RIVERSPRING STAR ISNP PRIOR AUTHORIZATION
|
|
|
- Marion Summers
- 5 years ago
- Views:
Transcription
1 ACROMEGALY RIVERSPRING STAR ISNP PRIOR AUTHORIZATION SIGNIFOR, SIGNIFOR LAR, SOMATULINE DEPOT, SOMAVERT 10 MG VIAL, SOMAVERT 15 MG VIAL, SOMAVERT 20 MG VIAL Must provide clinical documentation of Acromegaly diagnosis PAGE 1 LAST UPDATED 04/2016
2 AGE CARISOPRODOL 350 MG TABLET, CONCERTA, CYCLOBENZAPRINE 10 MG TABLET, CYCLOBENZAPRINE 5 MG TABLET, CYCLOBENZAPRINE 7.5 MG TABLET, DAYTRANA 15 MG/9 HR PATCH, DEXMETHYLPHENIDATE HCL, DEXMETHYLPHENIDATE ER 15 MG CP, DEXMETHYLPHENIDATE ER 30 MG CP, DEXMETHYLPHENIDATE ER 40 MG CP, DEXRAZOXANE, DEXTROAMPHETAMINE 10 MG TAB, DEXTROAMPHETAMINE 5 MG TAB, DEXTROAMPHETAMINE SULFATE ER, DICYCLOMINE 10 MG CAPSULE, DICYCLOMINE 10 MG/5 ML SOLN, DICYCLOMINE 20 MG TABLET, FOCALIN XR, HYDROXYZINE 10 MG/5 ML SOLN, HYDROXYZINE 10 MG/5 ML SYRUP, HYDROXYZINE 50 MG/25 ML SYRUP, HYDROXYZINE HCL 10 MG TABLET, HYDROXYZINE HCL 25 MG TABLET, HYDROXYZINE HCL 50 MG TABLET, HYDROXYZINE PAM 100 MG CAP, HYDROXYZINE PAM 25 MG CAP, HYDROXYZINE PAM 50 MG CAP, METADATE CD 30 MG CAPSULE, METADATE CD 40 MG CAPSULE, METHOCARBAMOL 500 MG TABLET, METHOCARBAMOL 750 MG TABLET, METHYLIN 10 MG CHEWABLE TABLET, METHYLIN 2.5 MG CHEWABLE TAB, METHYLIN 5 MG CHEWABLE TABLET, METHYLPHENIDATE ER, METHYLPHENIDATE 10 MG TABLET, METHYLPHENIDATE 10 MG/5 ML SOL, METHYLPHENIDATE 20 MG TABLET, METHYLPHENIDATE 5 MG TABLET, METHYLPHENIDATE 5 MG/5 ML SOLN, METHYLPHENIDATE HCL CD, METHYLPHENIDATE LA, METHYLPHENIDATE SR, ORPHENADRINE ER 100 MG TABLET, PROMETHAZINE 12.5 MG SUPPOS, PROMETHAZINE 12.5 MG TABLET, PROMETHAZINE 25 MG SUPPOSITORY, PROMETHAZINE 25 MG TABLET, PROMETHAZINE 50 MG TABLET, PROMETHAZINE 6.25 MG/5 ML SYRP, RITALIN LA 20 MG CAPSULE, RITALIN LA 30 MG CAPSULE, RITALIN LA 40 MG CAPSULE, THIORIDAZINE HCL, TRIMETHOBENZAMIDE 300 MG CAP, VYVANSE 20 MG CAPSULE, VYVANSE 30 MG CAPSULE, VYVANSE 40 MG CAPSULE, VYVANSE 50 MG CAPSULE, VYVANSE 60 MG CAPSULE, VYVANSE 70 MG CAPSULE, ZINECARD PAGE 2 LAST UPDATED 04/2016
3 Must be under the age of 65 unless there is documented proof that the benefit outweighs the risk. PAGE 3 LAST UPDATED 04/2016
4 ANTINEOPLASTICS ABRAXANE, AFINITOR, AFINITOR DISPERZ, ALIMTA, ANDROID, ARRANON, ARZERRA, AVASTIN, AZACITIDINE, BICNU, BLEOMYCIN SULFATE, BOSULIF, BUSULFEX, CAPRELSA, CARBOPLATIN, CISPLATIN, CLADRIBINE, CLOLAR, COMETRIQ, COSMEGEN, CYCLOPHOSPHAMIDE 25 MG CAPSULE, CYCLOPHOSPHAMIDE 50 MG CAPSULE, CYTARABINE 2 G/20 ML VIAL, CYTARABINE 20 MG/ML VIAL, DACARBAZINE, DAUNORUBICIN HCL, DECITABINE, DOCEFREZ 20 MG VIAL, DOCETAXEL 140 MG/7 ML VIAL, DOCETAXEL 160 MG/16 ML VIAL, DOCETAXEL 20 MG/2 ML VIAL, DOCETAXEL 20 MG/ML VIAL, DOCETAXEL 200 MG/20 ML VIAL, DOCETAXEL 80 MG/4 ML VIAL, DOCETAXEL 80 MG/8 ML VIAL, DOXIL, DOXORUBICIN HCL, ELIGARD, EMCYT, EPIRUBICIN HCL, ERIVEDGE, ERWINAZE, FARESTON, FASLODEX, FIRMAGON, FLUDARABINE PHOSPHATE, FOLOTYN, GEMCITABINE HCL, GILOTRIF, GLEEVEC, HALAVEN, HEXALEN, ICLUSIG 45 MG TABLET, IDARUBICIN HCL, IFOSFAMIDE, IMATINIB MESYLATE, IMBRUVICA, INLYTA, INTRON A 10 MILLION UNIT/ML, INTRON A 10 MILLION UNITS VIAL, INTRON A 18 MILLION UNITS VIAL, INTRON A 50 MILLION UNITS VIAL, INTRON A 6 MILLION UNIT/ML VL, IRINOTECAN HCL, ISTODAX, IXEMPRA, JAKAFI, JEVTANA, KADCYLA, LUPRON DEPOT, LUPRON DEPOT-PED MG 3MO, LUPRON DEPOT-PED 15 MG KIT, LUPRON DEPOT- PED 30 MG 3MO KIT, LUPRON DEPOT-PED 7.5 MG KIT, MATULANE, MEKINIST, MELPHALAN HCL, MITOMYCIN 20 MG VIAL, MITOMYCIN 40 MG VIAL, MITOMYCIN 5 MG VIAL, MITOXANTRONE HCL, MUSTARGEN, NEXAVAR, ONCASPAR, OXALIPLATIN, PACLITAXEL, PANRETIN, POMALYST, PROLEUKIN, REVLIMID, RITUXAN, SOLTAMOX, SPRYCEL, STIVARGA, SUTENT, SYNRIBO, TABLOID, TAFINLAR, TARCEVA, TARGRETIN 75 MG CAPSULE, TARGRETIN 75 MG SOFTGEL, TASIGNA, TESTRED, TOPOTECAN HCL, TORISEL, TREANDA, TRELSTAR, TRELSTAR DEPOT, TRELSTAR LA, TRISENOX, TYKERB, VELCADE, VINBLASTINE SULFATE, VINCASAR PFS, VINCRISTINE SULFATE, VINORELBINE TARTRATE, VOTRIENT, XALKORI, XTANDI, YERVOY, ZALTRAP, ZANOSAR, ZELBORAF, ZOLINZA, ZORTRESS PAGE 4 LAST UPDATED 04/2016
5 PAGE 5 LAST UPDATED 04/2016
6 ARANESP ARANESP 100 MCG/0.5 ML SYRINGE, ARANESP 100 MCG/ML VIAL, ARANESP 150 MCG/0.3 ML SYRINGE, ARANESP 150 MCG/0.75 ML VIAL, ARANESP 200 MCG/0.4 ML SYRINGE, ARANESP 200 MCG/ML VIAL, ARANESP 25 MCG/0.42 ML SYRING, ARANESP 25 MCG/ML VIAL, ARANESP 300 MCG/0.6 ML SYRINGE, ARANESP 300 MCG/ML VIAL, ARANESP 40 MCG/0.4 ML SYRINGE, ARANESP 40 MCG/ML VIAL, ARANESP 500 MCG/1 ML SYRINGE, ARANESP 60 MCG/0.3 ML SYRINGE, ARANESP 60 MCG/ML VIAL Must provide current labwork (Hemoglobin, transferrin saturation, and ferritin) Must be prescribed by hematology/oncology or nephrology PAGE 6 LAST UPDATED 04/2016
7 ASTHMA THERAPY XOLAIR Must have documented diagnosis of asthma and must provide all pulmonary function tests from within the previous 3 months. Must provide clinical documentation of proper diagnosis Must be prescribed by a pulmonologist or an immunologist. PAGE 7 LAST UPDATED 04/2016
8 BONE MARROW TRANSPLANT MOZOBIL Must provide clinical documentation of proper diagnosis. PAGE 8 LAST UPDATED 04/2016
9 BOTOX BOTOX 100 UNITS VIAL Must provide clinical documentation of proper diagnosis. PAGE 9 LAST UPDATED 04/2016
