Prior treatment with non-biologic Disease- Modifying Antirheumatic. Not to be used in combination with another biologic DMARD
|
|
- Edmund Fletcher
- 5 years ago
- Views:
Transcription
1 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): Active Adult RA 1. Rheumatologi st confirmed Active Juvenile Idiopathic Arthritis 1.Rheumatologist Confirmed 2.Over 6 years of age 3.Polyarthritis ( 5 joints) Congenital alpha 1- antitrypsin deficiency (AATD) and Emphysema Confirmed by Pulmonologist Contraindications/ Exclusions: Not to be used in combination with another biologic DMARD Not to be used in combination with another biologic DMARD IgA deficiency with antibodies against IgA due to the risk of developing hypersensitivity and anaphylactic reactions Step Therapy Required: Prior with non-biologic Disease- Modifying Antirheumatic Drug (DMARD) and failure due to 1 of the following: Significant intolerance Allergic response Continued symptoms after 3 months of Prior with a biologic DMARD (i.e., a TNF alpha antagonist) and failure due to 1 of the following: Significant intolerance Allergic response Continued symptoms after 6 weeks of Additional Required Clinical Criteria: Negative TB test or TB Risks of serious infection and cancer discussed with patient Negative TB test or TB Risks of serious infection and cancer discussed with patient Alpha 1-antitrypsin (AAT) < 11 um/l FEV1 30% and 65% Nonsmoker/ smoking cessation
2 J0256, J0257 Belimumab (Benlysta) J0490 Denosumab (Prolia) 56, 59 J0897 4, 20, 21, Active Systemic Lupus Erythematosus (SLE) 1. Rheumatologi st Confirmed (Board Certified) 2. Age 18 years Osteoporosis in postmenopausal women Osteoporosis in men Severe Active Lupus Nephritis (i.e., proteinuria 6 g/24 hr or serum creatinine 2.5mg/dl) Severe Active Central Nervous System Lupus Current with intravenous cyclophospha-mide Combination therapy Pregnancy Under 18 years of age with zoledronic acid within the past year Hypocalcemia Receiving standard of care for SLE, for at least 30 days, including (alone or in combination): 1.Corticosteroids 2.Antimalarials 3.Non-biologic immunosuppress-ive medications Tried and/or failed oral bisphosphonate-nates: Intolerance to/contraindicati on to/or failure to respond to oral If oral are not tolerated due to the oral route of administration, but there is no documented contraindication or failure to respond to otherwise, intolerance to/contraindicati May be used as a steroid sparing agent; when unable to wean from steroids; ongoing disease activity that is not controlled despite optimization of immunosuppressives. Osteoporotic (defined by T- score below -2.5) by dual x-ray absorptiometry (DXA), or low impact fracture Normal phosphorus and magnesium levels Planned supplementation with calcium and Vitamin- D Routine oral exam performed
3 Golimumab (Simponi Aria) 1, 2, 22, 33, 29, 42, 44, 45, 48, 51 J1602 Natalizumab (Tysabri) 23, 27, 38, 54, 58 J2323 8, 15, 19, Rheumatoid Arthritis (RA) 1.Rheumatologist Confirmed; with 2.Ongoing disease activity (in a commonly used scoring system) 3.Age 18 years Relapsing Remitting Multiple Sclerosis (RRMS) 1.Confirmed by a Neurologist 2.Over 18 years of age Inflammatory Bowel Disease [i.e., Crohn s Disease (CD) ] 1.Moderate to severe Combination drug therapy for MS Perianal fistulizing disease on to/or failure to respond to IV must be documented Prior with non-biologic Disease- Modifying Antirheumatic Drug (DMARD) and failure due to 1 of the following: after 3 months of Previous with 1 MS disease modifying drugs (biologic or glatiramer acetate) with failure, due to one of the following: 3.Progression of disability or worsening neurologic function 4.Significant relapse or new MRI lesions after therapy 6 months Previous with biologics with failure, due to one of the following: TB testing negative or TB treated Risks of serious infection and cancer discussed with patient May be combined with Methotrexate Risk of progressive multifocal leukoencephalopathy (PML) discussed with patient or caregiver Negative JC virus testing Enrollment in TOUCH Prescribing Program Risk of progressive multifocal leukoencephalopathy (PML) discussed with
