RAHF PFM ALPHANINE SD COAGULATION FACTOR IX J7193 COAGULATION FACTOR IX (RFIXFC)
|
|
|
- Janice Wood
- 6 years ago
- Views:
Transcription
1 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 ALPROLIX (RFIXFC) J7201 MOVEMENT APOKYN APOMORPHINE HCL J0364 CRYOPYRIN ASSOCIATED PERIODIC SYNDROMES ARCALYST RILONACEPT J2793 TRANSPLANT ASTAGRAF XL TACROLIMUS J7508 J7507 MULTIPLE SCLEROSIS AVONEX INTERFERON BETA 1A Q3027 BEBULIN FACTOR IX COMPLEX J7194 BENEFIX (RECOMB) J7195 MULTIPLE SCLEROSIS BETASERON INTERFERON BETA 1B J1830 CYSTIC FIBROSIS BETHKIS TOBRAMYCIN J7682 TRANSPLANT CELLCEPT MYCOPHENOLATE MOFETIL J7517 INFLAMMATORY BOWEL DISEASE CIMZIA CERTOLIZUMAB PEGOL J0717 J0718, C9249 RHEUMATOID ARTHRITIS CIMZIA CERTOLIZUMAB PEGOL J0717 J0718, C9249 MULTIPLE SCLEROSIS COPAXONE GLATIRAMER ACETATE J1595 FACTOR XIII CONCENTRATE CORIFACT HUMAN J7180
2 ELOCTATE RAHF PFM Q9975 PSORIASIS ENBREL ETANERCEPT J1438 RHEUMATOID ARTHRITIS ENBREL ETANERCEPT J1438 TRANSPLANT ENVARSUS XR TACROLIMUS J7508 EPOPROSTENOL SODIUM EPOPROSTENOL SODIUM J1325 S0155 MULTIPLE SCLEROSIS EXTAVIA INTERFERON BETA 1B J1830 FEIBA ANTIINHIBITOR COAGULANT CMPLX J7198 HEREDITARY ANGIOEDEMA FIRAZYR ICATIBANT ACETATE J1744 OSTEOPOROSIS FORTEO TERIPARATIDE J3110 HIV MEDICATIONS FUZEON ENFUVIRTIDE J1324 RELATED : GAMASTAN S/D IMMUNE GLOBULIN J1460 J1560, J1480, J1490, J1500, J1510, J1520, J1530, J1540, TRANSPLANT GENGRAF CYCLOSPORINE MODIFIED J7502 J7515, C9438 RELATED GENOTROPIN SOMATROPIN J2941 MULTIPLE SCLEROSIS GLATOPA GLATIRAMER ACETATE J1595 ONCOLOGY ORAL GLEEVEC IMATINIB MESYLATE S0088 TRANSPLANT HECORIA TACROLIMUS J7507 HELIXATE HEMOFIL M J7190
3 UNCLASSIFIED HEMOPHILIA RELATED : HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED HEPAGAM B HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED HEPATITIS B IMMUNE GLOBULIN J7199 J1573 HORMONAL THERAPIES HP ACTHAR GEL CORTICOTROPIN J0800 SEIZURE HP ACTHAR GEL CORTICOTROPIN J0800 RELATED INFLAMMATORY BOWEL DISEASE HUMATE P VWF J7187 HUMATROPE SOMATROPIN J2941 HUMIRA ADALIMUMAB J0135 PSORIASIS HUMIRA ADALIMUMAB J0135 RHEUMATOID ARTHRITIS HUMIRA ADALIMUMAB J0135 ONCOLOGY ORAL HYCAMTIN TOPOTECAN HCL J8705 RELATED : CRYOPYRIN ASSOCIATED PERIODIC SYNDROMES RELATED HYPERHEP B HEPATITIS B IMMUNE GLOBULIN ILARIS CANAKINUMAB J0638 INCRELEX MECASERMIN J2170 HEPATITIS C INFERGEN INTERFERON ALFACON 1 J9212 HEMOPHILIA IXINITY (RFIXFC) J7195 KOATE J7190 KOGENATE 90371, J1571 MONOCLATE J7190
