List 1 PRESCRIPTION DRUGS REQUIRING PRE-AUTHORIZATION LIBERTY HEALTH DRUG IDENTIFICATION NUMBER (DIN)

Transcription

1 PRESCRIPTION DRUGS REQUIRING PRE-AUTHORIZATION List 1 ACNE THERAPY If covered person over 30 years of age approval by Liberty Health required RETIN A CR 0.01% RETIN A CR 0.025% RETIN A CR 0.05% RETIN A CR 0.1% RETIN A GEL 0.01% RETIN A GEL 0.025% RETIN_A CR 0.05% RETIN_A CR 0.1% RETIN_A GEL 0.01% RETIN_A GEL 0.025% RETIN A GEL 0.1% RETISOL A CR 0.01% RETISOL A CR 0.025% RETISOL A CR 0.05% RETISOL A CR FORTE 0.1% STIEVA-A CR 0.01% STIEVA-A CR 0.025% STIEVA-A CR 0.05% STIEVA-A FORTE CR 0.1% STIEVA-A GEL 0.01% STIEVA-A GEL 0.025% STIEVA-A GEL 0.05% STIEVA-A SOLN 0.025% STIEVA-A SOLN 0.05% STIEVAMYCIN FORTE GEL STIEVAMYCIN GEL STIEVAMYCIN MILD GEL VIT A ACID CR 0.01% VIT A ACID CR 0.025% VIT A ACID CR 0.05% VIT A ACID CR 0.1% VIT A ACID GEL 0.025% VIT A ACID GEL 0.05% VIT A ACID GEL MILD 0.01% VIT-A ACID CR 0.01% VIT-A ACID CR 0.025% VIT-A ACID CR 0.05% VIT-A ACID CR 0.1% VIT-A ACID GEL 0.025% VIT-A ACID GEL 0.05%

2 ACNE THERAPY Cont d. If covered person over 30 years of age approval by Liberty Health required VIT-A ACID GEL MILD 0.01% VITINOIN CR 0.025% VITINOIN CR 0.05% VITINOIN CR 0.1% VITINOIN GEL 0.025% AMYOTROPHIC LATERAL SCLEROSIS RILUTEK TAB 50MG ATOPIC DERMATITIS PROTOPIC OINT 0.1% PROTOPIC OINT 0.03% BOTOX BOTOX INJECTION CROHN S DISEASE REMICADE INJ IV 100MG/VL COX-2 CELEBREX CAP 100MG CELEBREX CAP 200MG VIOXX SUSP 12.5MG/5ML VIOXX TAB 12.5MG VIOXX TAB 25MG MOBICOX TAB 7.5MG MOBICOX TAB 15MG CYCLOSPORINE NEORAL CAP 10MG NEORAL CAP 25MG NEORAL CAP 50MG NEORAL CAP 100MG NEORAL CAP 100MG NEORAL LIQ NEORAL LIQ 100MG/ML NEORAL_CAP 10MG NEORAL_CAP 25MG NEORAL_CAP 50MG

3 CYCLOSPORINE Cont. SANDIMMUNE AMP 50MG SANDIMMUNE CAP 25MG SANDIMMUNE CAP 50MG SANDIMMUNE CAP 100MG SANDIMMUNE LIQ 100MG/ML SANDIMMUNE ORL SOLN 100MG SANDIMMUNE_CAP 25MG SANDIMMUNE_CAP 50MG SANDIMMUNE_CAP 100MG CYSTIC FIBROSIS COTAZYM CAP 300MG COTAZYM CAP 65B COTAZYM ECS 4 CAP COTAZYM ECS 8 CAP COTAZYM ECS 20 CAP COTAZYM PDR COTAZYM_ECS CAP COTAZYM_ECS CAP CREON 5 CAP CREON 8 CAP CREON 10 CAP CREON 20 CAP CREON 25 CAP PANCREASE CAP PANCREASE CAP MT PANCREASE MT 10 CAP PANCREASE MT 16 CAP PANCREASE EC SR CAP VIOKASE PDR VIOKASE PDR (114G) VIOKASE TAB VIOKASE_PDR VIOKASE_PDR (114GM) VIOKASE_TAB 325MG VIOKASE_TAB 325MG VIOKASE TAB VIOKASE TAB 325MG

