera pegylated epoetin beta Red Blood Cell Progenitor Monovisc sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection Myalept metreleptin Leptin Analog Myobloc rimabotulinumtoxinb Specialty Drug Naftifine** naftifine Antifungal Naftin** naftifine Antifungal Natesto testosterone Topical Testosterone Drug Nesina alogliptin Type 2 Diabetes Neurontin** gabapentin Postherpetic Neuralgia/Anticonvulsant Norditropin somatropin Growth Hormone Northera droxidopa Neurogenic Orthostatic Hypotension Nucala mepolizumab Monoclonal Antibody Nutropin somatropin Growth Hormone Nutropin AQ somatropin Growth Hormone Nuvigil armodafinil CNS Stimulant Ocaliva obeticholic acid Bile Acid Analog Octagam immune globulin-intravenous Intravenous Immune Globulin Ofev nintedanib Pulmonary Fibrosis Olysio simeprevir Hepatitis C Protease Inhibitor Omnitrope somatropin Growth Hormone
6 One Touch Test Strips blood glucose test strips Blood Glucose Test Strips One Touch Ultra Test Strips blood glucose test strips Blood Glucose Test Strips Onglyza** saxagliptin Type 2 Diabetes Onmel itraconazole Antifungal Onsolis fentanyl soluble film Controlled Dangerous Substance Opsumit macitentan Pulmonary Vasodilator sweet vernal, orchard, perennial Oralair rye, timothy and kentucky blue grass mixed pollens allergen Allergy Immunotherapy extract Oravig** miconazole Antifungal Orencia / Clickject abatacept Selective Co-Stimulation Modulator for RA Orenitram treprostinil Pulmonary Vasodilator Orkambi lumacaftor/ivacaftor Cystic Fibrosis Orthovisc high molecular weight hyaluronan Hyaluronic Acid Derivative for Joint Injection Otezla apremilast Phosphodiesterase Inhibitor Otrexup** methotrexate Arthritis/Polyarticular Juvenile Idiopathic Arthritis/ Psoriasis Oxycontin- quantities greater than 90 per month oxycodone extended release Controlled Dangerous Substance Oxistat** oxiconazole Antifungal Pegasys peginterferon alfa-2a Interferon Peg-Intron peginterferon alfa-2b Interferon Perforomist** formoterol fumarate Beta Adrenergic (nebulized) PhosLo calcium acetate Phosphate Binder Phoslyra calcium acetate Phosphate Binder Pradaxa** dabigatran etexilate Anticoagulant Praluent alirocumab Cholesterol Precision SOF-TACT Test Strips blood glucose test strips Blood Glucose Test Strips Precision Xtra Test Strips blood glucose test strips Blood Glucose Test Strips Polygam S/D immune globulin-intravenous Intravenous Immune Globulin Privigen immune globulin-intravenous Intravenous Immune Globulin Prestige Test Strips blood glucose test strips Blood Glucose Test Strips Procrit epoetin alfa Red Blood Cell Progenitor Procysbi cysteamine bitartrate Nephropathic Cystinosis Agent
7 Prodigy Test Strips blood glucose test strips Blood Glucose Test Strips Prolia denosumab Osteoporosis/Bones Protopic** tacrolimus Immunomodulator Provenge sipuleucel-t Oncology Proventil HFA** albuterol Short Acting Beta Adrenergic (inhaled) Provigil modafinil CNS Stimulant Pulmicort Flexhaler** budesonide Corticosteroid (Inhaled) Qudexy XR** topiramate extended release Anticonvulsant Qutenza capsaicin Topical Anesthetic Ragwitek short ragweed pollen allergen extract Allergy Immunotherapy Rasuvo** methotrexate Rheumatoid Arthritis/ Psoriasis Rayos** prednisone Corticosteroid Reclast zoledronic acid Osteoporosis/Bones Relion Test Strips blood glucose test strips Blood Glucose Test Strips Remicade infliximab Monoclonal Antibody Remodulin treprostinil sodium Pulmonary Vasodilator Renagel sevelamer Phosphate Binder Renvela sevelamer Phosphate Binder Repatha evolocumab Cholesterol Restasis** cyclosporine Anti-Inflammatory/Immunomodulator Retin-A tretinoin Anti-Acne Retin-A Micro tretinoin Anti-Acne Revatio sildenafil citrate Pulmonary Vasodilator Rituxan rituximab Monoclonal Antibody Ruconest C1 esterase inhibitor (recombinant) Hereditary Angioedema Sabril vigabatrin Anticonvulsant Saizen somatropin Growth Hormone Savaysa** edoxaban Anticoagulant Seebri Neohaler** glycopyrrolate Anticholinergic Serostim somatropin Growth Hormone Signifor pasireotide Somatostatin/Cushing s Disease Signifor LAR pasireotide Somatostatin/Acromegaly Simponi golimumab Anti-Tumor Necrosis Factor Drug