4 MONONINE J7193 TRANSPLANT MYFORTIC MYCOPHENOLATE SODIUM J7518 RELATED : NABI HB/NP NABI HEPATITIS B IMMUNE HB GLOBULIN TRANSPLANT NEORAL CYCLOSPORINE MODIFIED J7502 J7515, C9438 RELATED NORDITROPIN SOMATROPIN J2941 NOVOEIGHT RPFVIII J7182 NOVOSEVEN RT COAGULATION FACTOR VIIA RECOMB J7189 IMMUNE (IDIOPATHIC) THROMBOCYTOPENIA PURPURA RELATED RELATED NPLATE ROMIPLOSTIM J2796 C9245 NUTROPIN SOMATROPIN J2941 NUWIQ OBIZUR RPFVIII RPFVIII OMNITROPE SOMATROPIN J2941 HEPATITIS C PEGASYS PEGINTERFERON ALFA 2A S0145 HEPATITIS C PEG INTRON PEGINTERFERON ALFA 2B S0148 PROFILNINE SD FACTOR IX COMPLEX J7194 TRANSPLANT PROGRAF TACROLIMUS J7507
5 CYSTIC FIBROSIS PULMOZYME DORNASE ALFA J7639 TRANSPLANT RAPAMUNE SIROLIMUS J7520 MULTIPLE SCLEROSIS REBIF INTERFERON BETA 1A Q3028 J1826, Q3026 RECOMBINATE REFACTO REMODULIN TREPROSTINIL SODIUM J3285 HIV MEDICATIONS RETROVIR ZIDOVUDINE S0104 REVATIO SILDENAFIL CITRATE S0090 RIASTAP RIXUBIS FIBRINOGEN CONCENTRATE (RECOMB) J7178 J7200 J7195, C9133 HEREDITARY ANGIOEDEMA RUCONEST C1 ESTERASE INHIBITOR (RECOMB) C9445 RELATED SAIZEN SOMATROPIN J2941 TRANSPLANT SANDIMMUNE CYCLOSPORINE J7502 J7515 RELATED SEROSTIM SOMATROPIN J2941 ACROMEGALY SOMATULINE LANREOTIDE ACETATE J1930 C9237 ONCOLOGY CHEMOTHERAPY SOMATULINE LANREOTIDE ACETATE J1930 C9237 PSORIASIS STELARA USTEKINUMAB J3357 C9261 HORMONAL THERAPIES SUPPRELIN HISTRELIN ACETATE (CPP) J9226 RESPIRATORY SYNCYTIAL VIRUS SYNAGIS PALIVIZUMAB C9003 ONCOLOGY ORAL TEMODAR TEMOZOLOMIDE J8700 RELATED TEV TROPIN SOMATROPIN J2941 CYSTIC FIBROSIS TOBI TOBRAMYCIN J7682
6 TRETTEN COAGULATION FACTOR XIII A SUB J7181 TYVASO TREPROSTINIL J7686 J7180 VELETRI EPOPROSTENOL SODIUM J1325 S0155 VENTAVIS ILOPROST Q4074 HIV MEDICATIONS VIDEX DIDANOSINE S0137 WILATE VWF J7183 C9267 ONCOLOGY ORAL XELODA CAPECITABINE J8520 J8521 DUPUYTREN'S COLLAGENASE CLOSTRID XIAFLEX CONTRACTURE HISTOLYT J0775 C9266 ALLERGIC ASTHMA XOLAIR OMALIZUMAB J2357 C9217 RELATED XYNTHA RECOMBINANT PAF J7185 ZORBTIVE SOMATROPIN J2941 TRANSPLANT ZORTRESS EVEROLIMUS J7527
MDwise Self-Administered Codes for Medical
The following codes are associated with medications that can be self-administered by the patient or a caregiver. As a result, MDwise will transfer coverage of these self-administered medications exclusively
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
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
Medication Prior Authorization Form
Section I Member Information Name (Last, First, Middle Initial) Date of Birth WEA Trust Subscriber Number Diagnosis Page 2 1. MEDICATION 2. STRENGTH 3. DIRECTIONS 4. QUANTITY FEIBA NF NovoSeven RT HEMOFIL
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
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
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
Quarterly Pharmacy Formulary Change Notice
Quarterly Pharmacy Formulary Change Notice Summary of Change: The formulary changes listed in the table below were reviewed and approved at our December 18, 2014 Value Assessment Committee (VAC) meeting.
