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1 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 delivery. This drug list is subject to change. For more information, please contact Express Scripts PricewaterhouseCoopers The following medications may require prior authorization prior to dispensing at a participating retail pharmacy or through the Express Scripts Pharmacy home delivery. This drug list is subject to change. For more information, please contact Express Scripts Member Services at Drug Name Abstral Actemra Acthar Gel Acticlate Actiq Adcirca Adderall Adderall XR Adempas Adipex-P Adoxa Adzenys XR-ODT Alodox Ampyra Androderm AndroGel Aptensio XR Aralast NP Aranesp Arcalyst Atralin Aveed Avidoxy Avita Avonex Axiron Belviq Belviq XR Therapeutic Category
2 Berinert Betaseron Bivigam Boniva IV Bontril PDM Botox BRAVELLE Carimune NF CETROTIDE Chenodal Cholbam CHORIONIC GONADOTROPIN Cimzia Cinqair Cinryze CLOMIPHENE CITRATE Concerta Contrave Copaxone Copegus Cosentyx CRINONE Cuvitru Daklinza Daliresp Daytrana Depo - Testosterone Desoxyn Dexedrine Didrex Doryx Doxycycline 40mg Capsule Dyanavel XR Dynacin Egrifta Eligard Emflaza Enbrel ENDOMETRIN Entyvio Epclusa Epogen Esbriet Euflexxa Evekeo Asthma Specialty Asthma/COPD Duchenne Muscular Dystrophy
3 Exondys 51 Extavia Eylea Fabior Fentora Firazyr FIRST-PROGESTERONE Flebogamma DIF Flolan Focalin Focalin XR FOLLISTIM AQ Forteo Fortesta Gammagard Liquid Gammagard Liquid Gammagard S/D Gammaked Gammaked Gammaplex Gamunex Gamunex-C Gamunex-C GANIRELIX ACETATE Gel-One Gelsyn-3 Genotropin GenVisc 850 Glassia Glatopa GONAL-F Granix Grastek Harvoni Hetlioz Hizentra Humatrope Humira Hyalgan Hymovis HyQvia Ilaris Increlex Inflectra Intuniv Duchenne Muscular Dystrophy Eye Conditions Allergies Sleep Disorder
4 Kalbitor Kalydeco Kapvay Keveyis Kineret Korlym Krystexxa Kuvan Lazanda Lemtrada Letairis Lidoderm Lomaira Lovaza Lucentis Lupaneta Lupron Depot Lupron Depot-PED Macugen Makena MENOPUR Metadate CD Metadate ER Methylin Minocin Mircera Moderiba Mondodox Monovisc Morgidox Myalept Myobloc Natesto Natpara Neulasta Neupogen Norditropin Northera NOVAREL Nplate Nucala Nutropin Nutropin AQ Nuvigil Ocaliva Gout Pain High Blood Cholesterol Eye Conditions Eye Conditions Hormone supplementation Asthma Specialty Narcolepsy
5 Octagam Ofev Olysio Omnitrope Onsolis Opsumit Oracea Oralair Orencia Orenitram Orkambi Orthovisc Otezla OVIDREL Pegasys PEG-Intron Plegridy PREGNYL Privigen Procentra Procrit Prolastin - C Prolia Promacta Provigil Qsymia QuilliChew ER Quillivant XR Ragwitek Rebetol Rebif Reclast Regimex Remicade Remodulin REPRONEX Retin-A Retin-A Micro Revatio Ribasphere Ritalin Ritalin LA Ritalin SR Rituxan Ruconest Allergies Narcolepsy Allergies
6 Saizen Samsca Saxenda Selzentry SEROPHENE Serostim Signifor Signifor LAR Simponi Solaraze Solodyn Sovaldi Spinraza Stelara Strattera Striant Subsys Supartz Supartz FX Suprenza Synagis Synvisc Synvisc-One Taltz Taradox Tazorac Technivie Testim Testopel testosterone enanthate Tracleer Tretin-X Tysabri Tyvaso Uptravi Vascepa Veletri Veltin Ventavis Vibramycin Viekira Vogelxo Vyvanse Xeljanz Xenazine HIV High Blood Cholesterol
7 Xenical Xeomin Xolair Zarxio Zemaira Zenzedi Zepatier Ziana Zinbryta Zomacton Zorbtive Zovirax Asthma Specialty
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
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
Prior Authorization Program Information (Effective April 1st, 2018)
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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
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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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
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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,
Specialty Drugs. The specialty drug list below is effective June 5, 2018 and is subject to change at any time.
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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
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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
STAT Bulletin. Drug Therapy Guideline Updates. To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business
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Workforce Safety & Insurance Revised Document Date: 07/23/2015 1600 E Century Ave Ste 1 PO Box 5585 Bismarck, ND 58506-5585 701.328.3800 1.800.777.5033 www.workforcesafety.com Pharmacy Benefit Management
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BCBS AZ ADV PLUS * CLASSIC * PREMIER For use with members associated with the BHN Network Prior Authorization List 2015
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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
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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
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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
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
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
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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)
2016 MDwise HIP Medical Services that Require Prior Authorization
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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
Medicaid Managed Care Prior Authorization List
Allergen Extracts Alzheimer's Angioedema Anthelmintics Trade Name: GRASTEK, ORALAIR, RAGWITEK Trade Name: NAMZARIC Trade Name: BERINERT, CINRYZE, FIRAZYR, RUCONEST Trade Name: EMVERM Attention Deficit
Drug Bill As Unit Common Directions Common Day Supply Common Billing Errors Oral Tablets/Capsules
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2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization
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Prior Authorization Drug List Drug Class 5-HT3 RECEPTOR ANTAGONISTS AKYNZEO ADRENALS EMFLAZA ADRENOCORTICAL INSUFFICIENCY H.P. ACTHAR ALPHA AND BETA ADRENERGIC AGONIST(RESPR) ADRENACLICK EPIPEN AUVI-Q
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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/
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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
Post-operative pain following CABG surgery Allergic-type reaction to aspirin, NSAIDs, or sulfonamides
Covered Uses (Including all FDA-approved indications not otherwise ) ACNE Atralin Gel Avita Cream Avita Gel Retin-A Cream Retin-A Gel Retin-A Micro Gel Tretinoin Cream Tretinoin Gel Acne vulgaris Keratosis
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GA KS KY LA MD NJ NV NY TN TX WA Applicable X N/A N/A X N/A X X X X X X N/A N/A X *FHK- Florida Healthy Kids. ADHD Narcolepsy
Override(s) Prior Authorization ADHD Narcolepsy Approval Duration 1 year *Louisiana, Washington and Maryland Medicaid See State Specific Information Below Medications Atomoxetine: Strattera generic Clonidine
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
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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
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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