SPECIALTY PHARMACY Master Clinical Drug List
|
|
|
- Thomasina Merritt
- 6 years ago
- Views:
Transcription
1 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 NO Adcetris J9042 Provider ONCOLOGY PA - Misc YES Aldurazyme J1931 Provider ENZYME DISORDERS INV/ COS NO Alferon N J9215 Provider INTERFERONS None NO Alimta J9305 Provider ONCOLOGY PA - all YES Amevive J0215 Provider PSORIASIS PA - all YES Aralast NP J0256 Provider PANICINAR EMPHYSEMA INV/ COS NO J0881 J0882 Self/Prov Pharm/Med BLOOD MODIFIER - ESF PA - all YES Aranesp Arranon J9261 Provider ONCOLOGY None NO Arzerra J9302 Provider ONCOLOGY PA - all YES Avastin J9035 Provider ONCOLOGY PA - all YES Benlysta J0490 Provider LUPUS PA - all YES Berinert J0597 Self/Prov Pharm/Med C1 INHIBITOR PA - all YES Botox J0585 Provider MUSCLE SPASM INV/ COS NO Campath J9010 Provider ONCOLOGY INV/ COS NO Camptosar J9206 Provider ONCOLOGY None NO Cerezyme J7186 Provider GAUCHER'S DISEASE INV/ COS NO Cimzia Vials J0718 Provider CROHN'S DISEASE PA - all YES Cinryze J0598 Self/Prov Pharm/Med C1 Inhibitor PA - all YES Cytovene IV J1570 Provider Anti-Viral None NO Dacogen J0894 Provider ONCOLOGY None NO Dysport J0586 Provider MUSCLE SPASM INV/ COS NO Elaprase J1743 Provider ENZYME DISORDERS None NO Elelyso J8499 Provider GAUCHER'S DISEASE PA-Misc YES Eligard IM J9217 Self/Prov Pharm/Med GYN/PROSTATE ONC None NO Eloxatin J9263 Provider ONCOLOGY None NO Epogen J0885 J0886 Q4081 Self/Prov Pharm/Med BLOOD MODIFIER - ESF PA - all YES March 25, 2013 Page 1 of 6
2 epoprostenol (Flolan, Veletri) J1325 Self/Prov Pharm/Med PULMONARY HTN PA - all YES epoprostenol (Flolan) diluent S0155 Self/Prov Pharm/Med PULMONARY HTN PA - all YES Erbitux J9055 Provider ONCOLOGY PA - all YES Erwinaze J9019 Provider ONCOLOGY PA - all YES Euflexxa J7323 Provider ARTHRITIS INV/ COS NO J0178 Q4026 Provider MACULAR DEGENERATION None NO Eylea Fabrazyme J0180 Provider ENZYME DISORDERS INV/ COS NO Factor VIIa - NovoSeven RT J7189 Self/Prov Pharm/Med ANTI-HEMOPHILIC FACTOR INV/ COS NO Firmagon J9155 Provider ONCOLOGY None NO Folotyn J9307 Provider ONCOLOGY PA - all YES Gammagard Liquid J1569 Self/Prov Pharm/Med IMMUNE GLOBULINS INV/ COS NO Gamunex C Self/Prov Pharm/Med IMMUNE GLOBULINS INV/ COS NO Gemzar J9201 Provider ONCOLOGY None NO Halaven J9179 Provider ONCOLOGY PA - all YES Herceptin J9355 Provider ONCOLOGY None NO Hyalgan J7321 Provider ARTHRITIS INV/ COS NO Hycamtin injection J9351 Self/Prov Pharm/Med ONCOLOGY None NO Hylenex (hyaluronate) J3473 Provider ARTHRITIS INV/ COS NO Ilaris J0638 Provider MONOCLONAL ANTIBODY None NO Immune Globulin - CytoGam Immune Globulin - IM J Provider Immune Globulins None NO J1460 J Provider Immune Globulins INV/ COS NO March 25, 2013 Page 2 of 6
3 Immune Globulin - IV SPECIALTY PHARMACY J1459 J1599 J1561 J1566 J1568 J1569 J1572 J Provider Immune Globulins INV/ COS NO J2788 J2790 J2791 J Provider Immune Globulins INV/ COS NO Immune Globulin - RhoD Intron A IV J9214 Provider INTERFERONS None NO Istodax J9315 Provider ONCOLOGY PA - all YES Ixempra J9207 Provider ONCOLOGY None NO Jetrea J3590 Provider OPTHAMOLOGY PA-Misc YES Jevtana J9043 Provider ONCOLOGY PA - all YES Kadcyla J3490 Provider ONCOLOGY PA-Misc YES Krystexxa J2507 Provider GOUT PA - all YES Kyprolis J9999 Provider ONCOLOGY PA-Misc YES Leukine J2820 Provider BLOOD MODIFIER - CSF None NO Lucentis J2778 Provider OPTHAMOLOGY None NO Lumizyme J0221 Provider POMPE'S DISEASE INV/ COS NO J1950 Lupron Depot IM J9217 Provider GYN/PROSTATE ONC INV/ COS NO Macugen J2503 Provider OPHTHAMOLOGY None NO J1725 Makena J3490 Provider HORMONE THERAPY None NO Marqibo J9999 Provider ONCOLOGY PA-Misc YES March 25, 2013 Page 3 of 6