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
Thank you for your request for information that has been processed under reference number
Corporate Development Contact us: dhft.foi@nhs.net Royal Derby Hospital Uttoxeter Road Derby DE22 3NE Tel: 01332 265500 Minicom: 01332 785566 www.derbyhospitals@nhs.uk Follow us on Twitter @DerbyHospitals
Cigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Clotting Factors and Antithrombin Effective Date... 4/15/2018 Next Review Date... 3/15/2019 Coverage Policy Number... 8007 Table of Contents Coverage Policy...
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
J-Code Trade Name Drug Name Required Medical Information
FIDELIS CARE NEW YORK DEPARTMENT OF PHARMACY SERVICES Updated: 10/31/2017 J-Code Prior Authorizations & Required Clinical Information Medicaid, Child Health Plus, HealthierLife, Metal-Level J-Code Trade
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
Medication Prior Authorization Form
Policy Number: 1041 FEIBA NF Novoeight Mononine NovoSeven RT RECOMBINATE BEBULIN HEMOFIL M Xyntha Profilnine SD Koate-DVI Obizur BeneFix Monoclate-P Alphanate RIXUBIS ADVATE HUMATE-P Corifact Helixate
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
Pharmacy Services Request Types
FOR DRUG REQUESTS, ONLY-- * NOTE: Only those drugs administered by a healthcare provider and billed medically would be entered via CareAffiliate. * Oral drugs would not be administered by a healthcare
1199SEIU Benefit Funds
1199SEIU Benefit Funds MEDICAL BENEFIT MANAGEMENT PROGRAM SPECIALTY DRUG LIST Effective October 1, 2016 As of April 1, 2015, providers must use the web-based Expressth platform to obtain prior authorization
FIDELIS CARE NEW YORK DEPARTMENT OF PHARMACY SERVICES J Code Prior Authorizations & Required Clinical Information 2011 (Updated 3/14/11)
FIDELIS CARE NEW YORK DEPARTMENT OF PHARMACY SERVICES J Code Prior Authorizations & Required Clinical Information 2011 (Updated 3/14/11) Brand Generic J Code Covered Uses Required Medical Information and
Method of Viral Inactivation or Depletion. Generation/ Human or Animal Protein in Culture. Third/ None 1. Immunoaffinity
TABLE I. Products Licensed in the U.S. to Treat HEMOPHILIA A A. Recombinant FACTOR VIII Concentrates The table includes bioengineered recombinant factor concentrates with altered properties such as extended
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
2010 Drugs Requiring Prior Authorization
2010 Drugs Requiring Prior Authorization Drugs Covered Uses Exclusion Criteria Actemra (tocilizumab) Adcirca (tadalafil) Alfa Interferons - Alferon N - Infergen - PEG-Intron - PEG-Intron Redipen - Pegasys
SPECIALTY 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
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
Medi-Cal DHCS Carve Out Medication List
Medi-Cal DHCS Carve Out Medication List The drugs shown below are non-capitated or carved-out of Managed Care Plans (MCPs). IE H P i s a man ag ed c a r e p l a n. T his means they are not reimbursed by
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)
Immune 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:
Advantage by Peach State Health Plan 2012 Prior Authorization Listing. Approved 10/23/2011 Effective October 2011
Advantage by Peach State Health Plan 2012 Approved 10/23/2011 Effective October 2011 Note to members: The prior authorization requirements are listed to provide you with information to discuss treatment
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
Self-Injected Medications and Disposal Recommendations
Actimmune (interferon gamma 1b) Apokyn (apomorphine hydrochloride) Arixtra (fondaparinux) Avonex (interferon beta 1a) Betaseron (interferon beta 1b) Copaxone (glatiramer acetate) Edex (alprostadil) InterMune
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
Positively Affecting the Lives of Members Each and Every Day. Volume 14 May Specialty Drug News