10 CARDIOVASCULAR THERAPY AGENTS PULMONARY ARTERIAL HYPERTENSIVE AGENTS ADCIRCA, ADEMPAS, CIALIS 2.5 MG TABLET, CIALIS 5 MG TABLET, LETAIRIS, OPSUMIT, REMODULIN, SILDENAFIL, TRACLEER Must have documentation of Pulmonary Arterial Hypertension Group 1 or Benign Prostatic Hypertrophy. Must be prescribed by a Cardiologist or Pulmonologist. PAGE 10 LAST UPDATED 04/2016
11 CARIMUNE CARIMUNE NF NANOFILTERED Must provide current progress notes. PAGE 11 LAST UPDATED 04/2016
12 CELLCEPT CELLCEPT Must provide clinical documentation of proper diagnosis. Must be prescribed by a cardiac or hepatic transplant specialist, or other physician experienced in immunosuppresive therapy and management of kidney transplant patients. PAGE 12 LAST UPDATED 04/2016
13 CINRYZE CINRYZE 1. Patient is diagnosed with idiopathic angioedema or drug induced angioedema. Must provide clinical documentation detailing diagnosis, treatment history and disease history. Verify medication is being used for prophylaxis of HAE attacks Must be prescribed by or in consultation with an allergist, immunologist or hematologist. PAGE 13 LAST UPDATED 04/2016
14 CMV CIDOFOVIR 375 MG/5 ML VIAL, GANCICLOVIR SODIUM Documentation of CMV Diagnosis. PAGE 14 LAST UPDATED 04/2016
15 COPD THERAPY DALIRESP Must have documented diagnosis of COPD. Must have be prescribed by a pulmonologist. PAGE 15 LAST UPDATED 04/2016
16 DESMOPRESSIN DESMOPRESSIN 40 MCG/10 ML VIAL, DESMOPRESSIN AC 4 MCG/ML AMPUL, DESMOPRESSIN AC 4 MCG/ML VIAL Diagnosis of Hemophilia A with Factor VIII coagulant level greater than 5% or Von Willebrands Disease Type 1 PAGE 16 LAST UPDATED 04/2016
17 DIASTAT DIAZEPAM 10 MG RECTAL GEL SYST, DIAZEPAM 2.5 MG RECTAL GEL SYS, DIAZEPAM 20 MG RECTAL GEL SYST, DIAZEPAM 5 MG/ML ORAL CONC Must provide clinical documentation detailing the diagnosis and treatment history. Must be prescribed by a neurologist, psychiatrist, or addiction medicine specialist. PAGE 17 LAST UPDATED 04/2016
18 EXJADE EXJADE, FERRIPROX 500 MG TABLET Documentation of trial and failure of Desferal. Must be prescribed by Hematologist. PAGE 18 LAST UPDATED 04/2016
19 FDA CARBAGLU, CYSTAGON, CYTOVENE, ESBRIET, FARYDAK, GATTEX, HETLIOZ, JUXTAPID 10 MG CAPSULE, JUXTAPID 20 MG CAPSULE, JUXTAPID 5 MG CAPSULE, KORLYM, KYNAMRO, LENVIMA, NORTHERA, OFEV, RAVICTI, SIRTURO, TARGRETIN 1% GEL, VPRIV PAGE 19 LAST UPDATED 04/2016
20 FENTANYL FENTANYL CIT OTFC 1,200 MCG, FENTANYL CIT OTFC 1,600 MCG, FENTANYL CITRATE OTFC 200 MCG, FENTANYL CITRATE OTFC 400 MCG, FENTANYL CITRATE OTFC 600 MCG, FENTANYL CITRATE OTFC 800 MCG Must provide clinical documentation detailing diagnosis of Cancer and trial/failure of Fentanyl patches. PAGE 20 LAST UPDATED 04/2016
21 FIRAZYR FIRAZYR 1. Medication is being used for prophylaxis of HAE attacks. 2. Patient is diagnosed with idiopathic angioedema or drug induced angioedema. Must provide clinical documentation detailing diagnosis, treatment history and disease history. Must be prescribed by or in consultation with an allergist, immunologist or hematologist. PAGE 21 LAST UPDATED 04/2016
22 FLECTOR FLECTOR Must provide clinical documentation that 2 or more oral NSAIDs are not effective and/or the inability to take oral medications. PAGE 22 LAST UPDATED 04/2016
23 FORTEO FORTEO Cannot be used for longer then 2 years Must provide clinical documentation detailing the diagnosis and treatment history, documented trial and failure or intolerance to oral biphosphonates and injectable biphosphonates (including date range of therapy), BMD results confirming T-score of -2.5 or less,evidence of supplemental treatment with Calcium and Vitamin D. PAGE 23 LAST UPDATED 04/2016
24 GAMMAGARD BIVIGAM, GAMMAGARD LIQUID, GAMMAGARD S-D, PRIVIGEN Must provide current progress notes. PAGE 24 LAST UPDATED 04/2016
25 GROWTH DEFICIENCY GENOTROPIN, INCRELEX, OMNITROPE Must provide clinical documentation of Primary Growth Deficiency diagnosis PAGE 25 LAST UPDATED 04/2016
26 HARVONI HARVONI Request is for repeat course of treatment with Harvoni with an identical treatment regimen following failure of a full course of treatment 2. Autoimmune hepatitis 3. Request is for greater than 24 weeks of therapy Documented diagnosis of Genotype 1a, 1b, 4, 5, or 6 infection, lab report documenting viral load, detailed medical history of previous treatment. Must be prescribed by a gastroenterology, hepatology, or infectious disease PAGE 26 LAST UPDATED 04/2016
27 HEPATITIS B TYZEKA Lab tests indicating diagnosis of Hepatitis B. Active Hepatitis B. Active Inflammation (serum transaminases). Applies to sylatron and tyzeka. PAGE 27 LAST UPDATED 04/2016
28 HEPATITIS C PEGASYS, PEGINTRON 50 MCG KIT, PEGINTRON REDIPEN, REBETOL 40 MG/ML SOLUTION, RIBASPHERE 400 MG TABLET, RIBASPHERE 600 MG TABLET, RIBAVIRIN Documentation of Hepatitis C. Documentation of appropriate genotype. Member must be greater than 18 years old. Member must have a negative pregnancy test and use 2 forms of contraception during and for 6 months post therapy. PAGE 28 LAST UPDATED 04/2016
29 INTUNIV INTUNIV ER 3 MG TABLET, INTUNIV ER 4 MG TABLET Must provide clinical documentation of ADHD 17 and under PAGE 29 LAST UPDATED 04/2016