4 Mirena J7302 Provider CONTRACEPTIVES None NO Mozobil J2562 Self/Prov Pharm/Med HEMATOPOIETIC None NO Myobloc J0587 Provider MUSCLE SPASM INV/ COS NO Myozyme J0220 Provider POMPE'S DISEASE INV/ COS NO Naglazyme J1458 Provider ENZYME DISORDERS INV/ COS NO Neulasta J2505 Self/Prov Pharm/Med BLOOD MODIFIER - CSF None NO Neumega J2355 Self/Prov Pharm/Med BLOOD MODIFIER - PSF None NO Neupogen J1440 J1441 Self/Prov Pharm/Med BLOOD MODIFIER - CSF None NO Nexplanon J7307 Provider CONTRACEPTIVES None NO Novantrone (mitoxantrone) J9293 Provider MULTIPLE SCLEROSIS None NO Nplate J2796 Provider THROBOPOIETIN RECEPTOR AGONIST None NO J0890 Q2047 Provider RENAL FAILURE PA - all YES Omontys Orencia J0129 Provider ARTHRITIS PA - all YES Orthovisc J7324 Provider ARTHRITIS INV/ COS NO Ozurdex J7312 Provider MACULAR EDEMA None NO Perjeta J9999 Provider ONCOLOGY PA-Misc YES Prialt J2278 Provider ANALGESIC None NO J0885 J0886 Q4081 Self/Prov Pharm/Med BLOOD MODIFIER - ESF PA - all YES Procrit Proleukin J9015 Provider ONCOLOGY None NO Prolia J0897 Provider OSTEOPOROSIS PA - all YES Provenge (limited) Q2043 Provider ONCOLOGY PA - all YES Qutenza J7335 Provider NEUROPATHIC PAIN None NO Reclast J3488 Provider OSTEOPOROSIS None NO Remicade J1745 Provider ARTHRITIS PA - all YES Remodulin (Curascript, Accredo, J3285 Caremark) Self/Prov Pharm/Med PULMONARY HTN PA - all YES Retisert J7311 Provider OPTHAMOLOGY None NO March 25, 2013 Page 4 of 6
5 J7178 J1680 BLEEDING-FIBRINOGEN RiaSTAP Q2045 Provider DEFICIENCY None NO Risperdal Consta J2794 Provider SCHIZOPHRENIA None NO Rituxan J9310 Provider ONCOLOGY PA - all YES Sandostatin LAR J2353 Provider ONCOLOGY None NO Skyla J3490 Provider CONTRACEPTIVES None NO Soliris J1300 Provider BLOOD MODIFIER PA - all YES Somatuline J1930 Provider ENDOCRINE/METABOLIC None NO Stelara J3357 Provider PSORIASIS PA - all YES Supartz J7321 Provider ARTHRITIS INV/ COS NO Supprelin J9226 Provider ENDOCRINE/METABOLIC None NO Synagis Provider RSV PA - all YES Synribo J9999 Provider ONCOLOGY PA-Misc YES Synvisc J7325 Provider ARTHRITIS INV/ COS NO Synvisc One J7325 Provider ARTHRITIS INV/ COS NO Temodar Inj J9328 Provider CHEMOTHERAPY PO PA - all YES Thyrogen J3240 Provider ONCOLOGY None NO Torisel J9330 Provider ONCOLOGY None NO Treanda J9033 Provider ONCOLOGY PA - all YES Trelstar J3315 Provider GYN/PROSTATE ONC None NO Trisenox J9017 Provider ONCOLOGY None NO Tysabri J2323 Provider MULTIPLE SCLEROSIS PA - all YES Vantas J9225 Provider GYN/PROSTATE ONC None NO Vectibix J9303 Provider ONCOLOGY PA - all YES Velcade J9041 Provider ONCOLOGY PA - all YES Veletri J1325 Self/Prov Pharm/Med PULMONARY HTN PA - all YES Vidaza J9025 Provider ONCOLOGY INV/ COS NO Vistide J0740 Provider ONCOLOGY None NO Visudyne J3396 Provider PHOTODYNAMIC THERAPY INV/ COS NO Vivitrol J2315 Provider OPIOID ANTAGONIST None NO Vpriv J3385 Provider GAUCHER'S DISEASE INV/ COS NO Xeomin J0588 Provider MUSCLE SPASM INV/ COS NO March 25, 2013 Page 5 of 6
6 Xgeva J0897 Provider OSTEOPOROSIS PA - all YES DUPUYTREN'S CONTRACTURE INV/ COS NO Xiaflex J0775 Provider Xolair J2357 Provider ASTHMA PA - all YES Yervoy J9228 Provider ONCOLOGY PA - all YES Zaltrap J9999 Provider ONCOLOGY PA-Misc YES Zemaira ( Accredo & Coram) J0256 Provider PANICINAR EMPHYSEMA INV/ COS NO Zoladex J9202 Provider GYN/PROSTATE ONC None NO Zometa J3487 Provider ONCOLOGY None NO Drugs & Codes in red are the newest changes to the specialty list Legend None - Indicates policies are implemented but do not have configuration INV/COS if P/D - Claim will deny investigational or cosmetic if a procedure/diagnosis conflict exists PA-All - Requires a orization, may be for all providers or only certain types of providers PA-Misc - Requires a orization for miscellaneous code. This PA will be re-evaluated once a specific Procedure becomes available. Miscellaneous Codes: J3490 Unclassified Drugs J3590 Unclassified Biologics J7199 Hemophilia Clotting Factor, Not Otherwise Classified J7699 NOC Drugs, Inhalation Solution istered thru DME J8499 Oral Drug, Non Chemo J8999 Oral Drug, Chemo J9999 Not Otherwise Classified, Antineoplastic Drug March 25, 2013 Page 6 of 6
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,
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
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
