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

Size: px
Start display at page:

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

Transcription

1 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 are the responsibility of participating providers. Out-of-Network Services: for any referral to a non-participating health care facility or provider, for any outof-network services, the participating provider must first obtain prior authorization from BCBS AZ Adv. In-Network Services: For the in-network services listed below, the participating provider must first obtain prior authorization from BCBS AZ ADV: Ambulance Services (Non-Emergent) Bariatric Surgery only if performed outpatient or ASC Breast Reconstruction: Non-Mastectomy only if performed outpatient or ASC Cosmetic Procedures and Reconstructive Surgeries (e.g: Breast Reduction, Blepharoplasty, Strabismus, Panniculectomy) only if performed outpatient or ASC DME over $1,000 (EXCEPT for Premier Plan) Electrical Stimulation Procedures- All (e.g.: Brain, Bladder, Spine) only if performed outpatient or ASC Joint Replacement Surgeries (e.g.: Knee, Hip, Shoulder, Ankle) only if performed outpatient or ASC Outpatient Diagnostic (CT, MRI, MRA, PET) (BHN: See HealthHelp Information Below) Orthognathic Surgery only if performed outpatient or ASC Pain Management Specialist Services-(Ongoing After Initial Evaluation) Prosthetics/Orthotics/Medical Supplies Proton Beam Therapy Skilled Nursing Facility Stays Spinal Surgeries only if performed outpatient or ASC Transplants (Excludes Corneal) Vein Treatment or Procedures only if performed outpatient or ASC Medicare Part B Rx Drugs and Home Infusion Drugs (see attached list) For Banner Health Network Members All CT/CTA/MRI/MRA/PET - Submit to Health Help at Fax (800) ; Phone (800) ; Website: All services and procedures, regardless of place of service, must meet medical necessity criteria. For questions or more information, please call Blue Cross Blue Shield Arizona Advantage at:

2 Medicare Part B Rx Drugs and Home Infusion Drugs Requiring Prior Auth Brand Name Generic Name Applicable Code Neupogen Filgrastim J1442 Actemra tocilizumab J3262 Aldurazyme laronidase J1931 Aveed testosterone undecanoate, injection 1mg C9023 Blood Clotting Factors Antihemophiliac Products require prior authorization Alprolix factor ix (antihemophiliac factor, recombinant), Alprolix per 10 i.u. C9135 Wilate Willebrand factor/coagulation Factor VIII complex (Human) J7183 Alphanate VWF complex Von Willebrand Factor complex Human ristocetin Cofactor J7187 Corifact Injection, factor XIII (antihemophilic factor, human), 1 IU J7180 Xyntha Injection, factor VIII (antihemophilic factor, recombinant) (xyntha), J7185 per I.U. Injection, antihemophiliac factor VIII/ Von Willebrand factor J7186 complex Factor VIIa (antihemophilic factor, recombinant), per 1 microgram J7189 Monarc-M Factor VIII (anti-hemophilic factor, human) per IU J7190 Factor VIII (antihemophilic factor, recombinant) Per I.U. J7192 Factor IX (antihemophilic factor, purified, non-recombinant) per J7193 I.U. Konyne-80, Factor IX complex, per IU J7194 Profilnine Heat Treated, Proplex T, Proplex SX-T Factor IX (antihemophilic factor, recombinant) oer I.U. J7195 Injection, antithrombin recombinant, 50 I.U. J7196 Thrombate III Antithrombin III (human), per IU J7197 Anti-inhibitor, per IU J7198 Hemophilia clotting factor, not otherwise classified J7199 Aralast Alpha 1-proteinase inhibitor-human J0256 Avastin bevacizumab J9035 C9257 Benlysta Injection, belimumab, 10mg J0490 Berinert Injection, C-1 esterase inhibitor (human), 10 units J0597 Botox botulinum toxin type A J0585, J0586, J0588 Cerezyme injection, imiglucerase 10 units J1786 Cidofovir vistide 75mg J0740 Cimzia certolizumab J0718