30 INVEGA INVEGA SUSTENNA 1. Member is not receiving concomitant treatment with Carbamazepine. 2. Members over 65 with dementia and psychosis. Must provide clinical documentation detailing diagnosis and treatment history, documented trial and failure of Risperdal and Zyprexa or Geodon. Must be 12 years or older. PAGE 30 LAST UPDATED 04/2016
31 IV ANTIBIOTICS CUBICIN, DORIBAX 500 MG VIAL, IMIPENEM-CILASTATIN SODIUM, PIPERACIL-TAZOBACT 2.25 GM VL, PIPERACIL-TAZOBACT GM VL, PIPERACIL-TAZOBACT 4.5 GM VIAL, PIPERACIL-TAZOBACT 40.5 GRAM, ZOSYN 2.25 GM/50 ML GALAXY BAG, ZOSYN GM/50 ML GALAXY, ZOSYN 4.5 GM/100 ML GALAXY BAG, ZYVOX 200 MG/100 ML IV SOLN, ZYVOX 600 MG/300 ML IV SOLN Current Culture and Sensitivity to support the use of the requested antibiotic and excludes use of non restricted antibiotics. Documentation of failure or rationale documenting why non-restricted antibiotics cannot be used. Must add current progress notes. Must be prescribed by an Infectious Disease Specialist. PAGE 31 LAST UPDATED 04/2016
32 IV ANTIFUNGAL ABELCET, AMBISOME, CANCIDAS, FLUCONAZOLE IN DEXTROSE, VORICONAZOLE 200 MG VIAL Current Culture and Sensitivity to support the use of the antifungal medication. Documentation of failure or rationale documenting why non-restricted antifungals cannot be used. Must add current progress notes. Must be prescribed by an Infectious Disease Specialist. PAGE 32 LAST UPDATED 04/2016
33 KALYDECO KALYDECO 150 MG TABLET Must provide clinical documentation detailing the diagnosis and treatment history, Genetic testing. Must be 6 years or older. PAGE 33 LAST UPDATED 04/2016
34 KINERET KINERET Diagnosis of Rheumatoid Arthritis. Failed intolerance to Methotrexate and Humira. PAGE 34 LAST UPDATED 04/2016
35 KUVAN KUVAN 100 MG TABLET Must have documentation of PKU PAGE 35 LAST UPDATED 04/2016
36 LEUKINE LEUKINE 250 MCG VIAL PAGE 36 LAST UPDATED 04/2016
37 LEUPROLIDE LEUPROLIDE 2WK 1 MG/0.2 ML KIT Must provide current progress notes. PAGE 37 LAST UPDATED 04/2016
38 LIDODERM LIDOCAINE 5% PATCH, LIDODERM Must provide clinical documentation of diagnosis of postherpetic neuralgia. PAGE 38 LAST UPDATED 04/2016
39 LOVENOX ENOXAPARIN 100 MG/ML SYRINGE, ENOXAPARIN 120 MG/0.8 ML SYR, ENOXAPARIN 150 MG/ML SYRINGE, ENOXAPARIN 30 MG/0.3 ML SYR, ENOXAPARIN 40 MG/0.4 ML SYR, ENOXAPARIN 60 MG/0.6 ML SYR, ENOXAPARIN 80 MG/0.8 ML SYR Documentation of intolerance or contraindication to Warfarin and Heparin -or- documentation of need for bridge to Coumadin -or- documentation of knee or hip arthroplasty. PAGE 39 LAST UPDATED 04/2016
40 LUMIZYME LUMIZYME, MYOZYME Confirmed diagnosis of Pompe's disease. PAGE 40 LAST UPDATED 04/2016
41 LUNG ENZYME THERAPY PROLASTIN C, ZEMAIRA Clinically documented alpha-1 antitrypsin deficiency. Clinical evidence of emphysema. PiZZ, PiZ() or Pi(,) phenotype (homozygous) alpha 1-antitrypsin deficiency or other phenotypes associated with serum alpha 1-antitrypsin concentrations less than 80 mg/dl. Serum alpha 1-antitrypsin (ATT) greater than 80mg/dl (35% of normal). Progressive panacinar emphysema with documented rate of decline in FEV1. Must be prescribed by a pulmonologist. PAGE 41 LAST UPDATED 04/2016
42 LUPUS BENLYSTA Documentation of diagnosis. Must be prescribed by a rheumatologist. PAGE 42 LAST UPDATED 04/2016
43 MULTAQ MULTAQ Patients with NYHA Class IV heart failure or NYHA Class II - III heart failure with a recent decompensation requiring hospitalization or referral to a specialized heart failure clinic. Second- or third- degree atrioventicular (AV) block or sick sinus synd Must provide clinical documentation of proper diagnosis. PAGE 43 LAST UPDATED 04/2016
44 MULTIPLE SCLEROSIS AMPYRA, AVONEX, AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, EXTAVIA, GILENYA, REBIF 22 MCG/0.5 ML SYRINGE, REBIF 44 MCG/0.5 ML SYRINGE, TYSABRI Must have documentation of multiple sclerosis diagnosis. Must be prescribed by neurologist. PAGE 44 LAST UPDATED 04/2016
45 NARCOLEPSY MODAFINIL, NUVIGIL All medically accepted indications not otherwise excluded from Part D Must provide clinical documentation detailing the diagnosis of Narcolepsy, Shift Work Sleep Disorder, or obstructive sleep apnea. If for Narcolepsy, must show trial and failure to at least one formulary/preferred agent, such as Methylphenidate or dextroamphetamine, or rationale as to why these agents cannot be used. If for obstructive sleep apnea, must show documentation of CPAP history and status. Must be 16 years or older. Must be prescribed by a Neurologist or Pulmonary specialist. PAGE 45 LAST UPDATED 04/2016
46 NEUMEGA NEUMEGA Must have received chemotherapy PAGE 46 LAST UPDATED 04/2016
47 NEUTROPENIC NEULASTA, NEUPOGEN Labs must be submitted that support the diagnosis of neutropenia. PAGE 47 LAST UPDATED 04/2016
48 NUEDEXTA NUEDEXTA Documented diagnosis of pseudobulbar affect (PBA) secondary to amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), or Bilateral Stroke. PAGE 48 LAST UPDATED 04/2016