4 Romiplostin (Nplate) 39, 60 J2796 3, 25, 34, Taliglucerase alfa (Elelyso) 28, 33, 36, 37, 61 J3060 Tocilizumab (Actemra) 1, 2, 7, 14, 17, 24, 32, 42, 44, 48, 49, 51, 53, 55 J3262 disease confirmed by a Gastroenterologist 2.Over age 18 Immune Thrombocytopenia (ITP) 1.Confirmed by a specialist 2.Maintenance therapy for platelet count < 30 x10 (9)/L 3.Over age 18 Type 1 Gaucher disease (confirmed by Beta-glucosylceramidase activity or GBA gene test) Active Rheumatoid Arthritis (RA) 1.Confirmed by Rheumatologist 2.Over 18 years of age Juvenile Idiopathic Arthritis (Systemic, Polyarticular) Bleeding episode (urgent) Age 18 and 65 Type 2 Gaucher Disease Type 3 Gaucher disease 2 years of age or findings 2 months Prior therapy with: Corticosteroid and/or immune globulin with failure, due to one of the following: 2.Continued platelet count < 30 x10 (9)/L 3.Allergic response Tried and/or failed 1 Disease-Modifying Antirheumatic Drug (DMARD) with failure due to: after 3 months of Previously treated for JIA (e.g. NSAIDs, corticosteroids, or patient Negative JC virus testing Enrollment in TOUCH Prescribing Program Risk of thrombosis discussed with patient With one of the following: Anemia Thrombocytopenia Splenomegaly Hepatomegaly Bone disease Negative TB test or TB Risks of serious infection and cancer discussed with patient Negative TB test or TB Risks of serious infection and
5 Vedolizumab (Entyvio) 52, 54) C , 38, 46, Velaglucerase Alfa (VPRIV) 28, 36, 47, 61 J3385 Zoledronic Acid 9, 21, 26, (Reclast) 35, 41, 43, 56, 59 J Rheumatologist Confirmed 2.Moderate to high disease activity 3.Active in 5 joints Inflammatory Bowel Disease (i.e., Crohn s Disease, ulcerative colitis) 1.Gastroenterologist Confirmed 2.Age 18 Type 1 Gaucher disease (confirmed by Beta-glucosylceramidase activity or GBA gene test) Osteoporosis or Osteopenia in postmenopausal women Osteoporosis in men Paget s Disease 1.With consistent radiographic findings 2.Elevated serum alkaline phosphatase Glucocorticoid- Perianal fistulizing disease Age 18 and 65 Type 2 Gaucher Disease Type 3 Gaucher disease Current with similar medication (e.g., Zometa, Xgeva, or Prolia) Pregnancy Under 18 years of age with zoledronic acid within the past year Hypocalcemia methotrexate) Previous with biologics with failure, due to one of the following: or findings 6 weeks Tried and/or failed oral Patients with creatinine clearance of 35mL/min and in those with evidence of acute renal impairment cancer discussed with patient Biologic therapy failure due to: or side effects 2. Allergic response 3. Continued symptoms or findings 2 months With one of the following: 1.Anemia 2.Thrombocytopenia 3.Splenomegaly 4.Hepatomegaly 5.Bone disease Osteopenic (T-score -1.0 to - 2.5) or osteoporotic (T-score below -2.5) by dual x-ray absorptiometry (DXA), or low impact fracture Renal function evaluated and no evidence of renal impairment Normal phosphorus and magnesium levels Planned supplementation with calcium and Vitamin- D Osteoporosis (postmenopausal females, males)
6 induced osteoporosis (GIO) or with glucocorticoids for more than 3 months and GIO : 5 mg once a year Osteoporosis prevention (post-menopausal women) : 5 mg once every 2 years Paget s disease : a single 5 mg infusion
Medical Policy. MP Specialty Drugs. Related Policies Guidelines for Prior Authorization of Pharmacologic Therapies
Medical Policy Last Review: 04/30/2018 Effective Date: 07/01/2018 Section: Prescription Drug Related Policies 5.01.501 Guidelines for Prior Authorization of Pharmacologic Therapies DISCLAIMER Our medical
More informationMP Specialty Drugs: Drug-Specific Criteria
Abatacept (Orencia) J0129 Moderate to Severe Active Adult RA 1. Rheumatologist confirmed Not to be used in combination with another biologic DMARD Prior treatment with nonbiologic Disease- Modifying Antirheumatic
More information1 P a g e. Systemic Juvenile Idiopathic Arthritis (SJIA) (1.3) Patients 2 years of age and older with active systemic juvenile idiopathic arthritis.