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 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
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
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
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
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
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
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
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
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
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
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)
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
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
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
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/
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
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
MDwise HIP Prior Authorization and Drug List
MDwise HIP Prior Authorization and Drug List Services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services With the exception of ER, Ambulance, Urgent Care Center
2014 AlohaCare Advantage (HMO) and AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Prior Authorization Requirements
2014 AlohaCare Advantage (HMO) and AlohaCare Advantage Plus Formulary (HMO SNP) with Prior Authorization Requirements You may need prior authorization for certain drugs that are on the formulary or drugs
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
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
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
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
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 Coding All Out of Network services Facility to facility ambulance transport
SUPPLEMENTARY INFORMATION
Table S1 Therapeutic biologic product approvals, classes and innovation categories: 16 24 Approval year Trade name Active Ingredient(s) Drug class Innovation category Approval date 16 Intron-A Interferon
MDwise Hoosier Care Connect Medical Services that Require Prior Authorization
MDwise Hoosier Care Connect Medical Services that Require Prior Authorization Certain Indiana Health Coverage Programs (IHCP) services require prior authorization (PA) for members enrolled in the Hoosier
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
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
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
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
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
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
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
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
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
Premera Blue Cross Medicare Advantage Plans Medical Policy Updates
Premera Blue Cross Medicare Advantage Plans Medical Policy Updates Medical Policy and Criteria Premera Blue Cross Medicare Advantage reviews all medical policies and criteria annually. The following updates
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,
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
Prior Auth Form Page Number
Prior Auth Form Page Number B vs D Oral Anti-Cancer 3 B vs D Oral Anti-Emetic 4 B vs D Oral Anti-rejection/Transplant 5 J0129 Abatacept, inj Orencia 6 J0180 Agalsidase beta injection Fabrazyme 7 J0205
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
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
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
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
Criteria for Medical Benefit Drugs Requiring Clinical Review
Note: Authorization of a service based on the clinical information provided does not guarantee payment. The claim must be properly submitted and the member must be eligible on the date of service for the
Criteria for Medical Benefit Drugs Requiring Clinical Review