49 NULOJIX NULOJIX Must provide clinical documentation of a new kidney transplant, patient must be Epstein-Barr virus seropositive Must be prescribed by a physician experienced in immunosuppresive therapy and management of kidney transplant patients PAGE 49 LAST UPDATED 04/2016
50 OCTREOTIDE OCTREOTIDE 1,000 MCG/5 ML VIAL, OCTREOTIDE 1,000 MCG/ML VIAL, OCTREOTIDE 5,000 MCG/5 ML VIAL, OCTREOTIDE ACET 0.05 MG/ML VL, OCTREOTIDE ACET 100 MCG/ML AMP, OCTREOTIDE ACET 100 MCG/ML VL, OCTREOTIDE ACET 200 MCG/ML VL, OCTREOTIDE ACET 50 MCG/ML AMP, OCTREOTIDE ACET 50 MCG/ML VIAL, OCTREOTIDE ACET 500 MCG/ML AMP, OCTREOTIDE ACET 500 MCG/ML VL Must provide current progress notes. PAGE 50 LAST UPDATED 04/2016
51 OLYSIO OLYSIO 1. Request is for repeat course of treatment with Olysio following failure of a full course of treatment with a regimen including Olysio 2. Autoimmune hepatitis. When used in combination with peginterferon alfa/ribavirin 4. Request is for greater than 24 weeks of therapy Documented diagnosis of Genotype 1 infection, lab report documenting viral load, detailed medical history of previous treatment. Must be prescribed by a gastroenterologist, Infectious Disease specialist or Hepatologist. PAGE 51 LAST UPDATED 04/2016
52 ORAL ANTIBIOTICS DIFICID, KETEK, XIFAXAN, ZYVOX 100 MG/5 ML SUSPENSION, ZYVOX 600 MG TABLET Current Culture and Sensitivity to support the use of the requested antibiotic and excludes use of non restricted antibiotics. Documentation of failure or rationale documenting why non-restricted oral antibiotics cannot be used. Must add current progress notes Must be prescribed by an Infectious Disease Specialist. PAGE 52 LAST UPDATED 04/2016
53 OSTEOPOROSIS PROLIA, RECLAST, XGEVA, ZOLEDRONIC ACID 5 MG/100 ML Must have labs and bone density scan submitted to establish proper diagnosis. PAGE 53 LAST UPDATED 04/2016
54 PART D VS PART B ACETYLCYSTEINE 10% VIAL, ACETYLCYSTEINE 20% VIAL, ALBUTEROL 2.5 MG/0.5 ML SOL, ALBUTEROL 5 MG/ML SOLUTION, ALBUTEROL SUL 0.63 MG/3 ML SOL, ALBUTEROL SUL 1.25 MG/3 ML SOL, ALBUTEROL SUL 2.5 MG/3 ML SOLN, ALOXI, AMIKACIN SULF 1 GRAM/4 ML VIAL, AMIKACIN SULF 500 MG/2 ML VIAL, AMINOSYN II 10% IV SOLUTION, AMINOSYN II 15% IV SOLUTION, AMINOSYN II 7% IV SOLUTION, AMINOSYN II WITH ELECTROLYTES, AMINOSYN M, AMINOSYN-HBC, AMINOSYN-PF, ANZEMET, ASTAGRAF XL, AZASAN, AZATHIOPRINE 50 MG TABLET, BUDESONIDE 0.25 MG/2 ML SUSP, BUDESONIDE 0.5 MG/2 ML SUSP, CALCITRIOL 1 MCG/ML SOLUTION, CALCIUM FOLINATE 10 MG/ML VIAL, CELLCEPT 200 MG/ML ORAL SUSP, CEREZYME, CESAMET, CLINIMIX, CLINIMIX E 2.75%-10% SOLUTION, CLINIMIX E 2.75%-5% SOLUTION, CLINIMIX E 4.25%-25% SOLUTION, CLINIMIX E 4.25%-5% SOLUTION, CLINIMIX E 5%-15% SOLUTION, CLINIMIX E 5%-20% SOLUTION, CLINIMIX E 5%-25% SOLUTION, CROMOLYN 20 MG/2 ML NEB SOLN, CYCLOPHOSPHAMIDE 25 MG CAPSULE, CYCLOPHOSPHAMIDE 50 MG CAPSULE, CYCLOSPORINE 100 MG CAPSULE, CYCLOSPORINE 100 MG/ML SOLN, CYCLOSPORINE 25 MG CAPSULE, CYCLOSPORINE 50 MG/ML AMPUL, CYCLOSPORINE 50 MG/ML VIAL, CYCLOSPORINE MODIFIED, DRONABINOL, ELITEK, EMEND 125 MG CAPSULE, EMEND 40 MG CAPSULE, EMEND 80 MG CAPSULE, ENGERIX-B ADULT, ENGERIX-B PEDIATRIC- ADOLESCENT, EPOGEN 10,000 UNITS/ML VIAL, EPOGEN 2,000 UNITS/ML VIAL, EPOGEN 20,000 UNITS/2 ML VIAL, EPOGEN 20,000 UNITS/ML VIAL, EPOGEN 3,000 UNITS/ML VIAL, EPOGEN 4,000 UNITS/ML VIAL, ERBITUX, FLUOROURACIL 1,000 MG/20 ML VL, FLUOROURACIL 2,500 MG/50 ML VL, FLUOROURACIL 2.5 GM/50 ML VIAL, FLUOROURACIL 5 GM/100 ML VIAL, FLUOROURACIL 5,000 MG/100 ML, FLUOROURACIL 500 MG/10 ML VIAL, GAMMAPLEX, GAMUNEX, GAMUNEX-C, GENGRAF, GRANISETRON HCL, HEPATAMINE, HERCEPTIN, IMURAN, INTRALIPID, IPRATROPIUM BR 0.02% SOLN, IPRATROPIUM- ALBUTEROL, LEUCOVORIN CAL 500 MG/50 ML VL, LEUCOVORIN CALCIUM 100 MG VIAL, LEUCOVORIN CALCIUM 200 MG VIAL, LEUCOVORIN CALCIUM 350 MG VIAL, LEUCOVORIN CALCIUM 50 MG VIAL, LEUCOVORIN CALCIUM 500 MG VL, LEVOCARNITINE 100 MG/ML SOLN, LEVOCARNITINE 330 MG TABLET, LEVOLEUCOVORIN CALCIUM, LUPRON DEPOT- PED MG KIT, METHOTREXATE 1 GM VIAL, METHOTREXATE 100 MG/4 ML VIAL, METHOTREXATE 2.5 MG TABLET, METHOTREXATE SODIUM, METOCLOPRAMIDE 10 MG/2 ML VIAL, MYCOPHENOLATE MOFETIL, MYCOPHENOLIC ACID, MYFORTIC, NALBUPHINE 10 PAGE 54 LAST UPDATED 04/2016
55 MG/ML AMPUL, NALBUPHINE 100 MG/10 ML VIAL, NALBUPHINE 20 MG/ML AMPUL, NALBUPHINE 200 MG/10 ML VIAL, NEBUPENT, NEORAL, NORMAL SALINE FLUSH SYRINGE, NUTRILIPID, ONDANSETRON 4 MG/2 ML AMPULE, ONDANSETRON 4 MG/5 ML SOLUTION, ONDANSETRON HCL 24 MG TABLET, ONDANSETRON HCL 4 MG TABLET, ONDANSETRON HCL 4 MG/2 ML VIAL, ONDANSETRON HCL 8 MG TABLET, ONDANSETRON ODT, OTREXUP 10 MG/0.4 ML AUTO-INJ, OTREXUP 15 MG/0.4 ML AUTO-INJ, OTREXUP 20 MG/0.4 ML AUTO-INJ, OTREXUP 25 MG/0.4 ML AUTO-INJ, PERJETA, PREMASOL, PRIVIGEN, PROCALAMINE, PROCRIT, PROGRAF, PROSOL, PULMOZYME, RAPAMUNE, RECOMBIVAX HB 10 MCG/ML VIAL, RECOMBIVAX HB 40 MCG/ML VIAL, RECOMBIVAX HB 5 MCG/0.5 ML VL, SANDIMMUNE, SANDOSTATIN LAR, SANDOSTATIN LAR DEPOT, SIROLIMUS 0.5 MG TABLET, SIROLIMUS 1 MG TABLET, SIROLIMUS 2 MG TABLET, SALINE 0.45% SOLN-EXCEL CON, SALINE 0.9% SOLN-EXCEL CONT, SODIUM CHLORIDE 0.45% SOLN, SODIUM CHLORIDE 0.45% SOLUTION, SODIUM CHLORIDE 0.9% 100 ML, SODIUM CHLORIDE 0.9% 250 ML, SODIUM CHLORIDE 0.9% 50 ML, SODIUM CHLORIDE 0.9% 500 ML, SODIUM CHLORIDE 0.9% IRRIG., SODIUM CHLORIDE 0.9% SOLN, SODIUM CHLORIDE 0.9% SOLUTION, SODIUM CHLORIDE 0.9% VIAL, SODIUM CHLORIDE 3% IV SOLN, SODIUM CHLORIDE 5% IV SOLN, SODIUM CL 2.5 MEQ/ML VIAL, TACROLIMUS 0.5 MG CAPSULE, TACROLIMUS 1 MG CAPSULE, TACROLIMUS 5 MG CAPSULE, TRAVASOL, TREXALL, TROPHAMINE, VECTIBIX, VIRAZOLE, ZOLEDRONIC ACID 4 MG VIAL, ZOLEDRONIC ACID 4 MG/5 ML VIAL, ZOMETA 4 MG/5 ML VIAL DETAILS This drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. PAGE 55 LAST UPDATED 04/2016
