DRUGS REQUIRING PRIOR AUTHORIZATION

Size: px
Start display at page:

Download "DRUGS REQUIRING PRIOR AUTHORIZATION"

Transcription

1 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 Aptensio XR Aralast NP Aranesp Arcalyst Atralin* Aveed Avita* Avonex Axiron Belviq Berinert Betaseron Bivigam Bontril* Bosulif Bosulif Botox Bunavail Bydureon Byetta Therapeutic Category

2 Cabometyx Caprelsa Carimune Caverject Chenodal Cholbam Cialis Cimzia Cinqair Cinryze Cometriq Concerta Contrave Copaxone Cosentyx Cotellic Daklinza Daliresp Daraprim Daytrana Delatestryl* Depo - Testosterone* Desoxyn Dexedrine Didrex* Dyanavel XR Dysport Edex Injection Egrifta Enbrel Entyvio Epclusa Epogen Erbitux Erivedge Esbriet Euflexxa Evekeo Exondys 51 Extavia Eylea Fabior Farydak Fentora Firazyr Asthma Specialty Asthma/COPD Toxoplasmosis Respiratory Miscellaneous Duchenne Muscular Dystrophy

3 Flebogamma Flolan* Focalin Focalin XR Forteo Fortesta* Gammagard Liquid Gammagard S/D Gammaked Gamunex Gamunex-C Gel-One Gelsyn-3 Genotropin Gilotrif Gilotrif Glassia Gleevec Gleevec* Granix Grastek Harvoni Herceptin Hetlioz Humatrope Humira Hyalgan Hymovis Hyqvia Ibrance Ibrance Iclusig Iclusig Ilaris Imbruvica Impulse Increlex Inlyta Intuniv * Iressa Iveegam EN Jakafi Juxtapid Kadcyla Kalbitor Bone Conditions Allergies Sleep Disorder

4 Kalydeco Kapvay* Keveyis Kineret Korlym Krystexxa Kuvan Kynamro Lazanda Lemtrada Lenvima Letairis Levitra Lidoderm* Lonsurf Lovaza* Lucentis Lumigan* Lynparza Lynparza Macugen Makena Mekinist Mekinist Metadate CD Metadate ER Methylin Mircera Monovisc Muse Myalept Myobloc Natesto Natpara Neulasta Neupogen Nexavar Ninlaro Norditropin Northera Nplate Nucala Nuedexta Nutropin Nutropin AQ Respiratory Miscellaneous Endocrine disorder Gout Pain Hormone supplementation Asthma Specialty Mood Stabilizer

5 Nuvigil* Ocaliva Octagam Odomzo Ofev Olysio Omnitrope Onsolis Opsumit Oralair Orencia Orenitram Orkambi Orthovisc Otezla Pegasys PEG-Intron Perjeta Plegridy Polygam Praluent Procentra Procrit Prolastin Prolastin - C Promacta Provigil* Qsymia QuilliChew ER Quillivant XR Ragwitek Rebif Regimex Remicade Remodulin Repatha Restasis Retin-A Micro* Retin-A* Revatio* Revlimid Ritalin Ritalin LA Ritalin SR Rituxan Narcolepsy Respiratory Miscellaneous Allergies Respiratory Miscellaneous Narcolepsy Allergies

6 Ruconest Saizen Samsca Saxenda Selzentry Sensipar Serostim Signifor Signifor LAR Simponi Sivextro Solaraze* Sovaldi Spansules Sprycel Sprycel Staxyn Stelara Stendra Stivarga Stivarga Strattera Striant Suboxone* Subsys Supartz Suprenza Sutent Symlin Synvisc Synvisc-One Tafinlar Tafinlar Tagrisso Tagrisso Taltz Tanzeum Tarceva Tarceva Tasigna Tasigna Tazorac Technivie Temodar* Testim* Endocrine disorder HIV Chronic Kidney Disease Endocrine disorder Endocrine disorder