LENGTH OF AUTHORIZATION: Initial: 3 months for Crohn s or Ulcerative Colitis; 1 year for all other indications. Renewal: 1 year dependent upon medical records supporting response to therapy and review
More informationPharmacy Management Drug Policy
SUBJECT: Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs POLICY NUMBER: PHARMACY-73 EFFECTIVE DATE: 01/01/2018 LAST REVIEW DATE: 06/11/2018 If the member s subscriber
More informationImmune Modulating Drugs Prior Authorization Request Form
Patient: HPHC member ID #: Requesting provider: Phone: Servicing provider: Diagnosis: Contact for questions (name and phone #): Projected start and end date for requested Requesting provider NPI: Fax:
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Humira (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationRegulatory Status FDA-approved indication: Orencia is a selective T cell co-stimulation modulator indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Orencia Page: 1 of 9 Last Review Date: September 20, 2018 Orencia Description Orencia (abatacept)
More informationRegulatory Status FDA-approved indications: Entyvio is an α4β7integrin receptor antagonist indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.12 Subject: Entyvio Page: 1 of 7 Last Review Date: September 20, 2018 Entyvio Description Entyvio
More informationDrug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases
Drug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases Line of Business: Medicaid P & T Approval Date: August 16, 2017 Effective Date: August 16, 2017 This policy
More informationCarelirst.+.V Family of health care plans
Carelirst.+.V Family of health care plans CVS Caremark POLICY Document for ACTEMRA The overall objective of this policy is to support the appropriate and cost effective use of the medication, specific
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Humira (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationRegulatory Status FDA-approved indication: Tysabri is an integrin receptor antagonist indicated for treatment of (1):
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.60.13 Subject: Tysabri Page: 1 of 6 Last Review Date: June 22, 2017 Tysabri Description Tysabri (natalizumab)
More information3. Has the patient shown improvement in signs and symptoms of the disease? Y N
Pharmacy Prior Authorization MERC CARE (MEDICAID) Orencia (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed
More informationCIMZIA (certolizumab pegol)
Pre - PA Allowance None Prior-Approval Requirements Age Diagnoses 18 years of age or older Patient must have ONE of the following: 1. Moderate to severe Crohn s Disease (CD) a. Inadequate response, intolerance
More informationRegulatory Status FDA-approved indication: Tysabri is an integrin receptor antagonist indicated for treatment of:
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.08.27 1 of 6 Last Review Date: December 5, 2014 Tysabri Description Tysabri (natalizumab) Background
More informationCLINICAL MEDICAL POLICY
Policy Name: Policy Number: Responsible Department(s): CLINICAL MEDICAL POLICY Tysabri (natalizumab) MP-042-MD-WV Provider Notice Date: 10/01/2017 Original Effective Date: 11/01/2017 Annual Approval Date:
More informationRegulatory Status FDA-approved indication: Orencia is a selective T cell costimulation modulator indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.18 Subject: Orencia Page: 1 of 8 Last Review Date: March 16, 2018 Orencia Description Orencia (abatacept)
More informationACTEMRA (tocilizumab)
Pre - PA Allowance None Prior-Approval Requirements Diagnoses Patient must have ONE of the following: 1. Active Polyarticular Juvenile Idiopathic Arthritis (PJIA) b. Patient has an intolerance or has experienced
More informationRegulatory Status FDA-approved indication: Orencia is a selective T cell costimulation modulator indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.18 Subject: Orencia Page: 1 of 6 Last Review Date: December 8, 2017 Orencia Description Orencia (abatacept)