56 PHOTOCHEMOTHERAPY METHOXSALEN 10 MG CAPSULE, OXSORALEN-ULTRA Must be undergoing photochemotherapy PAGE 56 LAST UPDATED 04/2016
57 PICATO PICATO Must provide clinical documentation detailing the diagnosis and treatment history, documented trial and failure of Fluorouracil or Imiquimod. PAGE 57 LAST UPDATED 04/2016
58 PROMACTA PROMACTA 25 MG TABLET, PROMACTA 50 MG TABLET, PROMACTA 75 MG TABLET Must provide current progress notes. PAGE 58 LAST UPDATED 04/2016
59 RANEXA RANEXA Diagnosis of angina with documentation of failure of nitrocglycerin. PAGE 59 LAST UPDATED 04/2016
60 RISPERDAL RISPERDAL, RISPERDAL CONSTA, RISPERDAL M-TAB Must provide clinical documentation detailing the diagnosis and treatment history, documented trial and failure or inability to use oral antipsychotic agents. PAGE 60 LAST UPDATED 04/2016
61 SABRIL SABRIL Must provide clinical documentation of refractory complex partial seizures or infantile spasms, documented trial and failure of 2 other anticonvulsant agents, baseline eye exam. Must be prescribed by a specialist in the neurology field of study and be registered with SHARE program. PAGE 61 LAST UPDATED 04/2016
62 SIMULECT SIMULECT Must provide clinical documentation detailing the diagnosis and treatment history. Must be prescribed by a physician experienced in immunosuppresive therapy and management of kidney transplant patients PAGE 62 LAST UPDATED 04/2016
63 SOVALDI SOVALDI 1. Request is for repeat course of treatment 2. Autoimmune hepatitis. 3. When used in combination with peginterferon alfa/ribavirin 4. Request is for greater than 24 weeks of therapy Documented diagnosis of Genotype 1a, 1b, 2, 3, 4, 5, or 6 infection,lab report documenting viral load, detailed medical history of previous treatment. Must be prescribed by a gastroenterologist, Infectious Disease specialist or Hepatologist. PAGE 63 LAST UPDATED 04/2016
64 SYMLIN SYMLINPEN 120, SYMLINPEN 60 Diagnosis of Type II diabeteshba1c greater than 7.5%Failed to reach HbA1c goal with maximum dose of metformin (1,500mg/day) or TZD (pioglitazone at 45mg/day, rosiglitazone at 8mg/day), for at least 90 days over the past 120 days or Diagnosis of Type I diabetes who have failed to achieve desired glucose control despite optimal insulin therapy. PAGE 64 LAST UPDATED 04/2016
65 SYNAGIS SYNAGIS 1. Patient has hemodynamically insignificant heart disease (eg. Secundum atrialseptal defect, small ventricular septal defect, pullmonic stenosis, uncomplicatedaortic stenosis, mild coarctation of the aorta, and patent ductus arteriosus). Must provide clinical documentation of proper diagnosis. PAGE 65 LAST UPDATED 04/2016
66 THALOMID THALOMID Must provide clinical documentation of proper diagnosis. PAGE 66 LAST UPDATED 04/2016
67 TNF ACTEMRA 200 MG/10 ML VIAL, ACTEMRA 400 MG/20 ML VIAL, ACTEMRA 80 MG/4 ML VIAL, ENBREL, HUMIRA 20 MG/0.4 ML SYRINGE, HUMIRA 40 MG/0.8 ML SYRINGE, HUMIRA PEN, HUMIRA PEN CROHN'S-UC-HS, HUMIRA PEN PSORIASIS, ORENCIA 125 MG/ML SYRINGE, REMICADE, SIMPONI 50 MG/0.5 ML SYRINGE Must provide clinical documentation of proper diagnosis. Must be prescribed by a dermatologist, gastroenterologist or rheumatologist. PAGE 67 LAST UPDATED 04/2016
68 TOBI TOBI, TOBRAMYCIN 300 MG/5 ML AMPULE Must provide clinical documentation of Cystic Fibrosis diagnosis PAGE 68 LAST UPDATED 04/2016
69 VIEKIRA VIEKIRA PAK Request is for repeat course of treatment with Viekira with an identical treatment regimen following failure of a full course of treatment 2. Autoimmune hepatitis 3. Request is for greater than 24 weeks of therapy Documented diagnosis of Genotype 1 infection, lab report documenting viral load, detailed medical history of previous treatment. Must be prescribed by a gastroenterologist, hepatology, or infectious diease PAGE 69 LAST UPDATED 04/2016
70 XENAZINE XENAZINE Must provide clinical documentation of Huntingtons Disease diagnosis PAGE 70 LAST UPDATED 04/2016
71 ZYTIGA ZYTIGA Must provide clinical documentation of proper diagnosis. PAGE 71 LAST UPDATED 04/2016
72 PAGE 72 LAST UPDATED 04/2016
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
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
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
2014 AlohaCare Advantage (HMO) and AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Prior Authorization Requirements
2014 AlohaCare Advantage (HMO) and AlohaCare Advantage Plus Formulary (HMO SNP) with Prior Authorization Requirements You may need prior authorization for certain drugs that are on the formulary or drugs
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
Specialty Drugs. The specialty drug list below is effective June 5, 2018 and is subject to change at any time.