7 Testopel Tev-Tropin Thalomid Tracleer Travatan/Z Tretin X Trulicity Tykerb Tykerb Tysabri Tyvaso Uptravi Vascepa Vectibix Veletri Veltin* Venclexta Venclexta Ventavis Viagra Victoza Viekira Vogelxo* Votrient Vyvanse Xalatan* Xalkori Xalkori Xenazine* Xenical Xeomin Xiidra Xolair Xtandi Xyrem Zarxio Zelboraf Zelboraf Zemaira Zenzedi Ziana* Zinbryta Zioptan Zomacton Zorbtive Asthma Specialty Narcolepsy

8 Zovirax Zubsolv Zydelig Zykadia Zykadia Zytiga Zytiga Zyvox* * Indicates generics available, generics require a PA same as brand List as of , lists subject to change

METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE ALPHA-1 PROTEINASE INHIBITORS ARANESP BLOOD CELL DEFICIENCY ARANESP ARCALYST

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

More information

Pulmonary Hypertension Weight Loss Skin Conditions. Skin Conditions Multiple Sclerosis Endocrine Disorder. Endocrine Disorder.

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

More information

2018 BCN Advantage Prior Authorization Criteria Last updated: November, 2017

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

More information

2018 BCN Advantage Prior Authorization Criteria Last updated: April, 2018

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

More information

Specialty Drugs. The following is a list of medications that are considered to be specialty drugs. Specialty drugs

Specialty Drugs. The following is a list of medications that are considered to be specialty drugs. Specialty drugs Specialty Drugs The following is a list of medications that are considered to be specialty drugs. Specialty drugs include self-administered injectables, medications that are high cost, and/or medications

More information

Specialty Drugs. The specialty drug list below is effective June 5, 2018 and is subject to change at any time.

Specialty Drugs. The specialty drug list below is effective June 5, 2018 and is subject to change at any time. Specialty Drugs The following is a list of medications that are considered specialty drugs. Specialty drugs include self-administered injectables, medications that are high cost, and/or medications that

More information

Aetna Better Health. Specialty Drug Program

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

More information

PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION

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

More information

PRESCRIPTION DRUGS REQUIRING PRIOR AUTHORIZATION

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

More information

Prior Authorization Program Information (Effective April 1st, 2018)

Prior Authorization Program Information (Effective April 1st, 2018) Prior Authorization Program Information (Effective April 1st, 2018) Prior Authorization Certain drugs require prior authorization to help promote safe, quality and affordable pharmacy care. Your doctor

More information

acromegaly Drugs Covered Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Coverage Duration

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

More information

LIMITED DISTRIBUTION MEDICATIONS

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

More information

Prior Authorization Drug List

Prior Authorization Drug List Prior Authorization Drug List This is a list of drugs that require Prior Authorization before coverage is provided. If you are prescribed a medication that requires Prior Authorization, your physician

More information

Prescription Drug Benefit Rider V

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

More information

Prescription Drug Benefit Rider

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

More information

Specialty Drug List - Sorted by Therapeutic Class Developed for the Mississippi Division of Medicaid by Mercer

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

More information

ALPHA1-PROTEINASE INHIBITOR

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,

More information

Lista de medicamentos especializados

Lista de medicamentos especializados Lista de medicamentos especializados Vigencia: 1o. de enero de 2016 A continuación se listan, en orden alfabético, los medicamentos de especialidad recetados más frecuentemente. Los medicamentos de especialidad

More information

Pharmacy and Medical Guideline Updates

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

More information

Ally Rx D-SNP Current as of r 1, 2017

Ally Rx D-SNP Current as of r 1, 2017 Ally Rx D-SNP Current as of r 1, 2017 AMPYRA AMPYRA PA Moderate to severe renal impairment (CrCL less than or equal to 50ml/min), patient not able to walk 25 feet in 8-45 seconds. Documentation of diagnosis,

More information

Drugs Requiring Prior Authorization When certain medications require prior authorization