More informationActemra. Actemra (tocilizumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.12 Subject: Actemra Page: 1 of 13 Last Review Date: September 20, 2018 Actemra Description Actemra
More informationTYSABRI Treatment Initiation Form
TYSABRI Treatment Initiation Form This form should be read carefully before starting treatment with TYSABRI. Please follow the advice in this form to ensure that you are fully informed of, and understand
More informationProgressive Multifocal Leukoencephalopathy (PML) in Natalizumab-Treated Patients: Experience of the FDA Division of Neurology Products
Progressive Multifocal Leukoencephalopathy (PML) in Natalizumab-Treated Patients: Experience of the FDA Division of Neurology Products M. Lisa Jones MD, MPH Russell Katz, M.D. Director Division of Neurology
More informationINFLIXIMAB Remicade (infliximab), Inflectra (infliximab-dyyb), Ixifi* (infliximabqbtx), Renflexis (infliximab-abda)
Pre - PA Allowance None Prior-Approval Requirements Diagnoses Patient must have ONE of the following: 6 years of age or older 1. Moderate to severe Crohn s disease (CD) a. Patient has fistulizing disease
More information3. Has the patient shown improvement in signs and symptoms of the disease? Y N
Pharmacy Prior Authorization MERC CARE (MEDICAID) Renflexis (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationCommittee Approval Date: May 9, 2014 Next Review Date: May 2015
Medication Policy Manual Policy No: dru248 Topic: Benlysta, belimumab Date of Origin: May 13, 2011 Committee Approval Date: May 9, 2014 Next Review Date: May 2015 Effective Date: June 1, 2014 IMPORTANT
More information2. Does the patient have a diagnosis of giant cell arteritis (GCA)? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Actemra (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More information3. Is the prescribed dose within the Food and Drug Administration (FDA)- approved dosing for giant cell arteritis?
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Actemra (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationHorizon Scanning Technology Summary. Abatacept (Orencia) for juvenile idiopathic arthritis. National Horizon Scanning Centre.
Horizon Scanning Technology Summary National Horizon Scanning Centre Abatacept (Orencia) for juvenile idiopathic arthritis June 2007 This technology summary is based on information available at the time
More informationUnitedHealthcare Pharmacy Clinical Pharmacy Programs
Program Number 2017 P 3041-8 Program Step Therapy Medications UnitedHealthcare Pharmacy Clinical Pharmacy Programs *Orencia (abatacept) *This step criteria refers to the subcutaneous formulation of abatacept
More informationFirst Name. Specialty: Fax. First Name DOB: Duration:
Prescriber Information Last ame: First ame DEA/PI: Specialty: Phone - - Fax - - Member Information Last ame: First ame Member ID umber DOB: - - Medication Information: Drug ame and Strength: Diagnosis:
More informationCoverage Criteria: Express Scripts, Inc. monograph dated 12/15/ months or as otherwise noted by indication
BENEFIT DESCRIPTION AND LIMITATIONS OF COVERAGE ITEM: PRODUCT LINES: COVERED UNDER: DESCRIPTION: CPT/HCPCS Code: Company Supplying: Setting: Kineret (anakinra subcutaneous injection) Commercial HMO/PPO/CDHP
More information2. Does the patient have a diagnosis of ulcerative colitis or Crohn s? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH LOUISIAA (MEDICAID) Remicade (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More informationMedication Policy Manual. Topic: Otezla, apremilast Date of Origin: May 9, 2014
Medication Policy Manual Policy No: dru342 Topic: Otezla, apremilast Date of Origin: May 9, 2014 Committee Approval Date: January 19, 2015 Next Review Date: January 2016 Effective Date: April 1, 2015 IMPORTANT
More informationStelara. Stelara (ustekinumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.90.04 Subject: Stelara Page: 1 of 9 Last Review Date: September 20, 2018 Stelara Description Stelara
More informationContents Please refer to Medical Policy I-31, Tocilizumab (Actemra) for additional information.