Note: Authorization of a service based on the clinical information provided does not guarantee payment. The claim must be properly submitted and the member must be eligible on the date of service for the
State: Virginia. Clinical Guidelines Applicable for Virginia
State: Virginia Clinical Guidelines Applicable for Virginia NOTE: Any Clinical Guideline not included in this standard adopted list that is needed to complete a ASO group-specific review requirement will
Drugs and Biologicals Payment Policy
Drugs and Biologicals Payment Applies to the following CarePartners of Connecticut products: CareAdvantage Premier CareAdvantage Prime CareAdvantage Preferred The following payment policy applies to CarePartners
Medical Injectable Prior Authorization Criteria Last updated: 07/10/2014
Medical Injectable Prior Authorization Criteria Last updated: 07/10/2014 A Abatacept... 6 Abobotublinumtoxin A... 8 Abraxane... 135 Actemra... 168 Acthar... 51 Actimmune... 108 Adagen... 141 Adalimumab...
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
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
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
Special Notes Implementation Date by CO. State CG number CG title CG Category Original Current Version
Anthem Blue Cross and Blue Shield Approved and adopted corporate Clinical Utilization Management (UM) Guidelines COLORADO Updated August 17, 2018 NOTE: Any Clinical Guideline not included in this standard
Clinical Utilization Management Guidelines
Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines below, which are applicable to Anthem HealthKeepers Plus members, were adopted by the medical operations committee
Clinical Utilization Management Guidelines
Clinical Utilization Management Guidelines Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program The Clinical Utilization Management (UM) Guidelines below were adopted by the medical operations
New Medicare Advantage HMO and PPO policy notifications posted October 1, 2014
New Medicare Advantage HMO and PPO policy notifications posted October 1, 2014 Below is a listing of the policy notifications available on our website for Medicare Advantage HMO and PPO policies that go
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
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
Clinical UM Guidelines for Indiana, Kentucky, Missouri, Ohio and Wisconsin
10/4/2018 State: State CG number CG title CG Category Date implemented CG-ADMIN-02 Clinically Equivalent Cost Effective Services Targeted Immune Modulators Admin 7/1/2018 CG-ANC-04 Ambulance services Air
Prior treatment with non-biologic Disease- Modifying Antirheumatic. Not to be used in combination with another biologic DMARD
Abatacept (Orencia) 1, 2, 7, 11, 13, 14, 18, 24, 31, 44, 48, 49, 51, 53, 55, 57 J0129 Alpha 1 - Proteinase inhibitor (Prolastin-C) 5, 6, 10, 12, 40 Medically Necessary (if all the following criteria apply):
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
Medical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and
Medical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and
The Oncology Drug Marketplace: Trends in Discounting and Site of Care
The Oncology Drug Marketplace: Trends in Discounting and Site of Care DECEMBER 2017 PREPARED BY: Aaron Vandervelde avandervelde@thinkbrg.com 202.480.2661 Eleanor Blalock eblalock@thinkbrg.com 202.480.2772
Re: Integrated Oncology Management Program with evicore healthcare: Update on codes requiring precertification
Ajani Nimmagadda, MD Senior Medical Director , , Re: Integrated Oncology Management Program with evicore
Provider Newsletter. Table of Contents. Reimbursement Policy: Improve member medication regimen. Page 2
Provider Newsletter https://providers.amerigroup.com/ April 2018 Table of Contents Improve member medication regimen Page 2 Medical Policies and Clinical Utilization Management Guidelines updated Page
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
Chemotherapy 101 for Radiation Oncology Workers