Drugs Requiring Prior Authorization When certain medications require prior authorization Drugs Requiring Prior Authorization When certain medications require prior authorization Express Scripts is required to review prescriptions for certain medications with your doctor before they can be

More information

after reconstitution No Yes Refrigerate; do Not freeze. Discard unused portions; do Not save for further Immune Deficiencies & Related

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

More information

STAT Bulletin. Drug Therapy Guideline Updates. To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business

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

More information

STAT Bulletin. Drug Therapy Guideline Updates. To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business

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

More information

Drug Name. J0129 Injection, abatacept (Orencia ), 10 mg Effective 01/01/2014. J0178 Injection, aflibercept (Eylea ), 1 mg Effective 04/01/2015

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,

More information

Buckeye Health Plan (MMP) 2016 Prior Authorization Criteria

Buckeye Health Plan (MMP) 2016 Prior Authorization Criteria Buckeye Health Plan (MMP) 2016 Prior Authorization Instructions: 1. With this file, at the top, click Edit, then click Find. 2. In the Find box type the name of the medication you want to find. 3. Click

More information

SPECIALTY PHARMACY Master Clinical Drug List

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

More information

ADCIRCA. Products Affected Adcirca. Prior Authorization Criteria 2017 MMP Effective Date: 11/01/2017 Approval Date: 11/01/2017

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

More information

Exclusion Reasons Presumption of Long- Term Non-Acute Administration C9399 Unclassified Drugs or

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

More information

Pharmacy Benefit Management (PBM) Program FORMULARY/PRODUCT RESTRICTIONS

Pharmacy Benefit Management (PBM) Program FORMULARY/PRODUCT RESTRICTIONS 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

More information

Provider Administered Drug Program (PADP) and Physician Administered Drug VPSS List

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

More information

Prior Authorization Approval Guidelines. May, 2017

Prior Authorization Approval Guidelines. May, 2017 Prior Authorization Approval Guidelines May, 2017 Prior Authorization Approval Guidelines Please be advised that in order to be considered for approval, all applicable prior therapies must be listed on

More information

Covered Uses All medically accepted indications not otherwise excluded from Part D.

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

More information

2010 Drugs Requiring Prior Authorization

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

More information

MedPerform Medium Preferred Drug List (PDL)

MedPerform Medium Preferred Drug List (PDL) What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs covered by your prescription drug plan. The PDL was created to promote

More information

MedStar Medicare Choice Pharmacy Services

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

More information

List of Designated High-Cost Drugs

List of Designated High-Cost Drugs List of Designated High-Cost Drugs UPDATED APRIL 25, 2018 For details on the High-Cost Drug policy, see Section 5.8 of the PharmaCare Policy Manual. Recent updates appear in red. Deletions are listed at

More information

Prior Authorization Drug List

Prior Authorization Drug List Prior Authorization Drug List This is a list of drugs that require Prior Authorization before coverage is provided. If you are prescribed a medication that requires Prior Authorization, your physician

More information

FirstCarolinaCare Preferred Drug List (PDL)

FirstCarolinaCare Preferred Drug List (PDL) FirstCarolinaCare Preferred Drug List (PDL) 2-tier Drug Plan Members What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs

More information

Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema, weight, A1-PI phenotype, A1-PI baseline level

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,

More information

2019 Prior Authorization

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

More information

BCBS AZ ADV PLUS * CLASSIC * PREMIER For use with members associated with the BHN Network Prior Authorization List 2015

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

More information

ACAMPROSATE (CAMPRAL)

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

More information

ACNE AGENTS_NVT Chinese Community Health Plan Senior Select Program (HMO SNP)

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

More information

FirstCarolinaCare Preferred Drug List (PDL)

FirstCarolinaCare Preferred Drug List (PDL) FirstCarolinaCare Preferred Drug List (PDL) 2-tier Drug Plan Member What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs

More information

Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema, weight, A1-PI phenotype, A1-PI baseline level