Positively Affecting the Lives of Members Each and Every Day LDI Volume 14 May 2008 Specialty Drug News 2008 Medications to Watch 1. Respiratory syncytial virus (RSV) Numax (motavizumab) Respiratory syncytial
Specialty conditions overview
Specialty conditions overview Prevalence and cost Click on the vials to learn more about these specialty conditions. 1. Approximate annual AWP cost per patient of top utilized drugs for UHC calendar year
1199SEIU Benefit Funds
1199SEIU Benefit Funds MEDICAL BENEFIT MANAGEMENT PROGRAM SPECIALTY DRUG LIST Effective April 1, 2017 As of April 1, 2015, providers must use the web-based Expressth platform to obtain prior authorization
Original Policy Date
MP 5.01.17 Specialty Drugs Medical Policy Section Prescription Drug Issue 12:2013 Original Policy Date 12:2013 Last Review Status/ Date Local policy Last updated/12:2013 Return to Medical Policy Index
1199SEIU Benefit Funds
1199SEIU Benefit Funds MEDICAL BENEFIT MANAGEMENT PROGRAM SPECIALTY DRUG LIST Effective October 1, 2017 As of April 1, 2015, providers must use the web-based ExpressPAth platform to obtain prior authorization
Injections Requiring Prior Authorization
At VIVA Health, we strive to keep our provider network informed of any changes. Most of you may currently obtain prior authorizations for administered injections. Below is a list of injection, infusion,
TRICARE Uniform Formulary. Pre-Authorization Requirements
TRICARE Uniform Formulary Pre-Authorization Requirements The Department of Defense (DoD) requires pre-authorization on select medications. These medications are on the DoD s pre-authorization list because
Texas Prior Authorization Program Clinical Edit Criteria
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document - Oral Drugs requiring prior authorization: the list of drugs requiring prior
Drug Name Tier Drug Name Tier
Drug Name Tier Drug Name Tier ABELCET 100 MG/20 ML VIAL 4 ACETYLCYSTEINE 10% VIAL 2 ACETYLCYSTEINE 20% VIAL 2 ACYCLOVIR 1,000 MG/20 ML VIAL 2 ACYCLOVIR 500 MG/10 ML VIAL 2 ADRUCIL 500 MG/10 ML VIAL 2 ALBUTEROL
ACTEMRA (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
CIMZIA (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
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
of our members each and
s p e c i a l t y d r u g n e w s Positively affecting the lives of our members each and every day Efalizumab (Raptiva ) Withdrawn from US Market On April 9, 2009 Genentech, Inc. announced that it is undergoing
LDI integrated pharmacy services
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/
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
Download full Test Bank for Focus on Nursing Pharmacology 6th Edition by Karch
Download full Test Bank for Focus on Nursing Pharmacology 6th Edition by Karch https://digitalcontentmarket.org/download/test-bank-for-focus-on-nursingpharmacology-6th-edition-by-karch Chapter 17 1. A
1199SEIU Benefit Funds
1199SEIU Benefit Funds MEDICAL BENEFIT MANAGEMENT PROGRAM SPECIALTY DRUG LIST Effective January 1, 2019 As of April 1, 2015, providers must use the web-based ExpressPAth platform to obtain prior authorization
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
Injectable Drugs Requiring Pre-Service Approval
Abatacept Orencia J0129, 10 mg 1500 FL LCD- L29051 1) For patients with rheumatoid arthritis with failure, intolerance or contraindications to methotrexate. Limit dosing to 40 mg Q 2 weeks. 2) For patients
Drug 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
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,
Xeljanz. Xeljanz, Xeljanz XR (tofacitinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.24 Subject: Xeljanz Page: 1 of 6 Last Review Date: March 16, 2018 Xeljanz Description Xeljanz, Xeljanz
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
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
Cosentyx. 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
Quick Reference: Plasma Protein Products