8 Sitavig** acyclovir Antiviral/Herpes Sovaldi sofosbuvir Hepatitis C Polymerase Inhibitor Spritam levetiracetam Anticonvulsant Stelara ustekinumab Anti-Tumor Necrosis Factor Drug Stiolto Respimat** tiotropium bromide/olodaterol Beta Adrenergic/Anticholinergic (Inhaled) Strensiq asfotase alfa Hypophosphatasia Striant testosterone Topical Testosterone Drug Subutex** buprenorphine Controlled Dangerous Substance Suboxone SL Film buprenorphine and naloxone Controlled Dangerous Substance Suboxone SL Tablets buprenorphine and naloxone Controlled Dangerous Substance Subsys fentanyl sublingual spray Controlled Dangerous Substance Supartz sodium hyaluronate Hyaluronic Acid Derivatives for Joint Injection SureStep Test Strips blood glucose test strips Blood Glucose Test Strips Symlin pramlintide Amylin Analogue Synagis palivizumab Monoclonal Antibody Synvisc hylan GF 20 Hyaluronic Acid Derivatives for Joint Injection Synvisc-One hylan GF 20 Hyaluronic Acid Derivatives for Joint Injection Syprine** trientine Wilson s Disease Taltz ixekizumab Monoclonal Antibody Tanzeum albiglutide Incretin Mimetic Agent Technivie ombitasvir, paritaprevir, ritonavir Hepatitis C Testim testosterone Topical Testosterone Drug Tev-Tropin somatropin Growth Hormone Tobi/Tobi Podhaler** tobramycin Cystic Fibrosis Topiramate ER** topiramate extended release Anticonvulsant Tracleer bosentan Pulmonary Vasodilator Tradjenta* linagliptin Type 2 Diabetes Travatan Z travoprost Anti-Glaucoma Travoprost travoprost Anti-Glaucoma Tresiba* insulin degludec Insulin Tretin-X tretinoin Anti-Acne Trokendi XR** topiramate extended release Anticonvulsant Trulicity dulaglutide Incretin Mimetic Agent Tudorza Pressair** aclidinium Anticholinergic (Inhaled)
9 Tyvaso treprostinil Pulmonary Vasodilator Tysabri natalizumab Monoclonal Antibody Unistrip1 blood glucose test strips Blood Glucose Test Strips Uptravi selexipag Pulmonary Vasodilator Utibron Neohaler** indacaterol/glycopyrrolate Beta Adrenergic/Anticholinergic (Inhaled) Vascepa icosapent ethyl Omega-3 Fatty Acid Vecamyl** mecamylamine hydrochloride Antihypertensive Veletri epoprostenol sodium Pulmonary Vasodilator Velphoro sucroferric oxyhydroxide Phosphate Binder Veltin tretinoin/clindamycin Anti-Acne Ventavis iloprost Pulmonary Vasodilator Victoza liraglutide Incretin Mimetic Agent Viekira Pak/XR ombitasvir/paritaprevir/ritonavir/ dasabuvir Hepatitis C Vogelxo testosterone Testosterone Replacement WaveSense Test Strips blood glucose test strips Blood Glucose Test Strips Wellbutrin SR/XL** bupropion Antidepressant Xalatan latanoprost Anti-Glaucoma Xeljanz/XR tofacitinib Janus Kinase Inhibitor Xenazine tetrabenazine Huntington s Chorea Xeomin incobotulinumtoxina Specialty Drug Xgeva denosumab Oncology/Bones Xiaflex collagenase clostridium Cord Injection Xigduo XR** dapagliflozin Type 2 Diabetes Xiidra lifitegrast Dry Eye Disease Xolair omalizumab Monoclonal Antibody Xolegel** ketoconazole Antifungal Xopenex HFA** albuterol Short Acting Beta Adrenergic (Inhaled) Xuriden uridine triacetate granule Hereditary Orotic Aciduria Xyrem** sodium oxybate Narcolepsy Zepatier elbasvir/grazoprevir Hepatitis C Ziana tretinoin/clindamycin Anti-Acne Zinbryta daclizumab Monoclonal Antibody Zioptan tafluprost Anti-Glaucoma
10 Zomacton somatropin Growth Hormone Zometa zoledronic acid Oncology/Bones Zorbtive somatropin Growth Hormone Zovirax cream/ointment** acyclovir Antiviral/Herpes Zubsolv buprenorphine and naloxone Controlled Dangerous Substance Zyflo/Zyflo CR** zileuton Asthma Therapy
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 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
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
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
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
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
Exclusion Reasons Presumption of Long- Term Non-Acute Administration C9399 Unclassified Drugs or
Noridian Healthcare Solutions, LLC Jurisdiction F Part B Self-Administered Drug (SAD) Exclusion List (A53033); Effective 8/7/2017 The following medications are considered self-administered and are not
