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1 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) Afinitor Agrylin Aldurazyme Alferon-N Alimta Alphanate Alphanine SD Alprolix Ampyra anagrelide (generic for Agrylin) anastrozole (generic for Arimidex) Antagon Apokyn Aralast Aralast NP Antiplatelet Multiple Sclerosis Antiplatelet Miscellaneous CNS Disorders Aranesp (INJ,SQ) Blood Cell Deficiency PA/Step Cryopyrin-Associated Periodic Arcalyst Syndromes PA Aredia Arestin Arimidex Arixtra Aromasin
2 Arzerra Atryn Aubagio Multiple Sclerosis PA/Step Avastin Avonex Multiple Sclerosis PA azacitidine Baygam Bebulin Bebulin VH Benefix Benlysta Inflammatory Conditions Berinert Hereditary Angioedema PA Betaseron Multiple Sclerosis PA/Step Bethkis Bivigam PA Blincyto Boniva Injectable Bosulif Osteoporosis Botox Neuromuscular Conditions/Cosmetic PA Bravelle Step Campath Camptosar capecitabine Carbaglu Carimune NF PA Ceprotin Cerdelga Ceredase Cerezyme Cetrotide Chorionic Gonadotropin Cimzia Inflammatory Conditions PA/Step Cinryze Hereditary Angioedema PA
3 Copaxone 20 mg Multiple Sclerosis PA Copaxone 40 mg Multiple Sclerosis PA/Step Copegus Corifact Cosentyx Inflammatory Conditions PA Crinone Cytogam Cytovene Dacogen DDAVP Decitabine Deferoxamine Desferal Desmopressin Dexferrum Docefrez Docetaxel Doxil Doxorubicin Antiviral Iron Toxicity Iron Toxicity Dysport Neuromuscular Conditions/Cosmetic PA Egrifta Elaprase Eligard Eloctate Elspar Enbrel Inflammatory Conditions PA enoxaprin (generic for Lovenox) Entyvio Inflammatory Conditions PA/Step Epogen Blood Cell Deficiency PA/Step Epoprostenol Diluent Epoprostenol Sodium Erbitux Erivedge
4 Esbriet Idiopathic Pulmonary Firbosis PA Euflexxa Osteoarthritis PA/Step exemestane (generic for Aromasin) Exjade Iron Toxicity Extavia Multiple Sclerosis PA Eylea Fabrazyme Faslodex Feiba VH / NF Femara Feraheme Ferric Gluconate Inj Ferrlecit Ophthalmic Conditions Firazyr Hereditary Angioedema PA Firmagon Flebogamma PA Flolan Flolan/diluent Follistim (SQ,IV) Step Folotyn fondaparinux (generic for Arixtra) Forteo Osteoporosis PA Fragmin Fusilev Fuzeon GamaSTAN S/D HIV Gammagard PA Gammagard Liquid PA Gammagard S/D Gammaplex PA Gammar-P Gamunex PA Gamunex C PA
5 ganciclovir (generic for Cytovene) Ganciclovir Sodium Ganirelix AC Gattex Gazyva Antiviral Antiviral Gel-One Osteoarthritis PA/Step Genotropin Growth Deficiency PA Gilenya Multiple Sclerosis PA/Step Gilotrif Glatopa Multiple Sclerosis PA Glassia Gleevec Gonal-F Gonal-F RFF Granix Blood Cell Deficiency PA Halaven Harvoni PA/Step Helixate FS Hemofil-M Hepagam Herceptin Hepatitis B Hetlioz PA Hizentra PA Humate-P Humatrope Growth Deficiency PA Humira Inflammatory Conditions PA Hyalgan Osteoarthritis PA/Step Hycamtin Hydroxyprogesterone HyperHep HyperRab S/D HyperRho S/D Hepatitis B HyQvia PA
6 ibandronate Iclusig Idamycin Idarubicin Ilaris Imogam Imovax Implanon Osteoporosis Cryopyrin-Associated Periodic Syndromes Contraceptive Incivek PA Increlex Growth Deficiency PA Infed Infergen Inlyta Innohep Intron-A (INJ, SQ) Iressa Irinotecan iron dextran (generic for Dexferrum) Istodax Ixempra Jakafi Jevtana Kadcyla Kalbitor Hereditary Angioedema PA Kalydeco PA Kepivance Kineret Inflammatory Conditions PA/Step Koate-DVI Kogenate FS Korlym PA Krystexxa Inflammatory Conditions PA PA