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,

More information

AAT DEFICIENCY. Products Affected Aralast Np INJ 1000MG, 500MG Glassia. Prior Authorization Criteria Health Alliance Plan_2016_HAPFB Updated: 10/2016

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

More information

SELF-ADMINISTERED MEDICATIONS LIST

SELF-ADMINISTERED MEDICATIONS LIST SELF-ADMINISTERED MEDICATIONS LIST Table of Contents Page Last Updated: January 23, 2019 INSTRUCTIONS FOR USE... 1 APPLICABLE CODES... 1 Related Commercial Policy LIST HISTORY/REVISION INFORMATION... 5

More information

RAHF PFM ALPHANINE SD COAGULATION FACTOR IX J7193 COAGULATION FACTOR IX (RFIXFC)

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

More information

2019 Prior Authorization

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

More information

Products Affected ACTEMRA SUBCUTANEOUS ACTEMRA INTRAVENOUS SOLUTION 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML)

Products Affected ACTEMRA SUBCUTANEOUS ACTEMRA INTRAVENOUS SOLUTION 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) Current as of October 1, 2016 ACTEMRA ACTEMRA SUBCUTANEOUS ACTEMRA INTRAVENOUS SOLUTION 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) PA Other Documentation of diagnosis, previous treatment with one or

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Self Administered Oncology Agents Page 1 of 13 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Self Administered Oncology Agents Prime Therapeutics will review Prior

More information

Drug Bill As Unit Common Directions Common Day Supply Common Billing Errors Oral Tablets/Capsules

Drug Bill As Unit Common Directions Common Day Supply Common Billing Errors Oral Tablets/Capsules Note: This is a guide for commonly misbilled medications. Please submit the claims according to directions for use indicated on the prescription order. Drug Bill As Unit Common Directions Common Day Supply

More information

ACNE AGENTS_NVT Chinese Community Health Plan Senior Select Program (HMO SNP)

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

More information

AAT DEFICIENCY. Products Affected Aralast Np INJ 1000MG, 500MG Glassia Prolastin-c INJ 1000MG Zemaira

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

More information

ACTEMRA. Products Affected ACTEMRA. Covered Uses All FDA-approved indications not otherwise excluded from Part D. N/A. Exclusion Criteria

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:

More information

Plan Year 2018 Prior Authorization (PA) Criteria

Plan Year 2018 Prior Authorization (PA) Criteria Plan Year 2018 Prior Authorization (PA) Criteria Prior Authorization: Commonwealth Care Alliance requires you (or your physician) to get prior authorization for certain drugs. This means that you will

More information

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

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

More information

Medicaid Managed Care Prior Authorization List

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

More information

ACITRETIN. Products Affected

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

More information

CENTENE PHARMACY & THERAPEUTICS COMMITTEE SECOND QUARTER 2017 AMBETTER GUIDELINE SUMMARY. Revision Summary or Description

CENTENE PHARMACY & THERAPEUTICS COMMITTEE SECOND QUARTER 2017 AMBETTER GUIDELINE SUMMARY. Revision Summary or Description CENTENE PHARMACY & THERAPEUTICS COMMITTEE SECOND QUARTER 2017 AMBETTER GUIDELINE SUMMARY Coverage Guideline Policy & Procedure HIM.PA.32 Long acting stimulants (Adderall XR, Dexedrine, Metadate CD, Ritalin

More information

ADHD Medications Table

ADHD Medications Table Stimulants are the first line treatment of choice for ADHD followed by Non-Stimulants, then off-label medications. We are providing this list of medications so that you can be familiar with the common

More information

Prescription Drug Benefit Rider

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

More information

Prior Authorization Drug List

Prior Authorization Drug List 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

More information

2017 Prior Authorization (PA) Criteria

2017 Prior Authorization (PA) Criteria 2017 Prior Authorization (PA) Certain drugs require prior authorization from GuildNet Gold Plus FIDA Plan Medicare Plans. This means that your doctor must contact us to get approval before prescribing