3 Cinryze C1 esterase inhibitor (human) J0598 Elaprase idursulfase, 1mg J1743 Entyvio vedolizumab, injection 1mg C9026 Fabrazyme agalsidase beta J0180 Flolan injection, epoprostenol, 0.5mg J1325 Glassia alpha 1 proteinase, inhibitor (human), 10 mg J0257 Ilaris Injection, canakinumab, 1mg J0638 Intravenous Immune All IVIG requires prior authorization Globulin (IVIG) Carimune/Carimune NF Immune globulin, lyophilized (IVIG) J1566 Flebogamma Immune globulin, non-lyophilized (IVIG) J1572 Gammagard/Gammagard Immune globulin, lyophilized (IVIG) J1566 SD Gammagard liquid injection Immune globulin, non-lyophilized (IVIG), Gammagard liquid J1569 Gammaplex Immune globulin, non-lyophilized J1557 Gammar-P Immune globulin, lyophilized (IVIG) J1566 Gamunex Immune globulin, non-lyophilized (IVIG) J1561 Hizentra Immune globulin, (injection) J1559 Immune Globulin NOS Immune globulin, non-lyophilized (injection) J1599 Iveegam EN immune globulin, lyophilized (IVIG) Octegam Immune globulin, non-lyophilized (IVIG) J1568, Panglobulin/Panglobulin Immune globulin, lyophilized (IVIG) J1566 NF Privigen Immune globulin, non-lyophilized (liquid) 500mg (IVIG) 90283, J1459 Euflexxa hyaluronan or derivative J7323 Gel-One hyaluronan or derivative J7326 Hyalgan or Supartz hyaluronan or derivative J7321 Jetrea ocriplasmin 0.125mg J7316 Kalbitor ecallantide J1290 Krystexxa injection, pegloticase 1mg J2507 Makena injection, hydroxyprogesterone caproate, 1 mg J1725 Mozobil injection, plerixafor 1mg J2562 MyoBloc (Botulinum toxin type B) MyoBloc (Botulinum toxin type B) J0587 Myozyme alglucosidase Alpha, 10mg J0220, J0221 Lumizyme alglucosidase Alpha J0221

4 Naglazyme galsulfase J1458 Natrecor nesiritide, 0.1mg J2325 NPlate injection, romiplostim, 10mcg J2796 Nulojix nesiritide 0.1mg J0485 Orencia abatacept J0129 Orthovisc hyaluronan or derivative J7324 Prolastin Alpha 1-protenase inhibitor human J0256 Prolia denosumab J0897 Remicade infliximab J1745 Reclast zoledronic acid, 1mng J3489 Remodulin tresprostinil,inhalation solution J7686 Retisert fluocinolone acetonide, intravitreal implant J7311 Rituxan rituximab J9310 C9800 Simponi golimumab J3590 C9399 (IV) Simulect baxiliximal J0480 Solaris eculizumab injection J1300 Stelara ustekinumab J3357 Synvisc or Synvisc-One hyaluronan or derivative J7325 Tysabri natalizumab J2323 Vibativ injection, telavancin 10 mg J3095 Vimizim Injection, elosulfase alfa, 1mg C9022 Vpriv velaglucerase alfa J3385 Xeomin incobotulinumtoxina 1 unit J0588 Xgeva denosumab J0897 Xiaflex injection, collagenase clostridium histolyticum, 0.01 mg J0775 Xolair omalizumab J2357 Zemaira Alpha 1-proteinase inhibitor - human J0256 Zometa zoledronic acid Q2051, J3489 Vivitrol Naltrexone J2315 HP Acthar Gel Injection repository Corticotropin Inj J0800 Kineret Anakinra J3490, J3590 Multiple Sclerosis Injectable Therapy

5 Hepatitis C Injectable Therapy Injectafer Ferric Carboxymaltose J1439 Erythropoiesis- Stimulating Agents (ESAs) Procrit or Epogen Aranesp J0885 J0881

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

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

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

2016 MDwise HIP Medical Services that Require Prior Authorization

2016 MDwise HIP Medical Services that Require Prior Authorization 2016 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance

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

2016 MDwise HIP Medical Services that Require Prior Authorization

2016 MDwise HIP Medical Services that Require Prior Authorization 2016 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Coding All Out of Network services Facility to facility ambulance transport

More information

PA Category Name Code(s) Additional Notes ABA 0364T 0365T 0366T 0367T 0373T 0374T H G0396. Applied Behavioral Analysis stage 3*