All plasma protein products a contraindicated in patients with any of the following: Hypersensitivity to the product or any ingdient in the formulation or component of the container. Pvious anaphylactic
Cimzia. 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
ACTEMRA. Cigna Medicare Rx (PDP) 2014 Cigna Medicare Rx Secure-Xtra Plan (PDP) Formulary. Products Affected Actemra. Prior Authorization Criteria
Cigna Medicare Rx (PDP) Medicare Part D Prescription Drug Plans 2014 Cigna Medicare Rx Secure-Xtra Plan (PDP) Formulary Prior Authorization ACTEMRA Products Affected Actemra PA Details Age Other Authorization
Regulatory 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)
Client Prior Authorization Program (CPA) PA Required (PA) Reimb Code. Reimb Code CLAIM EDIT. Reimb Code. Reimb Code. Reimb Code
Medical Benefit Management Specialty Drug List Effective October 1, 2015 The symbol [] next to a drug name indicates that this medication is subject to the Prior. The symbol [C] next to a drug name indicates
DME MAC Jurisdiction C Drug Fees, Pharmacy Dispensing Fees and Pharmacy Supply Fees Effective 01/01/2018 through 03/31/2018
G0333 PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A BENEFICIARY $57.000 J0133 INJECTION, ACYCLOVIR 5 MG $0.068 J0285 INJECTION, AMPHOTERICIN B 50 MG $32.987 J0287 INJECTION,
DME MAC Jurisdiction B Drug Fees, Pharmacy Dispensing Fees and Pharmacy Supply Fees Effective 01/01/2019 through 03/31/2019
G0333 PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A BENEFICIARY $57.000 J0133 INJECTION, ACYCLOVIR 5 MG $0.048 J0285 INJECTION, AMPHOTERICIN B 50 MG $31.668 J0287 INJECTION,
Funding Position of CCG Commissioned High Cost Drugs within Lancashire Health Economy Updated February 2016
Funding Position of CCG Commissioned High Cost Drugs within Lancashire Health Economy Updated February 2016 Drugs can only be recharged to CCGs if used in line with local or national policies as outlined
Medicare Part B Covered Medications
This table provides a reference guide for the most frequent Part B/D coverage determination scenarios facing Part D plans and Part D pharmacy providers. It does not address all potential situations. For
Trusted Health Plan Formulary
2018 Trusted Health Plan Formulary Version 19; Effective 10/22/18 Introduction... 6 The Trusted Health Plan Pharmacy and Therapeutics Committee (P&T)... 6 Notice...6 Preface...6 Product Selection Criteria...
Trusted Health Plan Formulary
2018 Trusted Health Plan Formulary Effective 7/1/2018 Introduction... 6 The Trusted Health Plan Pharmacy and Therapeutics Committee (P&T)... 6 Notice...6 Preface...6 Product Selection Criteria... 6 Formulary
The Effect of Current Managed Care Trends on Patient Access in 3 Specialty Classes MS, Hepatitis C & Pulmonary Arterial Hypertension
The Effect of Current Managed Care Trends on Patient Access in 3 Specialty Classes MS, Hepatitis C & Pulmonary Arterial Hypertension DISCLAIMER The information within this CME/CE activity is for continuing
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
Divya Jain Arwindekar, DO Transplant Nephrologist Advocate Christ Medical Center & Associates in Nephrology
Divya Jain Arwindekar, DO Transplant Nephrologist Advocate Christ Medical Center & Associates in Nephrology Not a cure to kidney disease, but it is a very effective treatment Patients still have chronic
J1556 INJECTION, IMMUNE GLOBULIN (BIVIGAM) 500 MG $ J1559 INJECTION, IMMUNE GLOBULIN (HIZENTRA) 100 MG $14.364
G0333 INITIAL 30-DAY SUPPLY AS A BENEFICIARY $57.000 J0133 INJECTION, ACYCLOVIR 5 MG $0.470 J0285 INJECTION, AMPHOTERICIN B 50 MG $10.280 J0287 INJECTION, AMPHOTERICIN B LIPID COMPLEX 10 MG $21.850 J0288
2011 Medicare National Preferred 4 Tier PA Criteria
2011 Medicare National Preferred 4 Tier PA Criteria ACTEMRA... 13 ACTEMRA... 13 ALPHA-1 PROTEINASE INHIBITORS... 15 ARALAST NP... 15 GLASSIA... 15 PROLASTIN C... 15 PROLASTIN... 15 ZEMAIRA... 15 AMEVIVE...