SELF-ADMINISTERED MEDICATIONS LIST
SELF-ADMINISTERED MEDICATIONS LIST Table of Contents Page Last Updated: January 23, 2019 INSTRUCTIONS FOR USE... 1 APPLICABLE CODES... 1 Related Commercial Policy LIST HISTORY/REVISION INFORMATION... 5
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,
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
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
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
Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List
Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List Code Drug Name Effective and/or Term Date J0129 Injection, abatacept (Orencia ), 10 mg J0178 Injection, aflibercept (Eylea
UPMC for You Pharmacy and Therapeutics Committee Meeting April 7, 2014 meeting
UPMC for You Pharmacy and Therapeutics Committee Meeting April 7, 2014 meeting 1. Call to order: The meeting was called to order at 7:05 a.m. 2. Review of the minutes: The minutes of the January meeting
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
Your Drug Coverage Will Change as of Jan. 1, 2017
Your Drug Coverage Will Change as of Jan. 1, 2017 October, 2016 Dear Member: Thank you for choosing us for your health and drug coverage. We at Blue Cross and Blue Shield of Louisiana and HMO Louisiana,
Prescription benefit updates Large group
Prescription benefit updates Large group Moda Health s prescription program is a pharmacy benefit that offers members a choice of safe effective medication treatments. The program also helps you save money
UPMC for You Pharmacy and Therapeutics Committee Meeting July 22, 2014 meeting
UPMC for You Pharmacy and Therapeutics Committee Meeting July 22, 2014 meeting 1. Call to order: The meeting was called to order at 7:05 a.m. 2. Review of the minutes: The minutes of the April meeting
Your Group s Drug Coverage Will Change as of Jan. 1, 2017 Notice of modification of drug coverage of a particular product
Your Group s Drug Coverage Will Change as of Jan. 1, 2017 Notice of modification of drug coverage of a particular product October, 2016 Dear Group Leader: Thank you for choosing us for your health and
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
Formulary Changes. One mission: you TABLE A. FORMULARY CHANGES 7/1/2018: Commercial 3-Tier Formulary. Commercial 4-Tier Formulary
One mission: you Changes July 1, 2018 Blue Cross of Idaho reviews its formularies (covered drug lists) periodically to allow members access to new drugs and to provide safe, cost effective options for
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
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
TRICARE Uniform Formulary. Pre-Authorization Requirements
TRICARE Uniform Formulary Pre-Authorization Requirements The Department of Defense (DoD) requires pre-authorization on select medications. These medications are on the DoD s pre-authorization list because
PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION
ABSTRAL fentanyl citrate oral tablet ACCU-CHEK TEST STRIPS blood glucose test strips Blood Glucose Test Strips ACTEMRA tocilizumab Monoclonal Antibody ACTHAR corticotropin Hormone ACTIMMUNE interferon
CENTENE PHARMACY & THERAPEUTICS COMMITTEE SECOND QUARTER 2017 AMBETTER GUIDELINE SUMMARY. Revision Summary or Description
CENTENE PHARMACY & THERAPEUTICS COMMITTEE SECOND QUARTER 2017 AMBETTER GUIDELINE SUMMARY Coverage Guideline Policy & Procedure HIM.PA.32 Long acting stimulants (Adderall XR, Dexedrine, Metadate CD, Ritalin
Oregon Health Plan prescription benefit updates
Oregon Health Plan prescription benefit updates EOCCO s prescription program is a pharmacy benefit that offers members a choice of safe and effective medication treatments. The program also helps you save
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
Pharmacy Clinical Prior Authorization Assistance Chart Effective February 2018
About Pharmacy Clinical Prior Authorizations Clinical prior authorizations (PA) are based on evidence-based clinical criteria and nationally recognized peer-reviewed information. The PA may apply to an