In This Issue January 2018 Coverage Criteria Revised for Alpha1-Proteinase Inhibitor Infusions... 2 Coverage Criteria Revised for Eculizumab (Soliris)... 3 Coverage Criteria Revised for Chimeric Antigen
More informationAETNA BETTER HEALTH Prior Authorization guideline for Injectable Osteoporosis Agents
AETNA BETTER HEALTH Prior Authorization guideline for Injectable Osteoporosis Agents Injectable Osteoporosis Agents Forteo (teriparatide); zoledronic acid Prolia (denosumab)] Authorization guidelines For
More informationThis Coverage Policy applies to Individual Health Insurance Marketplace benefit plans only.
This Coverage Policy applies to Individual Health Insurance Marketplace benefit plans only. INJECTABLE OSTEOPOSIS AGENTS SUBJECT Pharmacologic Agents: Bisphosphonates: Boniva IV (ibandronate) Reclast (zoledronic
More informationCimzia. Cimzia (certolizumab pegol) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.11 Section: Prescription Drugs Effective Date: April 1, 2018 Subject: Cimzia Page: 1 of 5 Last Review
More informationORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION
UnitedHealthcare Community Plan Medical Benefit Drug Policy ORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION Policy Number: CS2018D0039J Effective Date: March 1, 2018 Table of Contents Page INSTRUCTIONS
More informationBiologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary Biologic Immunomodulators Prior Authorization with Quantity Limit (with a preferred option) OBJECTIVE The intent of the
More informationRHEUMATOID ARTHRITIS DRUGS
Rheumatology Biologics Criteria from the Exceptional Access Program RHEUMATOID ARTHRITIS DRUGS DRUG NAME BRS REIMBURSED DOSAGE FORM/ STRENGTH Adalimumab Humira 40 mg/0.8 syringe and 40mg/0.8 pen for Anakinra
More informationPharmacy Management Drug Policy
SUBJECT: - Forteo (teriparatide), Prolia (denosumab), Tymlos (abaloparatide) POLICY NUMBER: Pharmacy-35 EFFECTIVE DATE: 9/07 LAST REVIEW DATE: 9/29/2017 If the member s subscriber contract excludes coverage
More informationRemicade. Remicade (infliximab), Inflectra (infliximab-dyyb) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.02 Subsection: Gastrointestinal nts Original Policy Date: May 20, 2011 Subject: Remicade Page: 1 of
More informationMedication Policy Manual. Topic: Xeljanz, tofacitinib Date of Origin: January 21, 2013
Medication Policy Manual Policy No: dru289 Topic: Xeljanz, tofacitinib Date of Origin: January 21, 2013 Committee Approval Date: January 19, 2015 Next Review Date: January 2016 Effective Date: April 1,
More informationS H A R E D C A R E G U I D E L I N E Drug: Denosumab 60mg injection Indication: treatment of osteoporosis in postmenopausal women
S H A R E D C A R E G U I D E L I N E Drug: Denosumab 60mg injection Indication: treatment of osteoporosis in postmenopausal women Introduction Indication: Denosumab (Prolia ) is recommended in NICE TA204
More informationPharmacy Management Drug Policy
SUBJECT: - Forteo (teriparatide), Prolia (denosumab), Tymlos (abaloparatide), Boniva injection (Ibandronate) POLICY NUMBER: Pharmacy-35 EFFECTIVE DATE: 9/07 LAST REVIEW DATE: 10/15/2018 If the member s
More informationRemicade. Remicade (infliximab), Inflectra (infliximab-dyyb) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Remicade Page: 1 of 9 Last Review Date: June 22, 2017 Remicade Description Remicade (infliximab),
More informationHARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES HUMIRA PEDIATRIC
Generic Brand HICL GCN Exception/Other ADALIMUMAB HUMIRA 24800 HUMIRA PEDIATRIC GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Is the patient currently taking Humira? If
More informationDrug Therapy Guidelines
Simponi, Simponi Aria Applicable Medical Benefit x Effective: 2/13/18 Pharmacy- Formulary 1 x Next Review: 12/18 Pharmacy- Formulary 2 x Date of Origin: 7/2010 Pharmacy- Formulary 3/Exclusive x Review