More information

FirstCarolinaCare Preferred Drug List (PDL)

FirstCarolinaCare Preferred Drug List (PDL) 3-tier Drug Plan Members What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs covered by your prescription drug plan. The

More information

2017 Prior Authorization (PA) Criteria

2017 Prior Authorization (PA) Criteria 2017 Prior Authorization (PA) 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

More information

Antidepressants: -amitriptyline -venlafaxine. Alpha-agonists: -clonidine -guanfacine. Beta blockers: -atenolol -nadolol. AEDs: -carbamazepine

Antidepressants: -amitriptyline -venlafaxine. Alpha-agonists: -clonidine -guanfacine. Beta blockers: -atenolol -nadolol. AEDs: -carbamazepine Commissioner for the Department for Medicaid Services Selections for Preferred Products This is a summary of the final Preferred Drug List (PDL) selections made by the Commissioner of the Department for

More information

Specialty Overview by Prior Authorization Approval or Denial 4th Quarter 2016

Specialty Overview by Prior Authorization Approval or Denial 4th Quarter 2016 Specialty Overview by Prior Authorization Approval or 4th Quarter 2016 Carrier Physician Specialty Drug Drug Class Decision Comments Reporting Year Reporting Month 3961 GASTROENTEROLOGY Humira RHEUMATOID

More information

ACITRETIN. Products Affected

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

More information

Three-Tier Prescription Drug Benefits Rider

Three-Tier Prescription Drug Benefits Rider Three-Tier Prescription Drug Benefits 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

More information

Post-operative pain following CABG surgery Allergic-type reaction to aspirin, NSAIDs, or sulfonamides

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

More information

Three-Tier Prescription Drug Benefit Rider A

Three-Tier Prescription Drug Benefit Rider A Three-Tier Prescription Drug Benefit Rider A 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

More information

Drug Name Generic Name J-Code Unclassified Drugs in excess of $10,000

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

More information

PHARMACY AND THERAPEUTICS COMMITTEE 4 th Quarter 2017

PHARMACY AND THERAPEUTICS COMMITTEE 4 th Quarter 2017 PHARMACY AND THERAPEUTICS COMMITTEE 4 th Quarter 2017 A meeting of the Health Partners Pharmacy and Therapeutics (P&T) Committee was held on September and December 2017. The following are the recommendations

More information

Quantity Management. April 2018

Quantity Management. April 2018 Quantity Management April 2018 What Is Quantity Management? It s a quality and safety program that promotes the safe use of medications. The program limits the amount of some medications we cover. We base

More information

SelectHealth Advantage 2015 Prior Authorization Criteria

SelectHealth Advantage 2015 Prior Authorization Criteria 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.

More information

Pharmacy Clinical Prior Authorization Assistance Chart Effective February 2018

Pharmacy Clinical Prior Authorization Assistance Chart Effective February 2018 About Pharmacy Clinical Prior Authorizations Clinical prior authorizations (PA) are based on evidence-based clinical criteria and nationally recognized peer-reviewed information. The PA may apply to an

More information

Network Health Insurance Corporation 2013 P A Criteria

Network Health Insurance Corporation 2013 P A Criteria Network Health Insurance Corporation 2013 P A Criteria ACTEMRA... 10 ACTEMRA... 10 ACTHAR... 11 H.P. ACTHAR... 11 AMPYRA... 12 AMPYRA... 12 ANDROGEL... 13 ANDRODERM... 13 ANDROGEL... 13 AXIRON... 13 FORTESTA...

More information

Prior January 2016 Authorization What Is Prior Authorization? What Happens at a Retail Pharmacy? Please Note: Which Medications Are Included?