7 Kuvan Kynamro Kyprolis Letairis letrozole (generic for Femara) Leukine Blood Cell Deficiency PA Leuprolide inj Lipodox Lovenox Lucentis Lumizyme Lupaneta Lupron Lupron Depot Lupron Depot Ped Luveris Macugen Makena Mekinist Menopur Mesna Mesnex Micrhogam Mitomycin Mitoxantron HCl Inj Moderiba Monoclate-P Mononine Ophthalmic Conditions Ophthalmic Conditions Hepatitis Monovisc Osteoarthritis PA Mozobil Mugard Myalept Blood Cell Deficiency Myobloc Neuromuscular Conditions/Cosmetic PA
8 Myozyme NABI-HB Naglazyme Hepatitis B Neulasta Blood Cell Deficiency PA Neumega Blood Cell Deficiency Neupogen Blood Cell Deficiency PA Nexavar Nexplanon Nipent Contraceptive Norditropin Growth Deficiency PA Northera Novantrone Novarel Novoseven Nplate Nulecit Nulojix Blood Cell Deficiency Transplant Nutropin Growth Deficiency PA/Step Nutropin AQ Growth Deficiency PA/Step Obizur Octagam PA Octreotide Acetate PA Ofev Idiopathic Pulmonary Firbosis PA Oforta Olysio PA Omnitrope Growth Deficiency PA/Step Oncaspar Opsumit Oralair PA Orencia (IV and SQ) Inflammatory Conditions PA/Step Orenitram Orfadin Orkambi Cystic Fibrosis PA
9 Orthovisc Osteoarthritis PA Otezla Inflammatory Conditions PA/Step Ovidrel Ozurdex Pamidronate Disodium Panretin Ophthalmic Conditions Miscellaneous Skin Conditions Pegasys PA PEG-Intron PA/Step Pentostatin Perjeta Plegridy Multiple Sclerosis PA Pomalyst Praulent Metabolic Disorders PA Pregnyl Prialt Pain Privigen PA Prochieve Procrit Blood Cell Deficiency PA Procysbi Profasi Profilnine SD Proleukin Prolia Osteoporosis PA Promacta Prothelial Pulmozyme Qutenza RabAvert Blood Cell Deficiency Pain Rapamune Transplant Rapatha Metabolic Disorders PA Ravicti Rebetol Rebif Multiple Sclerosis PA
10 Rebif Rebidose Multiple Sclerosis PA Reclast Osteoporosis PA Recombinate Remicade Inflammatory Conditions PA/Step Remodulin Repronex Retisert Revatio Revlimid Rhogam Rhophylac RiaSTAP Ribapak Ribasphere Ribatab Ribavirin Rilutek Riluzole Ophthalmic Conditions Fibrinogen Deficiency Amyotropic Lateral Sclerosis Amyotropic Lateral Sclerosis Rituxan PA/Step Rixubis Ruconest Hereditary Angioedema PA Sabril Miscellaneous CNS Disorders Saizen Growth Deficiency PA/Step Samsca Sandostatin PA Sandostatin LAR PA Sensipar Hyperparathyroidism Serostim Growth Deficiency PA Signifor sildenafil Simponi Inflammatory Conditions PA/Step Simponi Aria Inflammatory Conditions PA/Step Soliris
11 Somatuline Depot Somavert Sovaldi PA Sprycel Stelara Inflammatory Conditions PA Stimate Stivarga Sucraid Supartz Osteoarthritis PA/Step Supprelin LA Sutent Sylatron Sylvant Synagis RSV Prevention PA Synarel NS Synribo Pituitary Suppressant Synvisc Osteoarthritis PA Synvisc One Osteoarthritis PA Tafinlar Tarceva Targretin Tasigna Taxotere Tecfidera Multiple Sclerosis PA/Step Temodar Temozolomide Tev-Tropin Growth Deficiency PA/Step Thalomid IV Thalomid PO Theracys Thyrogen Tikosyn TOBI Antiarrythmic
12 TOBI podhaler tobramycin (for inhalation) topotecan (generic for Hycamtin) Torisel Tracleer Treanda Trelstar Depot Trelstar LA tretinoin (generic for Vesanoid PO) Tretten Tykerb Tysabri Multiple Sclerosis PA Tyvaso Valchlor Valstar Vantas Vectibix Velcade Veletri Venofer Ventavis Vesanoid PO Vfend IV Viadur Antifungal Victrelis PA Vidaza Viekira PA Vimizim Visudyne Marquio A Syndrome Ophthalmic Conditions Vivaglobin PA Vivitrol Voriconazole IV Votrient Miscellaneous CNS Disorders Antifungal