More informationRegulatory Status FDA- approved indication: Simponi and Simponi ARIA are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 9 Last Review Date: March 16, 2018 Simponi / Simponi
More informationLocal Natalizumab Treatment Protocol
Local Natalizumab Treatment Protocol 1. New medicine name: Natalizumab 300mg concentrate for solution for infusion (Natalizumab ) 2. Licensed indication(s): Natalizumab is indicated for single disease
More information2. Has the patient had a response to treatment? Y N. 3. Does the patient have a diagnosis of rheumatoid arthritis (RA)? Y N
12/21/2016 Prior Authorization Aetna Better Health of West Virginia Humira (WV88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and
More informationCosentyx. Cosentyx (secukinumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.90.11 Subject: Cosentyx Page: 1 of 7 Last Review Date: September 20, 2018 Cosentyx Description Cosentyx
More information3. Does the patient have a diagnosis of rheumatoid arthritis (RA) with moderate to high disease activity?
Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Enbrel (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationThe 2017 CMS Merit-based Incentive Payment System includes 2 inflammatory bowel disease (IBD) measures.
The 2017 CMS Merit-based Incentive Payment System includes 2 inflammatory bowel disease (IBD) measures. Measure Specifications for Registry Reporting MIPS #271: Inflammatory Bowel Disease (IBD): Preventive
More informationSimponi / Simponi ARIA (golimumab)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 6 Last Review Date: September 15, 2016 Simponi / Simponi
More informationOsteoporosis challenges
Osteoporosis challenges Osteoporosis challenges Who should have a fracture risk assessment? Who to treat? Drugs, holidays and unusual adverse effects Fracture liaison service? The size of the problem 1
More informationCimzia. Cimzia (certolizumab pegol) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.11 Subject: Cimzia Page: 1 of 5 Last Review Date: December 8, 2017 Cimzia Description Cimzia (certolizumab
More informationONE of the following:
Medical Coverage Policy Belimumab (Benlysta) EFFECTIVE DATE: 01 01 2012 POLICY LAST UPDATED: 11 21 2017 OVERVIEW Belimumab (Benlysta ) is indicated for the treatment of adult patients with active, autoantibody-positive,
More informationPharmacy Management Drug Policy
Clinical criteria used to make utilization review decisions are based on credible scientific evidence published in peer reviewed medical literature generally recognized by the medical community. Guidelines
More informationMEDICATION GUIDE. (tocilizumab)
MEDICATION GUIDE ACTEMRA (AC-TEM-RA) (tocilizumab) Read this Medication Guide before you start ACTEMRA and before each infusion. There may be new information. This Medication Guide does not take the place
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization AETA BETTER HEALTH KETUCK Enbrel (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationEvidence review for Surrey Prescribing Clinical Network SUMMARY
East Surrey CCG, Guildford & Waverley CCG, North West Surrey CCG, Surrey Downs CCG, Surrey Heath CCG, Crawley CCG, Horsham & Mid-Sussex CCG Evidence review for Surrey Prescribing Clinical Network Medicine
More informationCorporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: abatacept_orencia 4/2008 2/2018 2/2019 2/2018 Description of Procedure or Service Abatacept (Orencia ), a
More informationInflectra Frequently Asked Questions
Inflectra Frequently Asked Questions 1. What is the funding status of Inflectra (infliximab)? Earlier in 2016, Inflectra (infliximab) was added to the Ontario Drug Benefit (ODB) Formulary as a Limited
More informationBone Densitometry Pathway
