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1 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/ zidovudine AUBAGIO Multiple Sclerosis CETROTIDE Infertility ABRAXANE AVASTIN chorionic gonadotropin Infertility ACTEMRA Rheumatoid Arthritis AVONEX Multiple Sclerosis cidofovir ACTHAR HP azacitidine CIMZIA Crohn's Disease ACTIMMUNE B CIMZIA Rheumatoid Arthritis ADCETRIS BARACLUDE Hepatitis B CINRYZE Hereditary Angioedema ADCIRCA BEBULIN Hemophilia cisplatin adefovir dipivoxil Hepatitis B BEBULIN VH Hemophilia cladribine ADEMPAS BELEODAQ CLOLAR ADRIAMYCIN BENEFIX Hemophilia colistimethate sodium Infection-Bacterial ADRUCIL BENLYSTA Lupus COLY-MYCIN M Infection-Bacterial ADVATE Hemophilia BERINERT Hereditary Angioedema COMBIVIR AFINITOR BETASERON Multiple Sclerosis COMETRIQ ALDURAZYME BETHKIS Cystic Fibrosis COMPLERA ALFERON N Condylomata Acuminata BICNU COPAXONE Multiple Sclerosis ALIMTA BIVIGAM Immunodeficiency COPEGUS ALKERAN bleomycin COSMEGEN ALOXI Adjunct BONIVA Osteoporosis CRIXIVAN ALPHANATE Hemophilia BOSULIF cyclophosphamide ALPHANINE SD Hemophilia BOTOX Cervical Dystonia CYRAMZA ALPROLIX Hemophilia BRAVELLE Infertility CYSTAGON Nephropathic Cystinosis amifostine Adjunct BUPHENYL Urea Cycle Disorder cytarabine AMPYRA Multiple Sclerosis BUSULFEX CYTOGAM Cytomegalovirus ANZEMET Postoperative Nausea C CYTOVENE Cytomegalovirus APTIVUS CAMPTOSAR D ARALAST NP capecitabine dacarbazine ARANESP Anemia CAPRELSA DACOGEN ARCALYST Cryopyrin associated Periodic Syndromes CARBAGLU NAGS daunorubicin ARIXTRA Anticoagulant carboplatin DAUNOXOME 1 of 5
2 DDAVP Hemophilia ERWINAZE GAZYVA decitabine estradiol valerate gemcitabine DELESTROGEN ETHYOL Adjunct GEMZAR desmopressin acetate Hemophilia ETOPOPHOS GENOTROPIN Growth Hormone dexrazoxane etoposide GILENYA Multiple Sclerosis didanosine EUFLEXXA Osteoarthritis GILOTRIF DOCEFERZ EXJADE Iron Overload GLASSIA docetaxel EXTAVIA Multiple Sclerosis GLEEVAC doxercalciferol F GONAL-F Infertility DOXIL FABRAZYME Fabry's Disease granisetron Adjunct doxorubicin FASLODEX GRANIX Adjunct doxorubicin liposomal FEIBA NF Hemophilia H E FIRAZYR Hereditary Angioedema HALAVEN EDURANT FIRMAGON HARVONI EGRIFTA FLEBOGAMMA Immunodeficiency HECTOROL Secondary Hyperparathyroidism ELAPRASE Hunter Syndrome FLOLAN HELIZATE FS Hemophilia ELELYSO Gaucher's Disease floxuridine HEMOFIL M Hemophilia ELIGARD FLUDARA HEPSERA Hemophilia ELLENCE fludarabine HERCEPTIN ELOCTATE Hemophilia fluorouracil HETLIOZ Sleep-Wake Disorder ELOXOXITIN flutamide HEXALEN ELYEA Macular Edema FOLLISTIM AQ Infertility HIZENTRA Immunodeficiency EMCYT FOLOTYN HUMATE P Hemophilia EMEND Adjunct fondaparinux Anticoagulant HUMATROPE Growth Hormone EMTRIVA FORTEO Osteoporosis HUMIRA Crohn's Disease ENBREL Psoriasis FRAGMIN Anticoagulant HUMIRA Plaque Psoriasis ENBREL Rheumatoid Arthritis FUSILEV Adjunct HUMIRA Rheumatoid Arthritis enoxaparin Anticoagulant FUZEON HUMIRA Rheumatoid Arthritis entecavir Hepatitis B G HUMIRA Ulcerative Colitis ENTYVIO Crohn's Disease GAMASTAN S/D Immunodeficiency HYALGAN Osteoarthritis epirubicin GAMMAGARD Immunodeficiency HYCAMTIN EPIVIR GAMMAGARD S/D Immunodeficiency HYCAMTIN EPIVIR HBV Hepatitis B GAMMAKED Immunodeficiency HYPERRHO S/D RH Hemolytic Disease EPOGEN Anemia GAMMAPLEX Immunodeficiency HYQVIA Immunodeficiency epoprostenol GAMUNEX-C Immunodeficiency I EPZICOM ganciclovir Cytomegalovirus ibandronate sodium Osteoporosis ERBITUX GANIRELIX ACETATE Infertility ICLUSIG ERIVEDGE GATTEX Short Bowel Syndrome IDAMYCIN PFS 2 of 5