Prior January 2016 Authorization What Is Prior Authorization? What Happens at a Retail Pharmacy? Please Note:    Which Medications Are Included? Prior January 2016 Authorization What Is Prior Authorization? It s a quality and safety program that promotes the proper use of certain medications. If your doctor prescribes a medication that is included

More information

Specialty Overview by Prior Authorization Approval or Denial 2nd Quarter 2016

Specialty Overview by Prior Authorization Approval or Denial 2nd Quarter 2016 Specialty Overview by Prior Authorization Approval or 2nd Quarter 2016 3961 DERMATOLOGY Humira RHEUMATOID ARTHRITIS Approval Approved from 04/13/2016 thru 04/13/2018 3961 DERMATOLOGY Stelara PSORIASIS

More information

Section I contains changes to the Highmark Select/Choice Formulary.

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

More information

Central Nervous System Stimulants Drug Class Prior Authorization Protocol

Central Nervous System Stimulants Drug Class Prior Authorization Protocol Line of Business: Medi-Cal Effective Date: August 16, 2017 Revision Date: August 16, 2017 Central Nervous System Stimulants Drug Class Prior Authorization Protocol This policy has been developed through

More information

Plan Year 2017 Prior Authorization (PA) Criteria

Plan Year 2017 Prior Authorization (PA) Criteria Plan Year 2017 Prior Authorization (PA) Criteria Prior Authorization: Commonwealth Care Alliance requires you (or your physician) to get prior authorization for certain drugs. This means that you will

More information

2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization

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

More information

Prior Authorization Program

Prior Authorization Program Prescription Drug List January 2011 Prior Authorization Program The prior authorization program helps us offer broad prescription drug coverage and promotes safe, clinically appropriate drug usage. Under

More information

Formulary Changes. One mission: you TABLE A. FORMULARY CHANGES 7/1/2018: Commercial 3-Tier Formulary. Commercial 4-Tier Formulary

Formulary Changes. One mission: you TABLE A. FORMULARY CHANGES 7/1/2018: Commercial 3-Tier Formulary. Commercial 4-Tier Formulary One mission: you Changes July 1, 2018 Blue Cross of Idaho reviews its formularies (covered drug lists) periodically to allow members access to new drugs and to provide safe, cost effective options for

More information

2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization

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

More information

MedPerform High Preferred Drug List (PDL)

MedPerform High Preferred Drug List (PDL) What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs covered by your prescription drug plan. The PDL was created to promote

More information

Plan Year 2019 Prior Authorization (PA) Criteria

Plan Year 2019 Prior Authorization (PA) Criteria Plan Year 2019 Prior Authorization (PA) Criteria Prior Authorization: Commonwealth Care Alliance requires you (or your physician) to get prior authorization for certain drugs. This means that you will

More information

Rationale for Decision Excluded Generic OTC equivalent available (Flonase Allergy Relief) Medicare status (if differs)

Rationale for Decision Excluded Generic OTC equivalent available (Flonase Allergy Relief) Medicare status (if differs) BLUE SHIELD OF CALIFORNIA FIRST QUARTER 2015 FORMULARY AND MEDICATION POLICY UPDATES EFFECTIVE MARCH 19, 2015 The Blue Shield of California (BSC) Pharmacy and Therapeutics (P&T) Committee, consisting of

More information

Descriptor Brand Name. Alprostadil, Caverject, Edex, Prostin VR Pediatric. Calcimar, Miacalcin

Descriptor Brand Name. Alprostadil, Caverject, Edex, Prostin VR Pediatric. Calcimar, Miacalcin Self-Administered Drug Exclusion List R2 This article from Medicare A News, Issue 2106 dated January 23, 2013 and Medicare B News, Issue 283 dated January 23, 2013 is being revised to add Acthar ACTH gel

More information

Percent Brand Name Generic Name Strength How Supplied NDC from AWP/SWP Adcetris. Amprya dalfampridine 10 mg 60 count bottle

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,

More information

ANDROID. Products Affected ANDROID. Prior Authorization Criteria HEALTH CHOICE EXCHANGE Effective Date: 12/01/2016

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

More information