Bone Densitometry Pathway The goal of the Bone Densitometry pathway is to manage our diagnosed osteopenic and osteoporotic patients, educate and monitor the patient population at risk for bone density
More informationRegulatory Status FDA- approved indication: Simponi and Simponi ARIA are tumor necrosis factor (TNF) blockers indicated for the treatment of:
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 8 Last Review Date: March 17, 2017 Simponi / Simponi
More informationCarefirst.+.V Family of health care plans
Carefirst.+.V Family of health care plans CVS care mark POLICY Document for ENTYVIO The overall objective of this policy is to support the appropriate and cost effective use of the medication, specific
More informationCenter for Evidence-based Policy
P&T Committee Brief Targeted Immune Modulators: Comparative Drug Class Review Alison Little, MD Center for Evidence-based Policy Oregon Health & Science University 3455 SW US Veterans Hospital Road, SN-4N
More informationCorporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: golimumab_simponi 8/2013 2/2018 2/2019 3/2018 Description of Procedure or Service Golimumab (Simponi and
More informationC. Assess clinical response after the first three months of treatment.
Government Health Plan (GHP) of Puerto Rico Authorization Criteria Tumor Necrosis Factor Alpha (TNFα) Adalimumab (Humira ) Managed by MCO Section I. Prior Authorization Criteria A. Physician must submit
More informationDrug Class Review Targeted Immune Modulators
Drug Class Review Targeted Immune Modulators Final Update 5 Report June 2016 The purpose of reports is to make available information regarding the comparative clinical effectiveness and harms of different
More informationPharmacy Management Drug Policy
SUBJECT: Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn s Disease, Psoriatic Arthritis and Rheumatoid Arthritis POLICY NUMBER: PHARMACY-07 EFFECTIVE DATE: 5/2009 LAST REVIEW DATE: 6/13/2018
More informationADALIMUMAB Generic Brand HICL GCN Exception/Other ADALIMUMAB HUMIRA GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)
Generic Brand HICL GCN Exception/Other ADALIMUMAB HUMIRA 24800 GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Does the patient have a diagnosis of moderate to severe rheumatoid
More informationRheumatoid arthritis
Rheumatoid arthritis 1 Definition Rheumatoid arthritis is one of the most common inflammatory disorders affecting the population worldwide. It is a systemic inflammatory disease which affects not only
More informationCorporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: infliximab_remicade 5/2002 2/2017 2/2018 2/2017 Description of Procedure or Service Infliximab (REMICADE
More informationCimzia. Cimzia (certolizumab pegol) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Cimzia Page: 1 of 5 Last Review Date: March 17, 2017 Cimzia Description Cimzia (certolizumab pegol)
More informationOsteoporosis Clinical Guideline. Rheumatology January 2017
Osteoporosis Clinical Guideline Rheumatology January 2017 Introduction Osteoporosis is a condition of low bone mass leading to an increased risk of low trauma fractures. The prevalence of osteoporosis
More informationWhat prescribers need to know
HUMIRA Citrate-free presentations in an Electronic Medical Record (EMR) What prescribers need to know 2 / This is your guide to identifying HUMIRA Citrate-free presentations in your Electronic Medical
More informationHELPING YOU AND YOUR PATIENTS TALK OPENLY ABOUT MODERATELY TO SEVERELY ACTIVE RA
SIMPONI ARIA (golimumab) is indicated for the treatment of adults with moderately to severely active rheumatoid arthritis (RA) in combination with MTX, active psoriatic arthritis, and active ankylosing
More informationBiologics for Autoimmune Diseases