3 idarubicin L MYOBLOC Cervical Dystonia IFEX lamivudine MYOZYME Pompe Disease ifosfamide lamivudine/zidovudine N ifosfamide/mesna LETAIRIS NAGLAZYME Mucopolysaccharidosis ILARIS Juvenile Idiopathic leucovorin calcium NAVELBINE Arthritis Adjunct IMBRUVICA leuprolide acetate NEBUPENT INCIVEK LEXIVA NEULASTA Adjunct INCRELEX Growth Hormone LIPODOX NEUMEGA Adjunct INLYTA LOVENOX Anticoagulant NEUPOGEN Adjunct INTELENCE Macular LUCENTIS nevirapine Degeneration INTRON-A LUMIZYME Pompe Disease nevirapine er INTRON-A LUPANETA PACK Endometriosis NEXAVAR INVIRASE LUPRON DEPOT NEXAVIR Infection - Viral IPRIVASK Anticoagulant LYSODREN NIPENT irinotecan M NORDITROPIN Growth Hormone ISENTRESS MACUGEN Macular NORTHERA Degeneration Orthostatic ISTODAX MAKENA Preterm Birth NORVIR IXEMPRA KIT MARQIBO NOVAREL Infertility J MATULANE NOVOSEVEN RT Hemophilia JAKAFI Myelofibrosis MEKINIST NPLATE Immune Thrombocytopenic Purpura Symptomatic JETREA melphalan NULOJIX Vitreomacular Adhesion Kidney Rejection JEVTANA MENOPUR Infertility NUTROPIN Growth Hormone Familial JUXTAPID mesna NUTROPIN AQ Hypercholesterolemia Adjunct Growth Hormone K MESNEX Adjunct O KADCYLA MICRHOGAM PLUS RH Hemolytic Disease OCTAGAM Immunodeficiency KALBITOR Heriditary Angioedema mitomycin octreotide acetate Acromegaly KALETRA mitoxantrone OLYSIO KALYDECO Cystic Fibrosis MODERIBA OMNITROPE Growth Hormone KEYTRUDA MONOCLATE-P Hemophilia ONCASPAR KINERET Rheumatoid Arthritis MONONINE Hemophilia ondansetron Adjunct KOGENATE FS MONOVISC OPSUMIT Hemophilia Osteoarthritis KRYSTEXXA Gout MOZOBIL ORENCIA Rheumatoid Arthritis KUVAN Familial Hypercholesterolemia MUSTARGEN ORENITRAM KYNAMRO MYALEPT Leptin ORTHOVISC Osteoarthritis KYPROLIS MYLERAN OTEZLA Plaque Psoriasis 3 of 5
4 OTREXUP Rheumatoid Arthritis REMICADE Rheumatoid Arthritis SOVALDI OVIDREL Infertility REMICADE Ulcerative Colitis SPRYCEL oxaliplatin OXSORALEN ULTRA Psoriasis REMODULIN REPRONEX Infertility stavudine STELARA Plaque Psoriasis P RESCRIPTOR STIMATE Hemophilia paclitaxel RETROVIR STIVARGA pamidronate RETROVIR IV STRIBILD sodium Hypercalcemia pamidronate REVATIO SUCRAID sodium Paget's Disease Sucrase PEGASYS REVLIMID SUPARTZ Osteoarthritis PEG-INTRON Central Precocious REYATAZ SUPPRELIN LA Puberty PENTAM 300 RHOGAM PLUS RH Hemolytic Disease SUSTIVE PERJETA Adjunct RHOPHYLAC RH Hemolytic Disease SUTENT PLEGRIDY Multicentric Castleman s RIBAPAK SYLANT Multiple Sclerosis Disease POMALYST ribasphere SYLATRON PREGNYL Respiratory Syncytial RIBATAB SYNAGIS Infertility Virus PREZISTA ribavirin SYNRIBO PRIVIGEN Immunodeficiency RITUXAN SYNVISC Osteoarthritis PROCRIT Anemia RITUXAN Rheumatoid Arthritis T PROCYSBI Nephrotic Cystinosis RIXUBIS Hemophilia TABLOID PROFILNINE Hemophilia RUCONEST Hereditary Angioedema TAFINLAR PROLASTINE-C S TARCEVA PROLEUKIN SAIZEN Growth Hormone TARGRETIN PROLIA Osteoporosis SAMSCA Hyponatremia TASIGNA PROMACTA Thrombocytopenia SANDOSTATIN Acromegaly TAXOTERE PROVENGE Adjunct SANDOSTATIN LAR Carcinoid Syndrome TECFIDERA Multiple Sclerosis