Chemotherapy 101 for Radiation Oncology Workers James Sinclair, M.D. CCARE/Medical Director Scripps Cancer Center March 9, 2013 Category 1) Alkylating agents Alkylating agents directly damage DNA to prevent
Clinical Utilization Management Guidelines
Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines below were adopted by the medical
Clinical Utilization Management Guidelines update
Medicaid Managed Care The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division.
Clinical Utilization Management Guidelines
https://providers.amerigroup.com Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical
Clinical Utilization Management Guidelines
https://providers.amerigroup.com Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical
Clinical Utilization Management Guidelines
https://providers.amerigroup.com Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical
Medical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and
Clinical Utilization Management Guidelines
Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations
Clinical Utilization Management Guidelines
The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division. To see the full list
With prescription therapies at the center of more Americans health care, these medications have become invaluable. costs. Despite the 1.6% 1.2% 0.
Rx spending up, but challenges remain By Richard Monks No products play a greater role in setting drug stores and community pharmacies apart from other retailers than prescription drugs. One % prescription
Funding Position of CCG Commissioned High Cost Drugs within Lancashire Health Economy Updated February 2016
Funding Position of CCG Commissioned High Cost Drugs within Lancashire Health Economy Updated February 2016 Drugs can only be recharged to CCGs if used in line with local or national policies as outlined
Medical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies adopted for Anthem HealthKeepers Plus. The full list of Medical
HCPCS Code/ generic (Brand) Name J7506. J8520 capecitabine (Xeloda) 1. J8521 capecitabine. J8530 cyclophosphamide. (Cytoxan) 1
drug and administration compendia Current Price () J7506 Prednisone, oral, per 5 mg 12/1/07 $0.07 $0.19 N/A prednisone 2 J8520 capecitabine (Xeloda) 1 Capecitabine, oral, 150 mg 8/1/07 $5.79 $4.59 N/A
Medical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and
Medical Policies and Clinical Utilization Management Outpatient Guidelines
https://providers.amerigroup.com Medical Policies and Clinical Utilization Management Outpatient Guidelines Amerigroup Community Care began using Anthem s nationally recognized, evidence-based Medical
Medical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and
Clinical Utilization Management Guidelines
https://providers.amerigroup.com Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical
Clinical Utilization Management Guidelines
The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division. To see the full list
Medical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies adopted for. The full list of Medical Policies and Clinical Utilization
Medical Policies and Clinical Utilization Management Guidelines
Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies
Clinical Utilization Management Guidelines
Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines highlighted below were adopted by the medical operations committee for on January 3, 2019. For markets with
Medical Policies and Clinical Utilization Management Guidelines
Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical
Medical Policies and Clinical Utilization Management Guidelines
Medicaid Managed Care Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list
Tufts Health Public Plans Claim Edits
Tufts Health Public Plans Claim Edits The following claim edits apply to contracting facilities and providers who render services for Tufts Health Public Plans products. 1 Payment methodologies are generally
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