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
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
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
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
March 2017 Pharmacy & Therapeutics Committee Decisions
UCare s Pharmacy and Therapeutics Committee (P&T) is a group of physicians and pharmacists that meet throughout the year to make changes to the UCare formulary (approved drug list). These changes are reviewed
PA Category Name Code(s) Additional Notes ABA 0364T 0365T 0366T 0367T 0373T 0374T H G0396. Applied Behavioral Analysis stage 3*
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
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
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
MedPerform Medium Preferred Drug List (PDL)
What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs covered by your prescription drug plan. The PDL was created to promote
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
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
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
Select Inhaled Respiratory Agents
Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided
Quarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice Summary of change: The Pharmacy and Therapeutics Committee (P&T) reviewed and approved the formulary changes listed in the table below on March 29, 2016. What
University System of Georgia Prior Authorization, Step Therapy and Quantity Limit List (Updated 1/1/2016)
University System of Georgia, Step Therapy and Quantity Limit List (Updated 1/1/2016) (PA) Your doctor will need to obtain a prior authorization for the drugs listed below, before your prescription drug
OptumRx Focused Utilization Management Program
Utilization management updates - January 1, 2019 OptumRx Focused Utilization Management Program OptumRx focused step therapy with quantity limits programs If you have a prescription for any of the Step
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
MDwise Self-Administered Codes for Medical
The following codes are associated with medications that can be self-administered by the patient or a caregiver. As a result, MDwise will transfer coverage of these self-administered medications exclusively
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
FirstCarolinaCare Preferred Drug List (PDL)
FirstCarolinaCare Preferred Drug List (PDL) 2-tier Drug Plan Members What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs
2016 PRESCRIPTION DRUG LIST UPDATES
2016 PRESCRIPTION DRUG LIST UPDATES Evergreen Health 1 st Quarter Below are key updates to the four-tier EHB Prescription Formulary, effective January 1, 2016. Please consult the full formulary for more
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
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
Drug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases
Drug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases Line of Business: Medicaid P & T Approval Date: August 16, 2017 Effective Date: August 16, 2017 This policy
Quarterly pharmacy formulary change notice
Provider Bulletin June 24, 2016 Summary of change The Pharmacy and Therapeutics Committee reviewed and approved the formulary changes listed in the table below on March 29, 2016. What this means to you
TRELEGY ELLIPTA (fluticasone-umeclidinium-vilanterol) aerosol powder
TRELEGY ELLIPTA (fluticasone-umeclidinium-vilanterol) aerosol powder Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific
FirstCarolinaCare Preferred Drug List (PDL)
FirstCarolinaCare Preferred Drug List (PDL) 2-tier Drug Plan Member What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs
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
Step Therapy Criteria
ADCIRCA ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 ) ELIDEL 76-F ELIDEL Coverage will be provided if the member
Drug Formulary Update, October 2016 Commercial and State Programs
Drug Formulary Update, October 2016 Commercial and State Programs Updates to the HealthPartners Commercial and State Program Drug Formularies are listed below. Updates apply to all Commercial groups (PreferredRx,