PULMOZYME Cystic Fibrosis SELZENTRY TEMODAR R SEROSTIM temozolomide RASUVO sildenafil TEV-TROPIN Rheumatoid Arthritis Growth Hormone RAVICTI Urea Cycle Disorder SIMPONI Rheumatoid Arthritis THALOMID REBETEL SIMPONI Ulcerative Colitis THYROGEN REBIF Multiple Sclerosis sodium phenylbutyrate Urea Cycle Disorder TIVICAY RECLAST Paroxysmal Nocturnal SOLARIS TOBI Osteoporosis Hemoglobinuria Cystic Fibrosis RECOMBINATE Hemophilia SOMATULANE DEPOT Acromegaly TOBI PODHALER Cystic Fibrosis REMICADE Crohn's Disease SOMAVERT Acromegaly tobramycin neb Cystic Fibrosis 4 of 5
5 TOPOSAR VIRAMIUNE XR ZEVALIN topotecan VIRAMUNE ZIAGEN TOTECT Adjunct VIREAD zidovudine TRACLEER VISTIDE ZINECARD TREANDA VIVITROL Chemical Dependence ZOFRAN Adjunct TRELSTAR DEPOT VOTRIENT ZOLADEX TRELSTAR LA VPRIV Gaucher's Disease zoledronic acid tretinoin W zoledronic acid Osteoporosis TRETTEN Coagulation Factor XIII WILATE VMF/HUM Hemophilia ZOLINZA TRIUMEQ WINRHO RH Hemolytic Disease ZOMETA TRIZIVIR X ZORBTIVE Short Bowel Syndrome TRUVADA XALKORI ZORTRESS Antirejection TYBOST XELJANZ Rheumatoid Arthritis ZYDELIG TYKERB XELODA ZYKADIA TYSABRI Multiple Sclerosis XENAZINE Huntington's Chorea ZYTIGA TYVASO XEOMIN Cervical Dystonia TYZEKA Hepatitis B XGEVA Osteoporosis V XIAFLEX Dupuytren's Contracture VALCHLOR XOFIGO VANTUS XOLAIR Asthma VECTIBIX XYNTHA Hemophilia VELCADE XYNTHA SOLFUSE Hemophilia VELETRI XYREM Narcolepsy VENTAVIS XYTANDI VICTRELIS Y VIDAZA YERVOY VIDEX Z VIDEX EC ZALTRAP VIMIZIM Mucopolysaccharidosis ZANOSAR vinblastine ZAVESCA Gaucher's Disease VINCASAR PFS ZELBORAF vincristine ZEMAIRA vinorelbine ZEMPLAR Pompe Disease VIRACEPT ZERIT 5 of 5
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
Utilization Management
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)
Specialty Drugs. The following is a list of medications that are considered to be specialty drugs. Specialty drugs
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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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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
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
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
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
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
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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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
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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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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INJECTABLE MEDICINES. Resources, Links or Additional Information. J Code Brand Names Generic names Prior Authorization or Restrictions
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
2018 MDwise HIP Medical Services that Require Prior Authorization
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2018 MDwise HIP Medical Services that Require Prior Authorization
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COVERED USES All medically accepted indications not otherwise excluded from Part D
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