PA Category Name Code(s) Additional Notes ABA 0364T 0365T 0366T 0367T 0373T 0374T H G0396. Applied Behavioral Analysis stage 3* ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0364T 0365T 0366T 0367T 0373T 0374T H2020 96116

More information

MDwise HIP Prior Authorization and Drug List

MDwise HIP Prior Authorization and Drug List MDwise HIP Prior Authorization and Drug List Services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services With the exception of ER, Ambulance, Urgent Care Center

More information

MDwise Hoosier Care Connect Medical Services that Require Prior Authorization

MDwise Hoosier Care Connect Medical Services that Require Prior Authorization MDwise Hoosier Care Connect Medical Services that Require Prior Authorization Certain Indiana Health Coverage Programs (IHCP) services require prior authorization (PA) for members enrolled in the Hoosier

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

Pharmacy Services Request Types

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

More information

Injections Requiring 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,

More information

INJECTABLE MEDICINES. Resources, Links or Additional Information. J Code Brand Names Generic names Prior Authorization or Restrictions

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

More information

Medication Policy Manual. Policy No: dru408. Topic: Site of Care Review Date of Origin: July 10, 2015

Medication Policy Manual. Policy No: dru408. Topic: Site of Care Review Date of Origin: July 10, 2015 Medication Policy Manual Policy No: dru408 Topic: Site of Care Review Date of Origin: July 10, 2015 Committee Approval Date: August 17, 2018 Next Review Date: August 2019 Effective Date: October 1, 2018

More information

J-Code Trade Name Drug Name Required Medical Information

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

More information

Injectable Drugs Requiring Pre-Service Approval

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

More information

PA Category Name Code(s) Additional Notes ABA. Applied Behavioral Analysis stage 3*

PA Category Name Code(s) Additional Notes ABA. Applied Behavioral Analysis stage 3* ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0373T H2020 96116 96112 96113 96121 96130 96131

More information

Vivida Health Specialty Pharmacy Drugs (Injectable) Prior-Authorization Requirements Effective 1/1/19

Vivida Health Specialty Pharmacy Drugs (Injectable) Prior-Authorization Requirements Effective 1/1/19 Vivida Health Specialty Pharmacy Drugs (Injectable) Prior-Authorization Requirements Effective 1/1/19 All Non-Par Provider Requests Requires Authorization Regardless of Service J0178 J0180 J0202 J0205

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

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

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

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) 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

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

2017 MDwise HIP Medical Services that Require Prior Authorization

2017 MDwise HIP Medical Services that Require Prior Authorization 2017 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance

More information

New Billing Guidelines for Home Infusion, Enteral and Parenteral Therapies Home Infusion Fee Schedule Effective July 1, 2009

New Billing Guidelines for Home Infusion, Enteral and Parenteral Therapies Home Infusion Fee Schedule Effective July 1, 2009 STAT Bulletin PO Box 80 Buffalo, New York 14240-0080 May 12, 2009 Volume 15:Issue 18 To: All Home Health Care and Home Infusion Therapy Providers Contracts Effected: All Lines of Business New Billing Guidelines

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

2018 MDwise HIP Medical Services that Require Prior Authorization

2018 MDwise HIP Medical Services that Require Prior Authorization 2018 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance

More information

2018 MDwise HIP Medical Services that Require Prior Authorization

2018 MDwise HIP Medical Services that Require Prior Authorization 2018 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance

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

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

2018 MDwise HIP Medical Services that Require Prior Authorization

2018 MDwise HIP Medical Services that Require Prior Authorization 2018 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance

More information

State: Virginia. Clinical Guidelines Applicable for Virginia

State: Virginia. Clinical Guidelines Applicable for Virginia State: Virginia Clinical Guidelines Applicable for Virginia NOTE: Any Clinical Guideline not included in this standard adopted list that is needed to complete a ASO group-specific review requirement will

More information

High Risk Medications

High Risk Medications Department Policy Code: D: MM-5705 Entity: Fairview Health Services Department: Home Infusion Manual: Policies & Procedures Category: Medication Management Subject: High Risk Medications Purpose: To provide

More information

BCN Advantage SM requirements for drugs covered under the medical benefit

BCN Advantage SM requirements for drugs covered under the medical benefit J0586 ABOBOTULINUMTOXINA Dysport X X X the medication is being used to treat J0178 AFLIBERCEPT Eylea X X X X X of Neovascular (Wet) -Related Macular Degeneration of Macular Edema following either central

