Pharmacy Services Request Types
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- Emmeline Evans
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1 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 provider unless the member is currently inpatient. *Please note: most of the pharmacy Request Profiles display this alert in a pop-up box as soon as the provider chooses them in CareAffiliate: 1.**CRITICAL MESSAGE**: Use to request approval for medication that will be administered by a healthcare provider and billed as a medical claim. 2.**ATTENTION: YOU MUST ATTACH A SCANNED OR AN ELECTRONIC COPY OF THE MEDICAL RECORD TO THIS REQUEST** If you are using paper records and do not have a scanned copy, please STOP and go to to fill out a form and FAX to along with a copy of medical records. Please note this may delay processing. DRUG-Bone Health- DRUG-Bone Health-OFFICE admin DRUG-Erbitux or Vectibix- **For use to request authorization for osteoporosis and antiresorptive drugs when administered at an outpatient J0897 Prolia (denosumab) J0897 Xgeva (denosumab) **For use to request authorization for osteoporosis and antiresorptive (ex. Prolia/Xgeva) drugs when administered inoffice (i.e. provider's office is supplying the drug as a "buy J0897 Prolia (denosumab) and bill"; drug will NOT be billed to the patient's J0897 Xgeva (denosumab) **For use to request authorization for Erbitux or Vectibix, when administered at an outpatient infusion center (i.e. patient will go to an infusion center to receive the drug; drug will NOT be billed to the patient's J9055 Erbitux (cetuximab) J9303 Vectibix (panitumumab) used to treat colon & rectal cancer; other cancers you will get all drug request types if you by drug* *bone* *bone* *erbitux* *vectibix* DRUG-Erbitux or Vectibix- DRUG-General Request- HOME INFUSION admin **For use to request authorization for Erbitux or Vectibix, J9055 Erbitux (cetuximab) J9303 Vectibix (panitumumab) when administered in-office (i.e. provider's office is supplying the drug as a "buy and bill"; drug will NOT be billed used to treat colon & rectal cancer; other to the patient's cancers **DO NOT USE TO REQUEST: IVIG, Biologics to treat RA, CD/UC, Lupus, etc., Prolia, Xolair, Oncologics/Chemotherapy or any other drug/disease state that has a SPECIFIC Request Profile. Please review available choices under the name "DRUG-..."** This is for general Home Infusion requests where no other Request Type would apply Fabrazyme (agalsidase beta) for Fabry Disease *erbitux* *vectibix* *general* 1 last updated 9/11/15
2 DRUG-General Request- **DO NOT USE TO REQUEST: IVIG, Biologics to treat RA, CD/UC, Lupus, etc., Prolia, Xolair, Oncologics/Chemotherapy or any other drug/disease state that has a SPECIFIC Request Profile. Please review available choices under the name "DRUG-..."** This is for general Infusion Center requests where no other Request Type would apply Fabrazyme (agalsidase beta) for Fabry Disease *general* DRUG-General Request- **DO NOT USE TO REQUEST: IVIG, Biologics to treat RA, CD/UC, Lupus, etc., Prolia, Xolair, Oncologics/Chemotherapy or any other drug/disease state that has a SPECIFIC Request Profile. Please review available choices under the name "DRUG-..."** This is for general Office requests where no other Request Type would apply Fabrazyme (agalsidase beta) for Fabry Disease Testosterone implant (pellets) or injection *general* DRUG-GI Inflam Conditions- GI inflam conditions (CD, UC) when admin at an outpatient (CD=Crohn's Disease, UC=Ulcerative Colitis) *inflam* DRUG-GI Inflam Conditions- GI inflammatory conditions (ex. CD, UC), when administered inoffice (i.e. provider's office is supplying the drug as a "buy and bill"; drug will NOT be billed to the patient's (CD=Crohn's Disease, UC=Ulcerative Colitis) *inflam* DRUG-Hematologic conditions-infusion **Use: authorization for drugs to treat chronic hematologic conditions (ex. ITP) when administered at an outpatient (ITP=Idiopathic thrombocytopenic purpura; ahus=atypical Hemolytic-uremic syndrome) J2796 Nplate (romiplostim) J1300 Soliris (eculizumab) *hematologic* DRUG-Hematologic conditions- (ITP=Idiopathic thrombocytopenic purpura; chronic ahus=atypical Hemolytic-uremic syndrome) hematologic conditions (ex. ITP, ahus) when administered inoffice (i.e. provider's office is supplying the drug as a "buy and bill"; drug will NOT be billed to the patient's J2796 Nplate (romiplostim) J1300 Soliris (eculizumab) *hematologic* 2 last updated 9/11/15