Specialty Drugs The following is a list of medications that are considered specialty drugs. Specialty drugs include self-administered injectables, medications that are high cost, and/or medications that
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
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
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
BELEODAQ. Prior Authorization Criteria Memorial Hermann Advantage HMO & PPO Formulary ID: Version 10 Effective Date: 6/1/2015
Memorial Hermann Advantage HMO & PPO Formulary ID: 15190 Version 10 BELEODAQ BELEODAQ All FDA approved indications not otherwise excluded from Part D. Plan Year Y0110_PriorAuthCriteria4 IA 04/09/2015 PAGE
COVERED USES All medically accepted indications not otherwise excluded from Part D
BOSULIF BOSULIF Signed statement of diagnosis from the physician, hepatic panel and CBC, trial and failure ofofimiatinib or dasatinibi and documentation of a 90 day response 12/31/15 PAGE 1 LAST UPDATED
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
2013 Prior Authorization (PA) Criteria
2013 Prior Authorization (PA) Criteria Certain drugs require prior authorization from EmblemHealth Medicare HMO/PPO Medicare Plans. This means that your doctor must contact us to get approval before prescribing
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,
2016 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Prior Authorization Requirements
2016 AlohaCare Advantage Plus Formulary (HMO SNP) with Prior Authorization Requirements You may need prior authorization for certain drugs that are on the formulary or drugs that are not on the formulary.
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
BELEODAQ. Prior Authorization Criteria Memorial Hermann HMO Formulary ID: Version 19 Effective Date: 10/27/2015. PRODUCT(s) AFFECTED BELEODAQ
BELEODAQ BELEODAQ All FDA approved indications not otherwise excluded from Part D. Plan Year PAGE 1 BEXAROTENE BEXAROTENE All Medically Accepted Indications not otherwise excluded from Part D Patient must
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
Buckeye Health Plan (MMP) 2016 Prior Authorization Criteria
Buckeye Health Plan (MMP) 2016 Prior Authorization Instructions: 1. With this file, at the top, click Edit, then click Find. 2. In the Find box type the name of the medication you want to find. 3. Click
LIST OF DRUGS THAT MAY BE COVERED UNDER YOUR MEDICAL BENEFIT
LIST OF DRUGS THAT MAY BE COVERED UNDER YOUR MEDICAL BENEFIT The following medications may be covered under your medical benefit if they are provided to you in your doctor s office or outpatient infusion
GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP Prior Authorization (PA) Criteria
GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP 2014 Prior Authorization (PA) Certain drugs require prior authorization from GuildNet Gold and GuildNet Health Advantage Medicare Plans.
2012 Prior Authorization Criteria
GuildNet Gold HMO-POS SNP GuildNet Health Advantage HMO-POS SNP 2012 Prior Authorization Criteria ACTEMRA... 18 ACTEMRA... 18 ACTIMMUNE... 19 ACTIMMUNE... 19 ADAGEN... 20 ADAGEN... 20 ADCIRCA... 21 ADCIRCA...
2012 Prior Authorization Criteria
2012 Prior Authorization Criteria ACTEMRA... 17 ACTEMRA... 17 ACTIMMUNE... 18 ACTIMMUNE... 18 ADAGEN... 19 ADAGEN... 19 ADCIRCA... 20 ADCIRCA... 20 AFINITOR... 21 AFINITOR... 21 ALDURAZYME... 22 ALDURAZYME...