PA Category Name Code(s) Additional Notes ABA. Applied Behavioral Analysis stage 3*
ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0373T H2020 96116 96112 96113 96121 96130 96131
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
New and Novel Medications for Respiratory Care
New and Novel Medications for Respiratory Care JASON MOORE, PHARM.D. BCCCP CLINICAL STAFF PHARMACIST STORMONT-VAIL HEALTH Objectives Quick overview of the newest FDA-approved repiratory-related medications
March 2018 P & T Updates
March 2018 P & T Updates Commercial Triple Tier 4th Tier Applicable Traditional Prior Auth AURYXIA 3 2 12 tablets per BAXDELA TABLETS 3 2 2 tablets per Depending on your specific benefits and in which
Prior Authorization Drug List
Prior Authorization Drug List This is a list of drugs that require Prior Authorization before coverage is provided. If you are prescribed a medication that requires Prior Authorization, your physician
FirstCarolinaCare Preferred Drug List (PDL)
3-tier Drug Plan Members What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs covered by your prescription drug plan. The
INJECTABLE MEDICINES. Resources, Links or Additional Information. J Code Brand Names Generic names Prior Authorization or Restrictions
J9190 5-FU fluorouracil None. J0401 ABILIFY MAINTENA aripiprazole i.v. J9264 ABRAXANE paclitaxel protein bound J3262 ACTEMRA IV tocilizumab Yes, through Navitus. Restricted to (in at least consultation
Pharmacy Updates Summary
All of the following changes were reviewed and approved by the SFHP Pharmacy & Therapeutics (P&T) Committee on 7/16/2014 Effective date: 8/15/2014 Therapeutic Classes reviewed: Hepatitis C Ophthalmic Prostaglandins
1. Phosphodiesterase Type 5 Enzyme Inhibitors: Sildenafil (Revatio), Tadalafil (Adcirca)
This policy has been developed through review of medical literature, consideration of medical necessity, generally accepted medical practice standards, and approved by the IEHP Pharmacy and Therapeutic
WYOMING MEDICAID ADDITIONAL THERAPEUTIC CLASSES WITH CLINICAL CRITERIA
ABSTRAL ACTIQ AFREZZA AKYNZEO alprazolam ODT amoxicillin 775mg AMPYRA AMTURNIDE ANTIHYPERTENSIVES LONG ACTING ANTIPLATELET TREATMENTS APTIOM ARCAPTA ATOPICLAIR AUSTEDO ADDITIONAL THERAPEUTIC CLASSES WITH
Quarterly Pharmacy Formulary Change Notice
MEDICAID PROVIDER BULLETIN February 26, 2015 Quarterly Pharmacy Formulary Change Notice Summary of Change: The formulary changes listed in the table below were reviewed and approved at our September 24,
MEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 07/05/18 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:
CINQAIR (reslizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
WYOMING MEDICAID ADDITIONAL THERAPEUTIC CLASSES WITH CLINICAL CRITERIA
ABSTRAL ACTIQ AFREZZA AKYNZEO alprazolam ODT amoxicillin 775mg AMPYRA AMTURNIDE ANTIHYPERTENSIVES LONG ACTING ANTIPLATELET TREATMENTS APTIOM ATOPICLAIR AUSTEDO ADDITIONAL THERAPEUTIC CLASSES WITH Requires
PULMONARY ARTERIAL HYPERTENSION AGENTS
Approvable Criteria: PULMONARY ARTERIAL HYPERTENSION AGENTS Brand Name Generic Name Length of Authorization Adcirca tadalafil Calendar Year Adempas riociguat Calendar Year Flolan epoprostenol sodium Calendar
UPMC for You Pharmacy and Therapeutics Committee Meeting October 22, 2013 meeting
UPMC for You Pharmacy and Therapeutics Committee Meeting October 22, 2013 meeting 1. Call to order: The meeting was called to order at 7:05 a.m. 2. Review of the minutes: The minutes of the July and September
ALOGLIPTIN STEP. Step Therapy Requirements Effective June 1, 2018
Step Therapy Requirements Effective June 1, 2018 ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone
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
Alameda Alliance for Health Pharmacy & Therapeutics (P&T) Committee Decisions
Alameda Alliance for Health FORMULARY UPDATE Effective: April 21, 2017. Drugs notated with an * have an undetermined implementation date Alameda Alliance for Health Pharmacy & Therapeutics (P&T) Committee
