Vivida Health Specialty Pharmacy Drugs (Injectable) Prior-Authorization Requirements Effective 1/1/19
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1 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 J0207 J0220 J0221 J0256 J0257 J0485 J0490 J0585 J0586 J0587 J0588 J0594 J0597 J0598 J0637 J0640 J0641 J0717 J0775 J0878 J0881 J0881 J0885 J0885 J0894 J0897 J0897 J1290 J1300 J1322 AFLIBERCEPT 1MG AGALSIDASE BETA 1MG ALEMTUZUMAB 1MG ALGLUCERASE PER 10 UNITS AMIFOSTINE 500MG ALGLUCOSIDASE ALFA 10MG NOS ALGLUCOSIDASE ALFA 10MG (LUMIZYME) ALPHA 1 PROTEINASE INHIBITOR (HUMAN) 10MG NOS ALPHA 1 PROTEINASE INHIBITOR HUMAN (GLASSIA) 10MG BELATACEPT 1MG BELIMUMAB 10MG ONABOTULINUMTOXINA A 1 UNIT ABOBOTULINUMTOXINA A 5 UNITS RIMABOTULINUM TOXIN B 100 UNITS INCOBOTULINUM TOXIN A 1 UNIT BUSULFAN 1MG C-1 ESTERASE INHIBITOR HUMAN (BERINET) 10 UNITS C-1 ESTERASE INHIBITOR HUMAN (CYNRYZE) 10 UNITS CASPOFUNGIN ACETATE 5MG LEUCOVORIN CALCIUM 50MG LEVOLEUCOVORIN CALCIUM 0.5MG CERTOLIZUMAB PEGOL 1MG COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 0.01MG DAPTOMYCIN 1MG DARBEPOETIN ALFA 1MCG DARBEPOETIN ALFA 1MCG EPOETIN ALFA 1,000 UNITS EPOETIN ALFA 1,000 UNITS DECITABINE 1MG DENOSUMAB 1MG DENOSUMAB 1MG ECALLANTIDE 1MG ECULIZUMAB 10MG ELOSULFASE ALFA 1MG
2 J1439 J1442 J1447 J1453 J1458 J1459 J1460 J1556 J1557 J1559 J1560 J1561 J1562 J1566 J1568 J1569 J1571 J1572 J1573 J1575 J1599 J1602 J1640 J1645 J1650 J1652 J1743 J1745 J1786 J1930 J1930 J1931 J1950 J2315 J2323 J2353 J2355 J2357 FERRIC CARBOXYMALTOSE 1MG FILGRASTIM G-CSF 1MCG TBO FILGRASTIM 1MCG FOSAPREPITANT 1MG GALSULFASE 1MG Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg Injection, gamma globulin, intramuscular, 1 cc Injection, immune globulin (bivigam), 500 mg Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg Injection, immune globulin (hizentra), 100 mg Injection, gamma globulin, intramuscular, over 10 cc Injection, immune globulin, (gamunex-c/gammaked), non-lyophilized (e.g., liquid), 500 mg Injection, immune globulin (vivaglobin), 100 mg Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg Injection, immune globulin, (gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg Injection, hepatitis b immune globulin (hepagam b), intramuscular, 0.5 ml Injection, immune globulin, (flebogamma/flebogamma dif), intravenous, non-lyophilized (e.g., liquid), 500 mg Injection, hepatitis b immune globulin (hepagam b), intravenous, 0.5 ml Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified, 500 mg GOLIMUMAB FOR IV USE 1MG HEMIN 1MG DALTEPARIN SODIUM PER 2,500IU ENOXAPARIN SODIUM 10MG FONDAPARINUX SODIUM 0.5MG IDURSULFASE 1MG INFLIXIMAB 10MG IMIGLUCERASE PER 10 UNITS LANREOTIDE 1MG LANREOTIDE 1MG LARONIDASE 0.1MG LEUPROLIDE ACETATE PER 3.75MG (FOR DEPOT SUSPENSION) NALTREXONE DEPOT FORM 1MG NATALIZUMAB 1MG OCTREOTIDE DEPOT FORM INTRAMUSCULAR 1MG OPRELVEKIN 5MG OMALIZUMAB 5MG
3 J2426 J2430 J2469 J2503 J2504 J2505 J2507 J2562 J2778 J2783 J2796 J2820 J3060 J3095 J3240 J3262 J3315 J3380 J3385 J3396 J3489 J3489 J3490 J7311 J7312 J7313 J7323 J7324 J7325 J7328 J7504 J7511 J9000 J9015 J9017 J9019 J9025 J9027 J9032 PALIPERIDONE PALMITATE ER 1MG PAMIDRONATE DISODIUM PER 30MG PALONOSETRON 25MCG PEGAPTANIB SODIUM 0.3MG PEGADEMASE BOVINE 25IU PEGFILGRASTIM 6MG PEGLOTICASE 1MG PLERIXAFOR 1MG RANIBIZUMAB 0.1MG RASBURICASE 0.5MG ROMIPLOSTIM 10MCG SARGRAMOSTIM (GM-CSF) 50MCG TALIGLUCERACE ALFA 10 UNITS TELEVANCIN 10MG THYROTROPIN ALPHA 0.9MG TOCILIZUMAB 1MG TRIPTORELIN PAMOATE 3.75MG VEDOLIZUMAB 1MG VELAGLUCERASE