Lista de medicamentos especializados
Lista de medicamentos especializados Vigencia: 1o. de enero de 2016 A continuación se listan, en orden alfabético, los medicamentos de especialidad recetados más frecuentemente. Los medicamentos de especialidad
Ally Rx D-SNP Current as of r 1, 2017
Ally Rx D-SNP Current as of r 1, 2017 AMPYRA AMPYRA PA Moderate to severe renal impairment (CrCL less than or equal to 50ml/min), patient not able to walk 25 feet in 8-45 seconds. Documentation of diagnosis,
2014 Prior Authorization (PA) Criteria
2014 Prior Authorization (PA) Certain drugs require prior authorization from EmblemHealth Medicare HMO/PPO Medicare Plans. This means that your doctor must contact us to get approval before prescribing
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
ADCIRCA. Products Affected Adcirca. Prior Authorization Criteria 2017 MMP Effective Date: 11/01/2017 Approval Date: 11/01/2017
Prior Authorization 2017 MMP Effective Date: 11/01/2017 Approval Date: 11/01/2017 ADCIRCA Products Affected Adcirca PA Details All FDA-approved indications not otherwise Other Patients taking nitrates
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
ANTIDEPRESSANTS. Details. Step Therapy 2017 Last Updated: 5/23/2017
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 FETZIMA CAPSULE
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,
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,
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
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
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
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
Plan Year 2019 Prior Authorization (PA) Criteria
Plan Year 2019 Prior Authorization (PA) Criteria Prior Authorization: Commonwealth Care Alliance requires you (or your physician) to get prior authorization for certain drugs. This means that you will
Products Affected ACTEMRA SUBCUTANEOUS ACTEMRA INTRAVENOUS SOLUTION 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML)
Current as of October 1, 2016 ACTEMRA ACTEMRA SUBCUTANEOUS ACTEMRA INTRAVENOUS SOLUTION 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) PA Other Documentation of diagnosis, previous treatment with one or
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
Plan Year 2018 Prior Authorization (PA) Criteria
Plan Year 2018 Prior Authorization (PA) Criteria Prior Authorization: Commonwealth Care Alliance requires you (or your physician) to get prior authorization for certain drugs. This means that you will
Plan Year 2017 Prior Authorization (PA) Criteria
Plan Year 2017 Prior Authorization (PA) Criteria Prior Authorization: Commonwealth Care Alliance requires you (or your physician) to get prior authorization for certain drugs. This means that you will
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
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
8-MOP. Products Affected
2018 First Choice VIP Care Plus Document: 2018 Prior Authorization Formulary ID: 18395 Last Updated: 10/2018 Effective Date: 11-01-2018 8-MOP 8-MOP Age must be a dermatologist or an oncologist. 1 ABILIFY
Geisinger Health Plan Prior Authorization Requirements
ACTIQ FENTANYL CITRATE DOCUMENTATION OF USE TO MANAGE BREAKTHROUGH CANCER PAIN IN PATIENTS WITH CANCER CONCOMITANT MORPHINE 60 MG/DAY OR MORE, TRANSDERMAL FENTANYL 25 MCG/H, OXYCODONE 30 MG/DAY, ORAL HYDROMORPHONE
Prior Authorization Group AVITA CREAM, AVITA GEL, RETIN-A MICR GEL, TRETINOIN CREAM, TRETINOIN GEL
PA Criteria ACNE AVITA CREAM, AVITA GEL, RETIN-A MICR GEL, TRETINOIN CREAM, TRETINOIN GEL, keratosis follicularis (Darier's disease, Darier-White disease) Cosmetic use Approve for those 12 years of age
Formulary Chemotherapy Agents: (Current as of 6/2018) Therapeutic Class
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY Cancer LAST REVIEW 9/11/18 THERAPEUTIC CLASS Oncology REVIEW HISTORY 5/17, 5/16 LOB AFFECTED Medi-Cal (MONTH/YEAR) This 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
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...
ICON Formulary - October 2018 Legend - ICON Protocols Essential (previously Standard), Core, Enhanced Core, Enhanced Enhanced
ICON Formulary - October 2018 Legend - ICON Protocols Essential (previously Standard), Core, Enhanced Core, Enhanced Enhanced Class Medicine Name Nappi Strength Form Size Route Abiraterone Acetate ZYTIGA
List 1 PRESCRIPTION DRUGS REQUIRING PRE-AUTHORIZATION LIBERTY HEALTH DRUG IDENTIFICATION NUMBER (DIN)
PRESCRIPTION DRUGS REQUIRING PRE-AUTHORIZATION List 1 ACNE THERAPY If covered person over 30 years of age approval by Liberty Health required RETIN A CR 0.01% 00897329 RETIN A CR 0.025% 00897310 RETIN
ACITRETIN. Products Affected
ACITRETIN acitretin Other For prophylaxis of skin cancer in patients with previously treated skin cancers who have undergone an organ transplantation the request will be approved. For psoriasis: the patient
Covered Uses All medically accepted indications not otherwise excluded from Part D.
AAT DEFICIENCY Aralast NP intravenous recon soln 1,000 mg Glassia Prolastin-C intravenous recon soln Zemaira PA Details Age Other Diagnosis of severe congenital A1-PI deficiency who have clinically evident
Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema, weight, A1-PI phenotype, A1-PI baseline level
AAT DEFICIENCY Aralast NP intravenous recon soln 1,000 Prolastin-C intravenous recon soln mg Zemaira Glassia Other Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema,
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
HCPCS Code/ generic (Brand) Name J7506. J8520 capecitabine (Xeloda) 1. J8521 capecitabine. J8530 cyclophosphamide. (Cytoxan) 1
drug and administration compendia Current Price () J7506 Prednisone, oral, per 5 mg 12/1/07 $0.07 $0.19 N/A prednisone 2 J8520 capecitabine (Xeloda) 1 Capecitabine, oral, 150 mg 8/1/07 $5.79 $4.59 N/A
Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema, weight, A1-PI phenotype, A1-PI baseline level
AAT DEFICIENCY Aralast NP intravenous recon soln 1,000 mg Glassia Prolastin-C intravenous recon soln Zemaira Other Diagnosis of severe congenital A1-PI deficiency who have clinically evident emphysema,
Aetna Better Health of Illinois Medicaid Formulary Updates
October 2017 o DOXYLAMINE SUCCINATE 25mg-QL o DULOXETINE CAP 40MG DR-QL o GUANFACIN ER TABS (all strengths)-ql o TOBRAMYCIN NEBU SOLUTION- PA August 2017 Aetna Better Health of Illinois Medicaid 2017 Formulary
2014 Quantity Limits (QL) Criteria
2014 Quantity Limits (QL) Criteria Certain drugs covered through your EmblemHealth Medicare HMO/PPO Medicare Plan are covered for only a limited quantity. We do this to ensure compliance with the US Food
DRUGS REQUIRING PRIOR AUTHORIZATION
DRUGS REQUIRING PRIOR AUTHORIZATION Medication Abstral Actemra Acthar Gel Actiq* Adcirca Adderall Adderall XR Addyi Adempas Adipex* Adzenys XR-ODT Afinitor Afinitor Alecensa Alecensa Ampyra Androderm AndroGel
Quarterly pharmacy formulary change notice
Provider update This is an update about information in the provider manual. For access to the latest provider manual, go online to https://providers.amerigroup.com/md. Quarterly pharmacy formulary change
Post-operative pain following CABG surgery Allergic-type reaction to aspirin, NSAIDs, or sulfonamides
Covered Uses (Including all FDA-approved indications not otherwise ) ACNE Atralin Gel Avita Cream Avita Gel Retin-A Cream Retin-A Gel Retin-A Micro Gel Tretinoin Cream Tretinoin Gel Acne vulgaris Keratosis
SelectHealth Advantage 2015 Prior Authorization Criteria
ACROMEGALY Somatuline Depot, Somavert 1. Pt has had surgical resection of the pituitary gland OR is not a candidate for surgery/radiation therapy, 2. Patient has tried at least ONE of the following: a.