More information

Original Policy Date

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

More information

SUPPLEMENTARY INFORMATION

SUPPLEMENTARY INFORMATION Table S1 Therapeutic biologic product approvals, classes and innovation categories: 16 24 Approval year Trade name Active Ingredient(s) Drug class Innovation category Approval date 16 Intron-A Interferon

More information

Premera Blue Cross Medicare Advantage Plans Medical Policy Updates

Premera Blue Cross Medicare Advantage Plans Medical Policy Updates Premera Blue Cross Medicare Advantage Plans Medical Policy Updates Medical Policy and Criteria Premera Blue Cross Medicare Advantage reviews all medical policies and criteria annually. The following updates

More information

Clinical UM Guidelines for Indiana, Kentucky, Missouri, Ohio and Wisconsin

Clinical UM Guidelines for Indiana, Kentucky, Missouri, Ohio and Wisconsin 10/4/2018 State: State CG number CG title CG Category Date implemented CG-ADMIN-02 Clinically Equivalent Cost Effective Services Targeted Immune Modulators Admin 7/1/2018 CG-ANC-04 Ambulance services Air

More information

Prior treatment with non-biologic Disease- Modifying Antirheumatic. Not to be used in combination with another biologic DMARD

Prior treatment with non-biologic Disease- Modifying Antirheumatic. Not to be used in combination with another biologic DMARD 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):

More information

Special Notes Implementation Date by CO. State CG number CG title CG Category Original Current Version

Special Notes Implementation Date by CO. State CG number CG title CG Category Original Current Version Anthem Blue Cross and Blue Shield Approved and adopted corporate Clinical Utilization Management (UM) Guidelines COLORADO Updated August 17, 2018 NOTE: Any Clinical Guideline not included in this standard

More information

The following are J Code requirements

The following are J Code requirements The following are J Code requirements J Codes 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) A9579 Injection, gadolinium based

More information

Date - Current Version Implementation. Date - First Implementationby - CO 7/1/ /9/2012 7/1/2013 7/1/2013 4/16/2013 4/1/2016 1/1/2013 1/1/2013

Date - Current Version Implementation. Date - First Implementationby - CO 7/1/ /9/2012 7/1/2013 7/1/2013 4/16/2013 4/1/2016 1/1/2013 1/1/2013 State: Nevada Anthem Blue Cross and Blue Shield Approved and adopted corporate Clinical Utilization Management (UM) Guidelines NEVADA Updated January 2, 2018 NOTE: Any Clinical Guideline not included in

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medicaid Managed Care Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list

More information

Pre-authorization Form

Pre-authorization Form Northwest Montana Schools Consortium 2014 Please verify services not listed below on the pre-authorization list with Benefits and Eligibility (Customer Service) to determine coverage. Preauthorization

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

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

Clinical Utilization Management Guidelines

Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division. To see the full list

More information

Clinical Utilization Management Guidelines update

Clinical Utilization Management Guidelines update Medicaid Managed Care The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division.

More information

Clinical Utilization Management Guidelines

Clinical Utilization Management Guidelines https://providers.amerigroup.com Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical

More information

Clinical Utilization Management Guidelines

Clinical Utilization Management Guidelines https://providers.amerigroup.com Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and

More information

Clinical Utilization Management Guidelines

Clinical Utilization Management Guidelines https://providers.amerigroup.com Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical

More information

Clinical Utilization Management Guidelines

Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division. To see the full list

More information

Medical Policies and Clinical Utilization Management Outpatient Guidelines

Medical Policies and Clinical Utilization Management Outpatient Guidelines https://providers.amerigroup.com Medical Policies and Clinical Utilization Management Outpatient Guidelines Amerigroup Community Care began using Anthem s nationally recognized, evidence-based Medical

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies adopted for Anthem HealthKeepers Plus. The full list of Medical

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and

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

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and

More information

Clinical Utilization Management Guidelines

Clinical Utilization Management Guidelines Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations

More information

Clinical Utilization Management Guidelines

Clinical Utilization Management Guidelines Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines below, which are applicable to Anthem HealthKeepers Plus members, were adopted by the medical operations committee