Specialty Pharmacy Pipeline
Specialty Pharmacy Pipeline Drugs to Watch Anticipated Launches Q1 Q2 2017 Atopic Dermatitis Dupixent (dupilumab) Subcutaneous injection Regeneron Pharmaceuticals/Sanofi moderate-to-severe atopic dermatitis
Prior Authorization April 2018
Prior Authorization April 2018 Please Note: Not all benefit plans include prior authorization. Check your plan materials to see if this information applies to you. What Is Prior Authorization? It s a quality
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
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
2011 Medicare National Preferred 4 Tier PA Criteria
2011 Medicare National Preferred 4 Tier PA Criteria ACTEMRA... 12 ACTEMRA... 12 ALPHA-1 PROTEINASE INHIBITORS... 14 ARALAST NP... 14 GLASSIA... 14 PROLASTIN C... 14 PROLASTIN... 14 ZEMAIRA... 14 AMEVIVE...
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,
Health Choice Generations HMO Medicare Advantage Special Needs Plan PRIOR AUTHORIZATION GUIDELINES
Health Choice Generations HMO Medicare Advantage Special Needs Plan PRIOR AUTHORIZATION GUIDELINES Health Choice Generations presents these guidelines for prior authorized services for members who live
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
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
ANTIDEPRESSANTS. Details. Step Therapy 2018 Last Updated: 8/21/2018
ANTIDEPRESSANTS EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL FETZIMA
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
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
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
SUPPLEMENTARY INFORMATION
In format provided by Langer et al. (SEPTEMBER 2014) Supplementary table 1: Product examples for half-life extension / decreased dosing frequency Products based on depot formulations Parent drug Drug/carrier
2011 RxBlue PDP PA Criteria
2011 RxBlue PDP PA Criteria ACTEMRA... 9 ACTEMRA... 9 ALPHA-1 PROTEINASE INHIBITORS... 10 ARALAST... 10 PROLASTIN... 10 ZEMAIRA... 10 AMEVIVE... 11 AMEVIVE... 11 ANABOLIC STEROIDS... 13 ANADROL-50... 13
Medication 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
Medication 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,
Medical Policy An independent licensee of the Blue Cross Blue Shield Association
H.P. Acthar Gel (repository corticotropin) Page 1 of 7 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: H.P. Acthar Gel (repository corticotropin) Prime Therapeutics
Otezla. Otezla (apremilast) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Otezla Page: 1 of 5 Last Review Date: March 16, 2018 Otezla Description Otezla (apremilast) Background
Brand Generic J-Code 1 Billable. Exclusion Criteria. Information and Criteria. Unit
Affinity Health Plan Department Of Pharmacy (Medicaid, Child Health Plus, Family Health Plus, Medicare Part B) **Medications Requiring Authorization under Medical Benefit** Click Here For Medication Authorization
Prior Authorization Medications Requiring Review Criteria for Use
Prior Authorization Medications Requiring Review Criteria for Use The Medicare Part D formulary does not allow prior authorization or criteria restrictions on medications; this document applies to the
UnitedHealthcare Pharmacy Clinical Pharmacy Programs
UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2018 P 1097-7 Program Prior Authorization/Notification Medication *Stelara (ustekinumab) *This program applies to the subcutaneous formulation
Coding Implications Revision Log. See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Reference Number: CP.PHAR.215 Effective Date: 05.01.16 Last Review Date: 02.18 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of this policy
2018 Medicaid Preapproval Criteria
2018 Medicaid Preapproval Criteria ABILIFY MAINTENA... 13 ACTHAR HP... 14 ACTIMMUNE... 16 ADAGEN... 17 ADCETRIS... 18 ADCIRCA... 19 ADEMPAS... 20 AFINITOR... 22 AFINITOR DISPERZ... 23 ALDURAZYME... 24
Prior Authorization Medications Requiring Review Criteria for Use
Prior Authorization Medications Requiring Review Criteria for Use The Medicare Part D formulary does not allow prior authorization or criteria restrictions on medications; this document applies to the
(Last Revised 10/04/18)
Department Of Pharmacy (Medicaid, Child Health Plus, Medicare Part B, Qualified Health Plan, Essentials Plan, Enriched Health () Medications Requiring Authorization under Medical Benefit Fax request to