Biologics for Autoimmune Diseases Goal(s): Restrict use of biologics to OHP funded conditions and according to OHP guidelines for use. Promote use that is consistent with national clinical practice guidelines
More informationUNC INFLAMMATORY BOWEL DISEASE DRUG PROTOCOL VEDOLIZUMAB (ENTYVIO)
UNC INFLAMMATORY BOWEL DISEASE DRUG PROTOCOL VEDOLIZUMAB (ENTYVIO) TREATMENT PROTOCOL: Vedolizumab is a humanized immunoglobulin G1 monoclonal antibody that targets 41 integrin and blocks its interaction
More informationParathyroid Hormone Analogs
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.30.36 Subject: Parathyroid Hormone Analogs Page: 1 of 6 Last Review Date: September 15, 2017 Parathyroid
More informationCorporate Medical Policy
Corporate Medical Policy Infliximab, Infliximab-dyyb, Infliximab-abda File Name: Origination: Last CAP Review: Next CAP Review: Last Review: infliximab 5/2002 2/2018 2/2019 7/2018 Description of Procedure
More informationCircle Yes or No Y N. [If no, skip to question 7.] 2. Does the patient have a diagnosis of ulcerative colitis? Y N. [If no, skip to question 4.
06/01/2016 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Humira (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More informationSubject: Remicade (Page 1 of 5)
Subject: Remicade (Page 1 of 5) Objective: I. To ensure that Health Share/Tuality Health Alliance (THA) has a process by which the appropriate utilization of Remicade (Infliximab) for members whose diagnosis
More informationACTEMRA (tocilizumab)
ACTEMRA (tocilizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationClinical Policy: Natalizumab (Tysabri) Reference Number: ERX.SPA.162 Effective Date:
Clinical Policy: (Tysabri) Reference Number: ERX.SPA.162 Effective Date: 10.01.16 Last Review Date: 11.18 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More information[If no, skip to question 10.] Y N. 2. Does the member have a diagnosis of Paget s disease of bone? Y N. [If no, skip to question 4.
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Zoledronic Acid (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationOrencia (abatacept) DRUG.00040
Market DC Orencia (abatacept) DRUG.00040 Override(s) Prior Authorization Quantity Limit Approval Duration 1 year Medications Comments Quantity Limit Orencia (abatacept) - AGP, VA MCD only 4 vials per 28
More informationThe ORENCIA (abatacept) JIA Observational Registry
Moderate to Severe Juvenile Idiopathic Arthritis (JIA) Injection for Intravenous Use Injection for Subcutaneous Use The ORENCIA (abatacept) JIA Observational Registry Injection for Intravenous Use Injection
More informationBONIVA (ibandronate sodium)
BONIVA (ibandronate sodium) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationReporting Autoimmune Diseases in Hematopoietic Stem Cell Transplantation
Reporting Autoimmune Diseases in Hematopoietic Stem Cell Transplantation Marcelo C. Pasquini, MD, MSc HVD05_1.ppt Outline Review of autoimmune diseases (AID). Role of transplantation for AID Data collection:
More informationTherapeutic Agents in Rheumatic and Inflammatory Diseases Drug Class Prior Authorization Protocol
Therapeutic Agents in Rheumatic and Inflammatory Diseases Drug Class Prior Authorization Protocol Line of Business: Medi-Cal Effective Date: August 16, 2017 Revision Date: August 16, 2017 This policy has
More informationORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION
ORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION UnitedHealthcare Commercial Medical Benefit Drug Policy Policy Number: 2018D0039J Effective Date: March 1, 2018 Table of Contents Page INSTRUCTIONS
More informationBENEFIT CHANGES TO NBPDP
Bulletin #789 June 15, 2010 BENEFIT CHANGES TO NBPDP This update to the New Brunswick Prescription Drug Program (NBPDP) Formulary is effective June 15, 2010. Included in this bulletin: Regular Benefit
More information