ALFA 100 UNITS VERTEPORFIN 0.1MG ZOLEDRONIC ACID 1MG ZOLEDRONIC ACID 1MG UNCLASSIFIED INJECTION FLUOCINOLONE ACETONIDE INTRAVITREAL IMPLANT DEXAMETHASONE INTRAVITREAL IMPLANT 0.1MG FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT, 0.01 MG HYALURONAN OR DERIVATIVE (EUFLEXXA) FOR INTRA- ARTICULAR INJECTION PER DOSE HYALURONAN OR DERIVATIVE (ORTHOVISC) FOR INTRA- ARTICULAR INJECTION PER DOSE HYALURONAN OR DERIVATIVE (SYNVISC OR SYNVISC ONE) FOR INTRA-ARTICULAR INJECTION 1MG HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA- ARTICULAR INJECTION, 0.1MG Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25 mg DOXORUBICIN HCL 10MG ALDESLEUKIN PER SINGLE USE VIAL ARSENIC TRIOXIDE 1MG ASPARAGINASE (ERWINAZE) 1,000IU AZACITIDINE 1MG CLOFARABINE 1MG BELINOSTAT 10MG
4 J9033 J9034 J9035 J9039 J9040 J9041 J9042 J9043 J9045 J9047 J9050 J9055 J9060 J9065 J9070 J9098 J9100 J9120 J9130 J9145 J9150 J9155 J9160 J9171 J9176 J9178 J9179 J9181 J9185 J9190 J9200 J9201 J9202 J9205 J9206 J9207 J9208 J9209 J9211 J9214 BENDAMUSTINE HCL 1MG (TREANDA) BENDAMUSTINE HCL 1MG (BENDEKA) BEVACIZUMAB 10MG BLINATUMOMAB 1MCG BLEOMYCIN SULFATE 15 UNITS BORTEZOMIB 0.1MG BRENTUXIMAB VEDOTIN 1MG CABAZITAXEL 1MG CARBOPLATIN 50MG CARFILZOMIB 1MG CARMUSTINE 100MG CETUXIMAB 10MG CISPLATIN POWDER OR SOLUTION PER 10MG CLADRIBINE PER 1MG CYCLOPHOSPHAMIDE 100MG CYTARABINE LIPOSOME 10MG CYTARABINE HCL 100MG DACTINOMYCIN 0.5MG DACARBAZINE 100MG DARATUMUMAB 10MG DAUNORUBICIN 10MG DEGARELIX 1MG DENILEUKIN DIFTITOX 300MCG DOCETAXEL 1MG ELOTUZUMAB 1MG EPIRUBICIN HCL 2MG ERIBULIN MESYLATE 0.1MG ETOPOSIDE 10MG FLUDARABINE PHOSPHATE 50MG FLUOROURACIL 500MG FLOXURIDINE 500MG GEMCITABINE HCL 200MG GOSERELIN ACETATE IMPLANT PER 3.6MG IRINOTECAN LIPOSOME 1MG IRINOTECAN 20MG IXABEPILONE 1MG IFOSFAMIDE PER 1GM MESNA 200MG IDARUBICIN HYDROCHLORIDE 5MG INTERFERON ALFA-2B RECOMBINANT 1 MILLION UNITS
5 J9215 J9217 J9225 J9228 J9230 J9245 J9250 J9260 J9261 J9262 J9263 J9264 J9266 J9267 J9268 J9271 J9280 J9293 J9295 J9299 J9301 J9302 J9303 J9305 J9306 J9307 J9308 J9310 J9315 J9320 J9328 J9330 J9340 J9351 J9354 J9355 J9357 J9360 J9370 J9371 INTERFERON ALFA-N3 HUMAN LEUKOCYTE DERIVED 250,000IU LEUPROLIDE ACETATE FOR DEPOT SUSPENSION 7.5MG HISTRELIN IMPLANT 50MG IPILIMUMAB 1MG MECHLORETHAMINE HCL (NITROGEN MUSTARD)10MG MELPHALAN HYDROCHLORIDE 50MG METHOTREXATE SODIUM PER 5MG METHOTREXATE SODIUM PER 50MG NELARABINE 50MG OMACETAXINE MEPESUCCINATE 0.01MG OXALIPLATIN 0.5MG PACLITAXEL PROTEIN-BOUND PARTICLES 1MG PEGASPARGASE PER SINGLE DOSE VIAL PACLITAXEL 1MG PENTOSTATIN PER 10MG PEMBROLIZUMAB 1MG MITOMYCIN 5MG MITOXANTRONE HCL PER 5MG NECITUMUMAB 1MG NIVOLUMAB 1MG OBINUTUZUMAB 10MG OFATUMUMAB 10MG PANITUMUMAB 10MG PEMETREXED 10MG PERTUZUMAB 1MG PRALATREXATE 1MG RAMUCIRUMAB 5MG RITUXIMAB 100MG ROMIDEPSIN 1MG STREPTOZOCIN 1GM TEMOZOLOMIDE 1MG TEMSIROLIMUS 1MG THIOTEPA 15MG TOPOTECAN 0.1MG ADO-TRASTUZUMAB EMTANSINE 1MG TRASTUZUMAB 10MG VALRUBICIN INTRAVESICAL 200MG VINBLASTINE SULFATE 1MG VINCRISTINE SULFATE 1MG VINCRISTINE SULFATE LIPOSOME 1MG
6 J9390 J9395 J9400 Q0138 Q2017 Q2043 Q2049 Q2050 Q5101 VINORELBINE TARTRATE PER 10MG FULVESTRANT 25MG ZIV AFLIBERCEPT 1MG FERUMOXYTOL NON-ESRD 1MG TENIPOSIDE 50MG SIPULEUCEL-T MINIMUM 50 MILLION AUTOLOGOUS C54+CELLS ACTIVATED W/PAP-GM-CSF PER INFUSION DOXORUBICIN HCL LIPOSOMAL IMPORTED LIPODOX 10MG DOXORUBICIN HCL LIPOSOMAL NOS 10MG FILGRASTIM (G-CSF) BIOSIMILAR 1MCG
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,
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