3 DRUG-Hereditary Angioedema-INFUSION DRUG-Hereditary Angioedema- DRUG-IVIG-HOME admin hereditary angioedema when administered at an outpatient hereditary angioedema when administered in-office (i.e. provider's office is supplying the drug as a "buy and bill"; drug will NOT be billed to the patient's **For use to request authorization for IVIG (ex. Gammagard, Hizentra) when administered in-home (i.e. drug will be billed to home infusion J1744 Firazyr (icatibant) J1290 Kalbitor (ecallantide) J0598 Cinryze (complement C1 esterase C9445 Ruconest (conestat alfa) J0597 Berinert (complement C1 esterase J1744 Firazyr (icatibant) J1290 Kalbitor (ecallantide) J0598 Cinryze (complement C1 esterase C9445 Ruconest (conestat alfa) J0597 Berinert (complement C1 esterase J1569 Gammagard (immune globulin-- intravenous) J1559 Hizentra (immune globulin-- subcutaneous) *angioedema* *angioedema* *ivig* DRUG-IVIG-INFUSION **For use to request authorization for IVIG (ex. Gammagard, J1569 Gammagard (immune globulin-- Hizentra) when administered at an outpatient infusion intravenous) center (i.e. patient will go to an infusion center to receive the J1559 Hizentra (immune globulin-- drug; drug will NOT be billed to the patient's subcutaneous) *ivig* DRUG-IVIG- **For use to request authorization for IVIG (ex. Gammagard, J1569 Gammagard (immune globulin-- Hizentra) when administered in-office (i.e. provider's office is intravenous) supplying the drug as a "buy and bill"; drug will NOT be billed J1559 Hizentra (immune globulin-- to the patient's subcutaneous) *ivig* DRUG-Lupus-INFUSION lupus (ex. Benlysta), when administered at an outpatient infusion J0490 Benlysta (belimumab) center (i.e. patient will go to an infusion center to receive the drug; drug will NOT be billed to the patient's *lupus* DRUG-Lupus- lupus (ex. Benlysta), when administered in-office (i.e. provider's be billed to the patient's J0490 Benlysta (belimumab) *lupus* 3 last updated 9/11/15
4 DRUG-Multiple Sclerosis- multiple sclerosis (MS), when administered at an outpatient J9010 Lemtrada (alemtuzumab) use J3490 Ampyra (dalfampridine) J1826 Avoxex (interferon beta-1a) J1595 Copaxone (glatiramer) J1830 Extavia (interferon beta-1b) use J7599 Gilenya (fingolimod) J1826 Rebif (interferon beta-1a) *multiple* DRUG-Multiple Sclerosis- multiple sclerosis (MS), when administered in-office (i.e. provider's office is supplying the drug as a "buy and bill"; drug will NOT be billed to the patient's J9010 Lemtrada (alemtuzumab) use J3490 Ampyra (dalfampridine) J1826 Avoxex (interferon beta-1a) J1595 Copaxone (glatiramer) J1830 Extavia (interferon beta-1b) use J7599 Gilenya (fingolimod) J1826 Rebif (interferon beta-1a) *multiple* DRUG-Naltrexone inj.- **For use to request authorization for Naltrexone injection J2315 Vivitrol (naltrexone) (ex. Vivitrol) when administered at an outpatient infusion center (i.e. patient will go to an infusion center to receive the used to treat alcohol & narcotic drug drug; drug will NOT be billed to the patient's addiction *naltrexone* DRUG-Naltrexone inj.- **For use to request authorization for Naltrexone injection (ex. Vivitrol) when administered in-office (i.e. provider's be billed to the patient's J2315 Vivitrol (naltrexone) used to treat alcohol & narcotic drug addiction *naltrexone* DRUG-Oncology IV/SC- **For use to request authorization for intravenous (or SC) Oncologic drugs, when administered at an outpatient ORAL drugs would not be entered into CA; require a MRF ( *oncology* DRUG-Oncology IV/SC- **For use to request authorization for intravenous (or SC) Oncologic drugs, when administered in-office (i.e. provider's be billed to the patient's ORAL drugs would not be entered into CA; require a MRF ( *oncology* 4 last updated 9/11/15