13 Vpriv Wilate Winrho SDF Xalkori Xeljanz Inflammatory Conditions PA/Step Xeloda Xenazine Miscellaneous CNS Disorders Xeomin Neuromuscular Conditions/Cosmetic PA Xgeva Xiaflex Xolair PA Xtandi Xyntha Xyrem Zaltrap Zavesca Zelboraf Zemaira Zoladex Zoledronic acid Zolinza Zometa Miscellaneous CNS Disorders Osteoporosis Zorbtive Growth Deficiency PA Zykadia Zytiga
Aetna Better Health. Specialty Drug Program
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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
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
Specialty Drugs. The following is a list of medications that are considered to be specialty drugs. Specialty drugs
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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
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,
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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/
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
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
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
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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
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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
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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
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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
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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
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
Ally Rx D-SNP Current as of r 1, 2017
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Formulary Chemotherapy Agents: (Current as of 6/2018) Therapeutic Class
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY Cancer LAST REVIEW 9/11/18 THERAPEUTIC CLASS Oncology REVIEW HISTORY 5/17, 5/16 LOB AFFECTED Medi-Cal (MONTH/YEAR) This policy
Client Prior Authorization Program (CPA) PA Required (PA) Reimb Code. Reimb Code CLAIM EDIT. Reimb Code. Reimb Code. Reimb Code
Medical Benefit Management Specialty Drug List Effective October 1, 2015 The symbol [] next to a drug name indicates that this medication is subject to the Prior. The symbol [C] next to a drug name indicates
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
2012 Prior Authorization Criteria
2012 Prior Authorization Criteria ACTEMRA... 17 ACTEMRA... 17 ACTIMMUNE... 18 ACTIMMUNE... 18 ADAGEN... 19 ADAGEN... 19 ADCIRCA... 20 ADCIRCA... 20 AFINITOR... 21 AFINITOR... 21 ALDURAZYME... 22 ALDURAZYME...
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
RIVERSPRING STAR ISNP PRIOR AUTHORIZATION
ACROMEGALY RIVERSPRING STAR ISNP PRIOR AUTHORIZATION SIGNIFOR, SIGNIFOR LAR, SOMATULINE DEPOT, SOMAVERT 10 MG VIAL, SOMAVERT 15 MG VIAL, SOMAVERT 20 MG VIAL Must provide clinical documentation of Acromegaly
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
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
2012 Prior Authorization Criteria
GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP 2012 Prior Authorization Criteria ACTEMRA... 18 ACTEMRA... 18 ACTIMMUNE... 19 ACTIMMUNE... 19 ADAGEN... 20 ADAGEN... 20 ADCIRCA... 21 ADCIRCA...
Prior Authorization July 2017
Prior Authorization July 2017 Please Note: Not all benefit plans include prior authorization. Check your plan materials to see if this information applies to you. What Is Prior Authorization? It s a quality