More information

Essential Health Benefits Standard Specialty PA and QL List July 2016

Essential Health Benefits Standard Specialty PA and QL List July 2016 Anti-infectives Antiretrovirals, HIV SELZENTRY (maraviroc) Cardiology Antilipemic Pulmonary Arterial Hypertension Central Nervous System Anticonvulsants Depressant Neurotoxins Parkinson's Sleep Disorder

More information

Clinical Utilization Management Guidelines

Clinical Utilization Management Guidelines Clinical Utilization Management Guidelines Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program The Clinical Utilization Management (UM) Guidelines below were adopted by the medical operations

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and

More information

Clinical Utilization Management Guidelines

Clinical Utilization Management Guidelines https://providers.amerigroup.com Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies

More information

Criteria for Medical Benefit Drugs Requiring Clinical Review

Criteria for Medical Benefit Drugs Requiring Clinical Review Note: Authorization of a service based on the clinical information provided does not guarantee payment. The claim must be properly submitted and the member must be eligible on the date of service for the

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and Clinical

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

Medical Prior Authorization List Rosen Employee Plans For prescription drug requirements, contact EHIM toll-free at

Medical Prior Authorization List Rosen Employee Plans For prescription drug requirements, contact EHIM toll-free at For prescription drug requirements, contact EHIM toll-free at 1.800.311.3446. General Information These requirements are administered by Health First Health Plans ( Health Plan ). Benefits are determined

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and Clinical

More information

Criteria for Medical Benefit Drugs Requiring Clinical Review

Criteria for Medical Benefit Drugs Requiring Clinical Review Note: Authorization of a service based on the clinical information provided does not guarantee payment. The claim must be properly submitted and the member must be eligible on the date of service for the

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies adopted for Anthem HealthKeepers Plus. The full list of Medical

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and

More information

Highmark List of Procedure Codes Requiring NDC Effective 12/01/2017

Highmark List of Procedure Codes Requiring NDC Effective 12/01/2017 90378 RESPIRATORY SYNCYTIAL VIRUS, MONOCLONAL ANTIBODY, RECOMBINANT, FOR INTRAMUSCULAR USE, 50 MG, EACH C9399 Unclassified Drugs or biologicals J0129 INJECTION, ABATACEPT, 10 MG J0130 INJECTION ABCIXIMAB,

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies adopted for. The full list of Medical Policies and Clinical Utilization

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical

More information

Clinical Utilization Management Guidelines

Clinical Utilization Management Guidelines Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines below were adopted by the medical

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies

More information

March 2017 Pharmacy & Therapeutics Committee Decisions

March 2017 Pharmacy & Therapeutics Committee Decisions UCare s Pharmacy and Therapeutics Committee (P&T) is a group of physicians and pharmacists that meet throughout the year to make changes to the UCare formulary (approved drug list). These changes are reviewed

More information

Clinical Utilization Management Guidelines

Clinical Utilization Management Guidelines Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines highlighted below were adopted by the medical operations committee for on January 3, 2019. For markets with

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

Billing for Infusion Services in an Outpatient Neurology Clinic. Christine Mann, MBA Director of Infusion Services Dent Neurologic Institute

Billing for Infusion Services in an Outpatient Neurology Clinic. Christine Mann, MBA Director of Infusion Services Dent Neurologic Institute Billing for Infusion Services in an Outpatient Neurology Clinic Christine Mann, MBA Director of Infusion Services Dent Neurologic Institute Overview of Infusion Billing Codes Current Procedure Terminology

More information

Utilization Management

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)

More information

Drug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases

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

More information

Medical Policies and Clinical Utilization Management Guidelines

Medical Policies and Clinical Utilization Management Guidelines Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Guidelines and/or Medical Policies the

More information

1199SEIU Benefit Funds

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

More information

Medical policies update

Medical policies update On February 5, 2015, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following medical policies which are applicable to BlueChoice HealthPlan Medicaid. These medical policies

More information

LDI integrated pharmacy services

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/

More information

1199SEIU Benefit Funds

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

More information

Brand Generic J-Code 1 Billable. Exclusion Criteria. Information and Criteria. Unit

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

More information

Medical Policies and Clinical Utilization Management Guidelines update

Medical Policies and Clinical Utilization Management Guidelines update Medical Policies and Clinical Utilization Management Guidelines update Medical Policies update Summary: On July 26, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following

More information