LIMITED DISTRIBUTION MEDICATIONS
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1 ACTEMRA IV (USSC can dispense 162 mg PFS) ACTHAR HP ACTIMMUNE ADAGEN ADCETRIS CVS Specialty ADEMPAS ADVATE ALDURAZYME ALECENSA ALIQOPA ALUNBRIG AMPYRA APOKYN ARALAST NP ARCALYST ARZERRA ATRYN Limited to Hospital Pharmacies AVEED BAVENCIO Biologics BELEODAQ BENDEKA BENLYSTA BERINERT BETHKIS BIVIGAM BLINCYTO BOSULIF BRINEURA Provider must obtain WDRx Updated on July 1,
2 CABOMETYX CALQUENCE CAMPATH Shipped directly from manufacturer; physician must call CAPRELSA CVS Specialty Biologics CARBAGLU Foundation Care IV Solutions & Maxor CAYSTON Pharmacies Mckesson Plasma and Biologics CEPROTIN CERDELGA CEREZYME CHENODAL CHOLBAM CINRYZE COMETRIQ CORIFACT COTELLIC CUVITRU Option Care BriovaRx CYRAMZA CRYSVITA WDRx Updated on July 1,
3 Orsini Pharmacy PANTHERx CYSTADANE AnovoRx CYSTAGON CYSTARAN DACOGEN DARAPRIM DARZALEX DOPELET Kroger Specialty PANTHERx DUOPA DYSPORT Provider must obtain EGRIFTA ELAPRASE ELELYSO (USSC may be able to order this medication) EMFLAZA US Bioservices EMPLICITI ENDARI US Bioservices EPOPROSTENOL SODIUM ERIVEDGE ERLEADA BriovaRx ERWINAZE BriovaRx Infusion Option Care WDRx Updated on July 1,
4 ESBRIET (USSC will fill for all mandatory USSC plans) EVOMELA EXJADE Orsini Pharmacy EXONDYS 51 Option Care-I only have their fax # EYLEA FABRAZYME Acaria Health BriovaRx Cigna Specialty FASENRA Humana Special Care Pharmacy (Located in Puerto Rico) FERRIPROX FIRAZYR FLOLAN GAMMAPLEX GATTEX GAZYVA GILOTRIF GLASSIA HAEGARDA Option Care Orsini Pharmacy HEMLIBRA BioPlus Specialty Pharmacy WDRx Updated on July 1,
5 HETLIOZ Advance Care Scripts Vanda-Manufacturer of product Call Pharmacy Solutions for Available Pharmacies HUMIRA PEDIATRIC CROHN'S (20 MG) ACS Pharmacy HYQVIA IBRANCE CuraScript ICLUSIG PASS program Biologics IDHIFA ILARIS ILUVIEN IMBRUVICA IMFINZI IMPLANON INCRELEX INGREZZA PANTHERx INLYTA INTRON A IRESSA ISTODAX WDRx Updated on July 1,
6 JAKAFI JETREA JUXTAPID JYNARQUE PANTHERx KADCYLA KALBITOR KALYDECO BriovaRx Kroger Specialty KANUMA KEVEYIS PANTHERx KINERET RxCrossroads KITABIS PAK KORLYM KUVAN KYLEENA KYMRIAH Available at select treatment centers KYMRIAH-hcp.com KYNAMRO KYPROLIS LARTRUVO LEMTRADA LENVIMA Biologics LETAIRIS LILETTA LONSURF WDRx Updated on July 1,
7 LUCENTIS LUMIZYME LUXTURNA CuraScript LYNPARZA Biologics MACUGEN MAKENA MATULANE MEPSEVII MIRENA MYALEPT MYLOTARG Biologics Specialty Pharmacy NAGLAZYME NATPARA NERLYNX NEXAVAR NEXPLANON NITYR NORTHERA NOVOEIGHT NPLATE NUCALA NUPLAZID OBIZUR OCALIVA ONCASPAR Provider must obtain OCREVUS ODOMZO WDRx Updated on July 1,
8 OFEV ONIVYDE US Bioservices OPSUMIT ORALAIR ORENITRAM ORFADIN ORKAMBI BriovaRx OZURDEX PALYNZIQ PERJETA PHOTREXA Provider must obtain com PLEGRIDY POMALYST Biologics, Inc PORTRAZZA PROBUPHINE IMPLANT KIT Braeburn Access Plan PROCYSBI PROLASTIN-C PROVENGE Available only through approved cancer treatment centers (go to website to enter zip code for to find a Provenge Treatment Center) QUTENZA WDRx Updated on July 1,
9 RADICAVA RAVICTI REBINYN REMODULIN RETISERT REVLIMID RIASTAP RUBRACA RUCONEST SABRIL SAMSCA SEROSTIM SILIQ SIRTURO Aetna Specialty SKYLA SOLESTA SOLIRIS SOMAVERT SPINRAZA STIVARGA STRENSIQ PANTHERx SUBLOCADE SUCRAID US Bioservices SUTENT SYLVANT SYMDEKO BriovaRx WDRx Updated on July 1,
10 SYNAGIS TAGRISSO TARCEVA TAVALISSE US Bioservices TECENTRIQ TECFIDERA TESTOPEL THALOMID THIOLA TOBI (Generic formulation is NOT LD and can be filled through USSC) TOBI PODHALER TRACLEER TRETTEN TRIPTODUR PANTHERx TROGARZO CuraScript SD Option Care TYSABRI TYVASO UPTRAVI VALCHLOR VELETRI VENTAVIS VERZENIO VIMIZIM VISTOGARD Biologics VISUDYNE WDRx Updated on July 1,
11 VIVAGLOBIN BioRx VONVENDI VPRIV XALKORI XENAZINE (Generic formulation is NOT LD and can be filled through USSC) XERMELO Biologics XIAFLEX US Bioservices XOFIGO XOLAIR (USSC will fill for all mandatory USSC plans) Provider must order through manufacturer ; XofigoAccessOnline.com XTANDI XURIDEN Cardinal Health Specialty Pharmacy XYREM Xyrem Central Pharmacy YESCARTA Cancer Centers Mayo Clinic YONDELIS ZALTRAP ZAVESCA ZEJULA US Bioservices ZELBORAF ZEMAIRA ZEVALIN Y-90 Cell Therapeutics, Inc - Limited to Radiopharmacies ZINBRYTA ZYDELIG WDRx Updated on July 1,