Regulatory Status FDA-approved indication: Orencia is a selective T cell costimulation modulator indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.18 Subject: Orencia Page: 1 of 8 Last Review Date: March 16, 2018 Orencia Description Orencia (abatacept)
DIABETES (1 of 5) Generic. Generic $0 $5 $5-10 $0 $0 $0. Generic $0 $5 $5-10. Generic. Generic $0 $5 $5-10 $0 $0 $0. Generic $0 $5 $5-10 $0 $0 $0
Metformin DIABETES (1 of 5) Glucophage Glucophage XR ER $7 (500mg) $7 (500mg) $5 $5 500mg, 750mg only 500mg, 750mg only Sulfonylurea/Combinations Amaryl Glucotrol glimepiride glipizide $5 $5 Glucotrol
Specialty Pipeline Update
CLINICAL SOLUTIONS Drug Insights > September 2015 Specialty Pipeline Update New Drug Information Xuriden (uridine triacetate): The Food and Drug Administration (FDA) approved Wellstat Therapeutics oral
Drug Class Monograph. Policy/Criteria:
Drug Class Monograph Class: Pulmonary Arterial Hypertension Agents Drugs: Adcirca (tadalafil), Adempas (riociguat), Flolan (epoprostenol), Letairis (ambrisentan), Opsumit (macitentan), Orenitram (treprostinil),
WYOMING MEDICAID ADDITIONAL THERAPEUTIC CLASSES WITH CLINICAL CRITERIA
ABSTRAL ACTIQ AFREZZA AKYNZEO alprazolam ODT amoxicillin 775mg AMPYRA AMTURNIDE ANTIHYPERTENSIVES LONG ACTING ANTIPLATELET TREATMENTS APTIOM ATOPICLAIR AUSTEDO ADDITIONAL THERAPEUTIC CLASSES WITH Requires
Mountain Health Trust/WV Health Bridge
Mountain Health Trust/WV Health Bridge Preferred Drug List (PDL) The West Virginia Preferred Drug List (PDL) is a list of medications recommended to BMS by the West Virginia Medicaid Pharmaceutical and
New Billing Guidelines for Home Infusion, Enteral and Parenteral Therapies Home Infusion Fee Schedule Effective July 1, 2009
STAT Bulletin PO Box 80 Buffalo, New York 14240-0080 May 12, 2009 Volume 15:Issue 18 To: All Home Health Care and Home Infusion Therapy Providers Contracts Effected: All Lines of Business New Billing Guidelines
Advantage by Peach State Health Plan 2012 Prior Authorization Listing. Approved 10/23/2011 Effective October 2011
Advantage by Peach State Health Plan 2012 Approved 10/23/2011 Effective October 2011 Note to members: The prior authorization requirements are listed to provide you with information to discuss treatment
Pulmonary Arterial Hypertension Drug Prior Authorization Protocol
Pulmonary Arterial Hypertension Drug Prior Authorization Protocol Line of Business: Medicaid P&T Approval Date: February 21, 2018 Effective Date: April 1, 2018 This policy has been developed through review
REVISED RESPIRATORY MEDICATION USE QUESTIONNAIRE
REVISED RESPIRATORY MEDICATION USE QUESTIONNAIRE ID NUMBER: 0a) Date of Collection / / 0b) Staff Code Instructions: This form should be completed during the participant s clinic visit. 1) Are you regularly
Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary Biologic Immunomodulators Prior Authorization with Quantity Limit (with a preferred option) OBJECTIVE The intent of the
ALOGLIPTIN STEP. Step Therapy Requirements Effective April 1, 2018
Step Therapy Requirements Effective April 1, 2018 ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone
UPMC for You Pharmacy and Therapeutics Committee Meeting July 27, 2010 meeting
1. Call to order: The meeting was called to order at 7:10 a.m. UPMC for You Pharmacy and Therapeutics Committee Meeting July 27, 2010 meeting 2. Review of the minutes: The minutes of the April 6, 2010
HEALTH SHARE/PROVIDENCE (OHP)
HEALTH SHARE/PROVIDENCE (OHP) STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered
Regulatory Status FDA-approved indications: Entyvio is an α4β7integrin receptor antagonist indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.12 Subject: Entyvio Page: 1 of 7 Last Review Date: September 20, 2018 Entyvio Description Entyvio
1 P a g e. Systemic Juvenile Idiopathic Arthritis (SJIA) (1.3) Patients 2 years of age and older with active systemic juvenile idiopathic arthritis.
LENGTH OF AUTHORIZATION: Initial: 3 months for Crohn s or Ulcerative Colitis; 1 year for all other indications. Renewal: 1 year dependent upon medical records supporting response to therapy and review
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