5 DRUG-Plaque Psoriasis- plaque psoriasis, when administered at an outpatient infusion center (i.e. patient will go to an infusion center to receive the drug; drug will NOT be billed to the patient's J0215 Amevive (alefacept) J3357 Stelara (ustekinumab) *plaque* DRUG-Plaque Psoriasis- plaque psoriasis, when administered in-office (i.e. provider's office is supplying the drug as a "buy and bill"; drug will NOT be billed to the patient's J0215 Amevive (alefacept) J3357 Stelara (ustekinumab) *plaque* DRUG-Rheumatoid Conditions-INFUSION rheumatoid conditions, when administered at an outpatient J0129 Orencia (abatacept)--unless given J3262 Actemra (tocilizumab)--unless given J0129 subcutaneous Orencia (abatacept) J3262 subcutaneous Actembra (tocilizumab) *rheuma* DRUG-Rheumatoid Conditions-OFFICE administered rheumatoid conditions, when administered in-office (i.e. provider's office is supplying the drug as a "buy and bill"; drug will NOT be billed to the patient's J0129 Orencia (abatacept)--unless given J3262 Actemra (tocilizumab)--unless given J0129 subcutaneous Orencia (abatacept) J3262 subcutaneous Actembra (tocilizumab) *rheuma* DRUG-RSV prophylaxis- **For use to request authorization for RSV prophylaxis (ex. Synagis) when administered at an outpatient infusion center (i.e. patient will go to an infusion center to receive the drug; drug will NOT be billed to the patient's Synagis (Palivizumab IM injection) RSV-IGIM for IV infusion *rsv* 5 last updated 9/11/15
6 DRUG-RSV prophylaxis- DRUG-Sarcoidosis-INFUSION **For use to request authorization for RSV prophylaxis (ex. Synagis) when administered in-office (i.e. provider's office is Synagis (Palivizumab IM injection) supplying the drug as a "buy and bill"; drug will NOT be billed RSV-IGIM for IV infusion to the patient's sarcoidosis, when administered at an outpatient infusion center (i.e. patient will go to an infusion center to receive the drug; drug will NOT be billed to the patient's *rsv* *sarcoid* DRUG-Sarcoidosis-OFFICE admin DRUG-WRAP Member- HOME INFUSION DRUG-WRAP Member- OFFICE Admin DRUG-WRAP Member- OUTPATIENT HOSP Admin sarcoidosis, when administered in-office (i.e. provider's be billed to the patient's "**To request authorization for drugs for patients with HAP secondary coverage, when Medicare A+B are primary, when administered in-home (i.e. drug will be billed to HOME INFUSION " **To request authorization for drugs for patients with HAP secondary coverage, when Medicare A+B are primary, for inoffice administration (i.e. provider's office is supplying the drug as a "buy and bill")** **To request authorization for drugs for patients with HAP secondary coverage, when Medicare A+B are primary, when administered at an outpatient infusion center (i.e. patient will go to an infusion center to receive the drug)** home infusion administration for Medicare Wrap members (MC is primary/hap is secondary) office administration for Medicare Wrap members (MC is primary/hap is secondary) infusion center (OP hosp) administration for Medicare Wrap members (MC is primary/hap is secondary) *sarcoid* *wrap* *wrap* *wrap* DRUG-Xolair-INFUSION **For use to request authorization for Omalizumab (ex. Xolair) when administered at an outpatient infusion center (i.e. patient will go to an infusion center to receive the drug; drug will NOT be billed to the patient's J2357 Xolair (omalizumab) used to treat asthma *xolair* DRUG-Xolair- **For use to request authorization for Omalizumab (ex. J2357 Xolair (omalizumab) Xolair) when administered in-office (i.e. provider's office is supplying the drug as a "buy and bill"; drug will NOT be billed used to treat asthma to the patient's *xolair* 6 last updated 9/11/15
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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
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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):
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