Aetna Better Health. Specialty Drug Program
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Specialty Drugs. The following is a list of medications that are considered to be specialty drugs. Specialty drugs
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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
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
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
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
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
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
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
Medical Prior Authorization List Rosen Employee Plans For prescription drug requirements, contact EHIM toll-free at
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acromegaly Drugs Covered Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Coverage Duration
acromegaly SIGNIFOR, SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML, SOMAVERT SUBCUTANEOUS RECON SOLN 15 MG, 20 MG, 25 MG, 30 MG All medically accepted indications not
ALPHA1-PROTEINASE INHIBITOR
Ally Rx D-SNP Current as of Nov. 1, 2018 ALPHA1-PROTEINASE INHIBITOR ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG GLASSIA PROLASTIN-C INTRAVENOUS RECON SOLN ZEMAIRA PA Documentation of diagnosis, lab results,
Prior Authorization Drug List
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Utilization Management
Abraxane Abraxane Actemra (IV) Inflammatory Conditions PA/Step Actemra (SQ) Inflammatory Conditions PA/Step Acthar HP Miscellaneous CNS Disorders PA Actimmune NF Adcetris Adcirca Adempas Advate (all forms)
2018 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
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
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2017 MDwise HIP Medical Services that Require Prior Authorization
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AAT DEFICIENCY. Products Affected Aralast Np INJ 1000MG, 500MG Glassia Prolastin-c INJ 1000MG Zemaira
AAT DEFICIENCY Aralast Np INJ 1000MG, 500MG Glassia Prolastin-c INJ 1000MG Zemaira PA Details Other Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema, weight, A1-PI
AAT DEFICIENCY. Products Affected Aralast Np INJ 1000MG, 500MG Glassia. Prior Authorization Criteria Health Alliance Plan_2016_HAPFB Updated: 10/2016
Prior Authorization Health Alliance Plan_2016_HAPFB Updated: 10/2016 AAT DEFICIENCY Products Affected Aralast Np INJ 1000MG, 500MG Glassia Prolastin-c Zemaira Covered Uses All FDA-approved indications
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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
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,
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/
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
ACNE AGENTS_NVT Chinese Community Health Plan Senior Select Program (HMO SNP)
ACNE AGENTS_NVT adapalene topical cream adapalene topical gel Avita tretinoin tretinoin microspheres topical gel Age Other 1 ADAGEN_NVT Adagen Age Other 2 ADCIRCA_NVT 2017 Adcirca Diagnosis confirmed by
2017 Prior Authorization (PA) Criteria
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Ally Rx D-SNP Current as of r 1, 2017
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CENTENE PHARMACY THERAPEUTICS COMMITTEE THIRD QUARTER 2017 CLINICAL POLICY (BIOPHARM) SUMMARY TABLE Coverage Guideline/Policy &
Coverage Guideline/Policy & Status Revision Summary Description Procedure CP.PHAR.14 Hydroxyprogesterone Caproate (Makena/compound) 4/17 No criteria changes. Added compound to the title. Background section
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
STAT Bulletin. Drug Therapy Guideline Updates. To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business
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8-MOP. Products Affected
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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
Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema, weight, A1-PI phenotype, A1-PI baseline level
AAT DEFICIENCY Aralast NP intravenous recon soln 1,000 mg Glassia Prolastin-C intravenous recon soln Zemaira Other Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema,
Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema, weight, A1-PI phenotype, A1-PI baseline level
AAT DEFICIENCY Aralast NP intravenous recon soln 1,000 Prolastin-C intravenous recon soln mg Zemaira Glassia Other Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema,
2019 Prior Authorization
2019 Prior Authorization FID 19148 Prior Authorization ACTEMRA Products Affected Actemra INJ 162MG/0.9ML PA Details Age Other 1 ACTIMMUNE Products Affected Actimmune PA Details Age Other 2 ADEMPAS Products
ACITRETIN. Products Affected
ACITRETIN acitretin Other For prophylaxis of skin cancer in patients with previously treated skin cancers who have undergone an organ transplantation the request will be approved. For psoriasis: the patient
Covered Uses All medically accepted indications not otherwise excluded from Part D.
AAT DEFICIENCY Aralast NP intravenous recon soln 1,000 mg Glassia Prolastin-C intravenous recon soln Zemaira PA Details Age Other Diagnosis of severe congenital A1-PI deficiency who have clinically evident
BCBS AZ ADV PLUS * CLASSIC * PREMIER For use with members associated with the BHN Network Prior Authorization List 2015
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ADCIRCA. Products Affected Adcirca. Prior Authorization Criteria 2017 MMP Effective Date: 11/01/2017 Approval Date: 11/01/2017
Prior Authorization 2017 MMP Effective Date: 11/01/2017 Approval Date: 11/01/2017 ADCIRCA Products Affected Adcirca PA Details All FDA-approved indications not otherwise Other Patients taking nitrates
2019 Prior Authorization
2019 Prior Authorization FID 19148 Prior Authorization ACTEMRA Products Affected Actemra INJ 162MG/0.9ML Actemra Actpen Other 1 ACTIMMUNE Products Affected Actimmune Other 2 ADEMPAS Products Affected Adempas
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
ACTHAR GEL. Products Affected H.p. Acthar Prior Authorization Criteria Effective: 11/01/2017 Updated 11/2017
2017 Prior Authorization Effective: 11/01/2017 Updated 11/2017 ACTHAR GEL Products Affected H.p. Acthar Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Covered
ACITRETIN. Products Affected
ACITRETIN acitretin Other For prophylaxis of skin cancer in patients with previously treated skin cancers who have undergone an organ transplantation the request will be approved. For psoriasis: the patient
ACNE AGENTS_NVT Chinese Community Health Plan Senior Select Program (HMO SNP)
ACNE AGENTS_NVT adapalene 0.3% gel pump adapalene topical cream adapalene topical gel avita tretinoin tretinoin microspheres topical gel Age Other 1 ADAGEN_NVT ADAGEN Age Other 2 ADCIRCA_NVT 2017 ADCIRCA
ACTHAR GEL. Products Affected H.p. Acthar Prior Authorization Criteria Effective: 04/01/2017 Updated 04/2017
2017 Prior Authorization Effective: 04/01/2017 Updated 04/2017 ACTHAR GEL Products Affected H.p. Acthar Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Covered
ACTHAR GEL. Products Affected H.p. Acthar Prior Authorization Criteria Effective: 06/01/2017 Updated 06/2017
2017 Prior Authorization Effective: 06/01/2017 Updated 06/2017 ACTHAR GEL Products Affected H.p. Acthar Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Covered
ACTHAR GEL. Products Affected H.p. Acthar Prior Authorization Criteria Effective: 03/01/2017 Updated 03/2017
2017 Prior Authorization Effective: 03/01/2017 Updated 03/2017 ACTHAR GEL Products Affected H.p. Acthar Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Covered
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2016 Prior Authorization Effective: 11/01/2016 Updated 11/2016 ACTIMMUNE Products Affected Actimmune PA Details Age Other 1 ADAGEN Products Affected Adagen PA Details Age Other Contraindicated in bone
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SelectHealth Advantage 2018 Prior Authorization Criteria
ACROMEGALY SOMATULINE DEPOT, SOMAVERT * Acromegaly 1. Pt has had surgical resection of the pituitary gland OR is not a candidate for surgery/radiation therapy, 2. Patient has tried at least ONE of the
ABRAXANE. Products Affected. Prior Authorization Criteria 2019 Secure-Extra PDP 6 Tier Last Updated: 12/2018. Abraxane
Prior Authorization 2019 Secure-Extra PDP 6 Tier Last Updated: 12/2018 ABRAXANE Abraxane PA Details Age Other B vs D coverage determination 1 ACITRETIN Acitretin PA Details Documentation of diagnosis.