To help doctors give their patients the best possible care, the American
Patient Information Resources from ASCO What to Know ASCO s Guideline on Preventing Vomiting Caused by Cancer Treatment SEPTEMBER 2011 KEY MESSAGES The risk of nausea and vomiting depends on the specific
UP Health System Marquette Medication Guideline High Alert Drugs
1 ALTEPLASE SOLR 100 MG ACTIVASE 305010 50242008527 TRUE ALTEPLASE SOLR 50 MG ACTIVASE 305008 50242004413 TRUE AMIODARONE INJ 50 MG/ML CORDARONE IV 305035 63323061609 TRUE AMIODARONE INJ 50 MG/ML CORDARONE
AgeWell 5 Tier 2016 Prior Authorization Criteria
ADCIRCA - ADCIRCA TAB 20MG. Patient requires nitrate therapy on a regular or intermittent basis Statement of diagnosis from the physician Effective 05/01/2016 1 BOSULIF - BOSULIF TAB 100MG BOSULIF TAB
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
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
Product Name Strength Dosage Form Therapeutic Area Dossier Status. Aceclofenac 100mg Film coated Tablets Analgesia-inflammation Approved
Product Name Strength Dosage Form Therapeutic Area Dossier Status Aceclofenac 100mg Film coated Tablets Analgesia-inflammation Approved Alendronate Sodium 10/70mg Tablets Osteoporosis Approved Anastrozole
ACITRETIN. Products Affected
ACITRETIN acitretin Other For prophylaxis of skin cancer in patients with previously treated skin cancers who have undergone an organ transplantation the request will be approved. For psoriasis: the patient
ACROMEGALY THERAPY. Products Affected Somatuline Depot subcutaneous syringe 120 mg/0.5 ml, 60 mg/0.2 ml, 90 mg/0.3 ml
Prior Authorization Requirements Effective January 1, 2019 ACROMEGALY THERAPY Somatuline Depot subcutaneous syringe 120 mg/0.5 ml, 60 mg/0.2 ml, 90 mg/0.3 ml Somavert PA Age Other PATIENT PROGRESS NOTES,
Drug Bill As Unit Common Directions Common Day Supply Common Billing Errors Oral Tablets/Capsules
Note: This is a guide for commonly misbilled medications. Please submit the claims according to directions for use indicated on the prescription order. Drug Bill As Unit Common Directions Common Day Supply
Quarterly pharmacy formulary change notice
Provider update This is an update about information in the provider manual. For access to the latest provider manual, go online to https://providers.amerigroup.com/ga. Quarterly pharmacy formulary change
Agewell 1 Tier 2016 Prior Authorization Criteria
ADCIRCA - ADCIRCA TAB 20MG. Patient requires nitrate therapy on a regular or intermittent basis Statement of diagnosis from the physician Effective 07/01/2016 1 BOSULIF - BOSULIF TAB 100MG BOSULIF TAB
Quarterly pharmacy formulary change notice
Provider update This is an update about information in the provider manual. For access to the latest provider manual, go online to https://providers.amerigroup.com. Quarterly pharmacy formulary change
ABRAXANE. Products Affected. Prior Authorization Criteria 2019 Secure-Extra PDP 6 Tier Last Updated: 12/2018. Abraxane
Prior Authorization 2019 Secure-Extra PDP 6 Tier Last Updated: 12/2018 ABRAXANE Abraxane PA Details Age Other B vs D coverage determination 1 ACITRETIN Acitretin PA Details Documentation of diagnosis.
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,
ACROMEGALY THERAPY. Products Affected Somatuline Depot subcutaneous syringe 120 mg/0.5 ml, 60 mg/0.2 ml, 90 mg/0.3 ml
Prior Authorization Requirements Effective January 1, 2019 ACROMEGALY THERAPY Somatuline Depot subcutaneous syringe 120 mg/0.5 ml, 60 mg/0.2 ml, 90 mg/0.3 ml Somavert PA Age PENDING CMS APPROVAL PATIENT
ABRAXANE. Products Affected. Prior Authorization Criteria 2019 Secure-Essential PDP 5 Tier Last Updated: 10/01/2018. Abraxane
Prior Authorization 2019 Secure-Essential PDP 5 Tier Last Updated: 10/01/2018 ABRAXANE Abraxane PA Details Age Other B vs D coverage determination 1 ACITRETIN Acitretin PA Details Documentation of diagnosis.
WELLCARE/ OHANA HEALTH PLAN
WELLCARE/ OHANA HEALTH PLAN 2014 PRIOR AUTHORIZATION CRITERIA No Changes Made Since: 08/2014 **To get updated information about the drugs covered by WellCare, please visit our website (https://www.wellcare.com)
Acute Lymphocytic Leukemia
Acute Lymphocytic Leukemia Splenectomy (Removal of Spleen) 6-Mercaptopurine (Purinethol, 6-MP) Alemtuzumab (Campath ) Arsenic Trioxide (Trisenox ) Bendamustine (Treanda ) Bexarotene (Targretin ) Bleomycin
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
Quarterly pharmacy formulary change notice
Provider update This is an update about information in the provider manual. For access to the latest provider manual, go online to https://providers.amerigroup.com/fl. Quarterly pharmacy formulary change
Drugs That Require Prior Authorization (PA) Before Being Approved for Coverage
Drugs That Require Prior Authorization (PA) Before Being Approved for Coverage You will need authorization by your UA Medicare Part D Prescription Drug Plan before filling prescriptions for the drugs shown
Quarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice Provider update Summary: Effective August 1, 2018, the preferred formulary changes detailed in the table below will apply to District of Columbia Healthy Families
2018 Prior Authorizations (List of Prior Authorizations)
Prior Authorization Last Updated: April 24, 2018 Effective Date: May 1, 2018 2018 Prior Authorizations (List of Prior Authorizations) PLEASE READ CAREFULLY: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE
Quarterly pharmacy formulary change notice
Provider update This is an update about information in the provider manual. For access to the latest provider manual, go online to https://providers.amerigroup.com. Quarterly pharmacy formulary change
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
ALPHA1-PROTEINASE INHIBITOR
Ally Rx D-SNP Current as of Nov. 1, 2018 ALPHA1-PROTEINASE INHIBITOR ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG GLASSIA PROLASTIN-C INTRAVENOUS RECON SOLN ZEMAIRA PA Documentation of diagnosis, lab results,
Alprazolam 0.25mg, 0.5mg, 1mg tablets
Presbyterian Senior Care (HMO) / Presbyterian MediCare PPO Quantity Limits Effective November 1, 2014 For the most recent list of drugs or other questions, please contact the Presbyterian Customer Service
MEDICATION(S) ORENCIA 125 MG/ML SYRINGE, ORENCIA 50 MG/0.4 ML SYRINGE, ORENCIA 87.5 MG/0.7 ML SYRINGE, ORENCIA CLICKJECT
ABATACEPT ORENCIA 125 MG/ML SYRINGE, ORENCIA 50 MG/0.4 ML SYRINGE, ORENCIA 87.5 MG/0.7 ML SYRINGE, ORENCIA CLICKJECT Documentation that patient has had an inadequate response or intolerant to BOTH of the
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
ACTIMMUNE. Products Affected Actimmune Prior Authorization Criteria Effective: 11/01/2016 Updated 11/2016
2016 Prior Authorization Effective: 11/01/2016 Updated 11/2016 ACTIMMUNE Products Affected Actimmune PA Details Age Other 1 ADAGEN Products Affected Adagen PA Details Age Other Contraindicated in bone