4 CHRONIC HEPATITIS C PEG- INTRON INJ 50MCG/0.5ML PEG-INTRON INJ 80MCG/0.5ML PEG-INTRON INJ 120MCG/0.5ML PEG-INTRON INJ 150MCG/0.5ML RENAL DISEASE RENAGEL CAP 403MG RENAGEL TAB 400MG RENAGEL TAB 800MG RHEUMATOID ARTHRITIS ENBREL INJ 25MG/VIAL REMICADE INJ IV 100MG/VL KINERET TESTOSTERONE REPLACEMENT THERAPY ANDROGEL 25MG PER 2.5G GEL ANDROGEL 50MG PER 5.0G GEL ANDRODERM 12.2MG PATCH ANDRODERM 24.3 MG PATCH CHRONIC MYELOID LEUKEMIA GLEEVEC PULMONARY ARTERIAL HYPERTENSION TRACLEER 62.5MG TRACLEER 125MG FLOLAN 0.5MG/VIAL FLOLAN 1.5MG/VIAL INJECTIBLE IRON PRODUCTS INFUFER DEXIRON

5 MELANOMA MELACINE INJ KIDNEY TRANSPLANT THERAPY RAPAMUNE ORAL SOLN 1MG/ML ANTIBIOTICS ZYVOXAM TAB 600MG AGE RELATED MACULAR DEGENERATION VISUDYNE INJ 15MG VARICOSE VEIN/SCLEROSING AGENTS DEXTROJECT INJ 25% ETHANOLAMINE OLEATE INJ ETHANOLAMINE_OLEATE AMP SALIJECT SALIJECT INJ 570MG/ML SCLERODEX INJ SCLERODEX INJ 25% SCLERODEX IV INJ SCLERODINE INJ 3% SCLERODINE INJ 60MG/ML TROMBOJECT INJ 1% TROMBOJECT INJ 3% TROMBOVAR THERAPEX SOLN 1% TROMBOVAR THERAPEX SOLN 3% ANTI-EPILEPTIC DRUGS TRILEPTAL 150MG TABLETS TRILEPTAL 300MG TABLETS TRILEPTAL 600MG TABLETS TRILEPTAL 600MG/ML ORAL SUSPENSION

6 ANTI-ANEMIC DRUGS (ANEMIA ASSOCIATED WITH CHRONIC KIDNEY DISEASE) LIBERTY HEALTH ARANESP PF SYRINGE 10MCG - 0.4ML ARANESP PF SYRINGE 20MCG - 0.5ML ARANESP PF SYRINGE 30MCG 0.3ML, MCG 0.4ML, 50MCG 0.5ML ARANESP PF SYRINGE 60MGC 0.3ML, MCG 0.4ML, 100MCG 0.5ML ARANESP PF SYRINGE 150MCG 0.3ML CHRONIC LYMPHOCYTIC LEUKEMIA FLUDARA 10MG TABLET ANTI-OBESITY XENICAL CAP 120MG MERIDIA CAP 10MG MERIDIA CAP 15MG For Xenical and Meridia, the patient s physician must complete the Weight Loss Drug Therapy Authorization Form. ********************* 6

7 List 2 LIBERTY HEALTH ANTI NEOPLASTIC THERAPY FLUDARA INJ 50MG CANCER DRUGS INTRON A 3M IU PDR INTRON A 3M IU-0.5ML VIAL INTRON A 5M IU PDR INTRON A 5M IU-0.5ML VIAL INTRON A 5M IU/ML INTRON A 10M IU PDR INTRON A 10M IU-1ML VIAL INTRON A 18M IU M-DOSE PEN KIT INTRON A 18M IU-3ML VIAL INTRON A 18M IU-KIT INTRON A 25M IU-2.5ML VIAL INTRON A 30M IU M-DOSE PEN KIT INTRON A 60M IU M-DOSE PEN KIT INTRON-A 3M IU INTRON-A 5M IU INTRON-A 10M IU INTRON-A 10M IU ROFERON A PDR 3M IU ROFERON A PDR 9M IU ROFERON A PDR 18M IU ROFERON A SOLN INJ 3M IU ROFERON A SOLN INJ 4.5M IU ROFERON A SOLN INJ 6M IU ROFERON A SOLN INJ 9M IU ROFERON A SOLN INJ 18M IU ROFERON-A INJ 36M IU ROFERON-A PDR 18M IU ROFERON-A SOLN INJ 3M IU ROFERON-A SOLN INJ 9M IU ROFERON-A SOLN INJ 18M IU STEROIDS DUE TO GROWTH HORMONE FAILURE NUTROPIN AQ INJ 10MG NUTROPIN PDR 5MG NUTROPIN PDR 10MG PROTROPIN INJ 5MG PROTROPIN INJ 10MG PROTROPIN_INJ 5MG PROTROPIN_INJ 10MG SAIZEN PDR 5MG/VIAL SAIZEN PDR 10 IU (3.3MG VIAL)

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