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
2019 INJECTABLE DRUG PRIOR AUTHORIZATION CRITERIA
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ACTIMMUNE. Products Affected Actimmune Prior Authorization Criteria Effective: 06/01/2016 Updated 06/2016
2016 Prior Authorization Effective: 06/01/2016 Updated 06/2016 ACTIMMUNE Products Affected Actimmune Other 1 ADAGEN Products Affected Adagen Other Contraindicated in bone marrow transplantation and in
ACTHAR GEL. Products Affected H.p. Acthar Prior Authorization Criteria Effective: 01/01/2017 Updated 12/2016
2017 Prior Authorization Effective: 01/01/2017 Updated 12/2016 ACTHAR GEL Products Affected H.p. Acthar PA Details Covered Uses All medically accepted indications not otherwise excluded from Part D. Age
Somavert ALL FDA-APPROVED INDICATIONS NOT OTHERWISE EXCLUDED FROM PART D.
ACROMEGALY THERAPY Somatuline Depot subcutaneous syringe 120 mg/0.5 ml, 60 mg/0.2 ml, 90 mg/0.3 ml Somavert Age Other ALL FDA-APPROVED INDICATIONS NOT OTHERWISE PATIENT PROGRESS NOTES, DOCUMENTATION OF
ACTHAR GEL. Products Affected H.p. Acthar Prior Authorization Criteria Effective: 01/01/2017 Updated: 11/2016
2017 Prior Authorization Effective: 01/01/2017 Updated: 11/2016 ACTHAR GEL Products Affected H.p. Acthar Covered Uses All medically accepted indications not otherwise excluded from Part D. Other Covered
ACTHAR GEL. Products Affected H.p. Acthar Prior Authorization Criteria Effective: 07/01/2017 Updated 07/2017
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ACROMEGALY Somatuline Depot, Somavert 1. Pt has had surgical resection of the pituitary gland OR is not a candidate for surgery/radiation therapy, 2. Patient has tried at least ONE of the following: a.
ACTEMRA. Products Affected ACTEMRA. Covered Uses All FDA-approved indications not otherwise excluded from Part D. N/A. Exclusion Criteria
ACTEMRA ACTEMRA New starts: Patient has a diagnosis of moderate to severe rheumatoid arthritis (IV or subcutaneous dosage form) and has had a failure, contraindication, or intolerance to two of the following:
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Prior Authorization 2019 Secure-Essential PDP 5 Tier Last Updated: 10/01/2018 ABRAXANE Abraxane PA Details Age Other B vs D coverage determination 1 ACITRETIN Acitretin PA Details Documentation of diagnosis.
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
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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
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ANDROID. Products Affected ANDROID. Prior Authorization Criteria HEALTH CHOICE EXCHANGE Effective Date: 12/01/2016
Prior Authorization HEALTH CHOICE EXCHANGE Effective Date: 12/01/2016 ANDROID ANDROID Supporting statement of diagnosis from the physician. Other 1 BLINCYTO BLINCYTO Known hypersensitivity to blinatumomab
ACTEMRA SC. Products Affected
Advantra (HMO), Advantra (PPO), Advantra Advantage (HMO), Advantra Cares (HMO SNP), Advantra Choice (HMO), Advantra Freedom (PPO), Advantra Freedom Plus (PPO), Advantra Gold (PPO), Advantra Option 1 (HMO-POS),
1199SEIU Benefit Funds
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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
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